Whether IPL should be released during thoracoscopic upper lobectomy is still controversial, and some scholars believe that there was no difference [15–20], while some scholars believe that the release of IPL was beneficial to lung relaxation of patients, and can accelerate the recovery of remaining lung, eliminate residual cavity and prevent complications [21]. Other scholars maintain that the retention of the IPL during surgery can avoid surgical damage to surrounding tissues and bleeding, shorten the operation time [17], and preservation of IPL was conducive to lung secretion and reabsorption of pleural fluid, and avoid postoperative bronchial obstruction, lung torsion, and deformation, and lung function decline [11–13, 15, 16, 22].
Preservation and dissection of 100% IPL both had advantages in prognosis, and at present, no study had mentioned the surgical method of releasing 50% IPL. It was expected that releasing 50% IPL can combine the advantages of retention and release of 100% IPL. Our study showed that the surgical method of 50% IPL release was superior to both the retention group and the 100%IPL release group. The amount of intraoperative blood loss, drainage time, duration of hospital stay of dissecting 100% IPL were lower than those in preservation group, and the overall complications were similar with the preservation group. The overall rate of dissecting 100% IPL was slightly better than that in the preservation group.
Enhanced recovery after surgery (ERAS) and the concept of holistic minimally invasive surgery have become hot topics in thoracic surgery [23, 24]. This study followed the requirements of ERAS, in perioperative, the hospitals took a series of measures, such as preoperative education and assessment, perioperative anesthesia management, prevention of low-temperature operation, optimizing the operation process and operation method, guiding rehabilitation activities, the hospital told, to ensure the optimization of three groups of patients in the same condition to analyze prognosis.
The results of our study showed that there was no significant difference in surgery time among the three groups, and the surgical time of the preservation group was not lower than that of the release group. Maybe because the release of IPL was relatively fast and had little impact on the overall surgical time.
The results showed that the intraoperative blood loss of the preservation IPL group was larger than dissecting 50% IPL and dissecting 100% IPL, it may be related to the inconvenient operation of thoracoscopic surgery such as IPL implicated tissues and the upper lung lobe. Intraoperative infusion volume was determined according to the actual physical condition of patients and surgical conditions, and there were certain operational differences among different centers. In the next research, we can consider expanding the sample size to make the differences more obvious.
The postoperative drainage time, postoperative hospital stay, and incidence of complications in the 50%IPL group were less than those in the preservation group and 100%IPL group. Release of 50%IPL was less traumatic than the release of 100% IPL, and it can avoid upper lung cavity and bronchial angle torsion to a certain extent, which was conducive to lung reconstruction and postoperative recovery. However, the release of 100% IPL was less than the control group, but the complication rate was higher, including a higher atelectasis probability. The possible reason was that the release of 100% IPL affected pulmonary bronchial torsion and was not conducive to pulmonary revascularization. The inflammation rate of the release of 100% IPL was higher, which may be related to the greater trauma.
In addition, in this study, there were 7 patients in the preservation IPL group with 1–2 lymph nodes, and postoperative recovery would be poor after possible lymph node metastasis. There was only 1 case of lymph node metastasis in the 50% IPL group, and no lymph node metastasis occurred in the 100% IPL group. Therefore, the complexity of lymph node dissection may have little influence on the surgical operation data in this study. Yazgan Serkan [19] conducted a study, the conclusion was that in upper lobectomies, the status of station 9 did not have a significant impact on patient’s survival and lymph node staging. In the next study, we would take station 9 to the impact on patient’s survival.
Study limitations
In addition, there were some deficiencies in this study. The selected patients all met the inclusion criteria. The age of the retention group was 52(8) and 52(9) in the 50% IPL release group, while the age of the 100% IPL release group was 64(16). The high complication rate of 100%IPL may be related to high age and low physical fitness.
Future directions
Further research is needed on the physiological effects of dissecting IPL on patients undergoing VATS. (1) collect more patients, and ensure that the basic characteristics such as age have no difference. (2) To further understand the role of the IPL, factors such as tracheal deformation, bronchial torsion angle, and lung capacity can be added to the evaluation at 3, 6 and 12 months after surgery, and refer to the latest research: using computed tomography images to measure pre- and post-surgery lung volumes, bronchial angles (angle 1: axial angulation; angle 2: vertical angulation), and bronchial tortuosity (curvature index of the left or right main bronchus) for comparison[22]; (3) Further follow-up can be collected for recurrence or survival at 1, 3, and 5 years after the operation, evaluate the prognostic effect on long-term efficacy.