Thoracoscopic left lower lobectomy for stage I lung carcinoma

This 53-year-old female smoker has an undetermined excavated 2cm nodule in the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control but was non contributive. 18-FDG scintigraphy showed a significant and isolated fixation. It was decided to perform a left thoracoscopy, a new biopsy under thoracoscopic control and in case of positive frozen section a totally endoscopic left lower lobectomy with radical lymph node dissection. This technique is presented in the book : D. Gossot Atlas of endoscopic major pulmonary resections (2010) Springer-Verlag France www.springer.com/978-2-287-99776-1

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Thoracoscopic left lower lobectomy for stage I lung carcinoma

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Abstract

This 53-year-old female smoker has an undetermined excavated 2cm nodule in the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control but was non contributive. 18-FDG scintigraphy showed a significant and isolated fixation. It was decided to perform a left thoracoscopy, a new biopsy under thoracoscopic control and in case of positive frozen section a totally endoscopic left lower lobectomy with radical lymph node dissection.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1

Keywords

Thoracoscopic left lower lobectomy, stage I lung carcinoma

Media type

Surgical video

Duration

07'49''

Publication

2010-03

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E-publication

WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2908.htm

Thoracoscopic left lower lobectomy for stage I lung carcinoma

1. Patient and trocar position 00'07''

The patient is set in the lateral position with the arm hanging down. The surgeon is facing the patient. After single lung ventilation has been initiated, 4 trocars are inserted: one 10mm trocar in the 6th intercostal space in the mid-axillary line for the deflectable thoracoscope; one 5mm trocar in the 4th intercostal space in the anterior axillary line; one 15mm trocar in the 7th intercostal space in the anterior axillary line. An additional 3mm trocar can be inserted, if needed, in the 6th intercostal space in the posterior axillary line. A pathological diagnosis is obtained by a core gun biopsy. Frozen section reveals an adenocarcinoma.

2. Pulmonary ligament division 01'02''

The first step is the division of the pulmonary ligament.

3. Lymphadenectomy of stations 7, 8 and 9 01'05''

Lymph nodes of stations 8 and 9 are collected during this step. Dissection of station 7 is then carried out. It is advisable to perform this dissection before the lobectomy since the bronchial and venous stumps can hamper the approach of the subcarinal region. During this step, the esophagus is gently retracted backward using a 3mm blunt tip probe. At completion of station 7 lymphadenectomy, the 2 main stem bronchi are clearly visible. In case of mild oozing, a small gauze can be temporarily packed below the carina. Once the lymphadenectomy of stations 7, 8, and 9 has been completed, the lobectomy is started by opening the fissure.

4. Fissure opening 02'42''

Its thin anterior portion is divided either by bipolar cautery, as in this patient, or using a vessel-sealing device. The sheath of the pulmonary artery is then entered and cleared from all lymph nodes. The posterior portion of the fissure is opened and divided using a vessel sealing device or an endostapler if thick.

5. Pulmonary artery dissection 03'35''

Dissection of the pulmonary artery is pursued. The division of the anterior portion of the fissure is then completed with an Endostapler. This is done only after a clear identification of the lingular artery, which must be preserved. A full opening of the fissure allows to complete the dissection of the branches of the pulmonary artery. Note that in this case, there are 3 branches to the apical segment of the lower lobe, an unusual pattern.

6. Arterial stapling 05'30''

These arteries are stapled, as well as the basilar arterial trunk. The inferior pulmonary vein is then dissected and stapled.

7. Vein division 06'44''

Dividing the vein facilitates the dissection of the bronchus, which is cleared from all surrounding tissues and peribronchial lymph nodes.

8. Lower lobar bronchus division 07'25''

The lower lobar bronchus is then stapled, avoiding any impingement of the upper lobe bronchus. The specimen can now be removed. The last step is the lymph node dissection of stations 5 and 6, which is described in the “lymphadenectomy” video clip.