Thoracoscopic left superior segmentectomy for primary lung adenocarcinoma

This 59-old male patient, smoker, has a previous history of thymoma that was operated upon 15 years ago by sternotomy. He presented with a large nodule in the superior segment of the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma TTF1+. 18-FDG scintigraphy showed a significant and isolated fixation. Because of the impaired respiratory function, a limited resection was decided upon, i.e, a resection of the superior segment of the left lower lobe 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 superior segmentectomy for primary lung adenocarcinoma

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Abstract

This 59-old male patient, smoker, has a previous history of thymoma that was operated upon 15 years ago by sternotomy. He presented with a large nodule in the superior segment of the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma TTF1+. 18-FDG scintigraphy showed a significant and isolated fixation. Because of the impaired respiratory function, a limited resection was decided upon, i.e, a resection of the superior segment of the left lower lobe 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 superior segmentectomy, primary lung adenocarcinoma

Media type

Surgical video

Duration

06'23''

Publication

2010-03

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E-publication

WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2921.htm

Thoracoscopic left superior segmentectomy for primary lung adenocarcinoma

1. Patient and trocar position 00'06''

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 on the anterior axillary line; one 15mm trocar in the 7th intercostal space on the anterior axillary line. An additional 3mm trocar can be inserted, if needed, in the 6th intercostal space on the posterior axillary line.

2. Segmental apical artery dissection 00'54''

The first step is the dissection of the segmental apical artery in the fissure. Both lobes are retracted to expose the middle portion of the fissure. In this video, the white gauze visible at the apex is an “EndoClear” lens cleaning system that is left inside the chest throughout the procedure. There is no need to display the whole trunk of the pulmonary artery. Only its posterolateral surface must be clearly displayed. The posterior fissure is opened by inserting the tip of a dissecting forceps from the posterior aspect of the pulmonary artery to the posterior mediastinum. This may require forward retraction of the lobes in order to expose the posterior mediastinal pleura. The posterior fissure is then stapled or divided with a vessel-sealing device (Ligasure®), if thin enough as in this patient. The superior segmental artery, which runs anterior to the segmental bronchus, is usually single, sometimes double. It is dissected and clipped or stapled depending on its diameter.

3. Control of segmental apical vein 02'50''

The second step is the control of the segmental apical vein.

4. Dissection of lymph node stations 8 and 9 02'58''

Stations 8 and 9 lymph nodes are dissected and collected during this stage. The pulmonary ligament is incised up to the lower vein using both diathermy and gentle traction on the lower lobe. The inferior vein is cleared from lymph nodes and its surrounding tissues, until its uppermost tributary is identified. The vein lies inferior to the bronchus. It can be clipped or divided with a vessel-sealing device or stapled as in this case when the vein is large.

5. Segmental bronchus division 05'16''

Division of the segmental artery and vein gives access to the segmental bronchus, which is cleared and divided, while avoiding an impingement on the basilar bronchus. If there is any doubt, a reventilation test can be helpful. Division of the vein and bronchus helps lift up the superior segment. A long clamp is applied on the parenchyma, checking that the bronchial stump stays remote and that it will not get stuck within the stapler’s jaws, while constantly keeping the segmental vein in mind. A reventilation test allows to identify the intersegmental plane. The parenchyma is compressed by the clamp to ease stapler application.

6. Specimen extraction 06'13''

Finally, the specimen is retrieved through the 15mm incision enlarged over a 3 to 4cm length and the procedure is concluded by the lymph node dissection, as demonstrated in another video.