Thoracoscopic left upper lobectomy for stage I lung carcinoma

This is the case of a 59-old female smoker who had an undetermined 2cm nodule in the left upper lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma (stage I lung carcinoma). 18-FDG scintigraphy showed a significant and isolated fixation. A thoracoscopic left upper lobectomy is presented. 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 upper lobectomy for stage I lung carcinoma

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Abstract

This is the case of a 59-old female smoker who had an undetermined 2cm nodule in the left upper lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma (stage I lung carcinoma). 18-FDG scintigraphy showed a significant and isolated fixation. A thoracoscopic left upper lobectomy is presented.

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

Classification

basic techniques

Keywords

Thoracoscopic left upper lobectomy, primary adenocarcinoma, stage I lung carcinoma

Media type

Surgical video

Duration

06'50''

Publication

2010-02

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E-publication

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2869.htm

Thoracoscopic left upper 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, which is held by a mechanical scope holder; one 5mm trocar in the 4th intercostal space in the anterior axillary line for a grasping forceps; one 15mm trocar in the 7th intercostal space in the anterior axillary line, for dissecting instruments, vessel-sealing device, Endostapler and retrieval bag. This port will be enlarged on a 3 to 4cm length, at completion of the procedure, for specimen retrieval. An additional 3mm trocar can be inserted, if needed, in the 6th intercostal space in the posterior axillary line for a blunt-tipped retractor or a grasping forceps.

2. Lingular artery control and division 00'55''

The first step is the control of the lingular artery in the fissure. This artery can be single or double. The fissure is opened in front of the pulmonary artery. In this case, there are 2 main branches of the lingular trunk. Each branch is dissected and a loop is passed to facilitate stapling. Once the lingular arteries have been controlled, the anterior portion of the fissure can be divided safely. Its most anterior part is stapled. A passage is then created, by retracting the lobe backwards. This helps exposing the pulmonary veins. A dissecting forceps can then be passed and the stapling of the anterior part of the fissure is completed. The posterior part is then dissected using a combination of Endopeanut and dissecting forceps. Thanks to the deflectable scope, a bird’s eye view on the posterior aspect of the fissure can be obtained, facilitating the safe creation of a passage for the endostapler. Once the lingular artery has been divided and the fissure fully opened, the upper lobe is gently pulled forward, avoiding any undue traction which could lead to injure the vessels. Dissection is continued cephalad and all encountered posterior arteries are divided in turn. Traction helps in exposing the first segmental artery whose dissection is usually easy. It is controlled by clipping or a vessel-sealing device or a combination of both.

3. Pulmonary vein and anterior truncus control 04'06''

The operation is continued by the control of the pulmonary vein and the truncus anterior. The upper lobe is pulled backward and downward. The mediastinal pleura is incised posterior to the phrenic nerve. Dissection of the vein is achieved by a combination of bipolar cautery and gentle sweeping motion. The vein is retracted forward to facilitate its stapling. Division of the vein helps exposing the anterior aspect of the truncus anterior. It should not be encircled and stapled before its superior and posterior surfaces are perfectly visible and free. It is recommended to keep away from the takeoff of the arterial trunk and rather dissect the apico-posterior and anterior branches. Dissection of the truncus anterior can be more difficult when a large accessory artery supplies the lingula and the anterior segment, as shown in this case. In this instance, it is important to approach the vessels not only from the front but also from the back and even from above by using the multiple angles of vision offered by the deflectable scope. The uppermost posterior artery is controlled in order to get access to the anterior branch of the truncus anterior. The truncus anterior is dissected from the front and from above and then stapled. The accessory lingular artery is then dissected with great care since its course is usually very short, and then stapled. We now come back to the initial case.

4. Upper lobar bronchus division 06'40''

The procedure is ended up by the dissection of the upper lobar bronchus, which is cleared from peribronchial tissues and finally stapled flush to the lobar bifurcation.

5. Specimen extraction 06'53''

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.