Thoracoscopic right upper lobectomy for primary lung adenocarcinoma

This 51-year-old male patient, smoker, has an undetermined isolated 2cm nodule in the right upper lobe. Bronchoscopy was normal. A biopsy under CT-scan guidance revealed an adenocarcinoma. 18-FDG scintigraphy demonstrated a significant and isolated fixation. It was decided to perform a right upper lobectomy via a totally endoscopic approach. The additional lymphadenectomy is shown in another video. 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 right upper lobectomy for primary lung adenocarcinoma

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Abstract

This 51-year-old male patient, smoker, has an undetermined isolated 2cm nodule in the right upper lobe. Bronchoscopy was normal. A biopsy under CT-scan guidance revealed an adenocarcinoma. 18-FDG scintigraphy demonstrated a significant and isolated fixation. It was decided to perform a right upper lobectomy via a totally endoscopic approach. The additional lymphadenectomy is shown in another video.

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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contribution

Keywords

Thoracoscopic right upper lobectomy, primary lung adenocarcinoma

Media type

Surgical video

Duration

08'52''

Publication

2010-04

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WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2978.htm

Thoracoscopic right upper lobectomy for primary lung adenocarcinoma

1. Patient and trocar position 00'19''

The patient is set in the lateral position with the arm hanging down. The surgeon is standing at the back of 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; two 5mm trocars in the 3rd and 6th intercostal space in the posterior axillary line. The uppermost one is used for a grasping forceps and the lowest one for scissors and dissecting instruments. A 15mm trocar is inserted in the 7th intercostal space in the anterior axillary line, for a vessel sealing device, an endostapler and the retrieval bag. This port will be enlarged over a 3 to 5cm length, at completion of the procedure, for specimen retrieval.

2. Pulmonary artery dissection 01'13''

The first stage is the dissection of the interlobar portion of the pulmonary artery within the major fissure. Thorough progression using a combination of bipolar diathermy and blunt dissection is required until the artery is discovered. Once the interlobar artery is identified, the ascending branches to the upper lobe are dissected. In some cases, it may be preferable to first divide the posterior portion of the major fissure since it will facilitate the exposure of the posterior artery.

3. Posterior mediastinum exposure 02'20''

This is achieved by stretching the lobes forwards until the posterior mediastinum is fully exposed. The pleura facing the inferior aspect of the upper bronchus is opened using either cautery or blunt dissection or both. A dissecting forceps is then passed from the hilum to the periphery.

4. Applying the Endo-stapler 02'55''

A 60mm endostapler can then be applied. This helps exposing the posterior arteries whose number ranges from 1 to 3.

5. Division of ascending arteries 03'12''

The ascending arteries are clipped and divided. A vessel-sealing device or an ultrasonic coagulation can also be used if the vessels are small enough. The upper lobe is pulled backward. 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 with an endopeanut. The venous branch to the middle lobe must be clearly identified before encircling the superior pulmonary vein.

6. Dissection of superior pulmonary vein 05'06''

Dissection and mobilization of the superior pulmonary vein gives access to the two segmental branches (apical and anterior) of the truncus anterior.

7. Exposure of upper lobe bronchus 05'34''

The third stage is the exposure and control of the upper lobe bronchus. The upper lobe is pulled downward and forward so that the posterior and superior aspects of the bronchus are visualized. The peribronchial tissues and bronchial arteries are freed using a diathermy hook of scissors.

8. Bronchus stapling 05'56''

Peribronchial lymph nodes are removed during dissection. Traction on the lobe helps exposing the bronchus, which is then stapled.

9. Completion of the procedure 06'18''

Once the bronchus has been stapled, the last step is the division of the parenchyma since the transverse fissure is seldom complete. After having checked once again that the venous branch to the middle lobe keeps remote, a clamp is applied on the parenchyma and its correct position is adapted according to the reventilation test. Some pressure is applied on the clamp in order to mark the parenchyma and the stapler is then applied. One to three 4.8mm cartridges may be necessary to complete the fissure division. The specimen is extracted after minor enlargement of the largest port. Once the specimen has been retrieved, the pulmonary ligament is divided up to the inferior pulmonary vein using both diathermy and gentle traction on the lower lobe. When the minor fissure is complete, the middle lobe must be repositioned and secured to the lower lobe. Since this is better done under reventilation, there is no room for hand suturing and it is thus easier to use a stapler without knife such as an Endo-TA. The last stage that is demonstrated in an other video is the radical lymphadenectomy.