Video-assisted thoracoscopic (VATS) lobectomy: right upper lobe

Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via posterolateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients. One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain. Key aspects of the procedure include: - proper patient positioning; - access to the pleural cavity and appropriate positioning of operating incisions*; - careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks; - division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers. The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for neuro-endocrine carcinoma of the right upper lobe in a 71-year-old patient (the video emphasizes the steps of lobe resection —mediastinal lymph node dissection was effected, but is not shown). Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Martin RN, and Mélodie Leclerc RN for their continued support. *The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.

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Video-assisted thoracoscopic (VATS) lobectomy: right upper lobe

Authors

G Rakovich, D Ouellette, G Beauchamp

Abstract

Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via posterolateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.

One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.

Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.

The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for neuro-endocrine carcinoma of the right upper lobe in a 71-year-old patient (the video emphasizes the steps of lobe resection —mediastinal lymph node dissection was effected, but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Martin RN, and Mélodie Leclerc RN for their continued support.
*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.

Classification

contribution

Keywords

Video-assisted, thoracoscopic lobectomy, VATS, right upper lobe, liver

Media type

Surgical video

Duration

07'21''

Publication

2011-04

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E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3218.htm

Video-assisted thoracoscopic (VATS) lobectomy: right upper lobe

1. Case presentation 00'08''

We will be performing a VATS lobectomy in a 71-year-old patient with a neuro-endocrine carcinoma of the right upper lobe. Oncologic surgery includes mediastinal lymph node dissection. We emphasize the steps of anatomic right lower lobe resection - mediastinal lymph node dissection was effected but is not depicted in this video.

2. Patient positioning and placement of incisions 00'33''

Proper patient positioning is critical to a successful operation. The operating table should be flexed generously in order to widen the intercostal spaces and keep the patient’s hip from impeding the surgeon’s movements. The non-dependent arm should be positioned so as to allow good access to the upper chest and axilla, which is necessary to allow comfortable handling of the instruments. We use 4 incisions: 2 anteriorly, 1 posteriorly, and 1 inferiorly. The anterior superior incision may be enlarged to 3 or 4cm and used as a working incision. The inferior incision is used for the thoracoscope. Except for the scope, endoscopic ports are usually not used. Instruments are inserted directly through the incisions. We use a combination of endoscopic and open-surgery instruments.

3. Dissection of the anterior portion of the hilum: superior pulmonary vein and anterior branches of the pulmonary artery 01'40''

The lung is retracted posteriorly in order to expose the anterior portion of the hilum. It is necessary to identify and preserve the middle lobe vein. The portion of the superior pulmonary vein draining the upper lobe is identified and dissected using a right-angle clamp. Care is taken to avoid injuring the interlobar and middle lobe arteries, which course just deep to the vein. The vein is encircled with a suture to facilitate subsequent retraction. The anterior branch of the pulmonary artery is dissected out in a sub-adventitial plane using a right-angle clamp. A suture passed around the artery will facilitate retraction during stapling. It is critical to avoid any undue tension on the arteries. Blood vessels are stapled using an endoscopic stapler loaded with a vascular cartridge and inserted through the posterior incision. During stapling, it is critical to avoid any tension on the stapler, to avoid tearing the vessels. This is particularly true for branches of the pulmonary artery. During stapling, we always have a sponge-stick ready and are prepared to compress any bleeding by covering the vessel with lung parenchyma. Next the apical artery is dissected and divided using the technique previously described. The common origin of the anterior and apical arteries from the truncus anterior may be seen.

4. Dissection of the fissure and posterior ascending branch of the pulmonary artery 04'19''

The minor fissure between the upper and middle lobes is exposed and divided using an endoscopic stapler. While dividing the fissure, it is very important to stay superficial to the interlobar pulmonary artery, which should be visualized prior to firing the stapler. Dissection is carried on posteriorly along the interlobar artery, identifying the posterior ascending branch. The posterior ascending artery is dissected out in a sub-adventitial plane using a right-angle clamp. It is divided using an endoscopic stapler loaded with a vascular cartridge. We use the aforementioned precautions during any vascular stapling. Dividing the posterior ascending artery is a key step in gaining access to the origin of the right upper lobe bronchus and the posterior part of the fissure. The fissure is divided using an endoscopic stapler.

5. Dissection of the bronchus and specimen extraction 06'21''

The upper lobe is lifted to expose the upper lobe bronchus. Peribronchial lymphatic tissue is reflected toward the specimen. The bronchus is divided using an endoscopic stapler. The lobe is extracted through the anterior superior incision using a specimen retrieval bag. The incision may have to be slightly enlarged to allow extraction. The middle lobe is fixed to the lower lobe to avoid the risk of postoperative torsion. The upper lobe hilum is inspected. Any remaining lymph nodes may be removed at this time. The lung is re-expanded. We use 2 chest tubes introduced through 2 of the thoracoscopy ports. The remaining incisions are closed in standard fashion.