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|Figure 1: Computed tomography showing a typical right upper lobe lung lesion. surrounded by lung parenchyma suitable for VATS lobectomy|
VATS lobectomies are performed on patients with clinical stage I lung cancer assessed by computed tomography (CT) and positron emission tomography (PET). The procedure is usually performed for tumors less than 4 cm in maximum diameter, but we have resected tumors as large as 6.5 cm. This procedure can be performed regardless of tumor location within the lobe; however, procedures on very proximal hilar tumors are converted to open thoracotomy for better assessment whenever pneumonectomy is contemplated. Current contraindications to performing this procedure include chest wall involvement or surgery planned after neoadjuvant chemotherapy for N2 disease. Prior thoracotomy is not an absolute contraindication since the degree of adhesions and the ability to mobilize the lung adequately will vary among patients. The degree of emphysema, comorbidities, and age are not contraindications, and patients so affected are not managed differently than patients undergoing standard thoracotomy. Figure 1 demonstrates a computed tomography of the typical lesion that is amenable to VATS lobectomy.
|Figure 2: Patient in wrong position because hip would obstruct downward movement of camera|
The patient is placed in the lateral decubitus position with the table break maximally-flexed at the patient’s hip level, and then reverse Trendelenburg tilts the table so the patient’s lateral chest wall is parallel to the floor. Figure 2 shows the patient in a suboptimal position where the hip would limit adequate visualization of the hemithorax by obstructing downward movement of the thoracoscope. Figures 3 and 4 demonstrate the same patient in the proper VATS lobe position. Single lung ventilation is established and the camera port is placed at the eighth interspace in the anterior axillary line for right-sided lesions and in the posterior axillary line for left-sided lesions. The posterior port is then placed where the lower lobe edge touches the diaphragm (approximately the 8th interspace). A lung clamp used as a retractor is placed through the posterior port and the upper lobe is retracted laterally to allow visualization of the superior pulmonary vein (Figure 5). The utility incision (no larger than 4 cm in length) is placed directly over the superior pulmonary vein for upper lobectomies (approximately the 3rd or 4th interspace, and one interspace lower for middle and lower lobectomies (Video 1). A Weitlaner is used to retract the soft tissues; there is no need for rib spreading (Figure 6).
|Figure 3: Patient in maximally flexed position||Figure 4: Incision placement, external view||Figure 5: Endo-Duval lung retracting clamps, opened and closed||Figure 6: Weitlaner retractor for soft tissues of utility incision|
|Figure 7: Harken clamps, long and short|
|Figure 8: Curved ringed forceps, long and short|
|Figure 9: Surgical tissue pouch|
|Figure 10: Postoperative photograph of incisions|
The lower lobe is retracted superiorly, the pulmonary ligament is transected, and the level 9R lymph nodes are removed. Once the inferior pulmonary vein has been dissected, an endovascular stapler is placed via the utility incision to transect the vessel. The lower lobe bronchus is exposed from its inferior aspect to its bifurcation with the middle lobe bronchus. The bronchus is left intact until the interlobar pulmonary artery is exposed medially and superiorly within the fissure. After the pulmonary artery has been adequately exposed, the bronchus is transected with a 4.8 mm universal stapler placed through the utility incision. The pulmonary artery is then transected followed by division of the fissure via the utility incision.
The middle lobe is retracted laterally and the pleura overlying the middle lobe vein is incised. Once the vein is dissected it is transected by an endovascular stapler placed via the utility incision, exposing the middle lobe bronchus. After encircling the bronchus with a monofilament suture, an Endo-GIA 3.5 stapler is placed via the utility incision to transect the bronchus. A ring forceps is then placed on the middle lobe bronchus for traction, exposing the one or two branches of the middle lobe artery, which are then transected from the utility incision. On occasion, the angle is such that the middle lobe artery must be transected from the posterior port. The fissures are then completed by passing staplers via the utility incision.
The left upper lobe is retracted laterally and the vein is transected from the posterior port (Video 8). The first branch of the pulmonary artery is dissected and further exposure is obtained by removing the level 10L nodes. The artery is transected via the posterior port (Video 9). The bifurcation of the left upper and lower lobe bronchi is identified and the left upper lobe bronchus is transected from the posterior port by a universal stapler. A ring forceps is then used to retract the specimen stump of the bronchus laterally, which facilitates exposure of several branches on the pulmonary artery including the lingular artery (Video 10). These are then transected individually via the posterior port. The fissure is then completed by passing a universal stapler via the posterior port.
The lower lobe is retracted superiorly, the pulmonary ligament is transected, and level 9L lymph nodes are removed. Once the inferior pulmonary vein has been dissected, a stapler is placed via the utility incision to transect the vessel. The lower lobe bronchus is exposed from its inferior aspect to its bifurcation with the upper lobe bronchus. The bronchus is left intact until the interlobar portion of the pulmonary artery is exposed medially and superiorly from the overlying fissure. After the pulmonary artery has been adequately exposed, the bronchus is transected with a 4.8mm universal stapler placed through the utility incision. The pulmonary artery is then transected via the utility incision and the fissure is completed via the posterior port. Sometimes the superior segmental branch of the pulmonary artery originates from a very proximal location and may require separate dissection and division. In cases with a very thick incomplete fissure, the fissure between the lingula and lower lobe should be completed prior to dissection of the pulmonary artery to facilitate subsequent exposure.
A complete mediastinal nodal dissection or sampling is usually performed whenever a VATS lobectomy is performed for malignancy. For right sided resections, we routinely dissect levels 4R and 7 for upper lobes, and also include level 9R for lower lobes. For left sided resections we routinely dissect levels 5, 6, and 7 for upper lobes and also include level 9L for lower lobes. Our technique of thoracoscopic mediastinal nodal dissection will be described in a future technique section.
We have performed over 130 VATS lobectomies over a two year period at Memorial-Sloan Kettering without any intraoperative surgical or hospital mortality using the techniques described . Oncologic results appear similar to those of standard thoracotomy based on the experience of McKenna et al. in 298 patients . A learning curve exists and significant progress in technique can be expected after approximately 15 procedures. There have been no specific complications as a result of this technique that are not seen after open lobectomy. Pulmonary complications and atrial fibrillation appear to occur with similar frequency as with open lobectomy, although we have not performed a matched comparison to date. Overall, pain appears to be less in the VATS lobectomy patients than in the thoracotomy patients and this potential advantage is currently being studied at our institution.
Acknowledgment: The author would like to thank Robert McKenna, MD for allowing him to observe his operative technique.
Publication Date: 21-Apr-2005
Last Modified: 22-Aug-2008