VATS Major Pulmonary Resection

	Figure 1. With the flexion of the operating table to 30 degrees at the level of the nipple, the minithoracotomy naturally opens up, rendering rib spreading unnecessary throughout the procedure. Note the position of the thoracoscope and only a soft tissue retractor was used. (reproduced with permission from Yim APC. Video Assisted Pulmonary Resection. In Pearson FG, Cooper JD, Deslauriers J et al (eds) Thoracic Surgery (2nd edition) Churchill Livingstone).

The surgeon stands facing the patient who is in the lateral decubitus position under general anesthesia with selective one lung ventilation.³ We prefer to flex the operating table to open up the intercostal spaces for instrument maneuvering(Figure 1). The thoracoscope is normally placed in the seventh or eighth intercostal space over the mid to anterior axillary line, depending on the body build of the patient and the location of the pathology. From this position, a panoramic view of the hemithorax can be obtained. The basic principle is to align the thoracoscope, the pathology and the television monitor. This allows the surgeon to look straight ahead during the operation and provides the best ergonomic position for the surgeon.⁴

If there is no contraindication to proceed, a minithoracotomy (generally 6 to 8 cm in length) is placed over the fourth intercostal space in the anterolateral chest (Figure 2). In females, the skin incision can be made (if the anatomy allows) in the inframammary fold for cosmesis. The location of this wound usually means only a small portion, if any, of the latissimus dorsi muscle needs to be divided. The serratus anterior muscle is split along the direction of its fibers. Division of the intercostal muscles permits access into the pleural cavity. The placement of the minithoracotomy in this position provides direct access to the hilum, and because the anterior intercostal space is wider than the posterior space, it facilitates later retrieval of the specimen. We do not use rib spreader, only a soft tissue retractor for the minithoracotomy wound.

	Figure 2. Postoperative picture of a typical patient who underwent VATS major resection (a left pneumonectomy in this case). Note the position of the minithoracotomy scar. The anterior stab wound scar was for the thoracoscope, and the posterior scar for the sponge holding forceps for lung maneuvering. (reproduced with permission from Yim APC. Video Assisted Pulmonary Resection. In Pearson FG, Cooper JD, Deslauriers J et al (eds) Thoracic Surgery (2nd edition) Churchill Livingstone).

A sponge holding forceps is introduced through a separate tiny incision in the seventh or eighth intercostal space in the posterior axillary line. With two sponge holding forceps, one through the anterior minithoracotomy and the other through the posterior wound, the collapsed lung can be moved around and a thorough assessment made of the location and extent of the primary lesion. This technique also permits a search for associated pathology (satellite nodules; mediastinal or hilar lymphadenopathy which could be missed even by high resolution contrast chest CT).

Contrary to laparoscopic surgery, which generally does not allow digital palpation (because of the need to use valved ports to sustain carbon dioxide insufflation), digital palpation through the minithoracotomy, in addition to instrument palpation during VATS exploration, can provide valuable information to the surgeon and is encouraged. By bringing the lung towards the palpating finger placed through different sites, a large portion of the lung surface can be palpated (video segment 1). This is important as small nodules (

Conventional Metzenbaum scissors and DeBakey forceps are introduced through the minithoracotomy wound for sharp dissection of the hilum. The sponge holding forceps from the posterior wound is used to provide appropriate traction and to position the lobes so that the hilum can be easily accessed through the minithoracotomy. If there are adhesions of the lung to the chest wall or mediastinum, these should be taken down before starting the hilar dissection as it is essential to be able to freely move the lobes around.

If the interlobar fissure is complete or nearly complete, sharp incision of the visceral pleura and blunt dissection using a dental pledget mounted on a conventional curved clamp allow easy identification of the pulmonary artery. If the fissure is not complete, we find a monopolar diathermy forceps (Olsen Electrosurgical, Inc., Concord, CA) at a low setting to be useful for hemostasis when a layer of lung parenchyma has to be divided to access the interlobar vessels.

Dissecting around a pulmonary vessel is basically the same as in conventional, open surgery (video segment 2). We use a right-angle Mixter clamp to go around a vessel, and then loop it with a heavy silk ligature. With gentle traction on the suture, a dental pledget is used to gently dissect the undersurface of the vessel. A mechanical stapler (Endo-GIA 30V; Autosuture, United States Surgical, Norwalk, CT) is then introduced through one of the other two ports (depending on the alignment), but usually the camera port (with the thoracoscope repositioned to view through the minithoracotomy wound) to staple-transect the vessel (video segment 3). Appropriate traction (using a sponge holding forceps from the other port) is crucial in aligning the vessel with the stapler for transection (Figure 3). In recent years, we have been using more frequently ligation of pulmonary arterial branches with extracorporeal knots instead of mechanical staplers mainly to reduce cost.⁵ We tend not to use many endoclips for small pulmonary branches, as their presence could interfere with the subsequent use and functioning of the endostaplers.

	Figure 3a-b. Management of the left main pulmonary artery (PA) in a VATS pneumonectomy to illustrate our technique. (a) Under thoracoscopic vision, the PA is dissected around with a conventional right angle clamp. A #2 silk tie is about to be pulled around the vessel. (b) With traction on the silk tie, a dental pledget mounted on a right angle clamp is used to open up the space behind the PA. Any suspicious mediastinal lymph node, like level 5, is biopsied and a frozen section is performed before proceeding further.
	Figure 3c-d. (c) A vascular stapler (EndoGIA30V, Autosuture, USC) is used to staple-transect the PA. (d) Three rows of staples are left on either side of the transected PA. The final diagnosis in this patient is T2N0M0 Stage Ib squamous cell carcinoma. (reproduced with permission from Yim APC. Video Assisted Pulmonary Resection. In Pearson FG, Cooper JD, Deslauriers J et al (eds) Thoracic Surgery (2nd edition) Churchill Livingstone)

Lewis and his colleagues have accumulated extensive experience on simultaneously staple-transecting the pulmonary vasculature and lobar bronchus with excellent results.⁶ The author has modified and adopted this technique for lower lobectomy (for bronchiectasis) on a couple of occasions, during which individual isolation of the pulmonary artery and bronchus to the lower lobe proved to be technically difficult or even hazardous. On both occasions, the inferior vein was taken separately.

The lobar bronchus is divided with a linear mechanical stapler with a built in blade for transection (Endo-GIA 30 with closed staple height of 1.5 mm; Autosuture, USC, Norwalk, CT). The mainstem bronchus requires use of a different stapler that necessitates manual transection (Roticulator 30 with closed staple height of 2 mm; Autosuture, USC, Norwalk, CT) (video segment 4). The integrity of the bronchial stump is then tested to 35 cm of airway pressure in the usual manner underwater.

Release of the pulmonary ligament is required following upper and/or middle lobectomies. Although this is usually a straightforward maneuver, the positions of the ports and minithoracotomy mean that paradoxical motion would be difficult to avoid. Paradoxical motion is generated when the camera and instruments are facing each other. We have found that by turning the camera 180 degrees, a normal spatial relationship is restored for the operator.⁷ This simple maneuver allows the surgeon to use the camera and existing ports to his/her best ergonomic advantage.

We do not perform VATS mediastinal lymphadenectomy. If a complete lymph node dissection is considered necessary, it should be done through a thoracotomy. There are surgeons who advocate routine VATS lymphadenectomy, but just like open surgery, their results have not been shown to be superior to those who perform lymph node sampling.⁸

A wound protector should be used to avoid any potential implantation of tumor cells in the wound. When the primary tumor is less than 4 cm, we generally have found that a mechanical rib spreader is not necessary for retrieval of the resected lobe, bi-lobe or even the entire lung (although some manual rib retraction may be needed at the time of retrieval).

The entire hemithorax is then copiously irrigated with warm saline. If there is any significant parenchymal leak, endoscopic suturing can be done through the mini-thoracotomy.

The author describes his own technique here, but the readers are reminded that other variations in technique exist for this procedure.⁹