Left Video-Assisted Thoracoscopic Sleeve Lower Lobectomy

This video demonstrates a left video-assisted thoracoscopic (VATS) sleeve  lower lobectomy in a 68-year-old male smoker with a stage IA endobronchial squamous cell carcinoma, arising from the left lower lobe bronchial origin with distal collapse consolidation of the lung.

Single lung isolation of the left lung is obtained by placing a right-sided double lumen tube under bronchoscopic guidance. A right-sided double lumen tube is generally preferred for left pneumonectomy and sleeve resections as it allows for an unimpeded, tension-free bronchial closure without the endobronchial tube coming into the operative surgical field.

The VATS sleeve lobectomy technique is a totally endoscopic procedure, performed by directly watching the TV monitor. The lobectomy is done through an anterior approach, where the surgeon and camera assistant stand in front of the patient and the 2nd assistant and scrub nurse stand on the opposite side. The following non-rib-spreading ports are placed: a 5 mm, 30 degree camera placed over the major fissure in the 5th intercostal space; a 10 mm retraction port placed at the 6th intercostal space posterior and inferior to the scapula tip; a 10 mm working port in the 6th intercostal space anterior axillary line; and a 1 cm incision in the 3rd intercostal space.

In this case, the dissection in the interlobar fissure was made difficult by the presence of dense scarring from prior post-obstructive pneumonitis. The endostaplers for the vessels and fissures were introduced through the lowermost working port. A concomitant complete radical mediastinal lymphadenectomy was performed. The specimen was removed via an endobag by enlarging the lowermost port. The lowermost port then became the utility incision through which endoscopic sewing and tying were performed.

All bronchial margins were subjected to intra-operative frozen section analysis to ensure clear tumor margins before performing the anastomosis. The two bronchial ends were approximated initially by using a few interrupted, absorbable monofilament sutures (polydiaxone PDS 4-0), with all knots placed on the outside. Sewing was done with a 5 mm endoscopic needle holder. Monofilament suture allows for smooth passage of sutures through the bronchus, and facilitates in the sliding and tying of knots. Knots were tied either intra- or extra-corporeally, usually through the utility incision. A stay suture placed around the distal bronchus, held by the assistant, helped to approximate the two ends and relieve tension when approximating the ends. Once the ends of the bronchi were approximated and set in place, the rest of the cartilaginous part of the anastomosis was completed using a running continuous 4-0 PDS suture. The membranous part of the anastomosis was then completed similarly with a continuous running suture, and both ends of the two sutures were then tied to each other.

Intraoperative integrity of the anastomosis was checked bronchoscopically and by insufflating air under water at 30 cm H₂O pressure. A surveillance bronchoscopy one week post-operatively showed good healing of the anastomosis.

References

1. Agasthian T. Initial experience with Vats Bronchoplasty. Eu. J Cardiothorac Surg. Oct 2013;44(4),616-23
2. Right Video Assisted Thoracoscopic Sleeve Upper Lobectomy. CTSNet. 3rd Mar 2014