Hybrid VATS Right Upper Lobectomy With En Bloc Chest Wall Resection and Thoracoscopic Management of Major Stapler Injury

The authors present the case of a 71-year-old female former smoker who was referred for persistent right dorsal thoracic pain. Computed tomography (CT) and positron emission tomography (PET) scans revealed a 39 mm hypermetabolic tumor (SUVmax 10) in the apical segment of the right upper lobe, with direct invasion of the second rib. Preoperative staging, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), confirmed N0 status. With a clinical stage IIB (cT3N0M0) tumor, the patient was scheduled for a hybrid thoracoscopic lobectomy and en bloc chest wall resection. 

The video details the surgical technique, starting with the positioning and port placement strategy. The chest wall resection was performed simultaneously by the thoracoscopic team and an external team through a limited counter-incision. Distal and proximal costotomies of the second rib were completed to release the tumor-adhered segment. The dissection of the muscular planes was assisted internally by an ultrasonic energy device to ensure hemostasis and visualization. Intraoperative frozen section analysis of the pleuro-muscular margins confirmed the absence of malignancy. 

Attention was then turned to the hilar dissection. The fissure between the upper and lower lobes was divided to expose the hilar structures. The right upper lobe (RUL) bronchus and the posterior ascending artery (A2) were isolated; the A2 was divided using polymer clips and ultrasonic energy. The superior pulmonary vein was dissected and divided with a vascular stapler. 

The critical portion of the video demonstrates the management of an intraoperative vascular complication. During the division of the truncus anterior using a 30 mm vascular stapler, a mechanical failure occurred immediately upon firing, resulting in significant hemorrhage from the staple line. The surgeons proceeded rapidly to control the hemorrhage. A sponge clamp was initially applied to the stump to stop the bleeding while maintaining visualization via suction. This was subsequently exchanged for a fenestrated clamp to assess the extent of the vascular damage while carefully preserving the superior vena cava. 

To optimize exposure for the vascular repair, the decision was made to complete the lobectomy first. The RUL bronchus was stapled and divided, followed by the remaining parenchyma. The specimen was extracted through the chest wall defect to prevent traction on the hemostatic clamps. 

With the field cleared, the fenestrated clamp was replaced with a side-biting vascular clamp. The arterial stump of the truncus anterior was repaired using a running 4-0 polydioxanone (PDS) suture in a double layer. Extracorporeal ligation was performed, and absolute hemostasis was confirmed. The video concludes with the placement of oxidized regenerated cellulose over the repair site. 

The postoperative course was uneventful. The patient was monitored in the intensive care unit (ICU) for two days and was discharged on postoperative day four after chest tube removal. Follow-up appointments at one and three months showed no complications.  

Final histopathology revealed an invasive mucinous adenocarcinoma (40 x 40 x 15 mm) with invasion of the visceral pleura, parietal pleura, and costal bone (pT3N0M0, Stage IIB). Surgical resection margins were free (R0), and lymphovascular invasion was absent. All sampled lymph node stations (2R, 4R, 7, 8, 10R, 11R) were negative for malignancy.

This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.  

References

1. Meacci E, Nachira D, Zanfrini E, et al. Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience. J Thorac Dis. 2020;12(6):3376-3389. doi:10.21037/jtd.2020.01.12 
2. Dal Agnol G, Oliveira R, Ugalde PA. Video-assisted thoracoscopic surgery lobectomy with chest wall resection. J Thorac Dis. 2018;10(Suppl 22):S2656-S2663. doi:10.21037/jtd.2018.04.72
3. Decaluwe H, Petersen RH, Hansen H, et al. Major intraoperative complications during video-assisted thoracoscopic anatomical lung resections: an intention-to-treat analysis. Eur J Cardiothorac Surg. 2015;48(4):588-599. doi:10.1093/ejcts/ezv287
4. Gonfiotti A, Salvicchi A, Voltolini L. Chest-Wall Tumors and Surgical Techniques: State-of-the-Art and Our Institutional Experience. J Clin Med. 2022;11(19):5516. Published 2022 Sep 20. doi:10.3390/jcm11195516
5. Melek H, Özkan B, Volkan Kara H, et al. Minimally invasive approaches for en-bloc anatomical lung and chest wall resection. Turk Gogus Kalp Damar Cerrahisi Derg. 2023;31(3):374-380. Published 2023 Jul 27. doi:10.5606/tgkdc.dergisi.2023.23850

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