Right Video Assisted Thoracoscopic Sleeve Upper Lobectomy

This video demonstrates the technical details of performing a right video-assisted thoracoscopic sleeve lobectomy in a 42-year-old male smoker with a stage I adenocarcinoma of the right upper lobe of lung. The VATS sleeve lobectomy technique used is a totally endoscopic procedure. The following non-rib-spreading ports are placed: a 5mm 30-degree camera port placed over the major fissure in the 5th intercostal space; a 10mm retraction port placed at the 6th intercostal space posterior and inferior to the scapula tip; a 10mm working port in the 6th intercostal space anterior axillary line; and a 2cm non-rib-spreading utility incision in the 3rd intercostal space. The lobectomy is done through an anterior approach where the surgeon and camera assistant stand in front of the patient with the 2nd assistant and scrub nurse on the opposite side. The port placements and the position of the team is the same for all lobes of both lungs. The camera stays in the same position throughout the procedure. All lobar vessels are individually dissected and divided. The endostapler, used on the vessels and fissures, is introduced through the lowermost working port. A concomitant complete radical mediastinal lymphadenectomy is routinely performed.

All bronchial margins are subjected to intraoperative frozen section analysis to ensure clear tumor margins before performing the anastomosis. The anastomosis is done tension free with mucosa to mucosa approximation by using interrupted or continuous absorbable monofilament sutures (polydiaxone PDS 4 0) with all knots placed on the outside. Sewing is routinely done with a 5mm endoscopic needle holder. Monofilament suture allows for smooth passage of sutures through the bronchus and facilitates in the sliding and tying of knots. Knots are tied either intra- or extra-corporeally, usually through the utility incision. A stay suture between the proximal and distal ends of the airway, held by the assistant, helps to approximate the two ends, while relieving tension. Division of the inferior ligament is routinely done to relieve tension on the anastomosis. The inferior part of the anastomosis is done first, followed by the anterior wall, and finally the superior part of the anastomosis. The membranous part is always done last to avoid tension and subsequent tearing of the thin part of the membranous part of the anastomosis, as well as to obtain proper congruity and size matching of the distal and proximal bronchial anastomosis. Intraoperative integrity of the anastomosis is checked bronchoscopy and by insufflating air under water at 30cm of pressure.

References

1. Agasthian T. Initial experience with Vats Bronchoplasty. Eu. J Cardiothorac Surg. Oct 2013;44(4),616-23.