Subcostal Biportal Right Lower Lobectomy Day Surgery

This video describes a video-assisted thoracoscopic surgery (VATS) subcostal biportal right lower lobectomy performed as a day surgery. This abdominal extrathoracic approach is inspired by both Chinese and UK experience in VATS subxiphoid major pulmonary resections. The motivation was to explore an original way for better recovery and minimizing invasiveness, without making any concessions on safety or carcinologic resection. The patient was a 69-year-old man with normal pulmonary function who presented with a 2 cm carcinoid tumor proximally in the posterobasal segment of the right lower lobe.

The operation began with a 4 cm paramedian subxiphoid incision, opening only the anterior aponeurosis of the rectus abdominis and finding a subcostal way to the pleura with the finger. A wound retractor was pushed into the pleural cavity, giving anterior access via this working port. The second port was created under optic control, located subcostally on the middle axillary line. This port provided access for a 12 mm trocar dedicated to 30° thoracoscopic camera and an articulated 5 mm grasper for lung exposure. There was no intercostal incision. This was a fissureless lobectomy. The principal instruments used were a LigaSure Maryland jaw (37 cm) and a Scanlan curved suction instrument, associated with classical VATS dissectors.

The first step began with section of the inferior ligament, followed by dissection and stapling of the inferior pulmonary vein. The stapler came tangentially from the working port. The second step followed with the subcarinal lymphadenectomy of stations 8 and 7. Placing the thoracoscope in the second subcostal port is very useful to give a higher and more panoramic view than one would get with a camera located in the anterior subxiphoid port. The next step was the dissection of the 12R node, an important landmark, for exposure of the middle lobe carina. A tunnel fissure technique was then used to open the anterior part of the major fissure, giving access to the pulmonary artery. The lower lobe bronchus was then dissected and stapled. The 12R node was resected, and the lower lobe arteries were exposed. An accurate 3D pulmonary angiogram assessment is mandatory, especially for this fissureless approach to the procedure, in order to have perfect knowledge of potential anatomical variations. In case of such variations, the tunnel fissure technique could have been completed for better exposure of the artery in the fissure.

Both the A6 and basal arteries were then dissected and stapled. This provided access to the remaining fissure, which was also stapled, completing the lower lobectomy. The lymphadenectomy was continued on stations 2R and 4R for a free Barety space. The patient was integrated in an Enhanced Recovery After Surgery Program, permitting a day surgery lobectomy without any morphine use. The tube was removed at hour four under Medela Thopaz electric aspiration control, and the patient was comfortable and was discharged at hour eight. An atypic carcinoid tumor was diagnosed with a pT1N1 upstaging, and the patient’s follow-up was uneventful.