Subxiphoid Right Upper Lobectomy

This video demonstrates a right upper lobectomy through a subxiphoid biportal approach.

The authors use a biportal approach, divided in a 4 cm working port through a paramedian incision and a second port, 15 mm long incision coming through diaphragmatic insertion, without any damage, and dedicated to an articulated grasper for exposition and a 30° camera. The dissection was conducted with a LigaSure™ Maryland and an angulated sucker. The pulmonary artery was dissected inside the sheath, and hilar nodes were removed with the specimen. The authors used classical dissectors coming quite naturally from the working port. In the video, one can see the sucker pushed behind the vein, allowing space for stapling, then the arterial step with the dissection of the arterial truncus. The hilar and interlobar nodes are taken up with the specimen, allowing a free dissection of the upper lobar bronchus, which is also stapled. Then came the arterial step of A2, two arteries that are fused and ligated with a clip. The subxiphoid access allowed a quite adequate oblique angle for the fissure in the last step. The removal of the specimen appears quite easy, even for one so voluminous. Then comes the paratracheal lymphadenectomy, which is performed en bloc, and the authors have a satisfactory posterior view for the subcarinal lymphadenectomy. The final diagnosis was an adenocarcinoma stage I, and the patient had an uneventful follow-up.

When considering the benefits of this subxiphoid biportal approach, it offers first a safe and oncologic resection. The authors emphasize the interesting subcostal view from the top, without any conflict between the camera and other instruments from the working port. It allows for tension-free stapling and dissection, in safe conditions, with classical instruments used. It is easy to remove the specimen even for voluminous tumors, and the subxiphoid tube is really painless. Finally, considering the postoperative course, this approach allows for opioid-free analgesia and importantly, it works in synergy with enhanced recovery after surgery programs for better recovery.

Suggested Reading

1. Hernandez-Arenas LA, Lin L, Yang Y, et al. Initial experience in uniportal subxiphoid video-assisted thoracoscopic surgery for major lung resections. Eur J Cardiothorac Surg. 2016;50(6):1060-1066.
2. Dunning J, Elsaegh M, Nardini M, et al. Microlobectomy: a novel form of endoscopic lobectomy. Innovations (Phila). 2017;12(4):247-253.