Uniportal VATS Right Apical Segmentectomy

Case Summary

A 57-year-old asthmatic, non-smoker presented with a cough. This female patient had previously undergone a surgical excision of a chondrosarcoma from her right femur (during 2010). A CT scan showed a 1.4 cm lesion in the apical segment of the right upper lobe, close to the border of the anterior segment (S3). CT-guided biopsy determined the lesion to be a neuroendocrine tumor. As the patient was a candidate for further lung resection due to her chondrosarcoma disease, she was scheduled for an anatomic segmentectomy (S1). The patient recovered well. Her chest tube was removed on the first postoperative day, and she was discharged home on the third postoperative day.

Patient Positioning

The patient was placed in the left lateral decubitus position. Single-lung ventilation was achieved through a double-lumen endotracheal tube. The surgeon and his assistant were anterior to the patient. To begin the operation, a 3 cm utility incision was made anteriorly in the fourth/fifth intercostal space. A 10 mm, 30 degree thoracoscope was inserted through the posterior part of the incision during the surgery. Angled instruments (specially designed for uniportal VATS procedures), endo GIA staplers, and a ligasure device were used.

Surgical Procedure

1. Adhesiolysis was performed between the lung, lateral chest wall, and pericardial fat.
2. The lesion was digitally palpated through the incision and marked using a diathermy device.
3. The hilar structures were dissected, and the artery and vein to the right upper lobe were identified. 
4. The vein was distally dissected to expose the apical segment, which was ligated with the endovascular stapler.
5. The artery was distally dissected to the upper lobe to expose the segmental branches.
6. Two branches of the apical segment were identified and ligated.
7. The parenchyma was stapled at the border of the segment to provide better exposure for the vascular structures.
8. A third arterial branch to the apical segment was identified and ligated.
9. The bronchus was exposed, cleaned, and clamped. The lung was inflated to confirm clamping.
10. The bronchus was stapled and the parenchyma was transected.
11. The lymph nodes were sampled from the paratracheal and subcrinal stations.
12. An intercostal block and 24 French chest drain were inserted through the same incision.