Video Assisted Thoracoscopic (VATS) Lobectomy following Neoadjuvant Chemoradiotherapy

Induction chemoradiotherapy is a relative contraindication to VATS lobectomy due to oncological concerns regarding completeness of resection and technical difficulties arising from treatment-related fibrosis. This video demonstrates a VATS lower lobectomy and radical systematic lymphadenectomy in a 53-year-old male who recurred locally following induction chemoradiotherapy.

The patient was placed in a lateral decubitus position with supports to allow rotation to a semi-prone position. A 5 mm, 30 degrees telescope was placed in the 5^th intercostal space in the mid axillary line. Two 10 mm working ports (one in the 6^th intercostal space in the posterior axillary line, one in the 6^th space inferior and posterior to the scapular tip) and a 3 cm utility incision in the 3^rd intercostal space were then placed. The procedure was done totally endoscopically by watching the video monitor with the surgeon and camera assistant standing anterior to the patient. Lymphadenectomy of the subcarinal, paratracheal and hilar nodes was facilitated by rotating the patient to a semi-prone position.

Due to dense radiation-induced fibrosis at the hilum, safe dissection was facilitated by proximal clamping of the pulmonary artery with individual ligation of the pulmonary arterial branches. The lobectomy was completed after dividing the pulmonary vein and bronchus. Intraoperative frozen section pathological analysis confirmed the lymph nodes and bronchial margin were negative for malignancy. Due to possible risk of bronchial dehiscence and bronchopleural fistula from the radical preoperative radiotherapy, the bronchial stump was buttressed with a broad-based parietal pleural flap. The patient made an uneventful recovery and was discharged on the 4^th post operative day. Two years after resection he is without local recurrence, but developed a brain metastases 1 year after surgery which was treated successfully with whole brain radiation.