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Single-Incision VATS Right Upper Lobe Posterior Segmentectomy

Tuesday, March 14, 2017

A 62-year-old man with a history of arterial hypertension, diabetes mellitus, and prior smoking underwent a sigmoidectomy in 2011 for an adenocarcinoma, and received adjuvant chemotherapy. In 2013, after 24 months of follow-up, bilateral pulmonary nodules and mediastinal lymph nodes appeared. The first biopsy was negative. In 2014, a new fine-needle biopsy showed pulmonary metastases. Chemotherapy plus antiangiogenic treatments were administered. With no evidence of disease progression and two PET positive residual pulmonary nodules in the right-upper and left-lower lobes, surgery for both nodules was indicated.

As the RUL was initially accessible for a wedge resection, the LLL nodule was approached first. A non-intubated SI-VATS S6 LLL anatomical segmentectomy was performed in April 2016. Four months later, a segmental S6 bronchopleural fistula was diagnosed and successfully managed with an endobronchial valve. A new chest scan then showed growth of the RUL lesion, requiring a posterior S2 segmentectomy instead of the initial wedge planned (Figure 1).

Figure 1

A posterior segmentectomy was performed through a 4 cm incision placed in the 5th right intercostal space, involving intercostal blocks with bupivacaine of the 3rd to 7th intercostal spaces, as shown in the video.

There was no postoperative air leak, and the right chest tube was removed 48 hours after the surgery. The patient’s pain visual analogue scale scores were 3 and 2 at 24 and 48 hours after surgery. A contralateral empyema in the middle posterior pleural space due to bronchopleural fistula and the valve placement was diagnosed postoperatively. It was successfully managed with wide-spectrum antibiotic therapy and ultrasound-guided drainage. The patient was discharged on the 8th postoperative day with satisfactory chest X-ray (Figure 2). The final pathology report demonstrated a 2 cm intestinal metastasis with free bronchial, vascular, and fissural margins. The patient continues follow-up with medical oncology.

Figure 2

Anatomical segmentectomies are indicated for early stage primary adenocarcinomas, as well pulmonary metastasis and benign conditions. These lung-sparing resections are especially useful in metastatic disease as they preserve healthier parenchyma and functional reserve. This enables future resections in the event of new metastasis development and avoids a pulmonary lobectomy. Experience and anatomical knowledge are mandatory for these procedures in order to avoid complications. Single-incision VATS is a safe approach for these surgeries, as proved in many published series and illustrated in this video.


I'm not complete agree with indications for metastasis in all cases. You can also perform bilateral TAVA (axilaries thoracotomies) no need to be extended as the thecnique requiered but less you have also less pain,absolute control of the cavity in case of hemorragae and less complications. The stay of tube and patient in hospital is also short. And I wouldn't have wait 4 month to do the other side. I supposed that because of the fistula you had to delay but that is another reason I'm not complete convinced that single port-VATS is indicated for any surgery. Still congrats for your habilities in this thecnique
Thanks for your valuable comment Dr Panero. No doubt, the reason for the delay between both procedures was in fact the development of a segmental BPF after a succesfully solved episode of postoperative pneumothorax without evidence of fistula. The uniportal approach had no relation with the fistula, and remember that the patient had received preoperative chemotherapy and diabetes as risk factors for development of the fistula. I can't agree with you about your comments with axillary thoracotomy: uniportal VATS is also a "unique incision" but smaller, without the need of rib spread, and you can control and manage intraoperative complications safely. Chest tube removal is usually between 24-48 hours and postoperative course is speed up. In my experience there is further less pain with uniportal access, with very low VAS scores. The decision for the approach lies on the experience and self-confidence while performing VATS or uniportal approaches, but objective advantages are continuosly addressed. Thank you again for your feed-back and comments!

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