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Uniportal Posterior Approach for Videothoracoscopic Anatomical Resection of Posterior Segment of the Right Upper Lobe

Wednesday, January 4, 2017

This video demonstrates the case of a 73-year-old patient with a history of colon carcinoma, prostate carcinoma, and contralateral lobectomy for non-small cell lung cancer. The patient was admitted for a 12 mm large nodule in the posterior segment of the right upper lobe. Distant metastasis was excluded and a video-assisted thoracoscopic (VATS) segmentectomy and lymphadenectomy was planned.

A fissureless VATS resection of the posterior segment of the right upper lobe using a uniportal posterior approach was successfully conducted without any adverse effects. The postoperative course was complicated, involving a transient ischemic attack and a urinary tract infection. No respiratory complications developed. The chest tube was removed on the third postoperative day, and the patient was discharged on the sixth postoperative day.

The tumor was diagnosed to be a primary acinar adenocarcinoma and the final TNM was pT1aN2M0. Two lymph nodes out of 10 at the stations 2 and 4 were tumor positive.


Congrats to the author, a very interesting approach for this procedure. Some concerns about it: I think it can not be defined as fisureless, because fissure is almost complete and you use some stapler to discover vascular structures. Fisureless usually refers to procedures where fissure is managed at the end in order to avoid parenchymal tears and air leak. You just divided one vein for the S2, without checking all the vein branches for S3 and S2; that could be much more anatomic and safe, but I do agree that many times it's not useful for the final result, so we can discuss about it, for I will probably agree with you that that was the vein for the S2. Finally, the lymph node dissection seems not strictly "careful" with the hemostasis. Thanks for this very interesting video, and congrats again.
@ Carlos Galvez Munoz Tnx for your comment. I agree, it was not fissureless as I opened the fissure a bit. However, what is to be refered as "usual" when we speak about fissureless operations is of course debatable. The very first were done with a so called "tunnel" technique, still fissureless but not "fissure-last". I can only humbly recommend some of my others video with a fissureless in the title, as well as an article (and a video) from H.Decaluwe describing the formentioned "tunnel" fissureless technique. V2 is according to my experience almost always, and I am trying to be careful with the expression always, the one to be found just behind A2 (not that I have performed some anatomic study). In this particular case there was a V3 just behind to V2 (along with another V3 joining the upper lobe vein at the front hilum), it may be found on 1:47 of the video. Lymphadenectomy could have been done much better, I agree with that. It is our ultimative goal to remove everything possible there, preferably en bloc. How many times we succeed remains to be answered from each of us for himself. Again, tnx for watching this video and making the important comments.

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