Uniportal VATS Sleeve Right Lower Lobectomy for Mucoepidermoid Carcinoma

Introduction 

Mucoepidermoid carcinoma of the bronchial tree is a rare pulmonary neoplasm, accounting for less than one percent of all lung malignancies (1–3). It typically arises from the submucosal glands of the tracheobronchial tree and is more frequently encountered in younger patients. Low-grade tumors usually present as centrally located endobronchial lesions and demonstrate excellent prognosis following complete surgical resection (2, 3). Sleeve lobectomy allows for radical resection while preserving lung parenchyma and has been shown to provide oncological outcomes comparable to pneumonectomy or bilobectomy, with superior functional results (4, 5). Advances in minimally invasive surgery have enabled bronchoplastic procedures to be performed via video-assisted thoracoscopic surgery (VATS), including uniportal approaches in experienced centers (6–9). 

Case Presentation 

A young female patient with an insignificant smoking history was urgently admitted following an episode of hemoptysis. Her medical history was notable for celiac disease and recurrent respiratory infections. Contrast-enhanced computed tomography demonstrated a centrally located endobronchial tumor in the right lower lobe with peribronchial extension and no evidence of nodal or distant metastases.  
Rigid bronchoscopy confirmed tumor extension into the bronchus intermedius with sparing of the middle lobe bronchial orifice. An endobronchial biopsy was complicated by significant bleeding, and histopathological examination revealed a low-grade mucoepidermoid carcinoma. Clinical staging was classified as cT1cN0M0.  

After multidisciplinary tumor board discussion, a sleeve right lower lobectomy was selected to preserve the uninvolved middle lobe. Preoperative bronchoscopic debulking was avoided due to the risk of bleeding and limited impact on the surgical strategy. 

Surgical Technique 

The operation was performed via a uniportal VATS approach through a single 3.5 cm incision in the fifth intercostal space. After the division of the inferior pulmonary ligament, the posterior mediastinal pleura was opened, and station 7 lymph nodes were dissected. The bronchial bifurcation and secondary carina were exposed following removal of station 11 lymph nodes. 

The inferior pulmonary vein was divided, and the interlobar fissure was completed. An anomalous small pulmonary artery branch was identified and divided. An anatomical variation of the middle lobe arterial supply was encountered, consisting of a small retrograde branch arising from the lower lobe artery. This branch was sacrificed to allow safe exposure of the bronchial bifurcation and facilitate airway reconstruction. 

After the division of the lower lobe pulmonary artery, systematic lymphadenectomy of stations 10, 2R, and 4R was completed. The middle lobe bronchus was divided obliquely, followed by the transverse division of the bronchus intermedius. Frozen section analysis confirmed negative margins. Bronchial anastomosis was performed using a running double-armed 5-0 polypropylene suture, addressing airway caliber mismatch with tailored cuts and variable stitch spacing. Intraoperative bronchoscopy confirmed an intact anastomosis, and air leak testing was negative. 

Discussion 

Low-grade bronchial mucoepidermoid carcinoma is associated with excellent long-term outcomes following complete surgical resection (2, 3). Given the low incidence of nodal involvement, parenchyma-sparing resections are strongly recommended, particularly in young patients. Sleeve lobectomy has consistently demonstrated equivalent oncological efficacy to more extensive resections with improved postoperative pulmonary function and quality of life (4, 5). 

Minimally invasive sleeve lobectomy has evolved from multiportal VATS to uniportal techniques, offering favorable visualization and reduced surgical trauma (6–9). However, uniportal bronchoplastic procedures remain technically demanding and require meticulous airway mobilization, optimal vascular management, and precise suturing techniques to manage caliber mismatch and minimize anastomotic tension. 

In this case, preserving the middle lobe was prioritized based on oncological safety. Sacrificing a small anomalous arterial branch was necessary to achieve adequate exposure for reconstruction and avoid conversion to bilobectomy. This case underscores the importance of individualized intraoperative decision-making and highlights that uniportal VATS sleeve lobectomy can be safely performed in specialized centers. 

References

1. Travis WD, Brambilla E, Burke AP, Marx A, Nicholson AG. WHO Classification of Tumours of the Lung, Pleura, Thymus and Heart. 4th ed. Lyon: IARC; 2015.
2. Turnbull AD, Huvos AG, Goodner JT, Foote FW Jr. Mucoepidermoid tumors of bronchial glands. Cancer. 1971;28(3):539–544.
3. Vadasz P, Egervary M. Mucoepidermoid carcinoma of the lung: a review of 34 operated cases. Eur J Cardiothorac Surg. 2000;17(5):566–569.
4. Deslauriers J, Grégoire J. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites of recurrence. Ann Thorac Surg. 2004;77(4):1152–1156.
5. Ferguson MK, Lehman AG. Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques. Ann Thorac Surg. 2003;76(6):1782–1788.
6. Mahtabifard A, Fuller CB, McKenna RJ Jr. Video-assisted thoracoscopic sleeve lobectomy: a case series. Ann Thorac Surg. 2008;85(2 Suppl):S729–S732.
7. Nakanishi R, Yamashita T, Oka S. Thoracoscopic bronchoplasty and sleeve lobectomy for lung cancer: technical aspects and outcomes. Eur J Cardiothorac Surg. 2013;43(4):e1–e7.
8. González-Rivas D, Fieira E, Delgado M, Mendez L, Fernandez R. Uniportal video-assisted thoracoscopic sleeve lobectomy. J Thorac Dis. 2014;6(6):E1–E5.
9. Chen H, Zhang Z, Wang Z, et al. Uniportal versus multiportal VATS sleeve lobectomy: early outcomes from a single-center experience. J Thorac Dis. 2019;11(4):1325–1333.

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