VATS Right Upper Lobectomy in a Patient With Previous Ivor-Lewis Esophagectomy and Radiotherapy

A 72-year-old female, an ex-smoker for 25 years, had an incidental finding of a RUL mass on CT; this was PET positive (SUV 25, T1bN0M0). A CT biopsy demonstrated poorly differentiated carcinoma favoring a lung primary. Her past medical history included: Ivor-Lewis esophagectomy for adenocarcinoma of the lower esophagus T3N1 in January 2011 (the gastric conduit ended above the azygous vein), cholecystectomy, hypertension, and carcinoma of the right breast that was treated with lumpectomy and radiotherapy in 1999. Her lung function demonstrated an FEV1 of 136% and a KCO of 76% of predicted.

On inspection, the many adhesions seen were due to the previous surgery and radiotherapy. The adhesions were dissected and the lung was mobilized from the stomach. The planes between the lobes were enhanced and the fissure was dissected. The vascular bundle of the right upper lobe was located. The vascular bundle was stapled, and the bronchus was identified and stapled. The lung was then further mobilized and dissected off the stomach. The lung was stapled to remove it from its adhesion to the stomach. A retrieval bag was deployed and the lung was removed via the access port. The remaining middle lobe was sutured to the lower lobe to prevent torsion.