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In this video, the authors present a lower lobe lung volume reduction surgery (LVRS) case from their high-volume center, focusing on the surgical approach and key technical steps. The patient was a 54-year-old female with chronic obstructive pulmonary disease (COPD) and asthma overlap, a body mass index (BMI) of 30.7, and a history of gastric bypass in 2017, Streptococcus pneumonia sepsis in 2021, and prior endoscopic lung volume reduction of the left lower lobe, which was revised in 2024 with valve extraction in 2025. She has an 80-pack-per-year smoking history  and was on dual bronchodilation. Prehabilitation was performed twice weekly. 

Perfusion scintigraphy demonstrated marked hypoperfusion of the left lower lobe, designating it as the surgical target. Pulmonary function tests showed a forced expiratory volume in one second (FEV₁) of 41 percent, a residual volume (RV) of 208 percent, and a diffusing capacity of the lungs for carbon monoxide (DLCO) of 40 percent. After lower lobe LVRS. The patient was positioned in lateral decubitus with the table flexed to optimize intercostal spacing, ensuring shoulder abduction remained below 90 degrees to prevent traction injury. The surgeons utilized a trocar access system, a wound protector, a vascular clamp, an LVRS-specific clamp, and cherry dissectors. The surgeon stood anteriorly, while the assistant stood posteriorly. The utility incision was made anterolaterally in the seventh and eighth intercostal spaces, followed by one or two ports depending on lobe size. An open introduction was preferred to avoid vascular or pleural injury, dissecting down to the pleura between muscle fibers. The lung was deflated, and the surgeons checked for adhesions. Paraffin gel was applied to facilitate smooth movement. Adhesiolysis was performed using a peanut dissector to mobilize the lung without trauma. A second port was placed posteriorly, and one intercostal space lower, which also served added for comfort, even when epidural analgesia was present. Stapling began after complete mobilization of the lung was achieved. A vascular clamp provides tactile orientation before firing the stapler. Reinforced stapling was applied systematically in sequential lines. Each staple line was rinsed with paraffin to allow smooth sliding, avoiding traction on new staple zones. The surgeons started with 45 mm cartridges and switched to 60 mm at a further distance from the chest wall.  

Automated stapling assisted precise resection, gliding toward segment 6 while avoiding the fissure. The purple cartridge, being blunter, was used in areas with limited visibility to prevent lung injury, while the sharper silver side faced the visible field for better control. 

Five reinforced staple lines (3×60 mm, 2×45 mm) were used. Sealant application was performed to complete the procedure and minimize air leakage. The resected portion represent the most emphysematous and obstructive lung segment. Two chest tubes were placed at the end of the procedure, both left on water seal without suction. 

Critical technical principles included thorough adhesiolysis, including within the fissure, complete release of the inferior pulmonary ligament, and shaving of the lobe without distortion of the shape. Reinforced stapling, tissue sealants, and strict fissure avoidance we key to reducing postoperative air leaks. 

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