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It is important to perform a safe and effective surgery without compromising any established oncologic principles. Conversion to an open technique should be viewed as a sign of good judgment, not failure. The adequacy of resection should not be jeopardized by the predilection for a VATS approach.
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A thoracotomy tray with vascular clamps and chest retractors always should be available in the room. Sponge-stick and dental pledgets also should be ready and available on the field for tamponade of major bleeding sites while a thoracotomy is expeditiously and carefully performed.
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Once preoperative evaluation has deemed the patient to be a candidate for VATS lobectomy, the patient is brought to the OR. The patient is anesthetized and intubated. Bronchoscopy is performed to rule out endobronchial lesions that would preclude a VATS approach. Mediastinoscopy is performed when indicated. Lung isolation is obtained with a double-lumen endotracheal tube or bronchial blocker. Good lung isolation is an absolute need throughout the entire case. Once the position of the tube is confirmed, the patient is placed in the lateral decubitus position. The endotracheal tube is reconfirmed via bronchoscopy to ensure that it has not migrated out of position. The ipsilateral lung is immediately collapsed to permit ample time for atelectasis to occur before entering the chest. Suction also may be applied through a suction catheter or bronchoscope to aid in collapse of the isolated lung.
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Several different approaches have been described in the literature. Two to four ports which include the incision used to extract the lobe within a bag which is typically about 3 to 5 cm are required to perform a VATS lobectomy. We prefer to use three incisions: an inferior camera port, a posterior working port, and an anterior incision (Fig. 74-1). Avoidance of rib spreading is the key element in VATS lobectomy for preventing postoperative pain and trauma to the intercostal nerve bundles, which are responsible for the postthoracotomy pain syndrome.
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By exchanging the camera and instruments and using the angles afforded by the three ports, all visualization and most dissection techniques practiced in open lobectomy procedures can be duplicated. Port placement may vary slightly to account for patient body habitus, location of the tumor, and surgeon preference. However, optimal port placement is important for successful resection. The camera port is created first, and it is usually placed at the seventh or eighth intercostal space. This is the only incision which typically requires a rigid port. Whether to locate it in the anterior, middle, or posterior axillary line depends on multiple factors, including the level of the diaphragm, as determined by review of preoperative chest radiograph, the location of the pathology, and the side of the procedure (left vs. right). Ideally, this port should provide views of the anterior and posterior hilum and should align with the major fissure. We use a 30-degree scope almost exclusively. It provides optimal views not afforded by a 0-degree scope, particularly during the difficult dissection around the superior hilum, and avoids “crowding” of the working instruments. Once the scope is inserted, we inspect the chest cavity and select the ideal position for the remaining two ports. The anterior port should be placed immediately over the hilum because this will be used for vein and artery dissection. Dissection of both the hilum and fissure will be performed through this port. The initial incision is limited to 1 to 2 cm in length. It is not fully extended (i.e., 3–5 cm in length) until the decision is made to proceed with VATS lobectomy. The port is usually created anterior to the latissimus dorsi muscle in the fourth intercostal space for an upper lobectomy and the fifth intercostal space for a lower lobectomy. The third port is usually sited in the fifth intercostal space, either inferior or posterior to the scapular tip. This port usually serves as the lung retraction port. Hemostasis is very important when creating the ports because bleeding from the port sites onto the camera and into the surgical field during the procedure is a nuisance and can prolong the operation significantly.
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Once all the ports have been created, a more thorough exploration is performed. The pleural surface is inspected for implants. Adhesions may be encountered. These can be lysed and are not a contraindication to proceed with VATS lobectomy. Careful and complete adhesiolysis permits full mobility of the lung. Retraction of the lung is critical to completing the resection. For this reason, the inferior pulmonary ligament is always divided. The discovery of tumor invasion into the chest wall does not preclude a VATS approach. In experienced hands and for relatively limited chest wall involvement, an en bloc chest wall resection can be performed. Digital palpation of the tumor and lung is performed through the anterior access port not only to confirm the location and presence of the tumor but also to rule out additional unsuspected nodules or pathology not identified on preoperative studies. Before resection, the ipsilateral mediastinal lymph nodes are sampled, especially if mediastinoscopy was not performed earlier. If N2 disease is discovered on frozen section, the VATS resection is generally aborted, in keeping with treatment principles for N2 disease and the patient is treated with neoadjuvant therapy. If a preoperative tissue diagnosis has not been determined, a wedge or core biopsy is performed initially, followed by lobectomy if frozen section reveals carcinoma.
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A combination of conventional and endoscopic surgical instruments may be used for dissection. We have found the following conventional instruments to be particularly useful in accomplishing VATS lobectomy: ring forceps, right-angle clamps, Harken clamps, Pearson scissors, long Allis clamps, Frazier clamps, biopsy forceps, and a red rubber catheter. Familiarity with the use of these instruments in open techniques translates to facility in their use during the VATS resection.
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The order of division of the hilar structures is irrelevant in terms of oncologic outcome. Depending on the lobe, the order of division of the hilar structures differs and is described in detail below. Dissection of the hilar structures is fraught with danger, and one must have a comprehensive understanding of the anatomy and possible variations thereof, especially the pulmonary artery branches. Also, despite improved video technology, one must be aware of the limitations of performing three-dimensional dissections guided by a two-dimensional picture.
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Hilar dissection is carried out with instruments placed through the anterior access incision utilizing videoscopic visualization throughout. Using a combination of sharp and blunt dissection, we divide the pleura. The lung is retracted away to aid the dissection. The hilar structures then are divided sequentially with an endovascular stapler. We complete the fissures with serial firings of an endoscopic stapler. The resected specimen then is placed in a heavy laparoscopic extraction sac to prevent tumor seeding of the port and is removed through the anterior access incision without spreading the ribs.
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Next, we perform a complete lymph node dissection for accurate staging. This includes levels 2, 4, 7, 8, and 9 on the right and levels 5, 6, 7, 8, and 9 on the left. Finally, we test the stump for pneumostasis under water to a pressure of at least 30 to 35 mm Hg. Hemostasis is checked. Electrocautery of the ports is used sparingly to avoid injury to the neurovascular bundle. A single 24F chest tube is left in the chest for postoperative drainage. We rarely employ an epidural catheter for pain relief but perform a 5-rib block and port-site block using bupivacaine with epinephrine. We also routinely use intravenous anti-inflammatory drugs (ketorolac) for 24 hours. The ports are closed, and the patient is repositioned supine on the OR table. A completion bronchoscopy is performed to check the staple line and for pulmonary toilet before extubating the patient in the OR.
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The conduct of the operation for the different lobes is essentially the same and is described below with a few caveats based on experience.
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Right Upper Lobectomy
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For right upper lobectomies, we usually place the camera port in the seventh intercostal space along the anterior axillary line (Fig. 74-2A). This placement provides good visualization of the anterior and superior hilum, the area of most hazardous dissection. The access port usually is located in the fourth intercostal space anteriorly, just anterior to the anterior border of the latissimus dorsi muscle. The posterior port is placed inferior or posterior to the scapula tip, which usually depends on the morphology of the chest. The orientation of this port should provide a right-angle configuration between instruments in the access and working ports. After initial exploration, the dissection is begun in the anterior hilum. The right upper lobe (and sometimes the middle lobe) is grasped gently with ring forceps and retracted posteriorly. This maneuver creates excellent exposure of the anterior hilum. The superior pulmonary vein is isolated first in the anterior hilum by dividing its pleural covering with a Harmonic scalpel, Pearson scissors, and/or endo-Kittners. The phrenic nerve is carefully dissected away from the hilum to prevent injury. The draining veins of the middle lobe must be identified as well to prevent unintentional division. An oiled 2-0 silk suture then is looped around the superior pulmonary vein (Fig. 74-2B). The vein is divided with an endovascular stapler, usually introduced through the posterior port, which provides the best angle. After division of the superior pulmonary vein, the truncus anterior and its variable number of branches are exposed (Fig. 74-3). They are dissected free individually or as one trunk depending on their configuration and accessibility. They are then divided individually or as one trunk using an endovascular stapler. The “endoleader,” a rubber catheter, can be used to safely guide the stapler through the tight space around the arterial branches.25 The arteries are best divided with the endovascular stapler introduced through the camera port, with the camera switched to viewing from the access port (Fig. 74-3, inset). A sponge-stick or dental pledget on a clamp always should be in the scrub technician's hand “at the ready” for tamponade of bleeding from malfunction of the stapler or avulsion of the hilar vessels. This single maneuver bides time for adequate control and conversion to an open thoracotomy, if needed. Once the arterial branches are divided, the next step is to dissect the interlobar main pulmonary artery at the confluence of the fissures. This dissection can be difficult with incomplete fissures. There are several alternatives to address this problem. One maneuver is to partially, but carefully, divide the fissure with a stapler or Harmonic scalpel. This provides better exposure of the interlobar pulmonary artery for dissection. The goal of exposing the interlobar pulmonary artery is to identify the space between the recurrent ascending arterial branch to the posterior segment of the upper lobe and the artery to the superior segment of the lower lobe. This space permits safe division of the recurrent ascending branch and completion of the posterior fissure. The most commonly used option for dealing with the incomplete fissure or for isolating the recurrent posterior segmental arterial branch is to approach it anteriorly and/or superiorly with the bird's-eye view provided by the 30-degree scope. Once all the arterial branches to the upper lobe are divided, the right upper lobe bronchus is dissected free by sweeping all nodal tissue on the bronchus toward the specimen side (Fig. 74-4). An endoscopic stapler, usually loaded with “thick tissue” staples, then is introduced through the camera port to divide the bronchus, leaving a short, intact stump. The fissure is completed with serial firings of the endoscopic stapler, if not already performed. The specimen lobe then is placed in a heavy laparoscopic extraction sac and is removed through the access incision without rib spreading.
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In our opinion, the left upper lobectomy is the most difficult to perform technically because of the variability in the arterial circulation, which can have up to three to eight branches. The order of division of the hilar structures is the same as with the right upper lobe—vein, artery, bronchus. The inferior camera port is placed more posteriorly to avoid obstruction of view by the heart (especially if enlarged) and the pericardial fat pad. In patients with marginal pulmonary function and a small tumor, a lingular-sparing left upper lobectomy, or lingulectomy, as appropriate, should be considered. Anatomically, the lingula can be considered the equivalent of the middle lobe on the left side. The order of hilar structure division is the same as for a right middle lobectomy (see below).
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Right Middle Lobectomy
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For right middle lobectomy, the camera port usually is placed in the seventh intercostal space along the midaxillary line. This position provides an excellent view of both the anterior hilum and the major fissure. The anterior access port usually is placed in the fourth intercostal space, whereas the working port generally is placed posterior to the scapular tip in the sixth or seventh intercostal space. The right middle lobe is retracted laterally, and the middle lobe veins (usually two branches) are dissected free and divided using the endovascular stapler. The middle lobe bronchus then is exposed. We divide the bronchus first because the bronchus is anterior to the artery. One must be careful not to injure the artery when dissecting around the bronchus. Next, we dissect out the arterial branches to the middle lobe. These are looped and divided with the endovascular stapler. The “endoleader” technique may be helpful in guiding the stapler around these branches.2 The fissure is completed and the middle lobe is removed in a specimen sac through the access incision.
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Right and Left Lower Lobectomy
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The camera ports usually are placed in the eighth interspace to avoid crowding of the instruments. On the right, the camera port generally is positioned in the midaxillary line. On the left, in people with large hearts or “barrel chests,” the port is placed more posteriorly to avoid obstruction of the view by the heart. The access port usually is placed anteriorly in the fifth intercostal space. The posterior working port usually is placed posterior to the scapular tip in the sixth or seventh intercostal space. We first divide the inferior pulmonary ligament and sample the level 9 lymph nodes. The lower lobe is retracted superiorly with a ring forceps through the posterior port, putting the ligament under tension. A long-tip electrocautery or ultrasonic scalpel divides the ligament through the access port. The level 9 lymph nodes are removed and sent for frozen section. Next, the interlobar main pulmonary artery is dissected free in the fissure. The basilar trunk and artery to the superior segment are identified, dissected, looped, and divided with the endovascular stapler. Next, the inferior pulmonary vein is dissected free, looped, and then divided with an endovascular stapler. Finally, the bronchus to the lower lobe is dissected and divided with an endoscopic stapler. As in the open technique, care must be observed on the right side to avoid impingement on the middle lobe bronchus. The fissure is completed, and the lobe is removed in a specimen sac through the access incision without any rib spreading.