Video-Assisted Thoracic Surgery (VATS): right upper lobectomy with total lymphadenectomy

This video presents the surgical management of a suspicious peripheral pulmonary tumor, classified cT1bN0M0 after preoperative staging (positive PET-scan with positive cytology). This case has been presented in a thoracic oncology multidisciplinary meetin

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Video-Assisted Thoracic Surgery (VATS): right upper lobectomy with total lymphadenectomy

Authors

JM Baste, C Peillon

Abstract

This video presents the surgical management of a suspicious peripheral pulmonary tumor, classified cT1bN0M0 after preoperative staging (positive PET-scan with positive cytology). This case has been presented in a thoracic oncology multidisciplinary meetin

Classification

contribution

Keywords

Video-assisted thoracic surgery, VATS, right upper lobectomy, total lymphadenectomy

Media type

Surgical video

Duration

13'06''

Publication

2012-01

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E-publication

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3550.htm

Video-Assisted Thoracic Surgery (VATS): right upper lobectomy with total lymphadenectomy

1. Patient set-up 00'45''

The patient is placed in a left lateral decubitus. The shape of the iliac crest and the thoracic cavity is drawn using a marker pen. A line is drawn on the anterior border of the latissimus dorsi muscle, and the posterior border of the pectoralis major muscle. This defines the anterior part of the thorax. There is an angle between the hips and the thoracic cavity than can be opened by flexing the patient, which allows for an opening of intercostal spaces. This maneuver is very useful in patients with large hips. The entrance point of the first trocar, which will be the videoscope trocar, is found between the 5th and 6th intercostal space. The entrance point for the posterior trocar is then found, in a space underneath the video trocar, but anteriorly to the anterior line of the latissimus dorsi muscle. A line is then drawn at the entrance point of the utility incision, an incision made in the 4th intercostal space, although its location may vary according to the patient’s anatomy, and to the type of lobectomy performed. For inferior lobectomies, it is better to make the incision in the 5th space and for superior lobectomies, in the 4th space. The incision is known as the “utility incision”. The surgeon stands in front of the patient, and looks at the monitor in front of him. His assistant may be placed to his left. As you can see, the patient has already been excluded for a few minutes, in order to see how he reacts to single lung ventilation. A fibroscopic inspection must always be carried out in order to check the position of the Carlens-type endotracheal tube, as proper lung exclusion is fundamental in this type of surgery. The instruments used all have an angulation at their tip, an Olympus® video laparoscope, which is a light instrument, is used, as well as a 30-degree angulated laparoscope. A Ligasure® device will be used for the dissection.

2. Trocar positioning 03'36''

The procedure begins with the introduction of the video trocar. Care is taken to prevent any blood from dripping on the trocar. The location of the utility incision is then identified using the video feedback. The incision should be opposite the superior pulmonary vein. The middle lobe is then freed by dividing several adhesions by means of the Ligasure® device.

3. Exploration and exposure 04'20''

The anterior superior part of the hilum of the lung is then exposed. The mediastinal pleura is opened and the upper border of the vein is dissected. The mediastinal pleura is freed. The azygos vein is separated from the hilum of the lung. The pulmonary vein and middle vein are cleansed using a peanut swab, and at the same time making sure the phrenic nerve is properly retracted away. The superior part of the vein is still being cleansed. The spur (between the superior vein and the middle vein) is identified.

4. Pulmonary hilum dissection 05'31''

An angulated grasper is then used to control the superior pulmonary vein, which is still being dissected and separated from the pulmonary artery. The hilar lymph node is dissected. Control of the superior vein is achieved, taking care not to damage the pulmonary artery, which is located posteriorly. An Endo-GIA® linear stapler is used. It is equipped with the new Tri-Staple™ technology, in which the anvil is located in the grasper’s axis, which makes it much easier to control the vein posteriorly. The mechanical forceps is then introduced. Using a peanut swab, the distal tip of the forceps is controlled. The superior pulmonary vein is divided. This helps to posteriorly expose the pulmonary artery and its different branches. The pulmonary artery is then cleansed, hence allowing to free a posterior fissural branch as well as the anterior mediastinal artery. First of all, the first posterior fissural branch is controlled. It is divided using a linear Endo-GIA® stapler, with a vascular cartridge. Further freeing of the anterior mediastinal artery is completed by preserving the lymph nodes on the side of the specimen. The anterior mediastinal trunk is controlled, which is then divided using a linear Endo-GIA® stapler (vascular cartridge). The superior lobar bronchus is then cleansed off its peribronchial tissue by preserving the lymph nodes on the side of the upper lobe. The last posterior fissural branch is then identified, controlled, and divided using the vascular cartridge of the endo-GIA® stapler. Attention is now turned to the superior lobar bronchus and its spur is dissected. The superior lobar bronchus is controlled by means of the angulated forceps using a posterior approach. The bronchus is divided using the Endo-GIA® stapler, with a thicker bronchial cartridge. The superior lobe is then separated from the middle lobe by opening the small fissure and by performing a wedge resection on the middle lobe in order to go beyond the tumor, which invades the small fissure. The lobectomy is completed by dividing the posterior fissure using an Endo-GIA® linear stapler. The specimen is removed using an EndoCatch® bag through the utility incision.

5. Mediastinal lymphadenectomy 10'29''

The total lymphadenectomy is begun starting from the Barety’s space (4R node) and by using cardiac and videoscopic instruments providing outstanding ergonomics and precision. Consequently, the adenopathy stuck to the artery is freed. The lateral tracheal lymph node resection is carried out using a Ligasure® vessel-sealing device, hence allowing to achieve a total lymphadenectomy of the 4R and 2R regions. The triangular ligament is then freed and the lymph nodes are removed. The scope’s position is changed in order to approach the posterior mediastinum. The subcarinal region is then exposed. The intermediate trunk is lifted up in order to easily access this region. Once total lymphadenectomy has been completed, an extrapleural pouch is created using a needle and physiological saline. A catheter is then introduced into the extrapleural pouch. 20mL of ropivacaine (2%) is injected into the catheter.

6. End of procedure 12'33''

The catheter is then connected to an automatic liquid delivery bottle, which is kept until removal of the thoracic drain. The lobectomy is completed by closure on a posterior superior pleural drain. Here the view shows the patient’s position at the end of the intervention with simple dressings, which are removed after the drain has been taken out. The drain is connected to a water-seal system Pleurévac® As a conclusion, the length of the intervention was 135 minutes. Bleeding was noted (50 mL). On postoperative day 5, the patient was discharged. No major pain was observed. A control visit was scheduled at one month (Visual Analogue Scale = 1). The patient returned to his professional activity as a truck driver. Histology tests revealed a pT2N0MX epidermoid carcinoma, p stage pIIA with 16 sampled lymph nodes. An adjuvant chemotherapy was proposed to the patient.