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CHAPTER 8 Right Upper Lobectomy—video 8

Video-Assisted Right Upper Lobectomy (Video 8-1)

Step 1. Level 10 Nodes

♦ Exposure: Retract lung posteriorly and slightly inferiorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.

♦ The level 10 nodes are located within a triangle bounded by the SVC, azygous vein, and superior hilum of the lung.

♦ Just posterior and parallel to the phrenic nerve, incise the pleura from the hilum to the azygous vein and then posteriorly along the azygous vein to the right mainstem bronchus (Figure 8-1).

♦ From the hilum, dissect posteriorly along the superior aspect of the RUL vein and along the vein from the apical segment. This exposes the anterior trunk.

♦ Remove all the tissue in this triangle, including the level 10 nodes. At this point, the right mainstem bronchus, anterior trunk, and SVC are well exposed.

♦ After the level 10 nodes are removed, dissect along the superior aspect of the anterior trunk and posteriorly between the trunk and the right mainstem bronchus. This facilitates subsequent mobilization of the artery for later transection.

Figure 8-1 Level 10 nodes are removed by dissecting the triangle formed by the superior vena cava, the azygous vein, and the vein from the apex of the right upper lobe.

Step 2. Right Upper Lobe Vein

♦ Exposure: Retract the lung directly posteriorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.

♦ Clearly identify the RUL vein and the right middle lobe vein. Viewing the remnant of the minor fissure can help with orientation.

♦ Spread along the inferior aspect of the RUL vein. Lifting the vein shows the plane between the vein and the underlying pulmonary artery.

♦ Rotate the thoracoscope posteriorly with the lens pointed anteriorly to view the dissection between the vein and the artery.

♦ Dissect along the superior aspect of the RUL vein.

♦ To create a tunnel for the stapler, spread widely with a right-angle clamp between the RUL vein and the artery (Figure 8-2).

♦ Through incision 4, pass an endoscopic vascular stapler around the RUL vein. The anvil goes into the tunnel between the vein and artery. The stapler can be passed through incision 1, but the angle is better from the posterior incision (Figure 8-3).

Figure 8-2 A right-angle instrument is passed around the right upper lobe vein, exposing the artery behind the vein.

Figure 8-3 The stapler crosses the right upper lobe vein.

Step 3. Minor Fissure

♦ Exposure: Retract the lung inferiorly and directed toward the thoracoscope.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly, but it is pulled back as close as possible to the trocar.

♦ Look at the minor fissure on the lateral surface of the lung and at the confluence of the RUL and right middle lobe veins to determine the exact location of the minor fissure.

♦ Point the anvil of the stapler toward this venous confluence, and hold it in place. Pull the lung parenchyma into the jaws of the endoscopic stapler without moving the stapler. This is a key maneuver and ensures that the stapler remains above all vascular structures and avoids inadvertent injury. The 4.8-mm staple cartridge typically is used for stapling lung parenchyma.

♦ The first firing of the stapler usually completes about one half of the fissure. Another stapler is positioned with the anvil of the stapler between the veins and on the surface of the artery (Figure 8-4).

♦ Open the jaws of the stapler, and with ring forceps, pull the lung parenchyma into the jaws of the stapler.

♦ Firing the stapler completes the minor fissure (Figure 8-5).

Figure 8-4 The anvil of the stapler is on the pulmonary artery in preparation for completing the minor fissure.

Figure 8-5 The stapler is not moved as the ring forceps pulls the lung parenchyma into the jaws of the stapler.

Step 4. Anterior Trunk

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.

♦ The thoracoscope is positioned anteriorly with the 30-degree lens pointed posteriorly. Rotate the camera slightly clockwise.

♦ Sharply dissect the inferior aspect of the anterior trunk for 1 to 2 cm.

♦ Dissect the main right pulmonary artery to the level of the posterior ascending artery.

♦ Remove the lobar nodes between the anterior trunk and the main pulmonary artery.

♦ Mobilize the artery from the bronchus; a right-angle clamp then easily passes around the anterior trunk (Figure 8-6).

♦ With a stapler introduced from incision 4 (preferred) or incision 1, transect the artery (Figure 8-7).

Figure 8-6 The right-angle clamp passes behind the anterior trunk.

Figure 8-7 The stapler lies across the anterior trunk.

Step 5. Define Right Upper Lobe Bronchus

♦ Exposure: Retract the lung directly posteriorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ Remove the lobar nodes that hide the surface of the RUL bronchus (Figure 8-8).

♦ Cauterize or clip the one or two small bronchial arteries to the bronchus and nodes.

♦ The posterior ascending artery can be seen inferiorly on the inferior border of the RUL bronchus.

♦ With Metzenbaum scissors, spread between the artery and the RUL bronchus until the vertebral bodies can be felt posteriorly (Figure 8-9). Be careful to not close the scissors when dissecting along the bronchus because that can cut the posterior ascending artery.

Figure 8-8 After the vein and the anterior trunk have been transected, the lymph nodes around the right upper lobe bronchus can be seen.

Figure 8-9 Through incision 1, the Metzenbaum scissors dissect along the inferior border of the right upper lobe bronchus.

Step 6. Posterior Ascending Artery

♦ Exposure: Retract the lung directly posteriorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ With the lobar nodes on the RUL bronchus removed, the RUL bronchus and the posterior ascending artery can be seen clearly.

♦ Dissect bluntly along the posterior ascending artery to determine if there is a common trunk for that artery and the artery for the superior segment of the lower lobe.

♦ After the anatomy is clarified, double clip the origin of the posterior ascending artery (Figure 8-10). Do not clip the distal side of the artery because the clip would be in the staple line when the remainder of the fissure is stapled.

♦ The posterior ascending artery can then be cut distal to the two clips. This causes minor back bleeding, which can be ignored or the artery can be transected with the stapler that completes the posterior aspect of the fissure.

Figure 8-10 A clip is applied to the posterior ascending artery.

Step 7. Right Upper Lobe Bronchus

♦ Exposure: Retract the lung directly posteriorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ Spread the Metzenbaum scissors widely between the RUL bronchus and the posterior ascending artery. Remove the scissors before closing them, because they can cut the artery if they are closed before removal.

♦ Pass the endoscopic 4.8-mm stapler through incision 1. The anvil of the stapler is placed in the tunnel created by the scissors along the inferior border of the RUL bronchus. Fire the stapler (Figure 8-11).

Figure 8-11 The stapler is positioned across the right upper lobe bronchus.

Step 8. Completion of the Fissure

♦ Exposure: Retract the lung posteriorly and superiorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ Fire the endoscopic 4.8-mm stapler as many times as needed to complete the fissure (Figure 8-12).

Figure 8-12 The stapler completes the fissure between the posterior segment of the right upper lobe and the superior segment of the right lower lobe.

Step 9. Lobe Removal

♦ Exposure: With a ring forceps through incision 4, hold the right lower lobe by the diaphragm to keep it out of view.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed to the apex of the chest for a panoramic view of the chest.

♦ With a ring forceps through the incision in the auscultatory triangle, the RUL is held posteriorly by the diaphragm to keep it out of view.

♦ Pass the Lapsac bag through the utility incision; push the base of the bag to the apex of the chest. With a ring forceps through the utility incision and another through the mid-clavicular incision, hold the bag widely open so the lobe can be inserted (Figure 8-13A).

♦ After the lobe is partially inserted into the bag, pinch the two ring forceps to hold the lobe in the bag (Figure 8-13B).

♦ With the ring through the auscultatory triangle, grasp a part of the lobe that is not in the bag, and push the remainder of the lobe into the bag.

Figure 8-13 A, The bag is held open. B, The right upper lobe is placed into a bag for removal through the utility incision.

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CHAPTER 8 Right Upper Lobectomy—video 8

Video-Assisted Right Upper Lobectomy (Video 8-1)

Step 1. Level 10 Nodes

♦ Exposure: Retract lung posteriorly and slightly inferiorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.

♦ The level 10 nodes are located within a triangle bounded by the SVC, azygous vein, and superior hilum of the lung.

♦ Just posterior and parallel to the phrenic nerve, incise the pleura from the hilum to the azygous vein and then posteriorly along the azygous vein to the right mainstem bronchus (Figure 8-1).

♦ From the hilum, dissect posteriorly along the superior aspect of the RUL vein and along the vein from the apical segment. This exposes the anterior trunk.

♦ Remove all the tissue in this triangle, including the level 10 nodes. At this point, the right mainstem bronchus, anterior trunk, and SVC are well exposed.

♦ After the level 10 nodes are removed, dissect along the superior aspect of the anterior trunk and posteriorly between the trunk and the right mainstem bronchus. This facilitates subsequent mobilization of the artery for later transection.

Figure 8-1 Level 10 nodes are removed by dissecting the triangle formed by the superior vena cava, the azygous vein, and the vein from the apex of the right upper lobe.

Step 2. Right Upper Lobe Vein

♦ Exposure: Retract the lung directly posteriorly.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.

♦ Clearly identify the RUL vein and the right middle lobe vein. Viewing the remnant of the minor fissure can help with orientation.

♦ Spread along the inferior aspect of the RUL vein. Lifting the vein shows the plane between the vein and the underlying pulmonary artery.

♦ Rotate the thoracoscope posteriorly with the lens pointed anteriorly to view the dissection between the vein and the artery.

♦ Dissect along the superior aspect of the RUL vein.

♦ To create a tunnel for the stapler, spread widely with a right-angle clamp between the RUL vein and the artery (Figure 8-2).

♦ Through incision 4, pass an endoscopic vascular stapler around the RUL vein. The anvil goes into the tunnel between the vein and artery. The stapler can be passed through incision 1, but the angle is better from the posterior incision (Figure 8-3).

Figure 8-2 A right-angle instrument is passed around the right upper lobe vein, exposing the artery behind the vein.

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Atlas of Minimally Invasive Thoracic Surgery (Vats)