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CHAPTER 13 Sleeve Lobectomy

Right Upper Lobe – Video 13

Video-Assisted Sleeve Lobectomy of the Right Upper Lobe (Video 13)

Step 1. Initial Procedures

♦ Address the level 10 nodes, right upper lobe vein, and fissure as described for a standard right upper lobectomy in Chapter 8.

Step 2. Transection of Bronchi

♦ Exposure: Retract the lung posteriorly and slightly inferiorly (Figure 13-1).

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

♦ With a knife on a long handle through the utility incision, cut the mainstem and intermediate bronchi. Usually cut the bronchi from anterior to posterior so the cut is made away from the pulmonary artery (Figure 13-2).

Figure 13-1 The suction catheter in the subcarinal space exposes the bronchus for transection. PA, Pulmonary artery; RUL, right upper lobe.

Figure 13-2 The intermediate bronchus is transected with a knife on a long handle.

Step 3. Posterior Bronchial Anastomosis

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.

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

♦ Retract the RUL posteriorly and apically with a ring forceps through incision 4.

♦ Place a stay suture posteriorly on the intermediate bronchus to help approximate the intermediate and mainstem bronchi (Figure 13-3).

♦ It is not necessary to take down the inferior pulmonary ligament for a routine RUL, but it does help take tension off the anastomosis for a sleeve resection.

♦ Place the interrupted sutures from posterior to anterior along the membranous portion on the bronchus with a standard needle holder through the utility incision (Figure 13-4).¹

♦ Tie the knots inside or outside the lumen. Tie the knots as the sutures are placed because placing the sutures first and tying the knots later creates a very difficult task of keeping the sutures in order and preventing them from becoming crossed as later sutures are placed.

Figure 13-3 The stay suture is placed posteriorly in the intermediate bronchus.

Figure 13-4 The suture is placed in the posterior row of sutures.

4 Completion of Bronchi Anastomosis

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.

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

♦ Place the sutures for the remainder of the anastomosis so the knots are tied outside the lumen (Figure 13-5).

♦ The anastomosis is close enough to a properly placed utility incision so the knots may be tied extracorporeally and then pushed with a finger through the utility incision to the anastomosis. Rarely, a knot pusher is needed.

♦ Fill the chest with water (not saline) because the red blood cells explode in water, allowing better visualization through the water to examine the anastomosis for possible bleeding or air leak.

♦ Perform fiberoptic bronchoscopy at the conclusion of the anastomosis to confirm that the anastomosis is not narrowed and to remove any blood clots in the bronchial tree.

Figure 13-5 The anterior row of sutures is placed.

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CHAPTER 13 Sleeve Lobectomy

Right Upper Lobe – Video 13

Atlas of Minimally Invasive Thoracic Surgery (Vats)