Left Upper Lobe Apical Trisegmentectomy—Video 16-1

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CHAPTER 16 Left Upper Lobe Apical Trisegmentectomy—Video 16-1

Scott J. Swanson

Introduction

Segmentectomy is an option for a small, anatomically well-situated lung cancer. Creating the segmental fissure and dissecting out the segmental vessels can be done using a thoracoscopic technique. A left upper lobe apical trisegmentectomy (i.e., lingula-sparing left upper lobectomy) is similar to right upper lobectomy with preservation of the right middle lobe.

Approach to Video-Assisted Left Upper Lobe Apical Trisegmentectomy

Order of Operative Steps

The order of the steps of the operation is as follows: anterior, superior, and posterior pleurae over the hilum; upper division vein; anterior trunk; posterior artery; bronchus; and the fissure (Video 16-1).

Key Points

♦ The vessels help to determine the separation between the upper division and the lingula.
♦ Alternatively, the bronchus for the upper division can be divided and the lingula ventilated to determine where to place the staples to separate the upper division.

image Video-Assisted Left Upper Lobe Apical Trisegmentectomy

Step 1. Port Placement (Figure 16-1)

♦ Place the camera port in the seventh intercostal space in the anterior axillary line; it can be modified depending on heart size.
♦ Place the access port in the fourth intercostal space in the mid-axillary line.
♦ Place the posterior port in the sixth intercostal space, just inferior to the tip of the scapula.
image

Figure 16-1 The three ports for the left upper lobe apical trisegmentectomy are shown. The camera is placed in the seventh intercostal space in the anterior axillary line. The access port is in the fourth intercostal space in the mid-axillary line, and the posterior port is placed in the sixth intercostal space just inferior to the tip of the scapula.

Step 2. Dissect Anterior Hilum and Aortopulmonary Window (Figure 16-2)

♦ Exposure: Retract the lung posteriorly through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm to the left to look at anterior hilar structures.
♦ Dissect through the access port.
♦ Open the mediastinal pleura over the anterior hilum with an endokittner and the suction irrigator. This defines the venous drainage from the upper division of the left upper lobe (LUL). Dissect superiorly to the level of the aortopulmonary window.
♦ Removal of the level 5 nodes facilitates exposure of the vessels and prepares the superior and posterior aspect of the anterior trunk for subsequent transection.
image

Figure 16-2 A, The surgeon dissects out the level 5 lymph nodes using an endokittner and suction irrigator through the anterior access port. The assistant gently retracts the lung posteriorly through the posterior port. B, The surgeon uses the harmonic scalpel to divide the small nodal vessels to the level 5 lymph nodes to ensure hemostasis through the anterior access port.

Step 3. Open Posterior Mediastinal Pleura (Figure 16-3)

♦ Exposure: Retract the lung anteriorly through the access incision.
♦ Place the thoracoscope in the camera port with the side arm to the right.
♦ Open the posterior mediastinal pleura using blunt dissection with endokittners through the posterior port. Continue opening the pleural superiorly until the dissection connects with the posterior pleural opening with the anterior pleural dissection from steps 1 and 2.
image

Figure 16-3 A, The lung is retracted anteriorly using a ring forceps through the anterior access port while the surgeon uses two endokittners through the posterior port to open the posterior mediastinal pleura, which exposes the level 6 lymph nodes, the vagus nerve, and the pulmonary artery where it enters the posterior fissure. B, The surgical assistant retracts the lung anteriorly through the anterior access port and uses the suction irrigator to further retract the lung. Suction as needed while the surgeon bluntly dissects out the pulmonary artery in the fissure using two endokittners through the posterior port.

Step 4. Tumor Palpation (Figure 16-4)

♦ Exposure: Move the lung toward the access port with a ringed forceps placed through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm straight up.
♦ Carefully palpate and examine the tumor to be certain a sublobar resection constitutes optimal cancer treatment. This is done by corroborating the tumor size (T1, ideally less than 2 cm) and confirming that tumor is far enough away from the lingula so that the margins will be adequate if a trisegmentectomy is performed.
♦ When observing the LUL from an anterior position, the lingular vein helps to determine the superior aspect of the lingula. When retracting the LUL posteriorly, the upper division is just above the lingular vein. There is often a minimal fissure between the lingula and the upper division.
image

Figure 16-4 Through the anterior access port, the surgeon palpates the tumor to confirm its presence and determine that it is positioned centrally within the upper division.

Step 5. Upper Pulmonary Vein (Figure 16-5)

♦ Exposure: Retract the lung posteriorly with the ring forceps through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm to the left.
♦ Mobilize the upper division pulmonary vein with the endokittner and scissors or right-angle clamp. Carefully identify and preserve the lingular vein or veins. In some instances, it is necessary to divide a middle central vein, although it drains the upper division and lingula.
image

Figure 16-5 A right-angle clamp is passed around the upper division vein after it has been bluntly dissected free through the anterior access port. The assistant retracts the lung posteriorly through the posterior port.

Step 6. Proximal Artery Dissection (Figure 16-6)

♦ Exposure: Retract the lung posteriorly and slightly inferiorly with ringed forceps through the posterior port.
♦ Place the thoracoscope through the camera port with the side arm to the left.
♦ Identify and dissect free the proximal artery with the endokittner and scissors placed through the camera port. Identify and mobilize the first and second branches. After the vein is divided, this dissection becomes easier.
image

Figure 16-6 After division of the upper division vein, the surgeon dissects the first two branches of the left upper lobe artery through the camera port, with the camera shifted to the anterior access port before placing the vascular stapler.

Step 7. Dissection of the Pulmonary Artery in the Fissure (Figure 16-7)

♦ Exposure: Gently retract the lung superiorly and slightly anteriorly with the ringed forceps through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm to the left.
♦ Identify the pulmonary artery in the fissure. Usually, this is easiest where the artery turns inferiorly to form the basilar trunk near the distal end of the fissure. Often, there is a lymph node sitting superficially over the artery at this point.
♦ Use two endokittners through the access incision to bluntly open the pleura over the artery in this location to establish the plane over the artery. When the proper plane is obtained, the white and glistening artery can be seen. Create a tunnel along the artery, extending it posteriorly toward the proximal pulmonary artery where it enters the fissure. The pulmonary artery was previously identified in this posterior location during steps 1 through 3. Divide the fissure with the endostapler to expose the upper lobe pulmonary artery branches.
image

Figure 16-7 The surgeon dissects free the posterior segmental artery through the posterior port while the assistant retracts the lung anteriorly through the anterior access port with a ring forceps and suction irrigator.

Step 8. Upper Division Pulmonary Vein Division (Figure 16-8)

♦ Exposure: Retract the lung posteriorly with ringed forceps through the posterior port.
♦ Place the thoracoscope through the camera incision with the side arm to the left.
♦ Before placing the stapler, use an endokittner through the posterior port to confirm that the stapler will pass at an appropriate angle and without undue tension.
♦ Divide the upper division pulmonary vein using an endovascular stapler (white load cartridge, 30 to 45 mm) placed through the posterior port while retracting the lung with a ring forceps placed through the anterior port.
image

Figure 16-8 The stapler is passed through the posterior port around the upper division vein before dividing it.

Step 9. Pulmonary Artery Division (Figure 16-9)

♦ Exposure: Retract the lung posteriorly and inferiorly through the posterior port using a ringed forceps.
♦ Place the thoracoscope through the access incision with the side arm straight up.
♦ Divide the first and second branches of the pulmonary artery with the endovascular stapler placed through the camera port. Again test the angle of the proposed stapler placement using an endokittner.
image

Figure 16-9 A, The endokittner passed through the camera port is placed around the first two branches of the left pulmonary artery to show that the vessel is free and that the angle of approach is appropriate for the straight vascular stapler. The camera is introduced through the anterior access port. B, Through the camera port, the vascular stapler is passed around the first two branches of the left pulmonary artery, with camera placed through the anterior access port. Alongside the camera, an endokittner is placed to retract the lung apically to allow excellent visualization of the stapler.

Step 10. Posterior Artery Division (Figure 16-10)

♦ Exposure: Retract the lung anteriorly and apically with a ringed forceps through the access incision.
♦ Place the thoracoscope through the camera incision with the side arm to the right.
♦ Divide the posterior segmental artery with an endovascular stapler introduced through the posterior port. Because the first two pulmonary arterial branches have already been divided, the stapler should not be in danger of inadvertently injuring the branches.
♦ The vascular stapler goes through the posterior incision.
image

Figure 16-10 The vascular stapler is placed around the posterior segmental pulmonary artery through the posterior port. The lung is retracted with ringed forceps toward the anterior chest wall placed through the anterior access port along with an endokittner.

Step 11. Bronchus Division (Figure 16-11)

♦ Exposure: Retract the lung toward the anterior chest wall with a ringed forceps through the access incision to gain as much length on the bronchus as possible, and put it under some mild tension in the vertical plane.
♦ Place the thoracoscope through the camera incision with the side arm to the right.
♦ Dissect the posterior aspect of the bronchus.
♦ Identify the upper division bronchus in the fissure, and sweep all peribronchial tissue up onto the bronchus with endokittners. This helps to identify the carina between the upper division bronchus and the lingular bronchus.
♦ Dissect the anterior aspect of the bronchus. Retract the lung posteriorly with a ring forceps through the posterior port to bluntly dissect the same area from the anterior perspective using endokittners introduced through the access port. This helps to ensure that there is no tissue to impede the stapler.
♦ Use an endobronchial stapler (blue or green load cartridge, 30 to 45 mm) placed through the posterior port to divide the upper division bronchus. Staple height is chosen based on the size of the segmental bronchus. If small, use a blue load; if bigger, use a green load. The same type of decision making is used for the length of the staples.
image

Figure 16-11 A, The upper division bronchus is observed in the center, with the lingular artery adjacent to the suction irrigator coursing anteriorly (toward the left side). B, The endostapler (blue load cartridge) is passed around the upper division bronchus through the posterior port alongside an endokittner. The lung is retracted with a ringed forceps through the anterior access port. A suction irrigator is passed through the same port for additional retraction and suction, as necessary.

Step 12. Complete the Fissure Between the Upper Division and the Lingula (Figure 16-12)

♦ Exposure: Retract the lung toward the anterior chest wall and slightly posteriorly with a ringed forceps through the posterior port.
♦ Place the thoracoscope through the camera incision with the side arm to the left.
♦ Divide the lung anteriorly between the stump of the upper division vein and lingular vein by placing the stapler (45- to 60-mm, gold or blue cartridge) through the access port while retracting the lung toward the anterior chest wall and slight posteriorly with a ring forceps placed through the posterior port. Occasionally, ring forceps are placed next to the stapler through the access port to aid in straightening the lung for stapled division.
♦ Divide the lung posteriorly between the divided posterior segmental artery and the intact lingular artery by placing the stapler (45- to 60-mm, gold or blue cartridge) through the posterior port while retracting the lung with a ring forceps placed through the access port. Place the camera in the camera port with the side arm to the right.
♦ Finish the fissure from anterior to posterior with a stapler (45- to 60-mm, gold or blue cartridge) through the posterior port. Retract the lung anteriorly toward the anterior chest wall and slightly posteriorly with a ring forceps placed through the access port. Be careful to keep the divided upper division bronchus up with the specimen and to avoid encroaching on the lingular bronchus. Before firing the stapler, the anesthesiologist should inflate the left lung to be sure the lingula inflates adequately. Place the camera through the camera port with the side arm to the left.
image

Figure 16-12 A, The anterior fissure between the upper division and the lingula is created with a stapler placed through the anterior access port. The lung is retracted with a ringed forceps through the posterior port. The surgeon must be careful to align the staple line parallel and just cephalad to the lingular vein. B, After beginning the fissure posteriorly, completion of the fissure is performed with the endostapler passed through the posterior port. The surgeon must be careful to avoid kinking or injuring the long, narrow lingular bronchus.

Step 13. Lapsac Retrieval (Figure 16-13)

♦ Specimen retrieval is described in Chapter 1.
image

Figure 16-13 The specimen is placed in the Lapsac bag, which was brought in through the anterior access port after enlarging this incision to 5 cm.

Step 14. Inferior Pulmonary Ligament Takedown (Figure 16-14)

♦ Exposure: Retract the lung superiorly with a ring forceps placed through the posterior port.
♦ Place the thoracoscope through the camera incision with the side arm to the left.
♦ Take down the inferior pulmonary ligament with electrocautery through the access port while retracting the lung posteriorly and superiorly with a ring forceps through the posterior port.
image

Figure 16-14 The inferior ligament is taken down with a long-handled electrocautery device introduced through the anterior access port. The lung is retracted cephalad through the posterior port with a ringed forceps.

Step 15. Subcarinal Node Dissection (Figure 16-15)

♦ Subcarinal node dissection is described in Chapter 22.
image

Figure 16-15 The subcarinal nodes are dissected free through the anterior access port with a long Allis clamp and endokittner. The esophagus and aorta are gently retracted posteriorly with the suction irrigator to aid in opening up this space. The left bronchus can be seen just posterior to the Allis clamp.

Step 16. Lung Inflation, Air Leak Check, and Placement of a Chest Tube (Figure 16-16)

♦ Exposure: Inflate the lung to see it expand, and test for an air leak.
♦ Place the thoracoscope through the camera incision with the side arm to the left or right side, depending on the best view.
♦ Reinflate the left lung to be sure that the lingula expands well and is positioned normally. Test the bronchial stump by instilling irrigation fluid with the suction irrigator and using a dental pledget to hold the lung down so the bronchial stump can be visualized. Place a single 24-French chest tube through the camera port posteriorly to the apex, and close remaining incisions.
image

Figure 16-16 A, At the conclusion of the case, the lung is inflated under visualization to confirm a pneumostatic bronchial stump (irrigating fluid is introduced to submerge the bronchial stump) and ensure that the lingula expands well and is oriented properly. B, A 24-French chest tube is passed through the camera port posteriorly and toward the apex. Typically, an extra hole is created with a rongeur in the chest tube along the white radiopaque line at about 8 cm. C, The bronchial stump is submerged under saline introduced with the suction irrigator while the lung is inflated to test the stump.

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