♦ Incise the pleura along the superior aspect of the SPV and the vein from the apex of the lung. Continue over the superior aspect of the hilum, because this mobilizes the anterior trunk of the artery (Figure 7-1).

♦ With the Metzenbaum scissors, dissect the superior aspect of the SPV (Figure 7-2).

♦ Lift the SPV with a ring forceps (Figure 7-3), and with the Metzenbaum scissors or the Yankauer suction catheter through incision 1, dissect under the SPV. The bronchus is directly behind the vein.

♦ A right-angle clamp through incision 1 moves inferiorly to superiorly around the SPV (Figure 7-4). Blunt dissection with the right-angle instrument can be performed several times to mobilize the SPV. Progress of the dissection can be seen better if the 30-degree lens is rotated to look from posterior to anterior and if the SPV is lifted with a ring forceps or a pickup.

♦ Staple the vein (Figure 7-5). Have a ring forceps in the chest through incision 3 as the stapler fires. The staple line may leak, and a ring forceps in the chest can control the bleeding.

♦ Retract the lung anteriorly. Metzenbaum scissors through incision 1 incise the pleura posterior to the IPV. Dissection continues along the pericardium. A lymph node located posterior and superior to the IPV can be held with a ring forceps from incision 4. Removal of that node greatly facilitates IPV mobilization (Figure 7-6).

♦ Metzenbaum scissors, the Yankauer suction, or a right-angle clamp through incision 1 or 3 passes around the IPV (Figure 7-7).

♦ A stapler through incision 1 or 3 transects the IPV (Figure 7-8).

♦ A ring forceps from incision 4 can retract the esophagus posteriorly. This exposes the subcarinal nodes. When they are completely removed, the right and the left mainstem bronchi are seen clearly (Figure 7-9).

♦ The inferior aspect of the pulmonary artery is well exposed after the SPV and IPV have been transected. Perform blunt dissection with a Yankauer suction or Metzenbaum scissors through incision 3 between the pulmonary artery and the bronchus (Figure 7-10).

♦ Use an open stapler, such as the Covidien TA 30 or Ethicon TX 30 for the artery. Put the pin down, and pull the lung through the stapler to position the stapler (Figure 7-11).

♦ Incise the pleura along the inferior aspect of the azygous vein. To see this area well, retract the lung slightly more inferiorly. The 30-degree lens and the thoracoscope are rotated slightly clockwise (Figure 7-12).

♦ With the Metzenbaum scissors or the Yankauer suction catheter through incision 1, bluntly dissect between the SPV and the IPV (Figure 7-13).

♦ A right-angle clamp through incision 1 runs inferiorly to superiorly around the SPV (Figure 7-14). Blunt dissection with the right-angle clamp can be performed several times to mobilize the SPV. Progress of the dissection can be seen better if the 30-degree lens is rotated to look from posterior to anterior and the SPV is lifted with a ring forceps or a pickup.

♦ Staple the vein (Figure 7-15). Have a ring forceps in the chest through incision 3 as the stapler fires. If the staple line leaks, use a ring forceps to apply pressure and control the bleeding.

♦ Retract the lung anteriorly. Metzenbaum scissors through incision 1 incise the pleura posterior to the IPV. Dissection continues along the pericardium. A lymph node located posteriorly and superiorly to the IPV can be held with a ring forceps from incision 4. Removal of the node greatly facilitates IPV mobilization (Figure 7-16).

♦ Metzenbaum scissors, the Yankauer suction tip, or a right-angle clamp introduced through incision 1 or 3 passes around the IPV (Figure 7-17).

♦ Blunt dissection with the Yankauer suction tip or the Metzenbaum scissors through incision 1 begins on the surface of the pericardium (Figure 7-18). A ring forceps from incision 4 holds the soft tissue in the subcarinal space. The esophagus and the vagus nerve constitute the posterior border for the dissection. There is a tendency to dissect toward the esophagus, but the dissection should be away from the esophagus and toward the bronchus.

♦ Using a ring forceps from incision 4, retract the esophagus posteriorly. This exposes the subcarinal nodes. When they are completely removed, the right and left mainstem bronchi are seen clearly (Figure 7-19).

♦ The superior aspect of the right main pulmonary artery is well exposed after the level 10 nodes have been dissected. Blunt dissection with a Yankauer suction tip or Metzenbaum scissors through incision 3 mobilizes the inferior aspect of the artery away from the bronchus (Figure 7-20).

♦ Through incision 3, a right-angle clamp passes around the pulmonary artery after the blunt dissection has nearly completely mobilized the artery (Figure 7-21).

♦ Use an open stapler, such as the Covidien TA 30 or Ethicon TX 30 for the artery (Figure 7-22).

♦ Use an open stapler, such as the Covidien TA 30 or Ethicon TX 30 for the bronchus. Put the pin down, and pull the lung through the stapler to position the stapler as close as possible to the carina (Figure 7-23).