Right Middle Lobectomy—video 9

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CHAPTER 9 Right Middle Lobectomy—video 9

Robert J. McKenna, Jr.

Introduction

The anatomic variations of the right middle lobe (RML) include an accessory artery posterior and inferior to the bronchus and the dual venous drainage to the superior pulmonary vein and the inferior pulmonary vein. The surgeon should be aware of these anatomic variations, but they have little impact on the operation.

Approach to Video-Assisted Right Middle Lobectomy

Order of Operative Steps

The order of steps for the operation is as follows: RML vein, major fissure between the RML and the right lower lobe (RLL), RML bronchus, RML artery, and the minor fissure. The incisions are described in Chapter 1 (see Figure 1-2). For a right middle lobectomy, place the utility incision (i.e., incision 3) one intercostal space below the superior pulmonary vein.

Key Points

♦ Work anteriorly to posteriorly with little manipulation of the lung.
♦ Approximately 20% of patients have an accessory middle lobe artery located inferior and posterior to the RML bronchus.
♦ Five percent of RMLs drain to the superior and inferior pulmonary veins.

Video-Assisted Right Middle Lobectomy

Step 1. Right Middle Lobe Vein

♦ Exposure: Retract the lung directly posteriorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly toward the hilum.
♦ Use the standard incisions, although the auscultatory incision is often not necessary (Figure 9-1). The utility incision is made directly up from the superior pulmonary vein, as for an upper lobectomy.
♦ Dissect between the inferior and superior pulmonary veins to define the inferior border of the RML vein, and determine whether there is drainage from the middle lobe to the inferior pulmonary vein.
♦ With DeBakey pickups and Metzenbaum scissors, define the superior and inferior aspect of the RML vein (Figure 9-2).
♦ Using the same exposure, dissect out the RML vein.
♦ Pass a right-angle clamp through the utility incision around the RML vein (Figure 9-3).
♦ With a vascular stapler from the utility incision or the auscultatory triangle incision, if used, transect the RML vein.
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Figure 9-1 Standard incisions.

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Figure 9-2 Dissection of the middle lobe vein.

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Figure 9-3 The inferior pulmonary vein and a right-angle clamp passing behind the right middle lobe vein.

Step 2. Major Fissure

♦ Exposure: To line up the major fissure for stapling, retract the RLL inferiorly and slightly anteriorly while the RML is retracted inferiorly and medially to line up the major fissure with incision 1.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly and superiorly, directly down the fissure.
♦ Through incision 1, the anvil of the stapler is placed between the superior pulmonary vein and the inferior pulmonary vein. Hold the stapler in place as the lung parenchyma is pulled into the stapler. The cartridge of the stapler is lined up with the fissure, and the stapler is fired (Figure 9-4).
♦ Lift the remaining fissure with a ring forceps to expose the pulmonary artery in the fissure.
♦ Remove the lymph node between the RLL and RML bronchi.
♦ Define the pulmonary artery with the Metzenbaum scissors through incision 1 by spreading on the surface of the artery or with the Yankauer suction bluntly dissecting along the surface of the pulmonary artery.
♦ This dissection creates a tunnel for the stapler through incision 1 to complete the remainder of the major fissure to the level of the minor fissure.
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Figure 9-4 A and B, Completion of the major fissure between the middle lobe and the lower lobe.

Step 3. Accessory Right Middle Lobe Artery

♦ Exposure: Retract the RLL inferiorly and posteriorly, while the RML is retracted superiorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.
♦ A few patients have an accessory right middle lobe artery that is located inferior and posterior to the RML bronchus (Figure 9-5).
♦ With DeBakey pickups and Metzenbaum scissors, dissect the artery away from the bronchus.
♦ A right-angle clamp introduced through the utility incision mobilizes the artery. The artery is usually small, and it can be clipped or tied.
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Figure 9-5 Accessory artery to the right middle lobe.

Step 4. Right Middle Lobe Bronchus

♦ Exposure: Retract the RML toward the apex of the chest.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly but pulled back into the trocar.
♦ Remove the lobar nodes around the bronchus. Watch for the right middle lobe artery, which lies behind and parallel to the RML bronchus (Figure 9-6).
♦ With DeBakey pickups and Metzenbaum scissors introduced through the utility incision, dissect the bronchus away from the artery.
♦ Pass a right-angle clamp between the bronchus and the artery. Spread widely to create a tunnel for the stapler (Figure 9-7).
♦ Transect the bronchus with a stapler through the auscultatory or utility incision (Figure 9-8).
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Figure 9-6 Relationships of the right middle lobe bronchus, right middle lobe artery, main pulmonary artery, and a lobar lymph node.

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Figure 9-7 Right-angle clamp between the right middle lobe bronchus and the pulmonary artery.

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Figure 9-8 Stapler across the right middle lobe bronchus.

Step 5. Right Middle Lobe Artery

♦ Exposure: Retract the RLL posteriorly and inferiorly as the RML is retracted superiorly and anteriorly toward the apex of the chest.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly. The camera is rotated slightly clockwise.
♦ With the vein and bronchus transected, the RML artery is exposed as shown in Figure 9-9. Handling for the artery parallels that for the bronchus.
♦ With DeBakey pickups and Metzenbaum scissors introduced through the utility incision, dissect the artery. A right-angle clamp mobilizes the artery to create a tunnel through which the stapler will pass to transect the artery.
♦ Through the utility incision, a clip can be placed on the artery. Alternatively, a stapler (usually through the posterior incision) can transect the artery, or it can be tied.
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Figure 9-9 Relationships of the right middle lobe artery, right upper lobe vein, and pulmonary artery.

Step 6. Minor Fissure

♦ Exposure: Retract the RLL posteriorly and inferiorly. A ring forceps through the mid-clavicular incision retracts the RML inferiorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.
♦ Complete the minor fissure with a stapler that is brought through the utility incision.
♦ Place the anvil just inferior to the right upper lobe vein and on the surface of the artery (Figure 9-10).
♦ Line up the cartridge of the stapler with the minor fissure on the lateral surface of the lung. Hold the stapler stable as a ring forceps pulls the RML parenchyma into the stapler.
♦ Fire the stapler.
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Figure 9-10 The anvil of the stapler is positioned on the pulmonary artery, inferior to the right upper lobe vein.

Step 7. Removal of the Lobe

♦ Exposure: Retract the RML low in the chest near the diaphragm through the posterior auscultatory triangle incision.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed toward the apex of the chest for a panoramic view of the chest.
♦ With a ring forceps through the incision in the auscultatory triangle, hold the RML posteriorly and inferiorly by the diaphragm to keep it out of view while the Lapsac bag is passed through the utility incision to the apex of the chest.
♦ With a ring forceps through the utility incision and another through the mid-clavicular incision, hold the bag open so the lobe can be inserted.
♦ Place the RML into the bag through the auscultatory triangle incision.
♦ Through the utility incision, pull the bag out of the chest.

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