Biportal VATS Right Pneumonectomy

A 53-year-old man with no comorbidity was referred to the authors’ unit because of a multifocal wild-type adenocarcinoma of the right lung. A positron emission tomography scan was negative for metastasis and an endobronchial ultrasound-guided transbronchial needle aspiration staging of the mediastinum showed no lymph node involvement. After a multidisciplinary meeting, a right pneumonectomy indication was given. Preoperative evaluation showed no major contraindications. 

The video-assisted thoracoscopic approach was biportal, using a 6 to 7 cm utility port at the fifth intercostal space, mandatory for the size of the lung and its extraction, and a 2 cm port for the camera at the eighth intercostal space. The lung parenchyma was completely altered because of the multiple foci of adenocarcinoma. First, the authors resected the pulmonary ligament and opened the mediastinal pleura to isolate the inferior and superior veins. The veins were transected with a mechanical stapler in the sequence shown in the video. Once transected, the authors noticed a small vein draining the S6 segment and had to divide this separately. Then they carefully cleared the pulmonary artery just over the pericardium and transected it using a mechanical stapler inserted from the inferior access. Again, the authors cleaned the bronchus and decided to close it with a TA™ stapler. The utility incision was sufficient to introduce that stapler, and they were able to obtain a bronchial stump as short as possible. A systematic lymphadenectomy was then performed and the bronchial stump was covered with a surgical glue.

The length of surgery was 190 minutes. The patient was transferred to the intensive care unit and extubated after four hours. The postoperative period was uneventful. The chest drainage was removed in the first postoperative day and the patient was discharged from the hospital on the fifth postoperative day in optimal medical condition. The final pathology result was T3(5)N0M0, according to the AJCC 8th edition. The patient is now under evaluation for adjuvant chemotherapy.