An Easy Way to Perform a Biportal VATS Right Pneumonectomy

The Patient

A seventy-eight-year old man, a former smoker, was hospitalized for a six centimeter ground-glass opacity (GGO) with a central solid component arising from the upper lobe of the right lung and involving the lower lobe. His comorbidities included a pacemaker device for paroxysmal arrhythmia  and a 4.9 centimeter subrenal aortic aneurysm.

Clinicians had been aware of the lesion for three years but decided to follow up until it grew and reached the current dimensions. A PET scan showed FDG uptake and a transbronchial biopsy confirmed the diagnosis of pulmonary adenocarcinoma with predominant lepidic pattern with the following molecular features: PD-L1 negative and ALK, ROS1, EGFR not mutated. The final clinical staging was T3N0M0 (IIB).

Based on the dimension and the position of the neoplasm, a radical resection was only possible through a right pneumonectomy. Nevertheless, the absence of a clear wide involvement of hilar structures allowed a minimally invasive approach.

The Surgery

The patient was placed in a left lateral decubitus position with single-lung ventilation under general anesthesia.

Surgeons performed a standard biportal approach. First, intercostal nerve blocks were made, and the procedure was performed with Scanlan instrumentation, Ultracision Harmonic scalpel, and Echelon powered staplers. 

Once metastatic pleural involvement was excluded and the translobar extension was confirmed, the team proceeded with the right pneumonectomy. Hilar structures were easily dissected and the first branch of the right pulmonary artery, the upper pulmonary vein, the lower pulmonary vein were stapled, as is routine in VATS lobectomies. 

Next, the intermediate artery was easily exposed, dissected, and stapled. The main right bronchus was the last hilar structure to be dissected, then pulled up and stapled proximal to the carina. The lung was then removed with an endobag through the utility incision and a systematic lymph node dissection is carried out at stations two, four, seven, eight, and nine.

The postoperative course was uneventful and the patient was discharged on the sixth postoperative day. The histology report showed a 7.5 cm infiltrating lung adenocarcinoma, PL1 and STAS+ (pT4 N0 M0 R0).

Conclusions

Right pneumonectomy has a high complication rate and there can be significant postoperative sequelae. Pneumonectomy is seldom performed with a minimally invasive technique because of this challenging possibility. The dissection of the right pulmonary artery from its origin inside the pericardium is unusual in VATS and can be difficult and risky.

In this case, the hilum was not involved by the tumor and no hilar lymph adenopathy were present.
Once the first arterial branch and the two pulmonary veins are dissected, as in standard VATS lobectomies, the pulmonary artery is well exposed and gives rise medium and lower lobe branches, reducing risk and making the dissection very easy.

In conclusion, right lung VATS pneumonectomy in the absence of hilar involvement by both neoplasm or lymph nodes does not show considerable technical difficulties and is feasible for all surgeons with minimally invasive experience.

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