Uniportal Thoracoscopic Left Lower Lobectomy After Previous Wedge Resection

The authors present a case of uniportal VATS left lower lobe radical lobectomy. The patient was a 44-year-old woman with breast cancer multimodal treated. The patient’s surgical history was represented by Madden mastectomy on the left side in 2019 and a left lower lobe wedge resection through minithoracotomy in 2020. The pathological report was lung adenocarcinoma. During oncological surveillance, a nodule was discovered in the left lower lobe.

In the chest CT-scan, you can see an interlobar lymph node, the pulmonary nodule, and the staple line from previous surgery. A PET scan was performed and the lymph node and the pulmonary nodule were confirmed with a standardized uptake value more than 25. The authors also observed some progression in dimensions of the nodule and lymph node.

A left lower lobectomy was performed. As expected, there were some pleural adhesions at the level of the minithoracotomy from previous surgery, which the authors dissected with the blunt instruments or with the hook. The next step was dissecting the pulmonary ligament, harvesting the station 9 lymph node, and identifying the inferior border of the inferior pulmonary vein. They continue by sectioning the anterior and posterior mediastinal pleura, identifying the superior border of the inferior pulmonary vein, thus preparing the dissection of the vein. Since the authors expected a laborious dissection in the fissure. To avoid vascular tension, the stapling of the vein took place after the completion of the arterial dissection. After that, the authors released the fissure and identifi the pulmonary artery. To complete the fissure, they used the hook and the scissors. The interlobar lymph node was observed “sitting” between the lower lobe bronchus and branches of the pulmonary artery (A5, A6, A7- 10 truncus). Due to the tight adhesions of the lymphadenopathy to the bronchial and vascular structures, its dissection was difficult, being necessary both blunt dissection and the hook electrocautery dissection.

After making sure the arterial branches were “free of lymph node,” they completed the vascular dissection by applying a 35 mm white EndoStapler reload for each vessel. After arterial stapling, they saw the lymph node and the structures around it. For the inferior pulmonary vein, they also used a curved tip stapler reload to facilitate the passage of the stapler under the vessel.

The next step was releasing the bronchus by completing the interlobar lymphadenectomy and finalizing the dissection of the bronchus by applying a 45 mm green EndoStapler reload. Before “firing” the stapler, the authors usually check the inflation of the upper lobe (marked in the video by a blue arrow). They completed the mediastinal and hilar lymphadenectomy and drained the pleural cavity with one 24CH chest tube taken out through the working incision.

The postoperative chest X-ray was nearly normal. The patient was discharged three days after surgery.

References

1. Gonzalez-Rivas D, Fieira E, Delgado M, Mendez L, Fernandez R, de la Torre M. Uniportal video-assisted thoracoscopic lobectomy. J Thorac Dis. 2013 Aug;5 Suppl 3(Suppl 3):S234-245.
2. Anile M, Diso D, Mantovani S, Patella M, Russo E, Carillo C, et al. Uniportal video assisted thoracoscopic lobectomy: going directly from open surgery to a single port approach. J Thorac Dis. 2014 Oct;6(Suppl 6):S641-643.

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