Uniportal Video-Assisted Thoracoscopic Right Lower Lobectomy with Bronchoplasty of Right Middle Lobe

The penetration of uniportal VATS for lung cancer surgery has pushed surgeons to perform complex sleeve resections through the same approach. This video features a fifty-two-year-old male patient in good health who was diagnosed with mucoepidermoid carcinoma of the right lower lobe with endobronchial extension with the tertiary carina free of tumor. A uniportal VATS right lower lobectomy was performed with a bronchotomy of the right lower lobe bronchus close to its origin in view of the peribronchial tumor extension. Two futile attempts at closing the bronchotomy (with bronchoscopic guidance) to ensure successful ventilation of the middle lobe prompted the surgical team to proceed with uniportal VATS bronchoplasty of the right middle lobe. 

A 4'0' Prolene double-armed suture with smaller needle diameter was used for the anastomosis. Then, the middle lobe bronchus was hitched to the chest wall to keep it taut for suturing. 

The knuckle of the divided interlobar pulmonary artery was a constant obstacle to the anastomosis, and it was maneuvered with each throw on the bronchus intermedius using the thoracoscopic suction cannula. The discrepancy in the luminal diameter between the bronchi was amended while suturing the membranous portion of the bronchus. 

Avoiding the interlocking of sutures and patient unwinding any such knots aids in successfully completing the anastomosis thoracoscopically. Next, a nerve hook was used tighten the continuous suture to ensure a complete seal without snapping the thread. Overall, the choice of suture material, finer tricks to orient the structures in a favorable angle, selection of comfortable instruments for the surgeon, and balancing oncological principles with parenchymal preservation are pearls for a successful VATS sleeve resection. 

Refferences

1. Gonzalez-Rivas D, Yang Y, Stupnik T, et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†. Eur J Cardiothorac Surg. 2016;49 Suppl 1:i6-i16. doi:10.1093/ejcts/ezv410
2. Koryllos A, Stoelben E. Uniportal video-assisted thoracoscopic surgery (VATS) sleeve resections for non-small cell lung cancer patients: an observational prospective study and technique analysis. J Vis Surg. 2018;4:16. Published 2018 Jan 17. doi:10.21037/jovs.2017.12.22

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