Editing VATS lobectomy


== Comparison to open ==

* Equivalent 3 and 5 year survival for stage IA cancers
* Improved pain control
* Shorter admission
* Shorter chest tube duration
* Faster overall recovery, especially with elderly patients
* Better cosmetic result
* Less complications - AF, atelectasis, prolonged air leak, pneumonia, renal failure
* Few absolute contraindications to VATS
** Severe pleural fibrosis
** Inability to selectively ventilate lungs
* Factors making VATS harder
** Larger size tumour
** More central location
** Neoadjuvant chemoradiotherapy
** Chest wall invasion
** Need for sleeve resection


== '''Technique''' ==

* Access
** Anterior 3-incision
*** 12mm posterolateral port posterior axillary line (7th or 8th ICS) - initial exploration for contraindications to VATS
*** 12mm incision as anterior as possible 6th or 7th ICS
*** 4cm access incision mid-axilla along 4th ICS + Alexis wound retractor
***
* Mobilisation of the lobe
** Divide inferior pulmonary ligament to the level of the inferior pulmonary vein
* Dissection and management of vessels and bronchus
** Echelon 45 vascular to PV and PA
** Endo-GIA purple 45 to bronchus
* Fissure dissection
** Fissure first
** Fissure last
** Tunnel for stapler
* Remove specimen
* Lymph node dissection
** Upper lobectomy: paratracheal (2 + 4) and subcarinal (7)
** Lower: additional level 9 (inferior pulmonary ligament)
* Leak test
** Pleural sealant
** Chromic 2/0 figure-of-eight
* 28Fr chest tube

== Right upper lobectomy ==

* Open the posterior pleura over the inferior border of RUL bronchus and the pleura over the pulmonary artery in the interlobar fissure - allows dissection of the 'landing zone'
* Pleura over anterior hilum is mobilised using blunt dissection - beware of phrenic nerve
* Circumferentially dissect superior pulmonary vein (identify and protect middle lobe vein, and identify separate inferior pulmonary vein). Vessel loop around superior pulmonary vein. Staple across from posteroinferior port.
* Identify apical branches of pulmonary artery. Encircle and divide truncus anterior. 
* Identify pulmonary artery in the fissure. Expose full course of PA continuation. 
* Complete posterior fissure
* Encircle and divide bronchus

== Right middle lobectomy ==

* Pleura along anterior hilum dissected to identify superior pulmonary vein
* Identify confluence of middle lobe and upper lobe veins, and middle lobe vein divided
* Middle lobe bronchus controlled and divided
* Commonly lymph nodes surrounding bronchus
* PA branches to RML divided
* Fissure last, generally

== Right or left lower lobectomy ==

* Divide inferior pulmonary ligament with lung retracted superiorly
* Mobilise pleura anteriorly and posteriorly to allow mobilisation of inferior pulmonary vein
* Inferior pulmonary vein encircled and divided
* Pulmonary artery mobilised and divided
** Beware of aberrant ascending posterior or lingual artery to upper lobe
* Bronchus divided

== Left upper lobectomy ==

* Challenging due to variable arterial branches and a shorter left main pulmonary artery anatomy (harder to control vascular injuries)
* Mobilise pleura along anterior hilum
* Continue dissection along the superior pulmonary vein and anterior trunk of pulmonary artery
* Mobilise and divide superior pulmonary vein
* Apical branches PA
* Identify PA in major fissure and complete fissure
* Bronchus divided

== Post-op ==

* Ward HDU
* Chest tube on -10cm suction
* Off suction once drainage <400mL/24 hours
* Remove once drainage <150mL/24 hours


== Complications ==

* Conversion to open

[[Category:Thoracics]]