VATS lobectomy
Comparison to open
[edit | edit source]- 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
[edit | edit source]- 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
- Anterior 3-incision
- 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
[edit | edit source]- 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
[edit | edit source]- 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
[edit | edit source]- 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
[edit | edit source]- 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
[edit | edit source]- Ward HDU
- Chest tube on -10cm suction
- Off suction once drainage <400mL/24 hours
- Remove once drainage <150mL/24 hours
Complications
[edit | edit source]- Conversion to open