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Video-Assisted Thoracic Surgery Lobectomy

  • Michael S. Mulligan
    Correspondence
    Address reprint requests to Michael S. Mulligan, MD, Division of Cardiothoracic Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Box 356310, Seattle, WA 98195-6310
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    Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
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      When considering whether or not to incorporate video-assisted thoracic surgery (VATS) lobectomy techniques in your practice, several factors must be considered. From a patient perspective, there are obvious benefits when compared to open thoracotomy. However, in your enthusiasm, care should be taken not to stray too far from your established techniques and principles of resection.
      The introduction of VATS lobectomy to your practice should represent an evolution of your open techniques. Most surgeons have strayed from traditional thoracotomies, often including a rib resection for exposure to limiting the size of the incision progressively. For example, one might consider shingling a rib instead of removing a rib, then progressing to a muscle-sparing approach, and then downsizing the operative incision and moving your incision more anteriorly. In our own experience, we started out with a complete muscle-sparing approach via a fairly limited (6 cm) incision. We then downsized that incision a bit and started introducing instruments, particularly staplers, through chest tube incisions (which I made at the start of the operation as opposed to at its conclusion). After a brief visit with a colleague skilled in VATS lobectomy, we were performing VATS lobectomies within a reasonable amount of time. We have had no major bleeding and no vascular accidents and have converted to open thoracotomy in <5% of cases (almost exclusively related to pleural space disease not apparent on preoperative computed tomography scanning).

      Definition

      A thoracoscopic lobectomy is a totally anatomic, oncologically sound and thoracoscopic operation. The largest of the incisions is typically used for access and specimen removal and should be no longer than 4 to 6 cm in length. Although skin retractors and soft tissue deflectors may be appropriate on occasion, no rib retractors or spreading is permissible. The dissection through the hilum tends to proceed anterior to posterior and includes a mediastinal lymph node dissection as a critical and functional part of the anatomic dissection.

      Contraindications

      Previously a prior thoracic operation up to and including thoracotomy would have represented a contraindication to a thoracoscopic approach to lobectomy. The same has been said for the presence of benign adenopathy, induction chemo-radiotherapy, or the existence of an incomplete fissure. None of these constitute absolute contraindications to thoracoscopic lobectomy in the current era as techniques and expertise have evolved. However, if chest wall involvement is seen that mandates chest wall resection, the patient will not be spared the morbidity of rib manipulation and therefore a thoracoscopic approach is not clearly advantageous or appropriate. Likewise, the existence of calcified adenopathy in proximity to pulmonary arterial branches generally does contraindicate a thoracoscopic approach. These nodes are typically adherent to somewhat thin-walled vessels and their attempts at removal can be associated with significant intraoperative blood loss. The presence of an endobronchial tumor makes assessment of bronchial margins difficult as bronchi are typically taken with a closed, stapled technique. Therefore, if sleeve lobectomy is likely necessary to establish a clear surgical margin, VATS lobectomy is generally contraindicated. Of course, physiological intolerance to pulmonary resection also contraindicates thoracoscopic lobectomy as it would an open lobectomy. That said, there is now sufficient evidence to support the notion that frail and infirm patients, in particular, benefit from a less invasive approach. The diminished impact on pulmonary function associated with a thoracoscopic approach may make pulmonary resection more tolerable in compromised patients.

      Basic Technique

      These operations of course are done under general anesthesia with single lung ventilation. Instead of being positioned in the true lateral decubitus position, patients are rotated slightly posteriorly so that the anterior axillary line is presented toward the ceiling. A 30-degree scope or a roticulating scope is critical to allow visualization of hilar structures from multiple perspectives. Instrumentation is typically long and utilizes some degree of curve or offset and has a slide action or switch-back mechanism that allows the jaws to operate freely without being restricted by the ports or the small port site incisions. It is critical to have instrumentation that allows safe passage around vessels with limited haptic feedback. The best instrument in most experiences has been a right angle; however, this should not be too short or prime-tipped and at a medium right angle with either a switch back or a slide action handle being most appropriate. Excessively large right angles can be awkward and difficult to manipulate with limited degrees of freedom in the chest. Therefore, just the “right” angle is essential. Our favorite instrumentation for dissection tends to be the pediatric Yankauer sucker. These are available in longer versions and facilitate precise development of tissue points, particularly around named structures.
      Analgesics provided by long-acting intercostal nerve blocks can be introduced either percutaneously or under thoracoscopic guidance with the aid of a mediastinoscopy aspiration needle directly into the inner space. Supplementation with patient-controlled analgesia or nonsteroidal anti-inflammatory drugs is highly affective. Indeed, in patients under the age of 60 and with a predicted stay of <3 days, we do not favor the use of an epidural. However, epidural analgesia is effective in frail and debilitated patients with limited pulmonary reserve or multiple comorbidities. Furthermore, those that are older who have had induction therapy or who have other factors that would predict a longer hospital stay are favorably considered for epidural placement.
      There are some fundamental principles of dissection that are critical to safe and effective completion of videoscopic pulmonary resections. These are specifically discussed below.

      General Advice for Incision Placement

      Although a variety of techniques have been described, including two- and three-port access for performance of VATS lobectomies (with a more extended anterior/utility incision), I think these are not appropriate for the surgeon interested in beginning a practice in VATS lobectomy. The incisions should be designed to create unique degrees of freedom and angles of retraction. Therefore, my approach typically uses three to four ports (Fig. 1). The first port placed is typically in the mid clavicular line in the fifth or sixth intercostal space. This is designated the anterior incision. This means that it is typically at the anterior base of the major fissure and is meant to be approximately 1 inch in length. After demonstrating that the pleural space is uncomplicated, a 5-mm incision is made in the mid clavicular line and the eighth intercostal space is angled upward. This is where the camera with a 30-degree lens will be placed and will allow inspection for precise determination of ideal port placement for the remaining two ports. Notably this camera port is the only port that actually receives a thorascopic sleeve port (Fig. 2) . I otherwise pass the instruments in an out directly without ports. It has been my impression that the placement of sleeve ports to maintain site access not only limits the type of instruments that can be used but also further traumatizes the intercostal nerve and leads to postoperative neuralgia more frequently. After placing the anterior port and the camera port, the utility incision is then placed. This incision is typically at the level of the upper lobe vein for upper lobectomies and one interspace lower for middle and lower lobectomies. There is a tendency for this incision to be placed too low, which makes dissection, particularly at upper aspects of the hilum, exceedingly difficult. Therefore, the hilum should be visualized and the target site palpated for incision placement while getting a panoramic view. This will allow the surgeon to place the incision at the appropriate level. If doubt remains, the needle used for injecting local anesthetic can be used to aid in localization prior to making the utility incision. When first beginning to do VATS lobectomies, I found an additional traction port over the auscultatory triangle is essential. It allows maximum freedom of movement through the different ports and is separated enough from the other incisions that the instrumentation will not fight for domain during retraction and dissection. This incision need be no longer than 1.5 cm so as to admit either a stapler or a ringed forceps for retraction. As experience grows, this incision can be eliminated. However, this teaching or assistant port allows a straight axis approach to nearly all hilar structures (Fig. 3) . Indeed, control of the operation is effectively managed through this incision.
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      Figure 1The first incision is made anteriorly at approximately the sixth intercostal space (working port). The other incisions are for the camera (mid-axillary line at approximately the eighth intercostal space) the retraction port (in the auscultatory triangle) and the access incision is created in the mid-axillary line at the level of the superior pulmonary vein for upper lobe resections and one space lower for middle and lower lobe resections.
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      Figure 2The exposure for lower lobe resections is enhanced by placing a diaphragmatic traction stitch in the central tendon and delivering it out through the camera port.
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      Figure 3Creation of lobar separation with partial completion of the fissures allows enhanced exposure of hilar structures with parenchymal retraction. LLL, left lower lobe; LUL, left upper lobe.
      Generally, if a tissue diagnosis has not yet been established, only one or two of the port incisions are made initially. This will be sufficient to perform a diagnostic wedge resection (Figure 4, Figure 5). Once the diagnosis is confirmed on frozen section, the additional port incisions are made and the dissection can proceed.
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      Figure 4If a nodule is present but a tissue diagnosis is not achieved, a simple wedge resection can be planned through a two-port approach. RUL, right upper lobe.
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      Figure 5This is generally achieved with two instruments passed through the anterior working port. When needed, retraction is added with side-by-side use of the clamp next to the camera.

      Dissect from Anterior to Posterior

      Although in many open approaches the pulmonary vein is taken first, it is consistently true for all VATS techniques, particularly with regard to upper and middle lobectomies on the right and upper lobe resections on the left. This will enhance your exposure consistently to the underlying bronchus and arterial structures. This is not necessarily intuitive but with the VATS approach such an anterior to posterior approach toward sequential hilar structure isolation is essential to safe dissection and efficient conduct of the operation. When approaching the left upper lobe, this then allows ready exposure of the first two to three arterial branches to the upper lobe. On the right this provides immediate exposure of the superior arterial trunk. Likewise, the middle lobe bronchus is readily revealed after taking the middle lobe vein.

      Create Lobar Separation

      To provide optimal lobar retraction that separates and exposes hilar structures selectively, one must create discrete lobar separation. It is advisable very early in the conduct of VATS lobectomy to complete at least partially the anterior aspects of the pulmonary fissures (Fig. 4). For example, when attempting a right upper lobe resection, it is highly desirable to perform two to three firings of a stapler to complete the anterior part of the horizontal fissure. Having done so, inferior and posterior retraction of the middle lobe and posterior retraction of the upper lobe allow the venous drainage from the middle and upper and lobes to rotate independently; the middle lobe vein rotates posteriorly, thereby protecting it while the upper lobe venous drainage is dissected and prepared for legation and division. When approaching the left upper lobe, the lingula is typically quite anterior, particularly in relation to the anterior dissection port. Therefore, the anterior aspect of the fissure presents itself early for partial completion. After dividing the upper lobe vein, exposure of the bronchus and subsequently the lingular artery is virtually impossible if the fissure has not been completed. Particularly with lungs that are somewhat noncompliant and at times incompletely collapsed, lobar separation by completion of pulmonary fissures allows optimal retraction and selective rotation and exposure of hilar structures.

      No-Hands Diaphragmatic Retraction

      Having discussed VATS lobectomy and shared some tips with many of my colleagues, I have many thoughts on how best to retract the diaphragm. Diaphragms are often high riding in obese patients or patients with diminished lung volumes, secondary to restrictive lung disease. It can also appear to be problematic in many patients undergoing a lower lobectomy. I have therefore adopted the practice of almost routinely placing a retraction stitch in the central tendon of the diaphragm. I use a figure-of-eight monofilament suture. Monofilament is preferable so that on removal the “sawing” action on the diaphragmatic tissue is minimized. This stitch is then brought out through the camera site alongside the port so that the retraction is brought in line with the axis of the camera (Fig. 5). This allows maximum exposure for appropriate visualization in all directions. This avoids the necessity of placing another instrument through one of the remaining ports to depress the diaphragm and facilitate exposure. This way, the surgeon's and the assistant's hands are freed by utilizing the camera port for dual duty.
      It is also appropriate to consider CO2 insufflation to enhance visualization. CO2 insufflation requires that all ports be sealed or sleeved to maintain insufflation pressures for approximately 10 cm H2O. This is particularly useful with obese patients. Some adjustments in instrumentation are required however. Most conventional instrumentation can be passed through 12- to 15-mm ports but a right-angled dissector may not. It is best therefore to use an endo-right angle where appropriate. One also loses the ability to pass multiple instruments through single-port incisions if sleeves are used. However, this compromise is often worth the gains experienced with visualization and enhanced lung isolation.

      Basic Principles of Dissection of Vessels

      In a recent meeting where surgeons shared their technical approaches to VATS dissection, a number of techniques were espoused. Kitner dissection has been used by some to free the phrenic nerve from its investment in close proximity to the pulmonary venous drainage to upper and middle lobes on the right and the upper lobe on the left. I have found that Kitner dissection is imprecise, may risk traction injury to the nerve itself, causes an excessive amount of bleeding, and is not likely to reveal a clean, appropriate plane of dissection without risking potential hematoma or more serious injury to the underlying structures. I use sharp dissection with Metzenbaum scissors in my open cases and do most of my VATS dissection the same way.
      Many have recommended dissection around structures with very large right-angle clamps. Although the long foot of such instruments is desirable in its ability to reach completely around vascular structures (particularly the vein), their considerable mass reduces tactile feedback from the instruments during dissection. I have found that a medium right angle with a relatively blunt tip is not only safe, but provides the right balance of tactile feedback and range of dissection.
      Only 25% of the patients of the surgeons that I have encountered use a rubber vessel loop or other retraction device to hold “tunnels” around vessels open while passing staplers. This is a mistake. Many surgeons have tried to insinuate the anvil of the stapler behind vessels by wiggling, rotating, or overcoming resistance with direct pressure to pass the stapler. This is a less-than-optimal technique and risks significant vascular injury. This may explain why many of these surgeons reported rates of significant bleeding as high as 10% to 15%. It is my preference to dissect the tunnel cleanly with the right angle and make sure that it is large enough to accommodate the anvil of the stapler. A tie is then passed around the vessel and used as a point of retraction (Fig. 6). This can be passed out through a port that is at 90 degrees to the axis of the stapler being passed. Alternatively, the tie can be grasped with an instrument inside the chest and retracted in multiple different directions. This allows retraction of the vessel away from the hilum and the passage of the stapler easily under vision without excessive twisting, axial rotation, or application of undue force. This has not only proven to be safe but has allowed us to limit progressively the number and size of ports used to complete lobectomies safely. In contrast to using a vessel loop, the advantage of using a braided tie is that it can be included in the stapler firing and the loose ends can simply be trimmed. It is therefore not necessary to remove the tie during firing. Trying to slide such a tie out after the stapler is in position risks a “sawing” injury to the back wall of the vessel and is unnecessary.
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      Figure 6The lung is retracted posteriorly and the pleura is opened along the anterior hilum.
      “Rehearsal” before staple replacement can be achieved with dissection of the pathway with a pediatric Yankauer followed by a long-tipped metal Yankauer to create a tunnel or space around the vessel sufficient to accommodate the stapler. One does not want to dilate the space behind the vessel with the anvil. This is sharp and excessively traumatic. It is also critical that the stapler tips are visualized by passing beyond the target structure to be elongated and divided. Passage of the stapler tip to a so-called “free space” is essential for the safe conduct of this operation.

      Nodal Dissection Facilitates Anatomic Control

      When performing open surgery, emphasis is not often placed on the removal of N1 nodes prior to obtaining vascular or bronchial control. As these nodes are often included with the specimen, they are typically not taken out separately before planned lobectomy. In VATS lobectomy, performance of regional lymphadenectomy often facilitates dissection. Arterial branch points and lobar bronchial origins are marked by clusters of lymph nodes. Removal of these lymph nodes creates obvious anatomic pathways for circumferential dissection and subsequent surgical control. This is particularly true with regard to surrounding the upper lobe bronchus on the right. One or two nodes are typically present at the angle created by the inferior aspect of the upper lobe origin and the bronchus intermedius. On the left, separation of the upper and lower lobe of bronchia is facilitated not only by lymphadenectomy at this juncture, but separating those lymph nodes out often allows for creation of a tunnel that will protect the continuation of the pulmonary artery, which lies behind the bronchus. Therefore, it is advisable to perform a preemptive lymphadenectomy as part of your dissection technique.

      Open the Posterior Mediastinal Pleura Early

      To facilitate dissection of the hilar structures, there are several maneuvers that can be undertaken to separate and elongate those hilar structures. When attempting to retract the lung anteriorly on either side, it becomes apparent that it is tethered by the investment of pleura on the posterior hilum. By lysing this pleura widely (on the right, up and around the under surface of the azygos vein; on the left, all the way up and under the aortic arch), the hilar structures will be released and allowed greater anterior retraction and separation. This is particularly important when performing a right upper lobectomy as the bifurcation between the right upper lobe bronchus and continuation of bronchus intermedius is readily identified and the tunnel around it can be almost completely created from a posterior approach after having taken the superior trunk of pulmonary artery from the anterior exposure. By reflecting the lung then back into the paravertebral space, dissection of the remaining hilar structures from the anterior approach is facilitated. If one fails to open the mediastinal pleura, surrounding the upper lobe bronchus on the right from a purely anterior approach can be exceedingly difficult and posterior parenchymal tissue is often snared in the anvil, preventing easy passage of the stapler. During a left upper lobectomy, failure to lyse the posterior pleura will make a completion of the fissure difficult without significant risk of injury to the continuation of the pulmonary artery and will compromise visualization of the remaining arterial branches to the upper lobe.

      Complete the Posterior Fissure Last

      Injury to arterial branches may occur if undue dissection stress is applied as a result of an awkward dissection sequence. Some espouse leaving an arterial branch as a last named structure to be taken. However, this risks undue retraction stress on these arterial branches and may lead to surgical bleeding. By leaving a significant portion of the fissure until last, however, the lung parenchyma itself will absorb some of that retraction stress and, in my experience, that strategy has prevented traction injury to any named vessels.
      On the left side, after taking the upper lobe vein, the first two or three arterial branches, the bronchus, and subsequently the lingular artery, there are one to three arterial branches that remain. Although the anterior aspect of the fissure is typically taken early to enhance exposure of the bronchus and the lingular artery, it is important to leave any remaining parenchymal bridges between the upper and lower lobes intact so that posterior/lateral retraction on the specimen will display the arteries while distributing some of that tension through the lung tissue and not just the vessel.
      An important added benefit of this tactic is that by avoiding dissection in the fissure, postoperative air leaks are minimized. It has been our experience that by completing the fissure only with the stapler (and not utilizing excessive sharp dissection to accomplish separation) postoperative air leaks are a very infrequent occurrence.

      Management of Stapler Limitations and Division of Thick Tissue

      Oftentimes, fissures are incomplete. This is particularly true with the horizontal fissure on the right. Likewise, deep wedge resections and lingular-sparing resections of the left upper lobe require stapling of considerable amounts of parenchyma. The amount of tissue that has to be sealed and divided is often at or in excess of the limits of the stapler and 4.8-mm cartridge. The best technique to deal with this issue is to use a low profile, slightly angled ring forceps applied through the anterior dissection port in the mid clavicular line. This “precompression” of the tissue allows immediate and safe application of the stapler. This is particularly true if air trapping secondary to underlying emphysema is the etiology for difficulty in stapler application. However, if truly thick tissue is a limitation, it may be necessary to apply the stapler with the low-profile ring forceps left in place. If this is necessary, I have found it quite useful to enlarge the anterior incision by only 1 cm to allow side-by-side application of both the ring forceps and the stapler. The introduction of roticulating 4.8-mm cartridges and the availability of slightly angled, low-profiled ring forceps with sliding action has allowed these devices to be placed through the port without competing for domain. Maintaining compressive force on the tissue with the ring forceps allows the cartridge to slide on easily. At times it is helpful to leave the compressive grasper in place for several minutes. This can aid in displacing tissue edema in the stapler path. The ring forceps can then be removed and the load fired; this technique can be repeated as needed. We have had no failures of staple purchase or tissue disruption since developing this technique.

      Dissection Sequences

      Right Upper Lobectomy

      The right upper lobe vein is isolated first with care taken to protect and avoid ligating the middle lobe venous drainage, which also typically drains into the superior pulmonary vein on the right side. Dissection around this vein is facilitated through anterior dissective and accessory ports. Passage of the stapler is typically safest through the teaching/assistant port. Next, the superior trunk of the pulmonary artery is dissected circumferentially after station 10 lymph nodes have been cleaned out and the upper aspect of the hilar pleura has been widely opened. It is important to make sure that all branches of the superior trunk have been isolated and collectively taken together as typically the posterior branch takes off at an angle that often precludes visualization from an anterior perspective. After the superior trunk has been divided safely, usually by passing the stapler from the anterior port (Fig. 7), the posterior ascending artery is isolated. It is critical to identify the posterior ascending artery as from an anterior perspective it typically resides in the saddle between the upper lobe bronchial origin and a continuation of the bronchus intermedius. This is readily taken with a vascular stapler with a 2.0-mm staple height cartridge. This is my preference because I feel that the use of ligating clips is not quite as secure or safe. These clips can be dislodged with further blunt dissection and, if they happen to be entrapped in the jaws of the stapler when the stapler fires, it will avulse the clip and bleeding will ensue. Assuming that the posterior pleura has been opened prior to beginning the hilar dissection, the bronchus is readily controlled after the posterior artery has been taken. The bronchus is typically closed from the assistant/teaching port (Fig. 8) because this allows for cooptation of the membranous airway to the cartilaginous and avoids risk of airway fracture. Once all of the hilar structures are taken, the fissure is completed with a stapler from the anterior incision and the specimen is removed.
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      Figure 7The left superior pulmonary vein is circumferentially dissected and controlled in preparation for ligation and division.
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      Figure 8The stapler is passed from the auscultatory triangle port and the retraction on the vein anteriorly allows for safe stapling with protection of the pulmonary artery.

      Right Middle Lobectomy

      Oftentimes, the posterior assistance port or teaching port can be left out of this approach. Exposure of the hilar structures in their presentation anteriorly is facilitated typically by the development of the horizontal fissure with one to two firings of the stapler before beginning. Once that lobar separation has been achieved, the vein is taken first and the nodal tissue surrounding the bronchus is readily appreciated. The bronchus is controlled next and then taken typically with a 3.5-mm stapler height cartridge (Fig. 9). The artery is then controlled and taken. Oftentimes, development of the oblique fissure will more completely facilitate ligation and division of the artery by passing this stapler through the utility incision. Thereafter the horizontal fissure is completed and the specimen is removed.
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      Figure 9The first branch of the pulmonary artery to the left upper lobe is circumferentially controlled, looped and prepared for stapling from the auscultatory triangle port. A, artery; LLL, left lower lobe; LUL, left upper lobe; V, vein.

      Left Upper Lobectomy

      Despite initial trepidation about the complexity of an upper left lobectomy, this is perhaps one of the most enjoyable and technically satisfying resections that can be done videoscopically. The port incision is as described and the vein is taken first once the stapler passes, typically from the assistant or teaching port. It is critically important to identify the lower lobe vein before taking the upper lobe vein. A single or common vein is a hazard often unrecognized and can result in accidental pneumonectomy. The first maneuvers involve posterior retraction of the lung and opening the mediastinal pleura widely. This is done posterior to the phrenic nerve and carries superiorly over the top of the hilum (Fig. 10). The first structure to be ligated and divided is the superior vein (Fig. 11). This is best done with a vascular stapler passed through the assistant or teaching port while a blunt-tipped sucker is used to deflect and protect the pulmonary artery. The first two arterial branches are taken next (Fig. 12) and this facilitates development of the plane between the bronchus and the artery from the utility incision. The lymphatic tissue defining the saddle between the upper lobe and lower lobe bronchia needs to be cleaned out next (Fig. 13). It is critical to do this gently and remove the node completely as the lingular artery resides immediately behind this lymph node. After having done so, the plane between the bronchus and the artery is developed with dissection via the teaching/assistant port (posterior/inferior) and the access incision (superior). The stapler is then passed from this upper incision and the bronchus is closed and divided (Fig. 14). The lingular artery is taken next after partially completing the fissure anteriorly to enhance exposure. One or two remaining arterial branches are then readily recognized and taken with a vascular stapler. The posterior aspect of the fissure is then completed with the stapler passed from the anterior incision and retraction provided via the access and teaching/assistant incisions.
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      Figure 10After ligation and division of the first two arterial branches, the bifurcation of the left mainstem bronchus to upper and lower lobes is cleared by removing fatty and lymphatic tissue from the saddle of this bifurcation. LLL, left lower lobe; LUL, left upper lobe; PA, pulmonary artery; V, vein.
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      Figure 11After circumferential control of the bronchus is achieved, the stapler is passed from the upper access incision to allow cooptation of the membranous airway to the cartilaginous airway as the stapler is fired. LLL, left lower lobe; LUL, left upper lobe; PA, pulmonary artery; V, vein.
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      Figure 12The superior trunk of the pulmonary artery to the right upper lobe is divided by passing the stapler through either the anterior working port or the auscultatory triangle port. PA, pulmonary artery; RUL, right upper lobe; V, vein.
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      Figure 13After division of the vascular supply to the right upper lobe, the bronchus is taken with a stapler passed from either the auscultatory triangle port or the anterior working port. RPA, right pulmonary artery; RUL, right upper lobe.
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      Figure 14Having divided the mid-lobe venous drainage, the middle lobe bronchus is circumferentially controlled and taken with a stapler through the access incision. PA, pulmonary artery; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.

      Lower Lobectomy

      The inferior vein is taken first after visualizing and protecting the superior vein. The perspective from below the hilum is less likely to result in inadvertent control of a common or single vein. With retraction of the lobe superiorly, the vein can be isolated and divided after broadly opening the hilar pleura anteriorly and posteriorly. It is important to make sure that the superior segmental vein is included as this tends to reside in a more cephalad position and the vein therefore has a broader base than anticipated. If the fissure is complete, the artery is readily exposed and is dissected next, with care being taken once again to include ligation of the superior segmental artery. If the fissure is incomplete, the bronchus can be isolated next. Exposure of the right lower lobe bronchus distal to the middle lobe takeoff requires identification and division of the medial basilar artery. Once the bronchus is taken (from the anterior incision), the specimen is reflected back into its normal position, readily allowing visualization of the artery. A plane is then developed over the artery and the parenchymal tissue in the fissure is stapled from the anterior incision. After completing the anterior aspect of the fissure, the artery is taken from the anterior incision (Fig. 15). The posterior aspect of the fissure is stapled last (via the anterior incision) and the specimen is removed.
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      Figure 15Having achieved control of the pulmonary artery branches to the lower lobe, they are divided with a vascular stapler passed through anterior working incision. Care must be taken to make sure the branches to the basilar segments as well as the superior segment are included in the staple line firing. LLL, left lower lobe; PA, pulmonary artery.