Video-assisted thoracic surgery right upper lobe bronchial sleeve resection

Video-assisted thoracic surgery (VATS) is a new technology for nearly 30 years in the field of thoracic surgery most watched. However, there are still some controversy concerning the technical difficulties, operation duration, the extent of lymph node dissection and perioperative complications for VATS sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus).

A 66 years old man was admitted for coughing for 2 months. He had smoked for 30 years, 20 packs a day. Chest computed tomography (CT) revealed a 2.5 cm × 4.5 cm mass in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Pathology was squamous cell carcinoma. His pulmonary function result was forced expiratory volume in 1 second (FEV₁): 1.91 L (64.7% predicted), forced vital capacity (FVC): 4.36 L. He received general anesthesia with double-lumen endotracheal intubation and left lung ventilation. Left lateral decubitus position was chosen. The first 1.5 cm incision was selected in the eighth intercostal space in the midaxillary line, and was used for the camera. A 4 cm long incision was made in the 3^rd intercostal space in the preaxillary line. A third 1.5 cm incision was performed in the 9^th intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire right hilum were mobilized. Pulmonary vein is the most forward hilar structure, sometimes immediately prior pulmonary trunk. The right upper lobe vein was transected with a vascular stapler. Truncus and posterior ascending pulmonary artery were then divided and transected with a vascular stapler. Major and minor fissures were stapled by 60 mm green linear stapler. Following clearance of the mediastinal lymph nodes of level 7, 4R and 2R, the bronchial sleeve resection and reconstruction began. The distal right main bronchus and bronchus intermedius were fully mobilized to ensure adequate surgical exposure. Traction sutures were routinely placed on the lateral walls and to reduce tension. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures.

There were no complications and the patient was discharged 8 days postoperatively.

The 3^rd intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, providing convenient conditions for easy anastomosis. And avoid the operator fatigue for keeping the posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for satisfied explosion of the right main bronchus, the upper lobe bronchus and bronchus intermedius. And this would avoid pulling bronchial anastomosis for mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.