Thoracoscopic Extended Right Middle Plus Lower Sleeve Lobectomy for Non-Small-Cell Lung Cancer

Complete surgical resection is essential for resectable non-small-cell lung cancer. In selected patients who have received induction therapy, extended sleeve lobectomy (ESL) can obviate pneumonectomy while achieving R0 margins when central tumors cross inter-lobar boundaries. This study demonstrates the procedure of extended right middle plus lower lobe sleeve resection. Following three cycles of pembrolizumab plus platinum-doublet chemotherapy, a 57-year-old man with cT3N2M0 (IIIB) squamous cell carcinoma demonstrated radiological stability and persistent endobronchial invasion of the right secondary carina. A thoracoscopic extended right middle plus lower sleeve lobectomy was performed. First, the inferior and middle-lobe veins were stapled intra- and extra-pericardially. Subcarinal and ipsilateral paratracheal lymph nodes were dissected systematically. Radical removal of the middle and lower lobes was then achieved after temporary blockade of the right pulmonary artery and the superior pulmonary vein; hence, a safe dissection of the secondary carina can be performed. A "U"-shape portion of the right main bronchus was trimmed to adjust the appropriate size for bronchial anastomosis with the upper lobe bronchus, which was performed with a continuous suture. After leak-testing, the anastomotic site was covered by a free thymic fat flap. The duration of the surgery was 200 min with approximately 50 mL of blood loss. Bronchoscopy on postoperative day 6 confirmed an intact anastomosis. Histopathology revealed a 4 cm moderately differentiated squamous carcinoma with 1/31 positive nodes. Adjuvant PD-1 inhibitor monotherapy was given, and the patient remains under surveillance.