Lobe-specific intercostal strategy in video-assisted lobectomy

When performing video-assisted lobectomy for lung diseases, the incisional strategy for the minithoracotomy and two trocar ports is crucial for successful completion of the procedure. Our strategy is primarily determined according to three principles: The hilar bronchovascular structures should be easily accessible; the minithoracotomy should be readily convertible to a standard open thoracotomy; and the wounds should create only limited damage. To enable a quick conversion, the minithoracotomy incision must be placed on the scheduled posterolateral thoracotomy line regardless of its location. The entire procedure is best managed when the minithoracotomy is placed anteriorly on the inframammary line in the fourth intercostal space for upper and middle lobectomies and posteriorly over the auscultation triangle in the fifth intercostal space for lower lobectomies. Two trocars are used for thoracoscopy and retraction. The sequence of each operative step should be determined by the lobe to be resected. This lobe-specific incisional and operative strategy based on anatomical considerations not only facilitates the safe dissection of the hilum but also enables a rapid conversion to a standard posterolateral thoracotomy.