Thoracoscopic Right Upper Lobectomy Using a Full Posterior Dissection
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Introduction
Because lung cancer most often develops in the right upper lobe, right upper lobectomy is the most performed resection. However, it is not the simplest one, due to the features of its vascular and bronchial anatomy. Now that lobectomies are increasingly carried out via thoracoscopy (1), at least for early stage lung cancer, surgeons are looking for a straightforward and reproducible technique. In this context, the anterior approach and fissureless technique have gained popularity (2). However, the authors have found that this approach has some limitations and advocate for a posterior approach with gradual dissection of the fissure and of the pedicle elements from the back to the front. The authors herein report this technique, which is a full thoracoscopic one with a 100% video display, no access incision, and uses only trocars and endoscopic instruments (3).
Figure 1: Position of the surgeon at the back of the patient and port placement for a thoracoscopic right upper lobectomy
Figure 2A: Deflectable endoscope used for full thoracoscopic approach
Figure 2B: Example of 0° view on the right upper mediastinum
Figure 2C: Same position of the endoscope with 90° bending
Figure 3: Example of thoracoscopic instrument used during full thoracoscopic lobectomies
Figure 4: Ports
Video 1: Use of a 3 mm grasping forceps as an additional retraction tool
Figure 5: Dissection of the posterior ascending artery A2. B = bronchus; RUL = right upper lobe; RLL = right lower lobe
Figure 6A: Example of a frequently encountered anatomical variation
Figure 6B: Common rise of A2 and A6 arteries
Video 2: Opening the posterior portion of the major fissure and controlling the posterior ascending artery (example of a thin fissure)
Video 3: Opening the posterior portion of the major fissure and controlling the posterior ascending artery (example of a thick fissure)
Figure 7: Backward retraction of the right upper lobe bronchus using a loop
Video 4: Posterior control of the right upper lobe bronchus
Figure 8: Exposure of the truncus anterior after division of the upper lobe bronchus. Bs = stump of the right upper lobe bronchus; RUL = right upper lobe; RLL= right lower lobe
Video 5: Posterior control of the truncus anterior
Figure 9: Exposure of the upper root of the superior pulmonary vein. V = vein; Bs = stump of the right upper lobe broncus
Video 6: Posterior control of the upper root of the superior pulmonary vein
Video 7: Division of the minor fissure
Figure 10: Division of the pulmonary ligament. Note the use of a 3 mm grasping forceps for traction on the lower lobe (E = esophagus; IVC = inferior vena cava; D = diaphragm)
Figure 11A: Securing the middle lobe by anchoring it to the lower lobe, application of an Endo-TA
Figure 11B: Final result
