Uniportal Right Upper Lobe Sleeve Lobectomy
The authors present the case of a 65-year-old male patient who, during an episode of pneumonia, underwent a bronchoscopy that revealed a right upper lobe (RUL) endobronchial lesion. The biopsy confirmed an epidermoid carcinoma. A chest computed tomography scan showed a central 4.2 cm lesion in the right upper lobe with endobronchial invasion. It also showed mediastinal and hilar lymph nodes smaller than 10 mm in the larger axis. Positron emission tomography confirmed a hypermetabolic mass with an SUVmax of 16.2, without metabolic activity in the lymph nodes. Staging endobronchial ultrasound was negative. The full preoperative evaluation confirmed that the carcinoma was operable and resectable.
A videomediastinoscopy, which was negative for the biopsies of stations 2R, 4R, 7 and 4L, was followed by a sleeve right upper lobectomy via a single-port approach. In this case, the mediastinoscopy was important because of the lymphadenectomy and dissection of the right main bronchus. Single lung ventilation was induced under general anesthesia. The surgery was performed through a 4 cm incision at the fifth right intercostal space. After confirming the resectability, a standard right upper lobectomy was performed. The RUL bronchus dissection was saved for last. Under bronchoscopic vision, the proximal and distal bronchial ends were open. Once the specimen was removed, the right main bronchus and intermedius bronchus ends were left. The anastomosis was performed using a PDS 3.0 double-needled suture. Two running sutures were performed, one clockwise and one counterclockwise. While suturing, the anesthesiologist left the bronchoscope in the main bronchus to assure poise between both ends of the anastomosis. A pleural flap was used around the anastomosis to avoid contact between the pulmonary artery and the bronchial anastomosis. The postoperative period was uneventful and the patient was discharged on postoperative day four.
Through this video, the authors would like to highlight that a uniportal sleeve resection is feasible, but takes patience, perseverance, and practice.