Uniportal VATS Pneumonectomy
The authors’ uniportal video-assisted thoracoscopic pneumonectomy approach focuses on controlling the main pulmonary artery (MPA) first, to decrease lung congestion. Performing the most difficult step first ultimately decreases the chance of vascular accidents.
Patients must undergo proper evaluation of resectability and operability according to international guidelines. The authors routinely perform a radical lymphadenectomy.
Surgery was performed through a single 4.0 cm incision in the fifth intercostal space. Once resectability was confirmed, the authors dissected the pulmonary hilum. The anterior trunk of the MPA was freed and divided using a vascular load. This allowed for safe dissection of the right upper lobe vein. Once this vein was transected, the MPA was exposed, allowing a secure dissection. The only structure behind the artery was the airway, so it was safe to encircle and staple it. Following this, the middle vein and the inferior vein are divided. The right main bronchus was the last structure to be transected using a bronchial load, with care taken to avoid leaving a long bronchial stump.
The incision and initial evaluation were performed as described for a right pneumonectomy. The authors began by opening the mediastinal pleura. The dissection was carried out around the MPA to release adhesions between the artery, the superior vein, and main left bronchus anteriorly, and between the MPA and the aorta posteriorly. With vascular staple load at a right angle, the artery was encircled and divided. Once the MPA has been transected, the procedure becomes less demanding. Both veins were divided with a vascular load. Finally, the left bronchus was dissected to the main carina and stapled with a bronchial load, while under traction, to reduce the chance of a long stump.
Pneumonectomy is a challenging procedure due to a high risk of vascular accidents. With the strategy described here, the authors believe the risk of accidents is decreased.