Tutorial
Uniportal VATS left lower lobectomy: Fissure first technique
This video tutorial describes a left lower lobectomy performed by the uniportal approach. A single 2-cm incision in the lateral chest wall is used as the utility port. The procedure begins with division of the inferior pulmonary ligament and isolation of the inferior pulmonary vein. This patient has densely adherent interlobar nodes, which are then dissected to demonstrate the interlobar pulmonary artery. Then we proceed to divide the anterior part of the fissure after identifying and safeguarding the lingular branches of the pulmonary artery. This step is followed by the division of the posterior part of the fissure after identification of the posterior branches of the pulmonary artery to the upper lobe. Then we identify the basilar trunk and divide it using endostaplers. Other branches of the interlobar artery are clearly identified, and the apicobasal artery is taken separately. This is followed by division of the inferior pulmonary vein and a systematic mediastinal nodal dissection.
The fissure first technique, first described in thoracoscopy by Decaluwe et al. [1], has various advantages. It does not involve extensive dissection in the fissure, and it helps to identify variant anatomy, as we have demonstrated in this case. Many authors have recommended a "fissureless" technique for VATS lobectomies [2], which involves dissecting the hilum first and then stapling off the fissure without any dissection. This technique reduces the incidence of prolonged air leaks; however, identification of variant anatomy and division of all the branches under vision are sometimes compromised. Other surgeons dissect into the fissure to identify the vascular structures before division as in the conventional open method. The fissure first technique demonstrated in this video tutorial combines the advantages of both techniques and has been proven to be safe and effective.
This video tutorial also demonstrates how to handle difficult nodes during a VATS lobectomy.
The patient is a 35-year-old man who presented with complaints of cough and mild hemoptysis. He was evaluated with a contrast enhanced CT scan that showed a 4.5-cm lesion in the left lower lobe with surrounding consolidation and enlarged hilar and interlobar nodes. The CT guided biopsy of the lesion indicated a mucoepidermoid carcinoma. PET CT demonstrated no distant metastases.
1 - Patient details, imaging, and port placement (0:20)
It is important to thoroughly study the radiological images before any thoracic procedure. As we can see here, the lesion is surrounded by consolidated lung and some enlarged nodes. This configuration points to a difficult dissection, so the operator must plan and be mentally prepared for the same.
The port position is the standard uniportal utility incision. On the left side we prefer to go into the 5th intercostal space because the left hilum is slightly inferior to the right.
The incision can be placed between the posterior and midaxillary line. However, this is a personal preference of the operating surgeon, and some surgeons prefer to place it more anteriorly.
2 - Division of the inferior pulmonary ligament and isolation of the vein (1:45)
Dividing this ligament is a standard step in all lobectomies. In lower lobectomies, it helps to isolate the inferior pulmonary vein, and in upper lobectomies it helps the lung to expand and occupy the space in the upper part of the chest.
We do not divide the vein at this point because it is our institutional protocol to divide the vein at the end. We feel the lobe becomes congested and makes the surgical procedure more difficult. However, this point is controversial, and it is acceptable to divide the vein first.
3 - Division of anterior fissure and interlobar nodal dissection (2:33)
Densely adherent nodes can be troublesome: To handle them thoracoscopically is a challenge. But, it is important to dissect these nodes because leaving them behind can lead to an R plus resection. The trick to dissecting these nodes involves identifying a plane of separation between the underlying vessel and the node, which is usually achieved by a trial-and-error method. The "snake" dissector can be useful in identifying these planes.
4 - Pleural incisions and hilar nodal dissections (4:10)
The operator needs to be careful not to injure the underlying structures while making these cuts.
5 - Identification of lingular artery and division of anterior fissure (4:42)
The left upper lobe is known for its variant anatomy and short branches directly arising from the pulmonary artery. Hence it is important to demonstrate all these branches before dividing the lower lobar arteries. It is also sometimes helpful to dissect the left main pulmonary artery and keep it looped, because there is a chance of injuring these short branches during dissection. Proximal control during such a situation is valuable.
6 - Division of posterior fissure and identification of posterior branches (5:07)
Posterior segmental arteries can be easily injured or divided by mistake in the uniportal technique because the port is placed anteriorly, and sometimes one’s vision is compromised for posteriorly placed structures. Some surgeons use the "endochameleon" camera to overcome this disadvantage.
7 - Dissection of the interlobar artery and its branches (5:40)
The main advantage of the fissure first technique lies in this step. Identifying the variant anatomy and preserving all the upper lobar branches are the keys to a successful lower lobectomy. In any lobectomy, it is useful to identify and loop the vessels and not divide them initially. Once the anatomy is clear and all variants have been identified, the surgeon can proceed to divide the vessels.
8 - Identification of apicobasal artery and other posterior branches (6:32)
The apicobasal artery is also known for its variations: Sometimes there can be 2 separate branches arising from the interlobar artery supplying segment 6. Some surgeons prefer to take the basilar and apicobasal together.
But we feel it is safer to divide these arteries separately.
9 - Subcarinal nodal dissection and division of bronchus (8:17)
A systematic mediastinal nodal dissection should entail dissection of at least 3 mediastinal nodal stations and, to be considered adequate, must always include the subcarinal station. On the left side, this step can sometimes be challenging because the left paratracheal station (4L) is difficult to access by VATS. Usually stations 5, 6, and 7 are dissected on the left side. The left recurrent laryngeal nerve is at risk while one is dissecting the aortopulmonary window.
The fissure first technique avoids extensive fissural dissection, reduces the chances of a prolonged air leak, and is an important armamentarium in the thoracic surgeon's toolbox.
Decaluwe et al. introduced this technique in 2015. Their paper describes outcomes in 198 consecutively operated patients. The authors have demonstrated the non-inferiority of this technique compared to the conventional approach.
This technique is especially useful on the left side where variant anatomy is common and helps in identifying all the bronchovascular structures before division.
1. Decaluwe H, Sokolow Y, Deryck F, Stanzi A, Depypere L, Moons J, et al. Thoracoscopic tunnel technique for anatomical lung resections: a 'fissure first, hilum last' approach with staplers in the fissureless patient. Interact Cardiovasc Thorac Surg. 2015 Jul;21(1):2–7.
PubMed Abstract | ICVTS Full Text
2. Stamenovic D, Bostanci K, Messerschmidt A, Jahn T, Schneider T. Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak? Eur J Cardiothorac Surg. 2016 Jul;50(1):118–23.
PubMed Abstract | EJCTS Full Text
None declared.
Authors
Srinivas Kodaganur Gopinath, George Karimundackal, Devayani Niyogi, Virendrakumar Tiwari, Sabita Jiwnani and CS Pramesh
Authors Affiliation
Division of Thoracic Surgery,
Tata Memorial Hospital,
Mumbai, India.
Corresponding Author
Srinivas Kodaganur Gopinath
Division of Thoracic Surgery,
Tata Memorial Hospital,
Mumbai, India.
Email: srinivas.thoracic@gmail.com
© The Author 2021. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
