Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery for Non-Small-Cell Lung Cancer

Abstract

The morbidity and mortality of lung cancer rank second and first respectively in malignant solid tumors worldwide. As we all know, surgical resection is the cornerstone of comprehensive treatment of non-small-cell lung cancer (NSCLC). The current National Comprehensive Cancer Network (NCCN) guidelines for NSCLC suggest that for medically operable disease, resection is the preferred local treatment modality, anatomic pulmonary resection is preferred for the majority of patients with NSCLC, and video-assisted thoracoscopic surgery (VATS) or minimally invasive surgery should be strongly considered for patients with no anatomic or surgical contraindications. With many advantages, uniportal VATS (u-VATS) has been widely accepted and used. Therefore, in this article, we attempted to review the essentials of lobectomy under u-VATS for NSCLC.

1. Part 1. General principles

1.1 Introduction

Currently, the morbidity and mortality of lung cancer rank second and first respectively in malignant solid tumors worldwide [1, 2]. Right upper lobe has the highest incidence of lung cancer (23.8%–47.0%) among the five lung lobes [3, 4, 5, 6, 7, 8]. As we all know, surgical resection is the cornerstone of comprehensive treatment of non-small-cell lung cancer (NSCLC). The current National Comprehensive Cancer Network (NCCN) guidelines for NSCLC suggest that for medically operable disease, resection is the preferred local treatment modality, anatomic pulmonary resection is preferred for the majority of patients with NSCLC, and video-assisted thoracoscopic surgery (VATS) or minimally invasive surgery (including robotic-assisted approaches) should be strongly considered for patients with no anatomic or surgical contraindications [9]. Because VATS, compared with thoracotomy, is associated with reduced length of hospital stay, less postoperative pain, fewer postoperative complications, more rapid recovery to normal life, and less pulmonary injury without compromising oncology principles [10]. Previously, VATS was conventionally performed under multiportal (m-VATS). Compared with m-VATS, uniportal VATS (u-VATS) has the advantages of direct view, easy learning, less operation time and postoperative drainage duration, decreased postoperative pain and hospitalization, diminished inflammatory response, or faster access to chemotherapy [4, 11, 12]. Consequently, u-VATS has been widely accepted and used. Therefore, in this article, we attempted to review the essentials of lobectomy under u-VATS for NSCLC.

1.2 Instrument

Due to the restricted interspace available under u-VATS, the fewer processing instruments used the better. Figure 1 shows the instruments we commonly use. Among them, the suction with a slightly curved tip is recommended to obtain more operating space and angles. In addition, a manual-control electric hook is recommended to relieve the discomfort caused by standing on one leg when using a foot-control one too long. Furthermore, the ring forceps clamping a small gauze are used to turn and tow the lobes, instead of clamping the lobes directly, to reduce exudation from the residual lung after surgery. A high-definition thoracoscopic system is recommended too, because most of the procedures of lobectomy have to be finished very precisely. Meanwhile, a thoracoscopy with a freely rotatable optical fiber is also recommended to obtain more viewing angles. Since a three-dimensional thoracoscopic system can provide a high-definition and stereoscopic view, it is highly recommended for beginners. A 5 mm thoracoscope can further reduce the length of the incision; however, the technical requirements for the surgeon and the assistant holding the thoracoscopy are harder for its smaller view. Finally, the recommended length of the staple cartridge used for vessels and bronchus is 30 mm or 45 mm, so that there is sufficient space and angle to place it into the interstice between the tissues to be cut.

Figure 1.

The instruments commonly used.

1.3 Anesthesia and position

1.3.1 Anesthesia

Commonly, patients are anesthetized with intravenous coupled with inhaled anesthetics, and ventilation is maintained under contralateral endobronchial intubation with double-lumen endobronchial tube. For experienced surgical teams, tubeless anesthesia under regional combined with general anesthesia can be used.

1.3.2 Position for patient

The patient is placed in the contralateral decubitus position, and then the operating table is adjusted to a jackknife position to widen the intercostal space and elevate the hilum, which would facilitate intraoperative processing (Figure 2).

Figure 2.

The position for patient. The patient is placed in the contralateral decubitus position, and then the operating table is adjusted to a jackknife position.

1.3.3 Position for surgeon and assistant

In general, the display screen is placed on the back of the patient near the head end. The surgeon stands on the upper ventral side, while the assistant stands on a low-rise foot stool on the lower ventral side. This position could increase the interspace between the thoracoscopic body and the operating instruments and could further reduce mutual interference (Figure 3). In order to facilitate processing, the position of the surgeon and the assistant could be exchanged when cut the lower pulmonary ligament and dissect the groups 8 and 9 lymph nodes. If there are two movable display screens and the assistant is very experienced, the assistant can stand on the back of the patient to further increase the interspace.

Figure 3.

Position for surgeon and assistant. The surgeon stands on the upper ventral side, while the assistant stands on a low-rise foot stool on the lower ventral side.

1.3.4 Incision and orders of placing instruments

The location of the incision is very important. It directly affects the smoothness and safety of the processing. An optimal choice of incision will make the placement of a stapler smoother under better angle. We generally make all the incision at the fifth intercostal space, except for left upper lobectomy at the fourth, from the anterior axillary to the mid-axillary line. It can not only ensure the smoothness and safety of the processing, but also facilitate the conversion to thoracotomy by lengthening the incision if necessary. Commonly, the incision is made about 3–4 cm in length. For beginners or low volume centers, the length of incision could be appropriately extended and gradually shortened after their experience is mature and stable. This can ensure the operation safe and shorten the learning curve. Incision protective cover is used to reduce staxis and facilitate the entry and exit of instruments. The orders of placing the thoracoscopy and instruments are as follows: the thoracoscopy is always close to the upper border of the incision and fixed with a string or an infusion tube to reduce the fatigue of the assistant. When the lobes need to be towed to expose the operating area, the ring forceps should be close to the lower edge of the thoracoscopy or the lower border of the incision to ensure sufficient operating interspace for the surgeon to avoid mutual interference. The dominant hand of the surgeon holds an energy device (such as an electric hook or an ultrasonic scalpel) with the nondominant hand holding a suction or a long forceps to enter the thoracic cavity through the lower border or middle of the incision. As for whether it is better to hold an electric hook or an ultrasonic scalpel in the dominant hand, and a suction device or a long forceps in the nondominant hand, each has its own advantages and disadvantages. It mainly depended on the experience and habits of the surgeon. However, when in the learning phase, surgeons should try to use a fixed combination mode to shorten the learning curve. The author is used to holding an electric hook in the dominant hand with a suction in the nondominant hand. Because the tip of the electric hook is smaller which can perform a finer anatomy, and because that the suction can not only suck the smog generated by the energy device and the staxis exuded from the operating area in time to maintain a clear vision, but also can expose the operating area. Moreover, in the event of an accidental massive bleeding caused by a major vessel broken, the suction can be used to press it in time to control the bleeding and suck the blood to ensure a clear vision, which could provide a favorable condition for the next treatment (Figure 4).

Figure 4.

Incision and orders of placing instruments. Left, the incision is made at the fifth intercostal space from the anterior axillary to the mid-axillary line. Right, the orders of placing the thoracoscopy and instruments.

1.3.5 Specimen extraction

The resected lobe is bagged and dragged to the incision. After removing the incision protective cover, two ring forceps are used to drag the lung tissue and pull it out. If the lesion is longer than the incision, scissors are used to cut it into small in the bag. Here, the bag is in a semi-tight state. Then, the scissors are slightly opened with either lateral border close to the inner surface of the bag and slowly interposed to cut the lesion small. It can prevent scissors from cutting through the bag. After extracting the resected lobe, intersegmental, interlobar, and/or hilar lymph nodes are removed in vitro.

1.3.6 Systemic mediastinal lymphadenectomy

The extent of systemic mediastinal lymphadenectomy on the right side includes groups 2R, 3A, 3P, 4R, 7, 8, and 9 and groups 3A, 4 L, 5, 6, 7, 8, and 9 on the left. En bloc resection is used to ensure complete resection and reduce small residues. That is, the lymph nodes and pericentral adipose tissue are completely removed with the surrounding normal tissue as the boundary. It is relatively difficult to remove the lymph nodes of groups 2, 4, and 7. It is recommended to completely split the mediastinal pleura and use the surrounding normal tissue as the boundary to dissect to the depths layer by layer, rather than tunneling to the depths at one point. This can facilitate the exposure of the view and process. An ultrasonic scalpel can be used to reduce the difficulty of lymph node resection, because it can not only reduce bleeding, but also achieve the functions of dissecting, pulling, and cutting simultaneously, which thereby reduce the use and replacement of other instruments.

When resect group 2 and 4 lymph nodes, a suction (or other instrument) is used to push the azygos vein up, and ultrasonic scalpel is used to dissect lymph nodes and pericentral adipose tissue with the anterior edge of the trachea, the surface of the pericardium, and the posterior edge of the superior vena cava as the boundary. Then, the mediastinal pleura is split along the superior border of the azygos arch, the posterior border of the superior vena cava, and the anterior border of the trachea in a “△” pattern. After the whole piece of lymph nodes and pericentral adipose tissue being pushed posteriorly and upwardly with suction (or other instrument), ultrasonic scalpel is used to dissect them cephalad gradually until being completely removed. Care should be taken when dissecting is performed near the junction of the vagus nerve and the brachiocephalic artery on right side or arch of aorta on left side, since the recurrent laryngeal nerves come from there. Blunt and sharp dissection is used interchangeably before the vagus nerve and the recurrent laryngeal nerve being clearly identified to avoid nerve damage (Figure 5).

Figure 5.

Cut the posterior horizontal fissure with tunnel technique. A. Tunneling the fissure. B. Stapling the fissure. C. The outcomes after posterior horizontal fissure being cut off.

When resect group 7 lymph nodes, the middle and lower lobs are first pulled anteriorly and inferiorly at the posterior hilum with a clamped gauze to fully expose the carina area. Then, the mediastinal pleura is split along the superior border of the inferior pulmonary vein, the posterior border of the right main bronchus, and the anterior superior border of the esophagus in a “△” pattern. Suction (or other instrument) is used to push the whole piece of lymph nodes and pericentral adipose tissue backward and upward, and then ultrasonic scalpel is used to completely remove them cephalad (Figure 6).

Figure 6.

The procedure of “From posterior inferior to anterior superior.” A. Cutting the posterior ascending artery. B. Cutting the right upper bronchus. C. Cutting the remaining upper vessels simultaneously. D. The outcomes after right upper lobe being removed.

1.4 Dealing with special problems

1.4.1 Pleural adhesion

Pleural adhesion is often seen in diseases such as pleurisy, lobar pneumonia, obstructive pneumonia caused by massive or central lung cancer. In the past, pleural adhesion was considered a contraindication for VATS. But with the accumulation of experience and the improvement of instruments, thoracic surgeons now generally believe that there are more advantageous to dissect pleural adhesion with VATS for better viewing angle, finer dissection, and less bleeding. Of course, in the case of pleural adhesion caused by extensive rind thoracotomy is still recommended. Because the rind is too tough to make interspace for thoracoscopic process. After the incision is made, the adhesion around the incision is bluntly mobilized with fingers so that the thoracoscopy and processing instruments can be placed. Afterward, although the process is time-consuming and needs patience, the pleural adhesion dissecting can be completed with the cooperation of the curved suction and the electric hook. When the adhesion is close to some major vessels, it can remain and does not have to be completely removed, so as to avoid damage to the major vessels to cause massive bleeding or even threaten the patient’s life.

1.4.2 Massive bleeding

Massive bleeding caused by broken vessels is a relatively common but serious accident in lobectomy and can occasionally be fatal. It is more common in pulmonary artery injury and rupture, while veins are less likely to rupture due to its good elasticity. It is more common in central lung cancer, lymph node calcification, neoadjuvant radiotherapy, and/or chemotherapy. In such cases, preparations for thoracotomy should be done before surgery and finer dissecting is needed during surgery. Especially when turning and pulling the lobes, it should be gentle to avoid tearing the root of the vessels. When vessel is broken and bleeding, the surgeon should keep calm. First, use suction or gauze to compress the proximal end of the broken vessel to stop bleeding. When suction is used, the location and size of the rupture can be directly observed. Then, the surgeon should decide the next treatment strategy based on the location, size of the rupture, and his or her experience, such as repair with suture, hemo-lock clamp, conversion to thoracotomy, or pulmonary artery trunk blocking, etc. The treatment suggestions are as follows:

Location	Vessel sate	Size
		≤5 mm	>5 mm
Branch	Bound	Keep dissecting	Repair with suture or conversion to thoracotomy
	Unbound	Hemo-lock clamp	Hemo-lock clamp or repair with suture
Trunk	Bound	Repair with suture	Conversion to thoracotomy
	Unbound	Repair with suture	Conversion to thoracotomy or pulmonary artery trunk blocking

1.4.3 Difficult hilum

It refers to the situation that the hilar tissue is difficult to dissect due to the unclear and tough boundary for various reasons. It is more common in central lung cancer, lymph node calcification, neoadjuvant radiotherapy, and (or) after chemotherapy. Faced with such a situation, the surgeon should fully evaluate its resectability before surgery based on CT scan and experience. During operation, surgeon should not persist in a constant order or method of resection, but should treat it flexibly. If intraoperative exploration estimates that thoracoscopic resection is difficult, it should be timely and forwardly converted to thoracotomy, or directly thoracotomy after preoperative evaluation. Generally, it is recommended to deal with the relatively easily resectable tissue first to provide an opportunity for the more difficult one. Sometimes, it might be useful to lower the level of difficulty by splitting the pericardium and then cutting the pulmonary vein off or blocking the pulmonary artery trunk. In addition, for calcified lymph nodes, since it is the pericentral tissue that metastasizes, while itself (especially when it is completely calcified) hardly metastasizes, it is reasonable to resect it partially rather than completely. If the lateral wall of the artery trunk (<1/3 circumference) is invaded or cannot be unbound, a tri-stapler can be used to remove part of the lateral wall and the lesion simultaneously to ensure the safety of the process.

1.5 Conversion to thoracotomy

Although lobectomy under u-VATS has many advantages, thoracotomy is still better from the perspective of surgical safety. Therefore, in order to ensure the safety of patients, under any circumstance, if the surgeon is not fully confident to proceed with the next process or an uncontrollable event has occurred, it must be immediately converted to thoracotomy without hesitation. According to the emergency state when converting, it is divided into planned and forced conversion to thoracotomy. The former is that the surgeon forwardly decides to convert to thoracotomy when he or she estimates that the next process cannot be performed very safely based on their experience. At this time, the condition is relaxed and operations can be performed in an orderly manner. Generally, the anterolateral incision is lengthened to about 10 cm or through which the surgeon can reach the chest cavity with one hand for auxiliary process. Forced conversion to thoracotomy is an emergency that has occurred beyond the capability of the surgeon to handle under u-VATS. In order to save the patient’s life, it has to be converted to thoracotomy immediately. It is generally seen in massive bleeding caused by major vessels broken. At this moment, the condition is very tense. The surgeon has to race against time to control the bleeding. According to the state of bleeding, the chest wall can be incised layer by layer or just once.

1.6 Drainage tube placement and incision suture

At the end of the surgery, another incision is usually made to place drainage tube. However, we could place it at the same incision to minimize invasiveness [13]. First, when the u-VATS was completed, the skin and subcutaneous tissue were pulled up and the intercostal muscle in the same intercostal space was transpierced with a mosquito forceps about 2.0 cm beyond the distal end of the incision site. Second, the drainage tube was clamped and punctured into the cavity, which is as alike as the procedure of doing a chest drainage that is familiar to thoracic surgeons in general. Third, after the drainage tube was placed properly, the subcutaneous tissue was sutured conventionally. Fourth, the drainage tube was anchored about 1.0 cm beyond the incision with a silk thread, which was passed through the subcutaneous suture. Finally, the skin incision was closed by subcutaneous continuous suture with a 3-0 self-retaining suture (Quill TM knotless tissue-closure device, Angiotech Puerto Rico Inc., Vancouver, Canada), which was cut flush to the skin lastly. When removing, one end of the anchoring silk thread was snipped and the drainage tube was pulled out, which just like removing the stiches, and the wound was sealed with Vaseline gauze immediately.

1.7 Technological difficulty

1. U-VATS has higher requirements on assistants. The assistants need to be familiar with the surgeons’ habits and to ensure the processing area clearly and sufficient extrathoracic operating space for surgeon by flexibly rotating the angle of thoracoscopic body.

2. Placement of stapler under u-VATS. Compared with multi-portal VATS, the angle is relatively limited when the stapler is placed under u-VATS. Therefore, surgeons need to completely dissect the target organ and its surroundings first and then adjust the relative position of the lobe to achieve a better angle for stapler placement. In addition, a shorter or curved-tip stapler is usually useful to reduce the difficulty of stapler placement.

2. Part 2. Right upper lobectomy under u-VATS

2.1 Different orders of hilar cut

Although some studies have shown that cutting pulmonary vein first might reduce the incidence of recurrence and prolong the survival time [14, 15, 16, 17, 18]. However, other studies have claimed that there is no difference in the risk of recurrence and survival time between cutting the pulmonary vein first or later [19, 20, 21]. Moreover, the first intraoperative priority is to ensure the safety of the patient and the operation. Therefore, there is no need to subject to a fixed order of hilar cut. The optimal order of hilar cut is only determined by the specific situation during the operation and the surgeon’s habits. The general principle is to deal with the simple tissue first and then the more difficult ones. The common orders of hilar cut are as follows:

2.1.1 Vein-artery-bronchus (VAB)

That is, the right upper pulmonary vein is cut off first, then the branches of the artery, and finally, the bronchus. It derives from the experience of thoracotomy and theoretically minimizes the possibility of hematogenous tumor spread. In addition, when the bronchus is cut off last, the likelihood of massive bleeding, which is caused by tearing the vessels, is minimized. The main process is as follows:

1. To dissect the right upper pulmonary vein, the right upper lobe is pulled backward and caudalward to expose the anterior upper hilum. Since the right upper pulmonary vein is relatively located anteriorly and inferiorly to the hilum and is very close to the incision, it will increase the difficulty of the processing due to the poor angle and the possibility of damaging the apical anterior artery when using a stapler to cut it first. It would be more difficult due to the cover of the middle pulmonary vein if the anterior part of the horizontal fissure is incomplete. In the face of such circumstances, the following methods can be used: 1) using a tip-curved stapler; 2) ligation of the vein using sutures; 3) dissecting the distal end of the pulmonary vein and cut them off respectively; 4) dissecting the apical anterior artery and the upper pulmonary vein, then cutting them simultaneously to obtain an appropriate angle for the entry of the stapler; 5) using the “tunnel technique” (see the section of “from posterior inferior to anterior superior”) to cut off the horizontal fissure first to increase the mobility of the upper pulmonary veins; 6) transferring to the following other orders of hilar cut.

2. To dissect the apical anterior artery, the right upper lobe is pulled backward and caudalward to expose the anterior upper hilum as before. The apical anterior artery is no longer covered and is easy to be exposed and cut after the superior pulmonary vein having been cut off. However, it should be noted that the apical anterior artery is located at the highest position of the hilum, so it received the greatest strength when pulling the right upper lobe backward and caudalward. Therefore, it should be as gentle as possible to avoid tearing the root of the apical anterior artery. The author encountered such a situation. It is troublesome and risky to manage once it is torn here for the short of the right upper pulmonary artery trunk.

3. Continue to pull the right upper lobe backward and caudalward to expose the anterior upper hilum, and then resect the surrounding tissue along the surface of the pulmonary artery trunk. If the lymph node does not affect the process, its proximal end is resected and pushed to the distal end of the pulmonary tissue, which will be removed in vitro after the lobectomy is completed and removed to shorten the surgical and anesthesia time. Otherwise, it should be removed first to facilitate subsequent process. Here, there might be one to two variant arterial branches occasionally, which are generally tiny. For such tiny arterial branches, suture ligation, hemo-lock clip followed by scissors or ultrasonic scalpel is recommended to use. Because when cutting them off with a stapler, it is not only easy to tear them due to poor angle but also might bleed for being too tiny.

4. If the horizontal fissure is incomplete, the right upper lobe is pulled backward and caudalward to expose the anterior upper hilum as before, and the surrounding tissue along the surface of the pulmonary artery trunk is dissected. After identifying the middle pulmonary artery branch and the posterior ascending artery branch, the incomplete horizontal fissure was cut off use the “tunneling technique” (see the section of “from posterior inferior to anterior superior”) along the surface of the pulmonary artery trunk between them.

5. Then the right upper lobe is pulled forward and upward to expose the posterior lower hilum. If the horizontal fissure is complete or an incomplete one is cut off as step [4], the posterior ascending branch is no longer covered and easy to be exposed and cut off.

6. Then the right upper lobe is pulled upward to expose the hilum. The tissue around the bronchus of the right upper lobe and the proximal end of the lymph node are resected and pushed to the distal end of the pulmonary tissue. Finally, the right upper bronchus is cut off with a stapler, and the resection of the right upper lobe is completed.

2.1.2 From anterior superior to posterior inferior

That is, the apical anterior artery of the right upper pulmonary artery is cut off first, followed by the pulmonary vein and arterial variant branches, then the bronchus, and finally, the posterior ascending branch and the incomplete horizontal fissure. This order is particularly useful when the horizontal fissure is incomplete. Since the right upper lobe is always pulled backward and downward throughout the operation, the lungs are mostly prevented from turning. The main process is as follows:

1. The right upper lobe is pulled backward and caudalward to expose the anterior upper hilum. The apical anterior artery is dissected and cut off with stapler. When dissecting the apical anterior artery, its inferior border is covered by the superior border of the upper pulmonary vein. Therefore, the mediastinal pleura should be split along the superior border of the upper pulmonary vein, which is then pushed caudalward with a suction (or other device) to expose the inferior border of the apical anterior artery for safe dissection.

2. After the apical anterior artery being cut off, unless the incision is made too cephalad, the right upper pulmonary vein can be dissected and cut off relatively smoothly. When inserting the stapler, the staple cartridge should be rotated toward ventral slightly to through the interspace behind the upper pulmonary vein, which might avoid the tip of the stapler damaging the lateral wall of the pulmonary artery trunk or the possible variant arterial branches.

3. If a variant arterial branch is encountered, it is recommended to use suture ligation or hemo-lock clip or ultrasonic scalpel to cut off. The proximal end of the lymph node is dissected and pushed to the distal end of the lung tissue or directly removed.

4. After that, the right upper lobe bronchus is located at the last uppermost part of the hilum. Then, it was pulled slightly upward so that the bronchus was perpendicular to the mediastinum to increase the interspace between the bronchus and the posterior ascending artery. The tissue around the bronchi and the proximal lymph nodes are dissected and pushed to the distal end of the lung tissue or directly removed. The right upper lobe bronchus was cut off with a stapler.

5. The proximal end of the interlobar lymph nodes is dissected and then pushed to the distal end of the lung tissue or directly removed. If the posterior ascending artery is thick (> 3 mm in diameter), it needs to be dissected and cut off separately. Otherwise, it can be stapled with the incomplete fissure using a 60 mm stapler to complete the right upper lobe resection.

2.1.3 From posterior inferior to anterior superior

That is, the posterior ascending artery is first cut off, then the bronchus, and finally, the upper pulmonary vein and the apical anterior artery (including possible variant arterial branches) are cut off simultaneously. It is especially useful when the horizontal fissure is complete. Since most of the procedure is performed with the upper lobe in its natural collapsed status, it is rarely needed to turn it over. The main process is as follows as we reported before [22]:

1. If the horizontal fissure is complete, only the visceral pleura at the horizontal fissure need to be split with an energy device. If not, the “tunnel technique” is used to cut it off. First, the upper lobe is pulled backward and upward using a suction (or other instrument) to expose the anterior hilum, and the mediastinal pleura is split along the upper border of the middle pulmonary vein. Second, the proximal end of the adipose tissue and lymph nodes is dissected and pushed to the distal end of the lung tissue or directly removed until the surface of mid-pulmonary artery trunk is exposed. After that, forceps or ultrasonic scalpel is used to bluntly and sharply dissect the tissues along the surface of the mid-pulmonary artery trunk to make a factitious tunnel. Then, the anterior part of the horizontal fissure was cut off with a stapler through the factitious tunnel (Figure 7). After carefully identifying the posterior ascending artery, a stapler is used again to cut the posterior part of the horizontal fissure (Figure 8).

2. When the horizontal fissure is split, the posterior ascending branch is located at the lowest part of the right upper hilum. Then, the posterior ascending branch was dissected and cut off easily (Figure 5).

3. After the posterior ascending artery being cut off, there is usually a lymph node at the lower border of the upper bronchus, which is then dissected and pushed to the distal end of the lung tissue. When the anterior and superior borders of the upper bronchus are dissecting, more attention should be paid to observe whether there is dense adhesion between the apical anterior artery and the bronchus. If so, it would be treated as a difficult hilum (see the section of dealing with special problems). If not, it could be dissected along the anterior border of the upper bronchus with forceps or ultrasonic scalpel bluntly and sharply. Here, this process is relatively safe due to the lymph node separating the instrument from the anterior apical artery. Then, the right upper bronchus is cut off with a stapler.

4. After that, the adipose tissue and the proximal end of the lymph nodes are dissected and then pushed to the distal end of the lung tissue or directly removed. If the lymph nodes are covered by possible variant arteries, it can be dissect along the surface of the pericardium posteriorly. Then the right upper lobe is pulled backward and caudalward to continue to dissect the lymph nodes anteriorly. Subsequently, the lymph nodes are pushed to the distal end of the lung tissue or removed directly. Now, the remaining upper pulmonary vessels (including the right upper pulmonary vein, the apical anterior artery, and possible arterial variant arteries) are hollowed out. And, then they are cut off simultaneously with a stapler. Finally, the right upper lobe is completely removed (Figure 9).

Figure 7.

Resecting group 2 and 4 lymph nodes. A. a suction is used to push the azygos vein up, and ultrasonic scalpel is used to dissect lymph nodes. B. The mediastinal pleura is split in a “△” pattern. C. The whole piece of lymph nodes and pericentral adipose tissue being pushed posteriorly and upwardly with suction. D. The outcomes after group 4 and 2 lymph nodes being removed.

Figure 8.

A. The mediastinal pleura is split in a “△” pattern. B. The group 7 lymph nodes and pericentral adipose tissue is pushed backward and upward. C. The outcomes after group 7 lymph nodes being removed.

Figure 9.

Cut the anterior horizontal fissure with tunnel technique. A. To expose the mid-pulmonary artery trunk. B. Tunneling the fissure. C and D. Stapling the fissure. E. The outcomes after anterior horizontal fissure being cut off.

3. Part 3. Right middle lobectomy under u-VATS

Right middle lobectomy under u-VATS is relatively easy for its hilum is superficial to the mediastinum, especially when the fissures are complete.

1. First, the right upper and middle lobes are pulled backward and upward to expose the anterior hilum. The mediastinal pleura is split along the inferior border of the upper and middle pulmonary vein. And the middle pulmonary vein is then dissected and cut off with stapler. It is comparatively easy, because the backward of the middle pulmonary vein is the middle bronchus, which is less likely to be injured.

2. If the horizontal fissure is incomplete, the “tunnel technique” is used to cut it off as described before. Then, the medial segmental artery is clearly visible, which comes from the inferior of the middle-pulmonary artery. It is dissected and cut off with stapler or hemo-lock clip or ultrasonic scalpel.

3. The proximal end of the oblique fissure is split with ultrasonic scalpel or electric hook to expose the lateral segmental artery, which is then dissected and cut off with stapler or hemo-lock clip or ultrasonic scalpel.

4. The right middle lobe is pulled upward, and the right middle bronchus is dissected with surrounding lymph nodes and adipose tissue being dissected and pushed to the distal end of the lung tissue or directly removed. Next, the middle bronchus is cut off with stapler.

5. Finally, the incomplete oblique fissure is stapled to complete the right middle lobectomy.

4. Part 4. Right lower lobectomy with single-direction under u-VATS

The advantage of lobectomy with single directional is that the whole procedure starts from the shallowest structure of the hilum, proceeds in one direction, and cuts the fissure. This procedure is particularly useful when the oblique fissure is incomplete.

4.1 Surgical procedure

After the right lower lobe is pulled backward and cephalad, the inferior pulmonary ligament is cut to the lower boundary of the lower pulmonary vein with electric hook (Figure 1). And the group 8 lymph node is dissected and pushed to the distal end of the lung tissue or directly removed.

Dissect the inferior pulmonary vein and remove group 9 lymph node or push it to the distal end of the lung tissue, then separate and expand the interspace between the vein and lower bronchus by forceps (Figure 2).

Cut the inferior pulmonary vein off with stapler (Figure 3).

Dissect the lower bronchus and separate it from the lower pulmonary artery with a forceps by close to the upper boundary of the lower bronchus to avoid injuring the artery (Figure 4). Then cut the lower bronchus off with stapler (Figure 7).

Remove group 11 lymph node or push it to the distal end of the lung tissue. Then dissect the lower pulmonary artery and suspend it with suture (Figure 8).

Cut off the lower lobe artery with stapler (Figure 9).

Finally, cut off the oblique fissure with stapler to finish the right lower lobectomy (Figure 5).

4.2 Essential technology for right lower lobectomy with single direction under u-VATS

The sheath of the inferior pulmonary vein, especially the surrounding pleura, must be completely split to facilitate the placement of stapler. Moreover, the middle pulmonary vein may sometimes drain into the inferior pulmonary vein, so it needs to be carefully identified during dissecting.

More attention should be paid when separating lower bronchus to avoid injuring vessels. There are often lymph nodes around the bronchus. Sometimes these lymph nodes closely adhere to the bronchus and vessels, making it difficult to separate the interspace between the bronchus and vessels. On this occasion, it is impossible to place the stapler due to insufficient space. Therefore, the lower lobe bronchus should be cut off with scissors and then suture the bronchial stump after removing the lobe. In addition, it should be noted that the dissecting of the upper boundary of the lower bronchus should be performed on the interior of the middle lobe bronchus, because the lower lobe is pushed upward. Otherwise, if the dissecting is too close to the mediastinum, the middle bronchus may be injured or cut accidentally. Furthermore, the lower bronchus should be cut off at an appropriate distance (about 5 mm) to the middle lobe bronchus to avoid the stenosis of the middle lobe bronchus and subsequently postoperative atelectasis or occurrence of bronchopleural fistula.

In most cases, the lower pulmonary artery trunk can be cut off with one stapler. If the dorsal segment artery is far from the basal artery trunk, they need to be cut off respectively. In addition, when dissecting the artery, it should be gentle to avoid massive bleeding caused by tearing it.

5. Part 5. Left lower lobectomy under u-VATS

Left lower lobectomy under u-VATS can be performed as similar as right lower lobectomy reported before. Here, we describe another procedure, which is more commonly used.

1. First, the left lower lobe is pulled backward and cephalad to expose the inferior hilum. The inferior pulmonary ligament is cut to the lower boundary of the lower pulmonary vein with electric hook or ultrasonic scalpel. And the group 8 lymph node is dissected and pushed to the distal end of the lung tissue or directly removed.

2. If the oblique fissure is incomplete, the “tunnel technique” is used to cut it off as described before. Then, the basal artery trunk and the dorsal segment artery are clearly visible. If they are close to each other, they can be cut off with one stapler. Otherwise, they should be cut off respectively.

3. The left lower lobe is pulled upward, and the bronchus is dissected with surrounding lymph nodes and adipose tissue being dissected and pushed to the distal end of the lung tissue or directly removed. Finally, the bronchus is cut off with stapler to complete the left lower lobectomy.

6. Part 6. Left upper lobectomy under u-VATS

Left upper lobectomy under u-VATS is comparatively difficult for its special hilar anatomy and more frequent variant artery. Comparing with the right hilum, the left hilum is cephalad higher, and most of the arteries of the left upper division are covered by the upper bronchus. Therefore, the incision is made at the fourth intercostal space to facilitate dissection and placement of stapler.

1. First, the left upper lobe is pulled backward and caudalward to expose the anterior hilum. The mediastinal pleura is split along the upper hilum. A long right-angle forceps or an auricular appendage forceps is used to dissociate the upper vein from the upper bronchus and pulmonary artery trunk to make an artificial tunnel. When making the tunnel, the tip of the forceps should be rotated toward ventral slightly to through the interspace behind the upper pulmonary vein. It might avoid damaging the lateral wall of the pulmonary artery trunk. The tunnel should be made as wide as possible to facilitate the placement of the stapler. Otherwise, a tip-curved stapler is needed to cut the vein off.

2. Then, the left upper lobe is pulled toward ventral and caudal to expose the posterior hilum. The posterior mediastinal pleura is split, and the anterior and apicoposterior segmental arteries are dissected along the pulmonary artery trunk. After that, the anterior segmental artery is stapled with the upper lobe being pulled backward and caudalward again.

3. The left upper lobe is pulled toward ventral and caudal to expose the posterior hilum once again. And the apicoposterior and lateral subsegmental arteries are cut off respectively. Here, the apical and posterior subsegmental arteries might come from the pulmonary artery trunk respectively. They can be cut off simultaneously if they are close to each other or respectively if not. The lateral subsegmental artery is usually tiny and could be cut off with hemo-lock clip or ultrasonic scalpel.

4. The left upper lobe is pulled upward, and the bronchus is dissected with surrounding lymph nodes and adipose tissue being dissected and pushed to the distal end of the lung tissue or directly removed. Then, the bronchus is cut off with stapler.

5. The proximal end of the interlobar lymph nodes is dissected and then pushed to the distal end of the lung tissue or directly removed. If the lingular segmental artery is thick (> 3 mm in diameter), it needs to be dissected and cut off separately. Otherwise, it can be stapled with the incomplete fissure using a 60 mm stapler to complete the left upper lobectomy.

Sometimes, it is difficult to cut the pulmonary vein first because of insufficient angle for stapler placement (Figure 6A) or dense adhesion caused by calcified lymph node. In this case, the abovementioned procedure is reversed (Figures 6B–F and 10).

1. First, the anterior part of the oblique fissure is cut off with “tunnel technique” (Figure 6B).

2. The lingular segmental artery is dissected and cut off (Figure 6C).

3. The posterior part of the oblique fissure is cut off with “tunnel technique” (Figure 6D).

4. The arterial branches are dissected and cut off one by one from caudal to cephalic (Figures 6E–F and 10A).

5. Then, the upper pulmonary vein can be cut off easily (Figure 10B).

6. The left upper lobe is pulled upward, and the bronchus is dissected with surrounding lymph nodes and adipose tissue being dissected and pushed to the distal end of the lung tissue (Figure 10C). Then, the bronchus is cut off with stapler (Figure 10D) to complete the left upper lobectomy (Figures 10E and 11–19).

Figure 10.

Dissecting the inferior pulmonary ligament. IPL, inferior pulmonary ligament. RLL, right lower lobe. Dia, diaphragm. IVC, inferior vena cava.

Figure 11.

Dissecting the inferior pulmonary vein. IPV, inferior pulmonary vein. RLL, right lower lobe.

Figure 12.

Dissect the inferior pulmonary vein. IPV, inferior pulmonary vein. RLL, right lower lobe.

Figure 13.

Dissect the lower lobe bronchus. RLLB, right lower lobe bronchus. RMLB, right middle lobe bronchus.

Figure 14.

Cut off the lower lobe bronchus. RLL, right lower lobe. RMLB, right middle lobe bronchus.

Figure 15.

Dissect the lower lobe artery. RLLA, right lower lobe artery. RMLA, right middle lobe artery. RLL, right lower lobe. RUL, right upper lobe.

Figure 16.

Cut off the lower lobe artery. RLLA, right lower lobe artery. RLL, right lower lobe. RUL, right upper lobe.

Figure 17.

Cut off the interlobar fissure. RLL, right lower lobe. RUL, right upper lobe.

Figure 18.

The reversed procedure for left upper lobectomy. A. Insufficient angle for stapler placement. B. Dissecting the anterior part of the oblique fissure with “tunnel technique.” C. Stapling the LSA. D. Dissecting the posterior part of the oblique fissure with “tunnel technique.” E. Stapling the lateral subsegmental artery. F. Dissecting the APSA. PA, pulmonary artery. PV, pulmonary vein. BSAT, basal segmental artery trunk. LSA, lingular segmental artery. SSA, superior segmental artery. APSA, apicoposterior segmental artery.

Figure 19.

The reversed procedure for left upper lobectomy (continue). A. Dissecting the ASA. B. Stapling the PV. C. The surrounding lymph nodes and adipose tissue are dissected and pushed to the distal end of the lung tissue. D. Stapling the UB. E. The outcomes after left upper lobe being removed. ASA, anterior segmental artery. PV, pulmonary vein. LN, lymph node. UB, upper bronchus.