Thoracoscopic Extended Right Middle Plus Lower Sleeve Lobectomy for Non-Small-Cell Lung Cancer

The video aims to demonstrate the procedures for thoracoscopic right middle plus lower sleeve lobectomy for non-small-cell lung cancer. Early advanced non-small-cell lung cancers of the central airway may require bronchial reconstruction. Preoperative evaluations begins with a bronchoscopy to confirm the diagnosis and bronchial invasion.

Contrast enhanced CT scans is required to demonstrate the tumor and potential vascular involvement. Our patient was a 57-year-old man who presented with mild hemoptysis. He underwent a bronchoscopy and confirmed a squamous cell carcinoma in his bronchus intermedius.

A T3N2 stage IIIB disease was confirmed by a subsequent PET scan. Three cycles of PD-1 inhibitor with chemotherapy were given as induction treatment. The tumor showed minimal response to the treatment and the proximal edge of the tumor still involved the second carina of the right side.

For this reason, an extended sleeve resection was proceeded. Here you can find that the tumor nearly broken the bronchus intermedius and the image from the bronchoscopy clearly indicated the involvement of the secondary carina. The surgery was performed under loophole VATS approach.

The inferior primary ligament was divided as long as the posterior mediastinal pleura. Fibrosis can be found in the higher region making it hard to dissect the subcarinal lymph node initially. The pericardium was dissected in a U-shape with a harmonic scalpel to facilitate the division of the pulmonary vein and the inferior pulmonary vein was then divided by a white cartilage with the endoscopic staple and the middle vein was dissected in a similar fashion.

The subcarinal space can be dissected to expose the contralateral portion of the left main bronchus. The anterior mediastinal pleura was dissected later through the phrenic nerve and the anterior hilar lymph nodes was dissected below the arch in the whole package. The paratracheal lymph nodes were then dissected in the subaortic region and inverted vessels can be shielded under direct vision.

The pleura was then winded alongside the superior vena cava up to the inferior border of the subclavian artery. The lymph nodes around this region were then removed en bloc. An endoscopic harmonic cam was used introduced from the third of the truncus anterior to the subcarinal space to control the pulmonary artery and the superior primary vein together.

And the tonic takes that temporary brokes the vessels can be placed in the upper chest cavity during the surgery. Hook cautery can be used safely to identify the secondary carina. The upper lobe bronchus was divided first before the division of the right main bronchus and after cutting the bronchus, one can clearly visualize the tumor that invaded the secondary carina during this procedure.

Now you can see the tumor broking the secondary carina. And by retracting the bronchus to the cranial side, the anterior part of the subcarinal lymph nodes can be dissected. The interlobar lymph nodes and their surrounding fibrotic tissues were dissected to extend the margin for upper lobe bronchus.

And the subcarinal lymph nodes were then removed, facilitating the division of the remaining pulmonary artery and the horizontal fissure by a linear stapler with a gold cartilage. Middle lobe and lower lobes were then removed it in a specimen bag via the utility incision and extended bronchial margins from both the proximal and the distal bronchus were harvested and sent for frozen section to confirm an ideal resection. The aortic arch was retracted by a U-ring trail which was stitched to the posterior transfer to further expose the proximal airway.

And to approximate the caliber of the right main bronchus, a portion of the cartilage membrane section was involving a U-shape and interrupted sutures was used to decrease the caliber of the proximal airway. The bronchus was reconstructed with a continuous running suture with 4-0 PDS. To minimize the chance of tangling one end of the trachea can be hung to the parietal pleura while suturing the anterior portion.

Finally, the knot was tied gently in the cartilage portion. The setting irrigation test was then performed to confirm the integrity of the anastomosis. To finalize the operation, a free semi flap was obtained to cover and reinforce the anastomosis.

The patient tolerated the procedure well and his postoperative course was without complication. The pathology report demonstrated a 4 cm squamous cell carcinoma with a residual viable tumor percentage of 80%The final staging was ypT2aN2aM0 stage IIIA disease. In this picture, you can find a good hearing of the anastomosis and the remaining right upper lobe is bent well according to the CT examination.

To some, the VATS extended sleeve resection begins with proper patient selection and preoperative planning. Technique is essential to avoid pneumonectomy in certain patients. During the operation, caliber mismatch of the two ends of the bronchus can be found and occasionally proximal vascular control is also required.