INDICATIONS/CONTRAINDICATIONS

Indications

Despite the lack of large multicenter randomized controlled trials to compare oncologic outcomes of video-assisted thoracic (VATS) lobectomy to open lobectomy, comparative studies have demonstrated equivalent oncologic outcomes, shorter length of stay, and fewer postoperative complications with the VATS approach. VATS lobectomy is commonly performed for selected peripherally located T1 or T2 tumors in the absence of any significant hilar or mediastinal lymphadenopathy. Thoracoscopic resection of the left upper lobe can be the most challenging lobe by virtue of a heterogeneous branching pattern of the left pulmonary artery.

Contraindications

Although there are no absolute contraindications to VATS left upper lobectomy, the surgeon should consider the following characteristics as relative contraindications: Tumors >6 cm, centrally located tumors, bulky hilar (N1) or mediastinal (N2) lymphadenopathy, endobronchial disease within 2 cm of the origin of the left upper lobar bronchus, and patients who received induction radiation for locally advanced disease (stage IIIA). Performing VATS lobectomy on patients with previous coronary revascularization, particularly in patients who harbor a left internal mammary artery graft, can be challenging where early conversion to thoracotomy should be implemented.

PREOPERATIVE PLANNING

All patients should undergo preoperative examination with lung function testing, PET/CT, bronchoscopy, and endobronchial ultrasound (EBUS)/mediastinoscopy for preoperative staging (unless it is a peripherally placed T1 tumor with no PET activity in the hilum or mediastinum). All anatomically enlarged mediastinal lymph nodes should be sampled to rule out N2 disease. Epidural anesthesia can be considered for VATS lobectomy but is not routinely required. Hemodynamic monitoring with a radial arterial line should be routine for VATS lobectomy given the potential for vascular injury and rapid blood loss. It is always a good idea to have a thoracotomy tray in the operating room and the availability of a sponge stick and 5-0 Prolene suture for emergency control of hemorrhage.

SURGERY

Positioning

After successful placement of a right-sided (preferred) double-lumen endotracheal tube, the patient is placed in the maximally flexed right lateral decubitus position tilted slightly backward to prevent the hip from obstructing downward movement of the thoracoscope. The camera port is placed at the eighth or ninth interspace along the posterior axillary line, avoiding the apex of the heart. The posterior port is placed where the left lower lobe edge touches the diaphragm (in line with the scapular tip). Once intrapleural visualization is achieved, the left hilum and major fissure should be identified. Nerve blocks can be considered at this time using 0.25% to 0.5% bupivacaine under direct thoracoscopic guidance. An axillary utility incision (between 4 and 6 cm) is placed perpendicular to the anterior axillary line directly over the left superior pulmonary vein (Fig. 16.1). The soft tissue of the utility port can be separated with either a Weitlaner retractor or a wound protector (Fig. 16.2) to facilitate passage of instruments and avoid loss of pneumothorax while suctioning.

Technique

Instrumentation is important when performing thoracoscopic pulmonary resection, including the use of a 30-degree videoscope and long, curved instruments to improve retraction and dissection. High-definition video equipment improves visualization for difficult dissections. Linear staplers are used to control and divide lung parenchyma, vessels, and bronchus. After inspection of the pleural cavity (to rule out occult pleural-based metastases) and confirmation of the indication for lobectomy, the structures are divided as you encounter them during the operation from anterior to posterior. The pleura overlying the hilum is divided and the artery and superior pulmonary vein are identified. The left main pulmonary artery emerges from beneath the aortic arch and is located superior and posterolateral to the superior pulmonary vein. It is often a good time to confirm the presence of the inferior pulmonary vein to ensure no aberrant anatomy. The plane between the left main pulmonary artery and the upper lobe vein is opened, so the vein is exposed by a vessel loop coming from the anterior utility incision. Although there are numerous variations of which anatomic structures to isolate and divide in sequence, the recommended sequence is listed in Table 16.1

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