INDICATIONS/CONTRAINDICATIONS

Video-assisted thoracic surgery (VATS) left upper lobectomy is a minimally invasive technique that is indicated for resection of stage I lung cancers located in the left upper lobe. Induction therapy, chest wall invasion, and endobronchial tumor location are relative contraindications for VATS lobectomy. The VATS left upper lobectomy is contraindicated in patients who have had a previous pleurodesis procedure or in patients with an FEV₁ predicted of 40% or less. The reported benefits for VATS lobectomy include less postoperative pain, shorter hospital length of stay, and a faster recovery.

The author believes that patients with an FEV ₁ that is less than 40% predicted should be considered for a VATS sublobar resection or stereotactic radiosurgery as opposed to VATS lobectomy. The risk for pulmonary complications is higher when the preoperative FEV₁ is less than 40% regardless of the technique (VATS or open thoracotomy). An FEV₁ of less than 40% predicted is not a contraindication for lobectomy; however, the perioperative risk will be higher for pulmonary complications.

PREOPERATIVE PLANNING

Preoperative staging and a complete medical assessment should be completed for all patients undergoing VATS lobectomy. A complete history and physical examination should uncover medical comorbidities that may increase the perioperative risk for lobectomy. A chest CT scan and an integrated PET CT scan should be obtained to evaluate patients for lymph node metastasis or distant metastatic disease. Lymph nodes that are larger than 1 cm in diameter or have a maximum SUV value above 2 should undergo further staging with either cervical mediastinoscopy or endobronchial ultrasound (EBUS). Patients with metastatic carcinoma involving the N2 mediastinal lymph nodes should be referred for induction chemoradiotherapy.

Prior to VATS left upper lobectomy, a complete cardiopulmonary evaluation is necessary to identify patients who are at risk for perioperative morbidity and mortality. Complete pulmonary function tests with spirometry and diffusion capacity should be obtained. Patients with an FEV₁ less than 50% predicted or a diffusing capacity less than 50% predicted should be referred for quantitative perfusion scanning and exercise oxygen consumption testing. Patients with a maximum consumption (VO_2max) of less than 10 mL/kg/min are at high risk for lobectomy and should be considered for referral for stereotactic radiosurgery.

SURGERY

VATS Left Upper Lobectomy

The multiple variations of pulmonary artery anatomy that can be encountered during a left upper lobectomy make this particular VATS procedure the most challenging lobectomy. The VATS left upper lobectomy should be performed with extreme caution. The left main pulmonary artery may give off as many as seven branches to the left upper lobe.

Positioning

I routinely perform a fiberoptic flexible bronchoscopy before every lobectomy procedure to assess the airway anatomy and detect aberrant anatomy that may alter the operative plan. After the fiberoptic flexible bronchoscopy is completed with a single-lumen endotracheal tube, the patients are reintubated with a double-lumen endotracheal tube for selective lung ventilation. A right-sided double-lumen tube is preferable for a VATS left upper lobectomy because the subcarinal space is easier to dissect without a rigid endotracheal tube in left mainstem bronchus. Patients are then positioned in the right lateral decubitus position for left VATS upper lobectomy. All pressure points should be padded with gel pads to prevent nerve compression and skin necrosis. A padded bean bag is used to hold the patient in position. The operating room table is flexed with the patient’s anterior-superior iliac crest below the break in the bed. The flexion opens up the rib spaces to allow placement of VATS ports. The video monitors are placed at the head of the table and the surgeon stands in front of the patient.

Incisions

Three standard VATS incisions are used for left upper lobectomy (Fig. 26.1). The first incision is placed in the eighth intercostal space posterior axillary line. A 5-mm trocar is placed through the incision and 5-mm thoracoscope inserted in the left chest. The left hemithorax is inspected for evidence of pleural dissemination, such as a pleural effusion or tumor implants on the chest wall. The 5-mm thoracoscope is lower profile and is less likely to place torque on the intercostal nerve. A 10-mm incision is placed 3 to 4 fingerbreadths below the tip of scapula. A 4-cm utility incision is placed on the anterior border of the latissimus dorsi muscle. The particular interspace for the utility incision is based on the location of the left superior pulmonary vein. The index finger can be placed through the access incision for direct palpation of lung nodules. A 10-mm incision is also placed anteriorly at the level of the inframammary crease. I use low profile lung clamps and vascular clamps, which easily pass through the VATS incisions without placing pressure on the intercostal nerve.

Lymph Node Dissection

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