Step 1
Surgical Anatomy
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The anatomy for the right upper lobe (RUL) is consistent, thus the approach to a right upper lobectomy generally is consistent. The RUL vein is the most anterior structure. Posterior to the vein is the RUL bronchus. The arteries are superior and inferior to the bronchus, as seen in the accompanying figures.
Step 2
Preoperative Considerations
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The most common indication for a lobectomy is lung cancer, and the RUL is the most common lobe for lung cancer. Lung cancer affects 200,000 Americans each year, and it is the most common cancer killer in both men and women.
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For lung cancer, a wedge resection/segmentectomy has a 3- to 5-fold increase in local recurrence and a 20% lower cure rate than a lobectomy. The procedure should be a standard anatomic resection with individual ligation of the artery, vein, and bronchus and a lymph node dissection.
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Preoperative workup usually includes a chest computed tomography (CT) scan and a positron emission tomography (PET) scan. If the patient appears to have a higher stage of cancer or symptoms of metastatic disease, brain imaging is often performed. Pulmonary function tests are performed. Generally, expected postoperative forced expiratory volume in 1 second (FEV 1 ) should be greater than 800 mL or 40% predicted. If the patient is marginal, then a quantitative lung perfusion scan can be performed to determine the functionality of the area to be resected. If it is not functional, resection may still be undertaken.
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Mediastinoscopy with removal of lymph nodes in several stations is performed for patients other than stage 1A (T1N0) tumors, plus patients with synchronous primary lung cancers and patients with poor performance status. If the nodes are negative, pulmonary resection is undertaken.
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The video-assisted thoracoscopic surgery (VATS) procedure is performed using a double- lumen tube for single-lung ventilation. The patient is in the lateral decubitus position with a slight posterior tilt. The operating table is flexed so that the bend is at the level of the anterior superior iliac spine. This moves the hip out of the way and opens the intercostal space. In addition to general anesthesia, a long-acting local anesthetic is injected to block the intercostal nerves from T4-9.
Step 3
Operative Steps
1
The Overall Procedure
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The order of the steps of the operation are as follows: level 10 nodes, RUL vein, minor fissure, anterior trunk of the artery, posterior ascending artery, RUL bronchus, and the fissure. The incisions are the standard incisions with the utility incision placed directly up (lateral) from the superior pulmonary vein.
2
Incisions
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As seen in Figure 3-1 , four incisions are used.
Figure 3-1
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The first incision is in the sixth intercostal space in the midclavicular line. The incision is tunneled posteriorly through the tissues so that the instruments through the incision point toward the major fissure, not straight down toward the pericardium.
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The 5-mm trocar and thoracoscope are placed through the eighth intercostal space in the posterior axillary line.
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The third incision is the utility incision. For an upper lobe, the incision begins at the edge of the latissimus muscle and extends anteriorly about 4 cm. The interspace is chosen by looking in the pleural space and retracting the lung posteriorly. This incision is made directly up from the superior pulmonary vein.
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The fourth incision is made 3 finger breadths below the tip of the scapula and halfway to the spine.
3
Level 10 Nodes
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Removal of the level 10 nodes defines the anatomy and facilitates the mobilization of the vessels for the lobectomy.
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The level 10 nodes are between the superior vena cava (SVC), azygos vein, and superior hilum of the lung ( Fig. 3-2 ).
Figure 3-2
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Removing all the tissue in this triangle removes the level 10 nodes and exposes the right mainstem bronchus, anterior trunk, and SVC.
4
Right Upper Lobe Vein
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The RUL and right middle lobe (RML) veins are identified.
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Dissection is performed along the superior and inferior aspects of the RUL vein.
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The pulmonary artery is directly behind the vein.
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A right-angle clamp passes between the vein and the artery ( Fig. 3-3 ).
