(2)
Department of Thoracic Surgery, Peking University People’s Hospital, No.11 Xizhimen South Street, Beijing, 100044, China
6.1.1 Overview of Sleeve Lobectomy
In 1947, Price Thomas performed the first sleeve lobectomy for a patient diagnosed as pulmonary carcinoid of right main stem bronchus. And the first successful right upper lobe sleeve lobectomy was performed by Allison, and this was the first time to perform sleeve lobectomy for patient with lung cancer.
The sleeve lobectomy for lung cancer used to be thought of as a compromised operation, because some patients could not permit pneumonectomy for a low pulmonary function. Many studies have conformed that sleeve lobectomy could reduce the postoperative risks and loss of pulmonary function. With the development of surgical technique, sleeve lobectomy should be considered firstly for centrally located lesions of non-small cell lung cancer. The sleeve lobectomy consists of the resection of lobe with tumor and circumferential segment of the adjacent main stem bronchus, and then anastomosis of the proximal and distal bronchial resection edges, with or without resection of pulmonary parenchyma and vascular structures. It is a parenchyma-sparing surgical strategy of resection, and widely adopted with the double aim of ensuring the completeness of tumor resection and preserving lung function.
When the tumor involved the main or lobar bronchus, the sleeve lobectomy could be considered as a treatment plan. Non-small cell lung cancer is the most common indications for sleeve lobectomy when dealing with tumors which involved bronchus. Sleeve lobectomy can be performed in any lobe, but the right upper lobe sleeve lobectomy is the most common surgery. There are two explanations for this situation: the first is that the long bronchus intermedius makes it easier to anastomose the bronchial stump. Another is that the low incidence rate of lymphatic metastasis around the middle lobe bronchus. The sleeve lobectomy of left upper lobe is the second most common site. As a challenging surgery, it is very important to protect of the aorta and left recurrent nerve during this operation. When the pulmonary artery is involved, the vascular sleeve resection should be performed.
The common types of sleeve lobectomy including: (a) Tumor involving the right upper lobe orifice with or without hilar lymph node metastasis requiring bronchial sleeve resection of the right upper lobe; (b) Tumor involving the left upper lobe orifice with or without hilar lymph node metastasis requiring bronchial sleeve resection of the left upper lobe; (c) Tumor involving the left lower lobe orifice with or without hilar lymph node metastasis requiring bronchial sleeve resection of the left lower lobe; (d) Peripherally located tumor in the right upper lobe or left upper lobe with hilar lymph node metastasis; (e) Involvement pulmonary artery or vein with one of the situations mentioned above which needs partial or circumferential vascular resection and reconstruction. Involvement of the pleura, superior vena cava, atria, or transverse aortic arch is the contraindication of sleeve lobectomy. R0 resection for sleeve lobectomy is important for low incidence of local recurrence (Figs. 6.1 and 6.2).
Fig. 6.1
Illustration of the most common types of sleeve resections
Fig. 6.2
(a) Illustration of sleeve lobectomy by VATS (simple interrupted suturing of the posterior bronchial wall). (b) Illustration of sleeve lobectomy by VATS (simple continuous suturing of the membranous portion of the bronchial membrane)
6.1.2 Overview of VATS Sleeve Lobectomy
Video-assisted thoracoscopic surgery (VATS) lobectomy has been proven as a minimally invasive, safe, and feasible surgical approach for early-stage non-small cell lung cancer. However, the VATS have been usually thought not suitable for patients requiring sleeve resection for the operation difficulty. In 2002, Santambrogio and colleagues performed the first VATS sleeve lobectomy of left lower lobe for a 15-year-old female patients with low-grade mucoepidermoid carcinoma. In 2008, Mahtabifard and colleagues first reported a series study of VATS sleeve lobectomy.
In recent years, VATS sleeve lobectomy developed for lung cancer in selected patients is proven technically feasible and safe. The distinguishing feature of VATS sleeve lobectomy is bronchial anastomosis after the resection of the lobe with tumor, However, VATS sleeve lobectomy should be performed in comparatively experienced centers.
6.1.2.1 Preoperative Examinations
The most important preoperative examinations for potential candidates of sleeve lobectomy is flexible bronchoscopy, because the flexible bronchoscopy could demonstrate the endobronchial tumor extension and define the boundary of the sleeve resection. Meanwhile, the biopsies could be performed during the bronchoscopy examination to confirmed malignant tumor. Radiographic examinations should be also performed in potential patients to evaluate the situation of the tumor and the mediastinal lymph nodes. The preoperative staging examinations should be taken in all candidate patients to exclude local advanced lesions or distant metastasis (e.g. chest CT, brain magnetic resonance imaging, abdominal ultrasound or CT scan, bone scintigraphy, or PET-CT). We should ensure the pulmonary function testing could tolerate a pneumonectomy.
6.1.2.2 Anesthesia and Airway Management
The sleeve lobectomy surgery was performed under general anesthesia. The proximity of the tumor to the carina should be taken into consideration for the choice of endotracheal tube. The most common way of airway management is the using of double-lumen endotracheal tube to conform the single-lung ventilation. When the bronchial anastomosis is performed close to the carina, high-frequency positive pressure ventilation or jet ventilation should be taken into consideration. Intraoperative bronchoscopy performed by the anesthetist is helpful to inspect the anastomosis so that the surgeon could rectify the suture in time.
6.1.2.3 Surgical Technique
At the beginning of the operation, the exploration of the lesions by VATS should performed to conform the feasibility of the sleeve resection. Extensive nodal or bronchial wall involvement should be excluded. The proximal of the pulmonary artery and vein should be controlled firstly during the sleeve lobectomy. And then, division of the lobar artery and vein, and the mediastinal lymph nodes were dissected. As a routine for oncological surgery, the right side VATS sleeve lobectomy should include lymph node stations 2R, 2L, 4R, 4L, 7, 8, 9, 10L, 10R, 11, 12; and 4L, 5, 6, 7, 8, 9, 10R, 10L, 11, 12 for the left side. The resection of involved bronchus and removal of the lobe was followed the main stem bronchus was divided first, and then the bronchus intermedius was divided using endoscopic scissors.
The anastomosis of the bronchus should be performed with tension-free reconstruction. Frozen sections of the incisal margins must be confirmed negative before suture. If the tumor invades the pulmonary artery, resection and reconstruction of the pulmonary artery should also be performed. As reported in literatures, the patients who received sleeve lobectomy by VATS had less operation time, less chest tube time, less hospitalization time and less postoperative pain.
6.2 Right Upper Sleeve Lobectomy by Complete Video-Assisted Thoracic Surgery
(3)
Department of Thoracic Surgery, Peking University People’s Hospital, No.11 Xizhimen South Street, Beijing, 100044, China
6.2.1 Abstract
The sleeve lobectomy with bronchial or pulmonary vascular reconstruction was once one of the relatively contraindication in VATS. The surgical technical advances and the experience gained make it possible to perform the sleeve lobectomy by VATS in some experienced centers. The bronchial anastomosis is the core technology of VATS sleeve lobectomy. The bronchial anastomosis was performed by simple continuous suturing for the membranous portions of the bronchus and by simple interrupted suturing for the cartilaginous portions of the bronchus, respectively. The bronchial anastomosis began with the suturing of the posterior wall and a knot was tied to minimize anastomotic tension between the proximal and distal bronchial stumps. The right upper lobe is the most common location for sleeve lobectomy. If the patients meet the inclusion criteria of sleeve lobectomy, they may gain from all the advantages of minimally invasive techniques.
6.2.2 Anesthesia and Preoperative Preparation
6.2.2.1 Anesthesia and Airway Management
Surgery was performed under general anesthesia with single lung ventilation. The patient should be intubated with a left double-lumen endotracheal tube during the surgery. High-frequency positive pressure ventilation was used whenever bronchial anastomosis is performed close to the carina.
6.2.2.2 Patient Position
The patient should be set in the lateral position with arm hanging down. Surgeon stood at the abdominal side of the patient.
6.2.2.3 Trocar Position
After single lung ventilation, three trocars were inserted. The observation port was located in the seventh inter-costal space in right median axillary line. The incision made at the level of the fourth inter-costal space in the anterior axillary line was the main operation port. The additional operative port was in the level of the seventh inter-costal space in the subscapularis line (Fig. 6.3).
Fig. 6.3
Schematic diagram for patient position and incision location for right upper sleeve lobectomy of VATS: camera port at the seventh intercostal space, median axillary line; utility incision at the fourth intercostal space, anterior axillary line; additional operative port at the seventh intercostal space, ubscapularis line
6.2.3 Surgical Procedures
6.2.3.1 Mobilization and Dissection of the Mediastinal Pleura
Once the thoracoscopy has been placed in the thoracic cavity, the thoracic exploration should be performed to conformed the sleeve lobectomy could be done with R0 resection. At first, the right lower lobe was pulled in a cephalad direction by the ring forceps and then the inferior pulmonary ligament was divided.
The lung was retracted laterally and anteriorly and the posterior mediastinal pleura were incised up to the azygos vein level, meanwhile the bronchial artery was dissected carefully (Fig. 6.4).
Fig. 6.4
Schematic diagram for sleeve lobectomy of the right upper lobe: the posterior mediastinal pleura was incised up to the azygos vein level
And then we pulled the parenchyma into the posterior thoracic cavity by the ring forceps which placed from the auxiliary operation port.
The anterior mediastinum pleura was dissected by electrotome between the pulmonary vein and the phrenic nerve. The azygos vein could be preserved if the tumor or the metastatic lymph nodes did not affect the operation (Fig. 6.5).
Fig. 6.5
Schematic diagram for sleeve lobectomy of the right upper lobe: the mediastinal pleura between the pulmonary vein and the phrenic nerve were incised
6.2.3.2 Lobectomy of the Right Upper Lobe
We exposed the right superior pulmonary vein and divided them by the staplers. A ring forceps was placed holding the right upper lobe for a cephalad traction, electrocautery was used to dissect the border between the horizontal fissure and the oblique fissure (Fig. 6.6).
Fig. 6.6
The right superior pulmonary vein was divided
Then the mid-segment of the pulmonary artery adventitia was dissected in the incised fissure. We build an artificial tunnel in the lung fissure and then the minor fissure was divided by the staplers through the seventh inter-costal space of the right mid-axillary line. And then, the posterior ascending branch arising from the superior segmental artery of the right lower lobe was dissected by the using of 4-0 sutures. The apico-anterior artery and the posterior oblique fissure were divided by the staplers (Figs. 6.7, 6.8, and 6.9).
Fig. 6.7
The minor fissure was divided by the staplers
Fig. 6.8
Dissection of the posterior ascending branch artery
Fig. 6.9
Dissection of the apico-anterior artery
The surrounding connective tissue of the right main bronchus and the intermedius bronchi was removed. Stations 2, 4, 7, 8, 9, 10 and 11 lymph nodes were dissected before dissection of bronchus. It is beneficial for the anastomosis without tension. The specimen was packed into a surgical glove and then extracted through the fourth inter-costal space incision in the anterior axillary line. Then the right main stem bronchus and the bronchus intermedius were divided using scissors and a scalpel. Frozen sections of the margin of the right main bronchus and the bronchus intermedius were negative of tumor infiltration as confirmed pathologically during surgery (Fig. 6.7, 6.8, 6.9, 6.10, 6.11, and 6.12).
Fig. 6.10
Dissection of surrounding connective tissue of the right main bronchus
Fig. 6.11
The right bronchus intermedius was divided by using scissors
Fig. 6.12
The right main stem bronchus was divided by using the scissors
6.2.3.3 Anastomosis of the Bronchus Ends
The end-to-end bronchial anastomosis was then performed. When we deal with the membranous portions of the bronchus, the simple continuous suturing should be used. And for the cartilaginous portions of the bronchus, the simple interrupted suturing was recommended (Fig. 6.13).
Fig. 6.13
Bronchial stump of the right middle segmental bronchus and right main bronchus
The first step was to suture the posterior wall of bronchus, the simple interrupted suturing with 3-0 absorbable sutures was used in the process of the anastomosis, and a knot was tied to minimize the tension of the anastomotic bronchus (Fig. 6.14).
Fig. 6.14
Posterior bronchial wall, with anastomosis of simple interrupted 3-0 absorbable sutures
Then we should anastomose the membranous portion of the bronchus and the simple continuous 4-0 non-absorbable sutures were used for this process. The anastomosis was from the deepest portion of the posterior bronchial wall to mid-point of the anterior bronchial wall, which was tagged without making a knot (Fig. 6.15).
