CHAPTER 14 Sleeve Lobectomy

Right Middle Lobe Superior Segment – Video 14

Robert J. McKenna, Jr.

Introduction

Surgeons with excellent video skills can perform a standard sleeve lobectomy as video-assisted thoracic surgery (VATS). When a tumor involves the origin of the middle lobe bronchus and the intermediate bronchus or involves the origin of the superior segmental lobe bronchus and the intermediate bronchus, a sleeve lobectomy of the middle lobe and the superior segment of the lower lobe may be a good parenchyma-sparing operation that provides good margins around the tumor. A carcinoid tumor in this location may be a good indication for this procedure, which would avoid a pneumonectomy.

Approach to Video-Assisted Sleeve Lobectomy of the Right Middle Lobe Superior Segment

Order of Operative Steps

The order of the steps of the operation is as follows: right middle lobe (RML) vein, middle lobe artery, minor fissure, major fissure between the middle lobe and the lower lobe, superior segment separated from the basilar segments, superior segmental artery, the major fissure between the superior segment and the posterior segment of the right upper lobe, transecting the intermediate bronchus and the bronchus for the basilar segments, and anastomosis of the basilar segmental bronchus to the intermediate bronchus.

Key Points

♦ Use the standard approach for a RML initially, including the incisions shown in Figure 14-1.

♦ Place a stay suture posteriorly on the basilar segmental bronchus because it retracts into the lower lobe parenchyma and helps oppose the basilar segmental bronchi and the intermediate bronchus.

♦ Take down the inferior pulmonary ligament to minimize tension on the anastomosis.

♦ Place the posterior row of sutures first.

Figure 14-1 Incisions for a sleeve lobectomy of the right middle lobe superior segment.

Video-Assisted Sleeve Lobectomy of the Right Middle Lobe Superior Segment

Step 1. Right Middle Lobe Vein

♦ Exposure: Retract the lung directly posteriorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly toward the hilum.

♦ Dissect between the inferior and superior pulmonary veins to define the inferior border of the RML vein and to determine whether there is drainage from the middle lobe to the inferior pulmonary vein (Figure 14-2).

♦ With DeBakey pickups and Metzenbaum scissors, define the superior aspect of the RML vein.

♦ Pass a right-angle clamp through the utility incision around the RML vein (Figure 14-3).

♦ With the vascular endoscopic stapler introduced from the utility incision or the auscultatory incision, transect the RML vein.

Figure 14-2 Exposure for the right middle lobe vein, superior pulmonary vein, and inferior pulmonary vein.

Figure 14-3 The right-angle clamp passes around the right middle lobe vein.

Step 2. Middle Lobe Artery

♦ Exposure: Retract the lung posteriorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ The RML artery parallels the bronchus and is located just superior and slightly medial to the bronchus (Figure 14-4).

♦ With Metzenbaum scissors, separate the artery from the bronchus.

♦ Pass a right-angle clamp around the artery and spread widely.

♦ Tie or double clip the artery (Figures 14-5 and 14-6).

Figure 14-4 Relationship of the right middle lobe (RML) bronchus and artery.

Figure 14-5 Clips on the right middle lobe artery.

Figure 14-6 The anvil of the stapler is on the artery, and the stapler is held in that position.

Step 3. Minor Fissure

♦ Exposure: Retract the middle lobe posteriorly and slightly inferiorly.

♦ The thoracoscope is aimed anteriorly with the 30-degree lens pointed posteriorly.

♦ Identify the minor fissure.

♦ Pull the middle lobe and upper lobe inferiorly to line up the minor fissure with incision 1 or incision 3.

♦ If the fissure is thick, compress the lung parenchyma with a ring forceps.

♦ Pass the stapler (with a blue or green load cartridge) through either incision toward the lung. Carefully point the anvil of the stapler toward the space between the middle lobe and upper lobe veins. If the stapler is pointed more obliquely, it can tear into the lung parenchyma. Fire the stapler.

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1. Thoracoscopic Sympathectomy
2. Diaphragmatic Plication—Video 32
3. Left Upper Lobectomy – Video 11
4. Pneumonectomy—Video 7

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