INDICATIONS/CONTRAINDICATIONS

Sleeve lobectomies performed by video assisted thoracic surgery (VATS) are a natural evolution of VATS procedures from simple procedures, such as wedge resections, to advanced procedures. The indications for VATS sleeve lobectomies are the same as the indications for open sleeve lobectomies: Centrally located tumors that require resection of a bronchus or artery to obtain clear margins around a tumor. Contraindications for VATS sleeve lobectomies include inability to assess if the patient needs a pneumonectomy or sleeve resection, difficulty with the anastomosis, or surgeon’s discomfort. I usually perform vascular sleeve resections via thoracotomy because of the danger if a vascular clamp slips off the artery.

PREOPERATIVE PLANNING

Preoperative planning includes the standard workup for evaluation of pulmonary tumors. A chest CT scan with contrast helps to determine the relationship of the tumor to the pulmonary vessels, although intraoperative dissection is the ultimate determinate. A PET scan is done to evaluate for nodal or distant metastatic disease. Pulmonary function test determines that the patient is physiologically operable, although the lobe to be removed is often nonfunctional or minimally functional because the function of a lobe for sleeve lobectomy is usually reduced because the tumor has obstructed the lumen of the bronchus.

Surgery (Figures 41.1–41.8)

The patient receives antibiotics and DVT prophylaxis. Preoperative bronchoscopy is done for biopsy and to determine where the bronchus needs to be cut to obtain clear margins. If the mass has the typical brown–purple appearance of a carcinoid, a biopsy can be carefully obtained, but carcinoid tumors can be very bloody. If the bronchial mucosa is edematous or if the bronchial margin of the tumor is unclear, then multiple biopsies should be obtained to determine where the bronchus should be transected for the sleeve resection.

Mediastinoscopy is performed on the same day as the sleeve lobectomy. A complete node dissection is performed; this is only possible with the use of the video mediastinoscope. All the tissue from the superior vena cava to the trachea, from the pulmonary artery to the innominate artery, is removed and sent to pathology as level 2 and 4 lymph nodes. The dissection continues in the subcarinal space with blunt dissection on the posterior wall of the pulmonary artery, left main stem bronchus, right main stem bronchus, and the esophagus. This removes all the subcarinal nodes and mobilizes the right main stem bronchus in preparation for the sleeve resection.

Positioning

The patient is intubated with a double-lumen endotracheal tube. It should be contralateral to the side of the tumor (e.g., right-sided tube for a left-sided tumor). The patient is then placed in the lateral decubitus position with a slight posterior tilt.

Incisions

The incisions for a sleeve lobectomy are seen in Figure 41.1. Incision 1 is 2 cm long. It is made directly over an interspace and is tunneled posteriorly so instruments pass easily through the incision and directly into the major fissure. The incision is made as far inferiorly and medially as possible, usually in about the 6th intercostal space and one space below the mammary fold. A 5-mm re-usable trocar with a 5-mm, 33-degree thoracoscope pass through the 8th intercostal space in the posterior axillary line. Incision 3 (the utility incision) is a 4-cm incision that goes anteriorly from the edge of the latissimus muscle. It is made directly up from the superior pulmonary vein. That location is determined by pressing on the chest wall while looking with the thoracoscope up at the chest wall and then down at the hilum with the chest wall to pick the correct interspace. The 4th incision is made 4 fingerbreadths below the tip of the scapula and slightly posteriorly. It should be made directly over an interspace so that instruments pass easily into the chest.

Technique for Right Upper Lobe Sleeve Lobectomy

Level 10 nodes

Retract lung posteriorly and inferiorly

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