Biportal complete video-assisted thoracoscopic lobectomy and systematic lymphadenectomy

Abstract

The video-assisted thoracoscopic approach (VATS) for lobectomy of non-small-cell lung cancer (NSCLC) has not been standardized. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out via only two incisions. This video demonstrates a case undergoing biportal complete VATS (biportal cVATS) right upper lobectomy and systematic lymphadenectomy. Here we describe our technique of biportal approach by using a combination of conventional and endoscopic instruments. As our experience gained, we consider the knacks of biportal cVATS lobectomy imply two radical changes of perspectives from the traditional triportal technique. One fundamental step is how to achieve satisfactory exposure in the case of single utility incision for multiple instruments to insert. Another technical tip that should be taken into account is how to introduce staplers conveniently without the third posterior port. Optimization of the whole procedures is critical for accomplishing anatomic hilar vascular, bronchial, and lymphatic dissection via two ports. In conclusion, biportal cVATS lobectomy for lung cancer is a safe and reliable procedure that can achieves good postoperative results without oncological compromise.

Keywords: Complete video-assisted thoracoscopic surgery (cVATS); biportal lobectomy; lung cancer; systematic lymphadenectomy; uniportal lobectomy.

Figure 1

A shadow in the right upper lobe. (A) lung window; (B) mediastinal window.

Video 1

Biportal complete video-assisted thoracoscopic (cVATS) right upper lobectomy and systematic lymphadenectomy.

Figure 2

Soft tissues are retracted by silk only for utility incision.

Figure 3

A combination of conventional (A) and endoscopic (B) instruments.

Figure 4

The location of endostapler (A) and the thoracoscope (B) are interchangeable between two incisions for the resection of superior pulmonary vein.

Figure 5

Surgical image of right 2 and 4 dissection. (A) View from above azygos vein and (B) view from under azygos vein. (a) vagus nerve; (b) trachea; (c) aortic arch; (d) superior vena cava; (e) azygos vein; (f) stump of right upper bronchus; (g) stump of truncus anterior.

Figure 6

Surgical image of right 7 dissection. (a) azygos vein; (b) right main bronchus; (c) left main bronchus; (d) esophagus; (e) left atrium.

Figure 7

Single-chest tube placed in the thoracoscopy port up to the tip of the thoracic cavity.

Figure 8

Postoperative result of the incisions.

Figure 9

Bi-manual instrumentation showing “cross hand technique” in biportal procedure, more commonly used in uniportal procedure. (a) operator right hand; (b) operator left hand.