Unidirectionally progressive left pneumonectomy & mediastinal lymph node dissection

Abstract

The patient has lower left lung tumor and adenocarcinoma at the openings of both upper and lower left lung. Preoperative bronchoscopic biopsy has confirmed the diagnosis. The surgical approach is unidirectionally progressive left pneumonectomy + mediastinal lymph node dissection. The layers of structure are treated one after another until the fissure from a single direction through the working port. Hence, the resecting order should be left superior pulmonary vein-left lower pulmonary vein-left main bronchus-left pulmonary artery. The vessels and bronchi are cut using an endoscopic linear stapler or the Hemolock clips. The resected lobe is placed into a large-size specimen bag and retrieved through the working port to prevent contamination of the chest incision by any tumor tissue. Mediastinal lymph node dissection is performed at the end. The surgery is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in a 90-degree position lying on the unaffected side. Similar to traditional resection of left lung lobes, an approximately 1.5-cm observation port is created in the 7th intercostal space between the middle and anterior axillary lines, an approximately 4-cm working port in the 4th intercostal space between the anterior axillary line and the midclavicular line, and an approximately 1.5-cm auxiliary port in the 9th intercostal space between the posterior axillary line and the subscapular line. The operator stands in front of the patient, manipulating the endoscopic instruments while watching the monitor.

Keywords: Thoracoscopic operation; left pneumonectomy; unidirectionally progressive.

Video 1

Unidirectionally progressive left pneumonectomy & mediastinal lymph node dissection.

Figure 1

Chest AP. AP, anterior posterior.

Figure 2

Chest lateral.

Figure 3

Neoplasms at the openings of both upper and lower left lung on bronchoscopy.

Figure 4

Repeat CXR before discharge.

Figure 5

Retraction is performed with suture after the separation of the left superior pulmonary vein at the hilus. The suture is pulled over the linear stapler.

Figure 6

The left upper pulmonary vein stump after separation.

Figure 7

After the separation of the left lower pulmonary vein at the inferior pulmonary ligament, retraction is performed with suture, and the suture is pulled over the linear stapler.

Figure 8

The left lower pulmonary vein stump after separation.

Figure 9

After the separation of the left main bronchus at the hilus, retraction is performed with suture. The suture is pulled over the linear stapler, and the stapler is closed. Lung expansion testing is carried out via ventilation to confirm absence of air in the left lung, and the bronchus is then cut.

Figure 10

Stump of the cut bronchus.

Figure 11

After the separation of the left pulmonary artery at the hilum, retraction is performed with suture, and the suture is pulled over the linear stapler.

Figure 12

Stump of the cut left pulmonary artery.

Figure 13

The left lung has been completely resected, and put into the large-size specimen bag.

Figure 14

Retracted, and the operation is completed.