Single‐port video‐assisted thoracoscopic lobectomy for early‐stage nonsmall cell lung carcinoma

Single-port or uniport video-assisted thoracic surgery (VATS) has been gaining popularity in simple thoracic surgical procedures, such as sympathectomy, and pleural or lung biopsies.1 Recently, a Spanish group reported its successful attempt in performing single-port major lung resections, including lobectomy and pneumonectomy, in the literature.2-4 We describe our approach and surgical technique in single-port VATS right lower lobe lobectomy for early-stage nonsmall cell lung carcinoma. A 58-year-old lady with a 1.6-cm right lower lobe mass underwent right single-port VATS lower lobe wedge resection for frozen section, followed by single-port completion lobectomy and systematic mediastinal lymph node sampling (Fig. 1). The patient received general anaesthesia and double-lumen endobronchial intubation. In the lateral decubitus position, and with the operating table flexed at 30 degrees, the right lung was deflated. The surgeon, first assistant and scrub nurse were positioned on the same side and in front of the patient, while the second assistant was on the opposite side. Following preemptive wound infiltration with local anaesthesia, a 4.5-cm right chest wall incision was made at the sixth intercostal space just anterior to the anterior axillary line. A Weitlaner self-retaining retractor was used to retract open the soft tissue without rib spreading. Using a 10-mm, 120-degree Endocameleon thoracoscope (Karl Storz, Tuttlingen, Germany) and sponge holding forceps, the pleural cavity was inspected for metastasis, and the lesion near the apical segment of the right lower lobe was identified. Minor pleural adhesions between the right middle lobe and anterior chest wall were taken down with a long-tip diathermy pen. Wedge resection of the right lower lobe mass was performed with an Ethicon Echelon Flex 45 Endopath stapler (Johnson & Johnson, New Brunswick, NJ, USA), and delivered in a protective specimen bag. Following the frozen-section confirmation of adenocarcinoma, we proceeded to completion lobectomy through the single port. Ninety-degree, angulated sponge holding forceps provided the lung retraction, and using a specialized distally-angulated, 5-mm endosuction-coagulation cannula (Karl Storz, Germany) the inferior pulmonary ligament was freed, and the inferior pulmonary vein isolated. The major and minor vein branches were then divided using Ethicon Echelon Flex 45 Endopath white vascular staples (Fig. 2). Pleural reflections between the mediastinum and hilum were released with a combination of distally-angulated, 5-mm endodissecting hook electrode and blunt dissection to expose the lower lobe bronchus. The almost-complete oblique fissure down to the lower lobe pulmonary artery, and the absence of interlobar lymph nodes, allowed for the single-staple technique to be employed. The anterior fissure, lower lobe pulmonary artery and bronchus, and posterior fissure were divided in a single-staple line using multiple Ethicon Echelon Flex 45 Endopath blue staples; middle lobe and upper lobe inflation were checked before firing. The completion lobe was delivered in a protective bag. Systematic mediastinal lymph node sampling using distally-angulated, 5-mm endoscissors and endograspers was performed. Inferior pulmonary ligament and subcarinal lymph nodes were sampled, while exploration of the paratracheal area yielded no significant lymph nodes. Haemostasis was secured, and an underwater inflation test showed no air leak. A 24-Fr chest drain was inserted through the single port to the apex, and the lung reexpanded under direct thoracoscopic vision. The port was closed in layers with Vicryl 1, 2/O and subcuticular 3/O. The operative time was 170 min, with 50 mL blood loss recorded. The chest drain was removed on postoperative day 1, and the patient was subsequently discharged without complications. Preoperative positron emission tomography–computed tomography of the right lower lobe lung tumour. Single-port video-assisted thoracic surgery right lower lobe lobectomy. Single-port VATS lobectomy or pneumonectomy is considered by many to be the holy grail of minimally-invasive thoracic surgery major lung resection, by further reducing access trauma compared with standard VATS. Advances in thoracoscope technology with a 120-degree view; specialized angulated, 5-mm dissecting instruments; and angulated endostaplers have, in our experience, been the cornerstone in allowing single-port VATS major lung resection to be performed safely. In contrast, Gonzalez et al.,2, 3 who were the first to describe the single-port lobectomy technique in 2011, used a standard fixed, 30-degree thoracoscope and conventional endoscopic instruments. Although these might be more familiar to the surgeon, the latest angulated endoscopic instruments have the advantage of greatly reducing instrument fencing. In addition, the flexibility of the 120-degree endoscope allows a clear view of the tip of the endostapler and endoinstruments throughout the entire procedure, by providing a 120-degree ‘looking-back-at-yourself view’. This is not possible with a 30-degree endoscope when it is used parallel with the endostapler in the single-port setting. The correct port position in single-port VATS lobectomy is also of paramount importance. We prefer to place the anterior utility incision in single-port VATS lobectomy at one intercostal space that is more inferior to the standard three-port VATS lobectomy to facilitate dissection and lung retraction. Furthermore, the thorax is the ideal body cavity to perform single-port endoscopic surgery, because carbon dioxide insufflation is not required. Therefore, specialized ports designed for single-port VATS surgery are unnecessary. Single-port VATS lower lobe lobectomy can be safely performed with minimal chest wall access trauma. There is usually a steep learning curve for those familiar with three-port VATS lobectomy. The long term results need further investigation. Additional video images may be found in the online version of this article. Visit http://cshk.org/surgical_practice/multi-media_article/Feb_2013_issue_MM25_video.htm