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Two-port approach for fully thoracoscopic right upper lobe sleeve lobectomy
© Jiao et al.; licensee BioMed Central Ltd. 2013
Received: 20 January 2013
Accepted: 15 April 2013
Published: 17 April 2013
This report describes a case report of a minimally invasive technique for VATS right upper sleeve lobectomy with a two-port approach. To our knowledge it is the first report of this kind. A 50-year-old man with a pulmonary nodule occluding the orifice of the right upper lobe bronchus was referred to our department. Dissection, stapling the right upper lobe pulmonary vessels and anastomosis between the right intermediate and the right main bronchus were performed via the two port. To deal with blocking of pulmonary artery and obtain a satisfactory exposure and manipulating space in the course of bronchial anastomosis were the key points. Intraoperative blood loss was 150 ml and total operative time was 220 minutes. The postoperative course was uneventful. Chest X-rays showed no sign of atelectasis. Postoperative histopathological examination revealed that the tumor was T3N0M0 squamous cell carcinoma. The patient was discharged from hospital on postoperative day 9 without any complications. We conclude that video-assisted thoracoscopic sleeve lobectomy with mediastinal dissection by two-port approach is feasible and convenient.
Video-assisted thoracoscopic surgery is appealing alternative to thoracotomy due to numerous advantages . However, only a few reports exist on VATS sleeve lobectomy [2–4]. In most of these, bronchial anastomoses were accomplished in an open surgical technique through a minithoracotomy. This report describes a minimally invasive technique for VATS right upper sleeve lobectomy with a two-port approach.
The chest is then irrigated, and the anastomosis is checked for an air leak under water. A single chest tube was placed and the incisions were closed. The total surgery time was 220 min, including 60 minutes for performing the anastomosis. Estimated intraoperative blood loss was 150 mL.
Most of the thoracic surgeon performed VATS lobectomy using 3 to 4 ports, including a utility incision measuring about 3–5 cm and 2 to 3 other ports. Actually, the lobectomy may be successfully carried out using only two ports as the technique described by Burfeind and D’Amico . There are few teams in the world that carry out this procedure and the largest series of this procedure is at Duke Medical Center D’Amico’s group which reports on an extensive series of 500 cases [6, 7]. Two-port lobectomies are a consequence of greater skills acquired with experience. Borro and his colleagues reported that the realisation of two ports should neither prolong estimated operative time nor hinder cleaning of the lymph nodes, nor increase the likelihood of surgical or postoperative complications .
Sleeve lobectomy has been almostly absolute indication for conversion to thoracotomy until recently. The anastomosis was created partially or totally under direct vision. The first case report on a VATS sleeve lobectomy was given by Santambrogio and colleagues in 2002 . The maximum report with 13 patients who underwent VATS sleeve lobectomy was published in 2008 by McKenna and colleagues . Schmid and his colleagues report on a combined robotic and VATS approach for a true minimally invasive right upper sleeve lobectomy .
We began performing fully VATS lobectomies in June 2009. Up to October 2012, we undertook 260 major pulmonary resections by VATS, including lobectomy, bilobectomy, segmentectomy and sleeve lobectomy. The first 90 cases were operated on using three ports, but since March 2010, we started to perform fully VATS lobectomies and complete lymph node dissections using only two-port in almost all cases. In our literature review, we have found no reports of sleeve lobectomy performed through a two-port.
This case shows the technical feasibility and safety to do a VATS sleeve lobectomy with only two-port. Theoretically, this approach may produce less pain and less immunologic response due to less invasive. Moreover, obviating the posterior incision may reduce the possibility of hemorrhage of chest wall muscles. Further studies will be required to identify any quantifiable advantage of two-port approach.
Although an advanced technique is required for full thoracoscopic surgery by two-port, it is feasible to perform VATS sleeve lobectomy via this approach.
Written informed consent was obtained from the patient for publication of this report and any accompying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to thank our histopathology and radiology departments for providing the specimens and images shown.
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