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Arthur Vieira, Paula Ugalde Figueroa, Uniportal middle lobectomy after a previous right upper lobectomy, Interactive CardioVascular and Thoracic Surgery, Volume 24, Issue 3, March 2017, Pages 477–478, https://doi.org/10.1093/icvts/ivw367
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Abstract
Video-assisted thoracoscopic surgery (VATS) using a 3.5 cm single incision (uniportal) may not only result in better pain control, earlier mobilization and shorter hospital stays, but can also provide safer and clear visualization to perform thoracoscopic dissection during complex surgeries. This is a case of a 55-year-old woman who underwent redo-thoracoscopy through uniportal approach for a middle-lobe lobectomy, after a previous right-upper lobectomy.
INTRODUCTION
In the early 1990s, VATS operations were performed through multiple surgical ports. Progressively, surgeons developed the technique to use fewer ports even in complex cases. The 2 ports approach (1 for the camera and 1 as a working incision) was popularized in 2006 [1]. In 2004, the uniportal, or single-port, approach was first described, initially for wedge resection and subsequently, in 2010, for lobectomy [2].
Uniportal VATS is quickly gaining popularity, especially in Asia and Europe. In a propensity-matched analysis, uniportal VATS lobectomy was shown to be equivalent to multiport thoracoscopic lobectomy with the added advantages of better pain control and earlier patient mobilization [3]. Recently, a randomized trial compared uniportal VATS versus other VATS approaches regarding postoperative outcomes [4]. Even though this study was strongly criticized [5], it concluded that uniportal and multiportal VATS have similar outcomes.
CASE REPORT
A 55-year-old woman underwent a uniportal right-upper lobectomy for a stage I pulmonary adenocarcinoma. During follow-up, a 6-mm semi-solid nodule in the middle-lobe progressed to 11 mm. Due to high suspicion of a second primary adenocarcinoma, oncologic workout was completed. The positron emission tomography (PET) scan revealed a nodule with 3.6 standardized uptake value, no hilar or mediastinal lymphadenopathy and no signs of distant metastasis. A transthoracic needle biopsy confirmed an adenocarcinoma. The patient had normal pulmonary function and no previous cardiovascular comorbidities. Surgery was indicated.
Uniportal middle-lobe lobectomy after a right-upper lobe lobectomy. [Copyright 2015, used with permission from CTSNet (www.ctsnet.org). All rights reserved].
The most vital stage of the dissection occurred between the middle lobe vein and the pulmonary artery. Once the middle lobe vein was dissected, we decided to complete the anterior portion of the major fissure so to have better exposure of the hilum. Subsequently, the middle lobe vein was divided with a stapler and vascular load. We then turned our attention to the bronchus. This was a tedious part of the operation since there were important adhesions between the bronchus, lymph nodes and the artery. In this case, it was easier to staple first the bronchus, and at last the middle lobe artery. Fissure was completed and the lobe removed with a plastic bag. As usual, the lymphadenectomy was performed at the stations 4R, 10R and 11R, all sent for frozen analyses. During the patient’s previous right upper lobectomy, lymphadenectomy had been performed in the same stations. Therefore, we did not expect to find important adenopathy. We performed routinely intercostal nerve block and under water insufflation to test for any air leaks.
Pathology report revealed an adenocarcinoma, T1aN0M0, and immunohistochemistry suggested a second primary lung cancer. Patient recovery was uneventful and discharged home 2 days postoperatively.
DISCUSSION
The uniportal approach, as seen in this video, offers an excellent view and exposure, allowing a controlled and safe dissection, even in a previous manipulated pulmonary hilum.
Conflict of interest: none declared.
