Table 1: Open in new tab Examples of...

Procedure

Surgical steps

Lower lobectomy

Expose the pulmonary artery and divide the fissure
Expose and encircle the pulmonary artery ready for stapling
Expose and divide the lower lobe bronchus
Expose and divide the pulmonary ligament
Dissect, encircle and divide the inferior pulmonary vein
Complete the fissure
Remove mediastinal lymph node

Middle lobectomy

Dissect and divide the middle lobe vein
Dissect the middle lobe of the bronchus
Dissect the fissure between the lobes
Divide the middle lobe of the bronchus
Dissect and divide the branches of the pulmonary artery
Dissect the hilum
Divide the horizontal fissure of the middle lobe

Upper lobectomy

Dissect the upper lobe vein and anterior trunk of the pulmonary artery
Staple the anterior trunk of the pulmonary artery and of the upper lobe vein
Dissect and staple the upper lobe bronchus
Dissect and staple the posterior ascending branch of the pulmonary artery
Staple the fissure between the middle lobe and the upper lobe and the fissure between the lower and the upper lobes

Thymectomy

Enter the right chest
Mobilize the thymus and the thymic fat from the diaphragm
Release the thymus from the inferior pericardium, in a caudal to cranial direction
Dissect closely up to the superior vena cava and then mobilize the thymus off the right phrenic nerve up and beyond the right internal mammary vein
Dissect the pleura off the sternum following the medial to the right internal mammary artery
Dissect the thymus off the innominate vein
Dissect out the right superior horn of the thymus over the innominate artery then the trachea
Dissect out the left superior horn
Open the left pleura
Dissect the thymus off the right side of the pericardium up to the left phrenic nerve
Dissect up the medial to the left phrenic nerve
Dissect out the thymus and thymic fat from under the innominate vein and any fat tucked under the left phrenic nerve
Remove the thymus in a bag
Insert drain and inflate lungs and potentially remove drain at the end of the procedure

Diaphragm plication

Mobilize lung
Place first horizontal mattress suture in the middle of the diaphragm
Place a line of horizontal mattress sutures laterally and posteriorly, keeping the diaphragm as tight as possible
Place a line of horizontal mattress sutures medially and anteriorly
Test tightness with instruments and add additional sutures to any loose areas
Insert a single chest drain

Table 1:

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Examples of surgical steps in end-to-end procedures

Procedure	Surgical steps
Lower lobectomy	Expose the pulmonary artery and divide the fissure Expose and encircle the pulmonary artery ready for stapling Expose and divide the lower lobe bronchus Expose and divide the pulmonary ligament Dissect, encircle and divide the inferior pulmonary vein Complete the fissure Remove mediastinal lymph node
Middle lobectomy	Dissect and divide the middle lobe vein Dissect the middle lobe of the bronchus Dissect the fissure between the lobes Divide the middle lobe of the bronchus Dissect and divide the branches of the pulmonary artery Dissect the hilum Divide the horizontal fissure of the middle lobe
Upper lobectomy	Dissect the upper lobe vein and anterior trunk of the pulmonary artery Staple the anterior trunk of the pulmonary artery and of the upper lobe vein Dissect and staple the upper lobe bronchus Dissect and staple the posterior ascending branch of the pulmonary artery Staple the fissure between the middle lobe and the upper lobe and the fissure between the lower and the upper lobes
Thymectomy	Enter the right chest Mobilize the thymus and the thymic fat from the diaphragm Release the thymus from the inferior pericardium, in a caudal to cranial direction Dissect closely up to the superior vena cava and then mobilize the thymus off the right phrenic nerve up and beyond the right internal mammary vein Dissect the pleura off the sternum following the medial to the right internal mammary artery Dissect the thymus off the innominate vein Dissect out the right superior horn of the thymus over the innominate artery then the trachea Dissect out the left superior horn Open the left pleura Dissect the thymus off the right side of the pericardium up to the left phrenic nerve Dissect up the medial to the left phrenic nerve Dissect out the thymus and thymic fat from under the innominate vein and any fat tucked under the left phrenic nerve Remove the thymus in a bag Insert drain and inflate lungs and potentially remove drain at the end of the procedure
Diaphragm plication	Mobilize lung Place first horizontal mattress suture in the middle of the diaphragm Place a line of horizontal mattress sutures laterally and posteriorly, keeping the diaphragm as tight as possible Place a line of horizontal mattress sutures medially and anteriorly Test tightness with instruments and add additional sutures to any loose areas Insert a single chest drain

Procedure	Surgical steps
Lower lobectomy	Expose the pulmonary artery and divide the fissure Expose and encircle the pulmonary artery ready for stapling Expose and divide the lower lobe bronchus Expose and divide the pulmonary ligament Dissect, encircle and divide the inferior pulmonary vein Complete the fissure Remove mediastinal lymph node
Middle lobectomy	Dissect and divide the middle lobe vein Dissect the middle lobe of the bronchus Dissect the fissure between the lobes Divide the middle lobe of the bronchus Dissect and divide the branches of the pulmonary artery Dissect the hilum Divide the horizontal fissure of the middle lobe
Upper lobectomy	Dissect the upper lobe vein and anterior trunk of the pulmonary artery Staple the anterior trunk of the pulmonary artery and of the upper lobe vein Dissect and staple the upper lobe bronchus Dissect and staple the posterior ascending branch of the pulmonary artery Staple the fissure between the middle lobe and the upper lobe and the fissure between the lower and the upper lobes
Thymectomy	Enter the right chest Mobilize the thymus and the thymic fat from the diaphragm Release the thymus from the inferior pericardium, in a caudal to cranial direction Dissect closely up to the superior vena cava and then mobilize the thymus off the right phrenic nerve up and beyond the right internal mammary vein Dissect the pleura off the sternum following the medial to the right internal mammary artery Dissect the thymus off the innominate vein Dissect out the right superior horn of the thymus over the innominate artery then the trachea Dissect out the left superior horn Open the left pleura Dissect the thymus off the right side of the pericardium up to the left phrenic nerve Dissect up the medial to the left phrenic nerve Dissect out the thymus and thymic fat from under the innominate vein and any fat tucked under the left phrenic nerve Remove the thymus in a bag Insert drain and inflate lungs and potentially remove drain at the end of the procedure
Diaphragm plication	Mobilize lung Place first horizontal mattress suture in the middle of the diaphragm Place a line of horizontal mattress sutures laterally and posteriorly, keeping the diaphragm as tight as possible Place a line of horizontal mattress sutures medially and anteriorly Test tightness with instruments and add additional sutures to any loose areas Insert a single chest drain

Carbon dioxide was used for insufflation.

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