RUL The Day of Video-Assisted Thoracic Surgery

by Brie Eteson, Digital Surgery

Performing a Right Upper Lobectomy

Lung cancer is one of the most commonly diagnosed cancers in the world.1,2 A lobectomy can be performed for the treatment of lung cancer. This surgical procedure involves the removal of one of the five lobes of the lungs. It is particularly successful in cases of early-stage lung cancer.3

Lung cancer can be categorized into two major categories: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). The treatment options for most early-stage NSCLCs involve surgical lung resection, but for more advanced stages, multimodal therapy is considered.4

The type of resection performed depends on several factors, including the location, type, and size of the tumor.5 Various approaches can be used to perform lung resections. This simulation depicts a textbook video-assisted thoracic surgery (VATS) to the right upper lobe, where there is an adenocarcinoma in posterior segment 2, adjacent to fissure segment 6. The surgery consists of an anatomical resection, dividing the necessary branches of the pulmonary vein and artery, and the lobar bronchus. Mediastinal lymphadenectomy is also performed for cancer staging.

VATS and robotic-assisted thoracic surgery (RATS), unlike open thoracotomy, are minimally invasive procedures, which have been shown to result in fewer major complications, shorter recovery time, and reduced length of hospitalization.6,7,8 Lobectomies are considered safe and effective for NSCLC.9,10

This procedure involves many complicated and intricate objectives that are briefly outlined in this blog. For a more in-depth demonstration, featuring both animation and surgical video, head over to the Touch Surgery™ app.

Key Surgical Objectives

Patient Positioning and Preparation

After confirming the operative side of the patient, the right side in this case, the patient is positioned in left lateral decubitus, with the right arm on an armboard to ensure the operative side is exposed. The right lung is isolated, and the left lung is ventilated. The patient is then prepped and draped.

Port Placement 

Incision sites are marked at the following anatomical locations: just below the inferior tip of the right scapula, at the anterior edge of the latissimus dorsi muscle, between the tip of the scapula and underarm (for the utility port), and at the 4th intercostal space parallel to the ribs.

Examination of the chest cavity, via the utility port is performed once a wound protector is inserted. 

Both the posterior port and camera port are placed at the top level of the diaphragm, remaining at the upper level of the rib to avoid damaging the intercostal nerve. With the posterior port at the intercostal space, 15 mm parallel to the ribs, and the camera port aligned with the anterior edge of the utility port.

Patient Positioning in left lateral decubitus

Right lung isolation and left lung ventilation

Adhesion dissection on the chest wall

Adhesion Dissection is performed after inspection of the chest wall, entire lung, and adjacent structures. Any adhesions to the chest wall are identified and dissected at this stage.

Paravertebral Block is applied at intercostal spaces 2-9 by injecting the chest with Marcaine*.

Inferior Pulmonary Ligament Dissection is possible after the lungs are retracted cranially to allow for easier manipulation of the lung. Any level 9 lymph nodes present should be removed at the base of the inferior pulmonary ligament and sent for histology.

Tumor Identification is now possible and inspection occurs. Retracting the lung posteriorly exposes the anterior surface of the hilum.

Hilar Dissection

The mediastinal pleura surrounding the anterior and superior aspect of the hilum is dissected and divided to expose the superior pulmonary vein and truncus anterior (TA). Dissection continues along the azygos vein further facilitating the dissection of the TA.

Right Upper Lobe Vascular (RUL) Isolation begins with the dissection and isolation of the superior pulmonary vein until the venous drainage of the RUL is identified. The right middle lobe is isolated for preservation, working from superior to inferior, until the first venous branch to the middle lobe is encountered. There is great variation of the middle lobe vein. To learn more, see the full simulation in the app.

A right-angled clamp inserted behind the superior pulmonary vein is used to isolate drainage to the RUL before a staple, vessel loop, or silk tie is placed around its upper lobe branches to divide it.

Tissue around the TA is dissected to isolate the artery before dividing it. The posterior ascending pulmonary artery (A2) is identified, and the middle lobe and the A2 artery are dissected between for isolation.

Dissection and isolation of the superior pulmonary vein from the overlying pleura

Horizontal Fissure and A2 Dissection is performed, ensuring the stapling is maintained along the fissure line. Once the A2 is better exposed, it is isolated and divided.

Horizontal fissure dissection

Bronchial Dissection

Posterior to the A2 is the bronchus. Careful dissection starts on the surrounding tissue, and as the dissection gets deeper, blunt dissection is used to create passage around the airway. A vessel loop is used to encircle the bronchus, then a stapler transects it. Remaining lymphatic tissue around the bronchus is also dissected.

Completing the Horizontal Fissure is performed once the RUL is elevated for visualization, allowing full transection. 

Specimen Retrieval

The transected lobe is placed into a specimen retrieval bag, before removing it from the cavity.

Removal of Level 2 and 4 Lymph Nodes

The station 2 and 4 lymph nodes are located deep between the bronchus, the superior vena cava, and the azygos vein. Careful dissection of the pleura under the azygos vein exposes the station 4 lymph nodes. Following exposure, the branches of the superior vena cava are dissected and divided. This dissection continues along the pericardium and bronchus, incising pleura along the azygos vein and superior vena cava. The station 2 and 4 lymph nodes and surrounding fatty tissue are excised en bloc and removed through the utility port.

Removal of Level 7 Lymph Nodes

The lung is then retracted anteriorly to expose the hilar surface, allowing mobilization of the pleura along the posterior hilum to identify the level 7 lymph node packet. Dissection begins in the subcarinal space along the esophagus and left main bronchus and continues along the left main bronchus to the carina. The lymph node packet and surrounding fatty tissue is dissected and removed en bloc from the chest cavity through the utility port to be sent for histology.

Excision of the station 2 and 4 lymph nodes

An Intercostal Catheter is placed in the intercostal space, connected to a pump with continuous infusion of Marcaine*. 

Underwater Test

The lung is then rinsed, and the cavity is filled with sterile water to check for air leaks. The cavity can be drained once the surgeon is satisfied no air leaks are present.

Chest Tube Insertion is placed under monitoring via a thoracoscope inserted into the utility port. The chest tube is inserted via the original camera port and is positioned posteriorly towards the apex of the chest, following the curve of the chest. The right lung can then be inflated under vision. The chest tube is secured to the skin using a suture. 

Closure

The port sites are then closed using a suture. To learn more about the closure of port sites, and the differences in muscles, subcutaneous, and skin layers, search for the full simulation to view the breakdown of these steps.

Chest tube insertion

This simulation was authored by René Horsleben Petersen.

For more on the instrumentation, alternatives, and loads of handy tips on the main objectives, go to the VATS Right Upper Lobectomy simulation in the Touch Surgery™ app today!

Launch in App

or scan the QR code below.

How to cite this simulation: Petersen RH. VATS Right Upper Lobectomy. Touch Surgery Simulations. http://dx.doi.org/10.18556/touchsurgery/2021.s0182. Published May. 6, 2021.

References

1. National Cancer Institute. Common Cancer Types. Website. https://www.cancer.gov/types/common-cancers. Updated April 22, 2021. Accessed May. 5, 2021.

2. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975–2018. National Cancer Institute, posted to the SEER website, Updated Apr. 2021. Accessed May. 5, 2021.

3. Lynne Eldridge. Lobectomy Complications and Prognosis. Very Well Health Website. https://www.verywellhealth.com/lobectomy-complications-and-prognosis-2249329. Updated Nov. 5, 2020. Accessed May. 5, 2021.

4. Lackey A, Donington JS. Surgical management of lung cancer. Semin Intervent Radiol. 2013;30(2):133-140.

5. American Cancer Society. Surgery for Non-Small Cell Lung Cancer. Website. https://www.cancer.org/cancer/lung-cancer/treating-non-small-cell/surgery. Updated Oct. 1, 2019. Accessed May. 19, 2021.

6. O’Sullivan KE, Kreaden US, Hebert AE, Eaton D, Redmond KC. A systematic review and meta-analysis of robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy. Interact Cardiovasc Thorac Surg. 2019;28(4):526-34.

7. Montagne F, Bottet B, Sarsam M, et al. Robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy. Mini-invasive Surg. 2020;4(17).

8. Ma J, Li X, Zhao S, Wang J, Zhang W, Sun G. Robot-assisted thoracic surgery versus video-assisted thoracic surgery for lung lobectomy or segmentectomy in patients with non-small cell lung cancer: a meta-analysis. BMC cancer. 2021;21(1):1-6.

9. Petersen RH, Hansen HJ. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg. 2010;37(3): 516-520.

10. Petersen RH, Hansen HJ. Learning curve associated with VATS lobectomy. Ann Cardiothorac Surg. 2012;1(1): 47-50.

11. Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach – The Copenhagen experience. Ann Cardiothorac Surg. 2012;1(1): 70-76.

12. Wildgaard K, Petersen RH, Hansen HJ, Møller-Sørensen H, Ringsted TK, Kehlet H. Multimodal analgesic treatment in video-assisted thoracic surgery lobectomy using an intraoperative intercostal catheter. Eur J Cardiothorac Surg. 2012;41(5): 1072-1077.

13. Laursen LØ, Petersen RH, Hansen HJ, Jensen TK, Ravn J, Konge L. Video-assisted thoracoscopic surgery lobectomy for lung cancer is associated with a lower 30-day morbidity compared with lobectomy by thoracotomy. Eur J Cardiothorac Surg. 2016;49(3): 870-875.