Technical aspects of biportal video-assisted thoracoscopic left S1+S2 segmentectomy of the lung

General principles

As a rule we perform video-assisted thoracoscopic (VATS) anatomic segmentectomies through a biportal approach, including a 3–4 cm anterior utility incision and another 1.5 cm inferior port.

We utilize a 5 or 10 mm, 30 degree angled HD video-thoracoscope.

The surgeon and the assistant are usually positioned on the anterior (abdominal) side of the patient. The surgeon can change position and place himself cranially or caudally with respect to the assistant depending on the different steps of the operation.

Initially, the anterior utility incision is made and the wound is protected by a plastic soft tissue retractor (wound protector) kept in place by a ring in the chest cavity and one outside the skin (Alexis Retractor, Applied Medical USA). This incision is usually placed at the 4^th–5^th intercostal space between the tip of the scapula and the breast in the anterior axillary line.

A second 1.5 cm port is positioned more posteriorly at the level of the 7^th intercostal space just anterior to a straight line down from the tip of the scapula and is performed under endoscopic guidance using the thoracoscope through the utility incision made previously.

Operative steps (Figure 1)

Figure 1 Technical aspects of biportal video-assisted thoracoscopic left S1+S2 segmentectomy of the lung (1). Available online: http://www.asvide.com/article/view/25711

In case of the left S1+2 segmentectomy, the whole procedure can be performed with the thoracoscope placed through the inferior port. The upper lobe is retracted anteriorly throughout the procedure and the dissection is performed from posteriorly as demonstrated on the video. After identification of the nodule, dissection starts from the fissure using energy device. The posterior aspect of the fissure is divided with the use of endoscopic stapler. The segmental arteries for the posterior and apical segments are dissected and divided using endoscopic stapler. In the case presented, there was a single arterial branch.

After division of the artery, the bronchial division for the apico-posterior segment (B1+2) is exposed and dissected free from lymph nodes and surrounding tissues. Usually we clamp the bronchus and the anesthetist is asked to inflate the lung. The bronchus is isolated and divided using endoscopic stapler. As shown in the video the stapler is passed through the utility port.

Final step of the procedure is the division of the segment with serial linear staplers after identification of the intersegmental plane. This is accomplished through the inflation-deflation line. The specimen is then removed using an endobag. Finally a systematic lymph node sampling is performed. As shown in the video, dissection of the V1+2 vein is not necessary.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery for the series “Uncommon Segmentectomies”. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jovs.2018.06.22). The series “Uncommon Segmentectomies” was commissioned by the editorial office without any funding or sponsorship. AB served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Visualized Surgery from Dec 2016 to Nov 2018. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Brunelli A, Konstantinidis K. Technical aspects of biportal video-assisted thoracoscopic left S1+S2 segmentectomy of the lung. Asvide 2018;5:603. Available online: http://www.asvide.com/article/view/25711