Right Uniportal Video-Assisted Thoracoscopic Surgery and Right Upper Lobe Sleeve Lobectomy

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This video presents a right uniportal video-assisted thoracoscopic (VATS) right upper lobe sleeve lobectomy performed on a 75-year-old man with a synchronous right upper lobe carcinoid tumor and an incidental adenocarcinoma. The patient was a fit elderly man with a background of hypertension, who was asymptomatic and had a good functional status on presentation.  

Physical examination was unremarkable. However, a chest radiograph revealed collapse of the right upper lobe, which was further confirmed by computed tomography of the thorax. Imaging demonstrated a solid endobronchial lesion obstructing the bronchus of the right upper lobe, resulting in complete lobar collapse, with no other abnormalities detected in the remainder of the lung fields. 

Flexible bronchoscopy revealed a well-defined, smooth-surfaced endobronchial mass located at the entrance of the right upper lobe bronchus. Preoperative biopsy confirmed the diagnosis of a typical carcinoid tumor. In light of these findings, a decision was made to proceed with a uniportal VATS right upper lobe sleeve lobectomy. 

The patient was positioned in the left lateral decubitus position at 90 degrees, and a three-centimeter uniportal incision was made. Intraoperatively, the right upper lobe was found to be completely collapsed, with a partially developed fissure. Dissection began with the isolation and division of the A1 branch of the pulmonary artery using a vascular stapler, followed by similar management of the A3 branch. The right upper lobe pulmonary vein was then approached at the hilum and divided.  

The posterior oblique fissure was completed from the confluence of the pulmonary artery. The ascending A2 branch was identified anteriorly, clipped, and divided using an advanced bipolar energy device. The minor fissure was subsequently completed, ensuring that all distal stapler stumps were included in the specimen. 

At this stage, the right upper lobe was fully mobilized, with the bronchus remaining intact. Further dissection exposed the right main bronchus, the right upper lobe bronchus, and the bronchus intermedius. Using a wedge resection technique, the right upper lobe bronchus was divided with clear macroscopic margins, allowing direct visualization of the tumor within the bronchial lumen. The resected lobe was retrieved in an endobag. 

Reconstruction of the bronchial defect between the right main bronchus and the bronchus intermedius was performed using 4-0 barbed sutures, commencing from both ends and tied centrally. An air leak test demonstrated good expansion of the middle and lower lobes without evidence of leakage. A single chest drain was inserted through the uniportal incision. 

Postoperatively, a chest radiograph confirmed good lung re-expansion. The patient was extubated on the operating table and had an uneventful recovery, allowing for discharge on postoperative day three. This highlights the feasibility of enhanced recovery pathways when combining a uniportal minimally invasive approach with coordinated postoperative care. 

Final histopathological examination confirmed a Grade 1 typical carcinoid tumor with clear resection margins. Interestingly, an incidental 6-millimetre lepidic adenocarcinoma was also identified within the collapsed right upper lobe, a lesion that had not been detected on preoperative imaging. 

References

1. Jiao, Zhenhua, Zhe Tang, and Jun Yu. "Tracheal or bronchial wedge resection: Case report." Frontiers in Surgery 10 (2023): 1122075
2. Zhang, Zhi; Fangliang Yuan; Rong Yin; Lin Xu. “Left upper lobectomy with bronchoplasty in uniportal video-assisted thoracic surgery for bronchial carcinoid.” Journal of Visualized Surgery 2 (2016): 84 
3. Rizzardi, Giovanna; Giuseppe Marulli; Fiorella Calabrese; Francesco Sartori; Federico Rea. “Sleeve resections and bronchoplastic procedures in typical central carcinoid tumours.” The Thoracic and Cardiovascular Surgeon 56, no. 1 (2008): 43–47

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