Video-Assisted Thoracic Surgery (VATS)
Left Lower Lobe

Video-Assisted Thoracic Surgery (VATS) is a minimally invasive alternative to conventional open thoracic surgery, associated with enhanced patient-relevant outcomes, whilst maintaining or possibly improving clinical outcomes.

Steps in general

1. After inserting the camera, determine the location of all the incisions from the inside of the chest wall and localize the tumor
2. Dissect using Harmonic technology, scissors, dissector, ring forceps, suction device or Cherry (blunt) dissector
3. Identify & prepare pulmonary artery, superior- and inferior pulmonary vein and the bronchus using waxed Vicryl® (J&J Medical, Ethicon)
4. Introduce and close the Echelon® (straight or flex) endostapler, only when you feel no resistance
5. Reload options: 0,75mm (gray), 1,0mm (white), 1,5mm (blue), 1,8mm (gold) and 2,0mm (green)
Optional: spraying of the staple lines with a sealant (J&J Medical, Biosurgery)
6. Transect the fissure from ventral to dorsal and the vessels & bronchus away from lung tissue
7. Perform test insufflations of the lung before transecting the bronchus
8. Remove the specimen through the access incision
9. Optional: spraying of the staple lines with a sealant (J&J Medical, Biosurgery)
10. Placement and fixation of the chest tube

Incisions

• = Camera, mid-auxiliary 7th or 8th intercostal space (2cm)
• = Ventral, 5th or 6th intercostal space, in line with fissure (2cm)
• = Dorsal, approximately 7 centimeters below the scapula (2 cm)
• = Access (utility incision), front auxiliary at the level of the lung hilus (4 – 5cm)

Instruments

1. Echelon (Straight, Flex, Powered Echelon Flex)™ Endopath® Stapler
(J&J Medical, Ethicon Endo-Surgery)
2. Clip applier (J&J Medical, Ethicon Endo-Surgery)
3. Harmonic ACE® (23cm or 36cm) Ergonomic (J&J Medical, Ethicon Endo-Surgery)
4. Yankauer suction tube
5. Nelson – Metzenbaum scissors
6. Endoscopic vascular clamp (Scanlan)
7. Endoscopic diathermia hook
8. Foerster ring forceps
9. Cherry dissector® (J&J Medical, Ethicon Endo-Surgery)
10. Kantrowitz preparation clamp large

Preparing for lymph node dissection

Preparing for lymphnode dissection in left lower lobe. To the right is the descending aorta. Opening up of the posterior pleura will assist the remaining procedure. The Yankauer is in the subcarinal space. With the Harmonic Ace dissection can be performed without blood loss.

Isolation of the pulmonary vein

The pulmonary ligament is dissected to cranial. Lymph node 9 can be dissected and then the inferior pulmonary vein is isolated.
Before dissecting the vein the fissure is developed first because the inferior pulmonary vein is a
anatomic landmark.

Stapling of the fissure

Dissecting the fissure. The anvil of the stapler is directed right between the superior and inferior
pulmonary vein. Because the anterior port is directly in line with the fissure, the stapler will have the right angle to complete the fissure.

Stapling of the pulmonary vein

By opening the fissure, space is created to dissect the vein. Care is taken not to apply stress on the vein while stapling and not to move the stapler while firing.

Stapling of the bronchus

The fissure is dissected more so that the left lower lobe bronchus and artery are exposed. Because the posterior pleura is already opened with the dissection of lymph node 7, dissection of the bronchus and artery is facilitated.

Stapling of the artery

The segmental arteries to the lower lobe are exposed. Behind the cherry dissector is the lingular
artery. The lower lobe artery can be stapled. If there is a developed fissure it sometimes is possible to take the artery and complete the fissure with one stapler filling.

Completing the fissure

All anatomical structures are divided. Completion of the fissure is accomplished. The stapler is
advanced so that the already started stapling line is continued. Keep a clear view on the posterior
thoracic wall.

Removal of the specimen

The left lower lobe is put into a strong specimen bag. The bag is held up by two ring forceps which
are entering from the anterior side. From the posterior side the lobe is put into the bag. By careful
manipulation the specimen bag with lobe is removed through the utility incision.

Insufflating left upper lobe

The bronchus stump is checked for air leakage. The left upper lobe is insufflated under direct vision. A thoracic drain is left in the thoracic cavity.