Ann Thorac Surg 1998;65:282
© 1998 The Society of Thoracic Surgeons
How to Do It
Fissureless Lobectomy
R. Thomas Temes, MD,
Christopher D. Willms, MD,
Santiago A. Endara, MD,
Jorge A. Wernly, MD
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
Accepted for publication August 27, 1997.
Dr Temes, Department of Surgery, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, NM 87131 (e-mail: ttemes@salud.unm.edu).
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Abstract
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Traditional lobectomy techniques describe division of pulmonary parenchyma within the fissures for access to the pulmonary artery. This results in air leaks, which may prolong chest tube drainage and hospitalization times. We describe a technique for lobectomy in which all lung parenchyma is divided using a stapler.
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Introduction
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Conventional lobectomy is performed by ligation of branches of the pulmonary artery, vein, and bronchus to the lobe. Exposure of the pulmonary artery is by division of lung parenchyma overlying the artery within the fissure [1][2][3]. Although it is routine to complete fissures using staplers, the parenchyma over the artery is usually divided using electrocautery or blunt or sharp dissection. This produces air and fluid leaks, which may prolong chest tube drainage and hospitalization. We describe a technique for exposing the pulmonary artery using staplers for the entire dissection of lung parenchyma.
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Technique
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The techniques differ between right and left sides. The procedure is more easily accomplished on the left side, and the approach is identical for both upper and lower lobe resection (Fig 1).
After ligation of the appropriate pulmonary vein, the pulmonary artery is exposed in the posterior hilum. The periadventitial plane is followed in an anterior and caudal direction using gentle dissection to undermine the major fissure. The superior segmental artery to the left lower lobe and the anterior segment to the upper lobe are identified and protected; the dissection proceeds between these branches to the limits of visualization along the pulmonary artery. The stapler anvil is then introduced into this plane, the stapling arm is placed outside the lung along the fissure, and the parenchyma is divided. Sequential dissection followed by stapling is performed until the division of artery into lingular and basilar branches is reached. The dissection is then carried anteriorly over the bifurcation of the bronchus, protecting the lingular bronchus, and caudal to the superior pulmonary vein or vein stump. The fissure is divided using the stapler, and the remaining steps in the lobectomy are performed routinely.
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Division of left major fissure for left upper or lower lobectomy. (PA = pulmonary artery; PV = pulmonary vein.)
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On the right side the critical anatomic landmark is the posterior segmental artery to the right upper lobe. Regardless of lobectomy to be performed, this vessel may be identified immediately anterior and slightly cephalad to the bifurcation between right upper lobe bronchus and bronchus intermedius when the hilum is approached posteriorly. During right upper lobectomy this vessel may also be identified anteriorly after ligation of the vein and the superior division of the artery.
When the posterior segmental artery is exposed anteriorly for right upper lobectomy, it may be ligated after division of the right upper lobe vein and superior division of the artery (Fig 2). The dissection is directed posteriorly to emerge between the right upper lobe bronchus and bronchus intermedius. The stapler is used to divide the minor and major fissures along this dissection, and the upper lobectomy is completed routinely.
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Right upper lobectomy with anterior approach to posterior segmental artery (SPV). (PA = pulmonary artery.)
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When the posterior segmental artery is exposed from the posterior hilum for right upper lobectomy, ligation of the upper lobe vein and superior arterial division are still performed initially (Fig 3).
The posterior segment artery is identified by dissection between right upper lobe bronchus and bronchus intermedius. It is located anterior and slightly superior to this bifurcation. After identification, the anvil of the stapler is placed immediately caudal to the posterior artery. The other arm is placed over the parenchyma and the stapler is fired. Care is taken to prevent incorporation of the inferior division artery in the stapler jaws. The exposure achieved allows further identification of the posterior segment and inferior division arteries. The dissection is directed forward into the previously dissected anterior hilum, cephalad to the middle lobe vein. The stapler is used to divide the minor fissure, and the remaining steps in the lobectomy are completed.
When the posterior segment artery is exposed posteriorly for lower or middle lobectomy, the major fissure is again divided initially (Fig 4).
The anvil of the stapler is placed immediately caudal to the posterior segment artery. The other arm is placed over the lung parenchyma in the fissure and the stapler is fired. Care is taken to prevent inclusion of the inferior division artery within the jaws of the stapler. The exposure achieved allows further dissection of the inferior division artery and identification of the superior segment and middle lobe arterial branches as well as middle lobe bronchus. The major fissure is gently undermined caudal to the middle lobe arteries and middle lobe bronchus. The dissection is directed anteriorly between lower lobe and middle lobe veins or stumps. The stapler is used to divide the major fissure, and the lower or middle lobectomy is completed.
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Right middle or lower lobectomy with posterior approach to posterior segmental artery. (PV = pulmonary vein.)
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Alternatively, in middle lobectomy the minor fissure may be completed after identification of the plane of the inferior division of the artery. After posterior exposure of the superior segment artery, the anvil is directed anteriorly caudal to the posterior segment and upper division arteries. Care is taken to prevent inclusion of the inferior division artery within the stapler. The dissection is directed into the anterior hilum between the stump of the middle lobe vein and the vein to the upper lobe. The stapler is used to divide the minor fissure. The resultant exposures of the inferior division and middle lobe arteries as well as the middle lobe bronchus allow completion of the major fissure with the stapler. The right middle lobe lobectomy is then performed in a routine fashion.
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Comment
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We have routinely used these techniques in uncomplicated lobectomies for several years. They are easily learned, particularly on the left side, and are often more straightforward than conventional approaches. When the techniques are properly performed, air leaks from divided lung parenchyma are minimal because all lung division is with a stapler. The techniques are applicable to all lobectomies, and modifications may be adapted to less common resections such as segmentectomies. These techniques may allow application of video-assisted lobectomy to patients with incomplete fissures. Furthermore, these techniques do not violate principles of cancer surgery and should not affect postresection survival. However, they may decrease surgical morbidity produced by air and fluid leaks and result in earlier tube removal and hospital discharge.
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References
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- In: Ravitch MM, Steichen FM, eds. Atlas of general thoracic surgery. Philadelphia: Saunders, 1988:224-249.
- In: Urschel HC, Jr, Cooper JD, eds. Atlas of general thoracic surgery. New York: Churchill Livingstone, 1995:152-175.
- In: Hood RM, ed. Techniques in general thoracic surgery. Philadelphia: Saunders, 1985:106-125.
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Abstract
Introduction
