Ann Thorac Surg 2011;92:1530-1531. doi:10.1016/j.athoracsur.2011.03.128
© 2011 The Society of Thoracic Surgeons
How To Do It
A New Technique for Dissection of the Pulmonary Vessels
Sadanori Takeo, MD, PhD*,
Shuichi Tsukamoto, MD, PhD,
Daigo Kawano, MD,
Masakazu Katsura, MD
Division of General Thoracic Surgery, Respiratory Center and Clinical Institute, National Hospital Organization Kyushu Medical Center, Fukuoka City, Japan
Accepted for publication March 21, 2011.
* Address correspondence to: Dr Takeo, Department of Thoracic Surgery, National Kyushu Medical Center, Jigyohama 1-8-1, Chuo-ku, Fukuoka City, 810-8563, Japan (Email: sada{at}kyumed.jp).
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Abstract
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The conventional method for dissection of the pulmonary artery and vein has been described repeatedly [1–4]. However these sources have only presented dissection of the sheaths of vessels by exfoliation [1–3]. This article describes a new technique for the safe and rapid dissection of these vessels.
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Introduction
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In open and video-assisted thoracic surgery (VATS), dissection of the pulmonary artery and vein is sometimes performed by blunt dissection [4]. It is difficult to use this method when there is large lymph node swelling along the pulmonary artery.
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Technique
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In this method, we use the Mayo-type scissors for sharp dissection of the pulmonary artery and vein. First, the sheaths on the surface of the central part of the pulmonary vessels are dissected using scissors that measure about 5 mm in length. After the entire circumference of the central part of the vessel is revealed by pushing the vessel aside using scissors, the vessel is then single-ligated with 2-0 silk at the same site (Fig 1A).
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Fig 1. After the central part of the pulmonary artery is ligated with 2-0 silk (A), the portion of the pulmonary artery that is just distal to the first ligation is grasped directly and retracted centrally with vascular forceps (B).
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The range of dissection of the sheaths of the blood vessel is too large, so there is just enough space for the first ligation of the vessel.
The point on the blood vessel that is just distal to the first ligation is grasped directly and retracted centrally with a vascular forceps (Fig 1B). The distal side of the blood vessel is then aggressively exposed with the Mayo-type scissors by dissecting the connective tissue sheaths surrounding the vessel, including the perivascular lymph nodes (Fig 2A). It is important that the entire side of the blood vessel is clearly exposed using the scissors.
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Fig 2. The artery is exposed on the distal side with the Mayo-type scissors by dissecting the connective tissue sheath surrounding the artery (A). This pulmonary artery is ligated at both proximal and distal sides (B).
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When there is no invasion of the blood vessel, such as with a lymph node or a tumor, this procedure can be used to easily expose about 2 cm of a small vessel and more than 3 cm of a slightly larger vessel by dissecting the sheaths with the Mayo-type scissors. We ligated 1 of the more proximal and 1 of the distal vessels (Fig 2B), and then cut the vessel during open segmentectomy and lobectomy.
In video-assisted lobectomy, if the pulmonary artery is large, as is observed in the upper truncus of the pulmonary artery, we use automatic stapling devices for the vessels that have been exposed after the first ligation. If the pulmonary artery is small, as is observed in the left upper lobe branches, these vessels are ligated by ultrasonic cutting shears after exposing them using the same method described earlier.
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Comment
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It is usually taught that the sheaths on the surface of the pulmonary artery are dissected along the vessel longitudinally using scissors and that the tissue around the vessel is grasped while the vessel itself is pushed aside but not grasped. However in the method described here, the vessel is grasped just distal to the first ligation.
When a tumor is close to the pulmonary artery and when it is difficult to expose the pulmonary artery from the surrounding tissue and perivascular enlarged lymph node without direct invasion using the usual method, this procedure can be used to expose it easily. In addition this method is suitable for all pulmonary arteries and veins besides the main pulmonary artery. Another advantage of this method is that it is not a problem if part of the pulmonary vessel is injured during exposure because the proximal part of the vessel is ligated beforehand.
We have performed this technique for open segmentectomy, lobectomy, and pneumonectomy, and it is also useful for video-assisted lobectomy.
However, despite its utility, this method is not used in the case of lymph node or tumor invasion direct to the roots of the arterial branches or when significant inflammatory scarring or severe adhesion of the lymph nodes to the vessels is encountered.
Since 2001 this method has been applied in more than 800 cases of segmentectomy, lobectomy, and pneumonectomy in both open surgery and video-assisted thoracic surgery. None of these patients has had blood vessel injury. Therefore, based on our subjective experience, the length of surgery can be dramatically shortened by this method without compromising the safety or efficacy of the procedure.
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References
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- Fell SC, Decamp Jr. MM. Technical aspects of lobectomyIn: Shields TW, Locicero III J, Reed CE, Feins RH, editors. 7th ed.. General Thoracic Surgery. Vol 1. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. pp. 421-444.
- Roberts JR. The five lobectomiesIn: Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L, editors. Adult Chest Surgery. New York, NY: McGraw Hill; 2009. pp. 530-540.
- Anraku M, Keshavjee S. Lung cancer surgical treatmentIn: Sellke FW, del Nido PJ, Swanson SJ, editors. 8th ed.. Sabiston & Spencer Surgery of the Chest. Vol 1. Philadelphia, PA: Saunders; 2010. pp. 253-277.
- Sihoe ADL. Video-assisted pulmonary resectionsIn: Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW, editors. 3rd ed.. Pearson's Thoracic & Esophageal Surgery. Vol 1. Philadelphia, PA: Churchill Livingstone; 2008. pp. 970-988.
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Abstract
Introduction
