Ma Qianli, Liu Deruo
Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing 100029, China.
J Vis Surg. 2016 Jan 18;2:18. doi: 10.3978/j.issn.2221-2965.2016.01.03. eCollection 2016.
Video-assisted thoracic surgery (VATS) is a new technology for nearly 30 years in the field of thoracic surgery most watched. However, there are still some controversy concerning the technical difficulties, operation duration, the extent of lymph node dissection and perioperative complications for VATS sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus).
A 66 years old man was admitted for coughing for 2 months. He had smoked for 30 years, 20 packs a day. Chest computed tomography (CT) revealed a 2.5 cm × 4.5 cm mass in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Pathology was squamous cell carcinoma. His pulmonary function result was forced expiratory volume in 1 second (FEV): 1.91 L (64.7% predicted), forced vital capacity (FVC): 4.36 L. He received general anesthesia with double-lumen endotracheal intubation and left lung ventilation. Left lateral decubitus position was chosen. The first 1.5 cm incision was selected in the eighth intercostal space in the midaxillary line, and was used for the camera. A 4 cm long incision was made in the 3 intercostal space in the preaxillary line. A third 1.5 cm incision was performed in the 9 intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire right hilum were mobilized. Pulmonary vein is the most forward hilar structure, sometimes immediately prior pulmonary trunk. The right upper lobe vein was transected with a vascular stapler. Truncus and posterior ascending pulmonary artery were then divided and transected with a vascular stapler. Major and minor fissures were stapled by 60 mm green linear stapler. Following clearance of the mediastinal lymph nodes of level 7, 4R and 2R, the bronchial sleeve resection and reconstruction began. The distal right main bronchus and bronchus intermedius were fully mobilized to ensure adequate surgical exposure. Traction sutures were routinely placed on the lateral walls and to reduce tension. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures.
There were no complications and the patient was discharged 8 days postoperatively.
The 3 intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, providing convenient conditions for easy anastomosis. And avoid the operator fatigue for keeping the posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for satisfied explosion of the right main bronchus, the upper lobe bronchus and bronchus intermedius. And this would avoid pulling bronchial anastomosis for mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.
电视辅助胸腔镜手术（VATS）是近30年来胸外科领域备受关注的一项新技术。然而，在处理局部晚期中央型肺癌（累及气管和/或主支气管）时，VATS袖状支气管肺叶切除术在技术难度、手术时长、淋巴结清扫范围及围手术期并发症等方面仍存在一些争议。
一名66岁男性因咳嗽2个月入院。他有30年吸烟史，每天20包。胸部计算机断层扫描（CT）显示右上叶有一个2.5 cm×4.5 cm的肿块。支气管镜检查显示肿瘤阻塞右上叶支气管并累及右主支气管和中间支气管。病理为鳞状细胞癌。他的肺功能结果为第1秒用力呼气量（FEV）：1.91 L（预测值的64.7%），用力肺活量（FVC）：4.36 L。他接受双腔气管插管全身麻醉和左肺通气。选择左侧卧位。在腋中线第8肋间选择第一个1.5 cm切口用于放置摄像头。在腋前线第3肋间做一个4 cm长的切口。在腋后线第9肋间做第三个1.5 cm切口用于助手操作。游离肺韧带和整个右肺门。肺静脉是肺门最靠前的结构，有时紧位于肺动脉干之前。用血管吻合器切断右上叶静脉。然后用血管吻合器分离并切断肺动脉干和后升支。用60 mm绿色直线型吻合器缝合主、次裂。在清扫第7、4R和2R组纵隔淋巴结后，开始支气管袖状切除和重建。充分游离右主支气管远端和中间支气管以确保足够的手术视野。常规在侧壁放置牵引缝线以减轻张力。支气管吻合选择间断缝合。先缝合支气管膜部，然后用3-0可吸收缝线进行端端圆周吻合。
无并发症发生，患者术后8天出院。
建议在前腋线第3肋间进行右上叶支气管袖状切除。该切口可缩短吻合口与切口之间的距离和角度，为便于吻合提供有利条件。并避免术者因长时间保持姿势而疲劳。在切断支气管前清扫纵隔淋巴结有助于充分暴露右主支气管、上叶支气管和中间支气管。且可避免因清扫纵隔淋巴结而牵拉支气管吻合口。间断缝合对VATS支气管吻合安全有效。
