Thoracoscopic en bloc resection of left upper lobe lung cancer.

In this video tutorial we demonstrate our procedure for en bloc resection of the left upper lobe and the regional lymph nodes via video-assisted thoracic surgery in patients with primary lung cancer and outline some key surgical points. First, the operation should start with dissection of the posterior portion of the hilar and lower paratracheal nodes, which will provide excellent visualization of the left recurrent laryngeal nerve and also facilitate dissection of the subaortic and para-aortic (aorto-pulmonary) nodes. Second, the lower paratracheal nodes and aorto-pulmonary nodes should be mobilized together with their dominant lymphatic drainage pathways from the left upper lobe. During this procedure, care must be taken not to divide the peribronchial lymphatic pathway toward the lower paratracheal nodes or the subpleural lymphatic pathway toward the aorto-pulmonary nodes.  By following these guidelines, the left upper lobe and the regional lymph nodes can be resected en bloc without any division of their lymphatic connection. We believe that this procedure will help prevent pleural dissemination as well as prevent the surgeon's missing any metastatic lymph nodes.