Uniportal VATS Lobectomy Middle Lobe

Incision of approximately 4 cm in length in the area of the anterior axillary line at the upper edge of the 5th rib to access the 4th intercostal space above. A helpful orientation is often an imaginary line from the tip of the scapula to the nipple. Transection of the subcutis on the rib with the monopolar knife. Subsequently, stepwise preparation of the intercostal muscles with the monopolar knife. The pleura is opened bluntly with a finger. Palpation of the thoracic wall for adhesions and insertion of a wound protection film.

With a well-developed fissure, dissection can begin in the interlobar region. Here, superficial layers of the visceral pleura are dissected, and the pulmonary artery in the interlobar region is exposed primarily through blunt dissection.

After visualizing the pulmonary artery, the parenchymal bridges can be gradually dissected. It is essential to always expose and bluntly dissect the interlobar part of the pulmonary artery before the tissue above can be transected. This allows the pulmonary artery to be visualized over a longer section, and the vascular branches and the middle lobe artery can be better identified.

Note:

• In this operation, an arteriovenous malformation with an atypical segment 2 vein is observed, which will be removed as a segment resection in the further course of the operation.

After a good visualization of the central pulmonary artery, the remaining parenchymal bridges between the lower and middle lobes can now be removed. In this case, with only a narrow fissure, resection is performed using bipolar forceps and dissecting scissors.

Note:

• The parenchymal bridges could be transected using electrocautery, a stapling device, or a high-energy device.

After the depiction of the pulmonary artery and resection of the parenchymal bridges, the preparation at the lung hilum is now performed. The upper pulmonary vein is already visible in the situs without further preparation. Usually, the middle lobe vein drains into the upper pulmonary vein and can be clearly identified there. The closure is performed here using titanium clips.