Uniportal VATS pneumonectomy right

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 subcutaneous tissue 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.

First, the lung is luxated dorsolaterally, providing a view of the azygos vein. This is then freed from the pleural covering using an electric hook, bluntly dissected circularly, secured with titanium clips, and sharply transected.

Note:

• The resection of the azygos vein can be performed using clips, hand sutures, or a stapling device. Its transection facilitates the subsequent dissection and closure of the right main bronchus, although it is not mandatory.

After opening the mediastinal pleura, an incision with an electrocautery hook and blunt dissection of the mediastinal adipose tissue exposes the view of the lung hilum. Here, the anterior trunk of the central pulmonary artery is directly visible and is circumferentially dissected. The upper pulmonary vein is also clearly recognizable.

After circular presentation and blunt dissection of the anterior trunk, it can be safely transected using an endoscopic stapling device.

Note:

• The separate resection of the anterior trunk is often not possible with more central tumors, but as in this case, it facilitates the resection of the central pulmonary artery.

The superior pulmonary vein is already visible in the situs without further dissection. Typically, the middle lobe vein drains into the superior pulmonary vein and can be clearly identified there.

Note:

• Here, before transection of the superior pulmonary vein, the central pulmonary artery was looped with absorbable suture to avoid injury during resection of the superior pulmonary vein.
• The confluence of the middle lobe vein is not depicted here. Its depiction is not strictly necessary, but during further dissection, attention should be paid to whether it might still be in situ and either drains more centrally into the superior pulmonary vein or into the inferior pulmonary vein.