Uniportal VATS pneumonectomy right

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.

After transecting the superior pulmonary vein, the view of the central pulmonary artery is unobstructed. The anterior trunk was already divided in step 4, allowing the entire remaining right pulmonary artery to be prepared here.

Now the preparation in the pulmonary ligament is performed by stretching the lung apically until the lower pulmonary vein is exposed. This can now be bluntly dissected in a circular manner in the known way and then transected using a stapling device after traction.

By gently pulling the lung caudally, the right main bronchus can now be expanded. After circular, blunt dissection, resection can be performed using a stapling device or sharp transection and hand suture.

Note:

• To avoid circulatory disturbances and thus wound healing disorders with severe bronchial stump insufficiency, it is particularly important to use electricity sparingly here.
• To prevent complications, it is important that the bronchial stump is kept as short as possible.

The entire right lung can be removed using an extraction bag through the 3-4 cm incision.

Note:

• Instillagel or similar lubricants can often be very helpful here.
• The use of an extraction bag is mandatory to prevent cell seeding or tearing of the lung parenchyma.

This section demonstrates the endoscopic suture of the bronchial stump using a continuous double-layer technique with PDS 3-0 thread. Alternatively, a stapling device can be used. A short bronchial stump and an atraumatic technique when manipulating the bronchial edges are essential to avoid healing complications. Finally, after treating the bronchus, a leak test with water should always be performed.

To prevent the serious complication of bronchial stump insufficiency, reconstruction and coverage with vital tissue can be performed. Here, thymic fat tissue is prepared from the pericardium until it lies tension-free on the bronchial stump and is then fixed with sutures. The goal is to ensure that the bronchial stump does not protrude uncovered into the pleural cavity.

Note:

• In right-sided pneumonectomies, covering the bronchial stump is advisable, as the necessary coverage is not provided by mediastinal structures as it is on the left side.
• The performance of plastic bronchial stump coverage can be done routinely, but should especially be considered in the presence of risk factors such as metabolic diseases, pre-existing cachexia or protein deficiency, or when adjuvant radio- and/or chemotherapy is required.
• In addition to the thymic tissue shown here, a pedicled pericardial fat flap can also be used for covering the bronchial stump.

Removal of the wound retractor and under direct vision, insertion of a 24 Charrière chest drain at the medial edge of the incision with ventrocranial orientation. After final hemostasis and checking the lung for tightness and ability to expand, the wound is closed. Removal of the wound protection film. Continuous suture of the serratus anterior muscle and the subcutis. Intracutaneous continuous skin suture.