Perioperative management - Uniportal VATS sleeve resection of the right upper lobe

The indication for a sleeve resection essentially corresponds to the "former" indications of a pneumonectomy, when lung tissue can be preserved through a sleeve resection:

• Tumors with growth at the origin of the lobar bronchus and infiltration of the adjacent main bronchus
• Tumors involving the bronchus intermedius or proximal lower lobe bronchus
• N1 lymph node involvement with infiltration of the lymph nodes into the bronchial wall

• Lack of cardiopulmonary reserve for a lung resection procedure
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic concept regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

• Oncological Diagnostics

In case of suspected bronchial carcinoma, the staging examinations outlined in the guidelines should be performed before any surgery.

• Computed tomography of the thorax with upper abdomen, contrast-enhanced
• PET-CT
• MR of the skull
• Bronchoscopy
  • Note: Preoperative bronchoscopy by the surgeon is recommended, especially to recognize anatomical norm variants of the bronchial system.
• Cardiopulmonary Endurance

The assessment of cardiopulmonary endurance and estimation of postoperative outcomes is a very important and sometimes challenging aspect of thoracic surgery. Based on the algorithms of the ERS (= European Respiratory Society) and ESTS (= European Society of Thoracic Surgeons), the following procedure has proven effective:

• Basic diagnostics: Medical history, ECG
  • If there is an indication of increased perioperative cardiac risk ('Revised-Cardiac-Risk-Index"), further cardiological evaluation is necessary.
  • If there is a discrepancy between the anamnesis-based resilience (climbing stairs, gardening, walking) and the parameters of lung function tests, the results should be critically questioned and the tests repeated if necessary.
• Lung function: Diffusion capacity (DLCO), body plethysmography (FEV1)
  • FEV1 and DLCO >80% of the predicted value allows surgery up to pneumonectomy from a lung function perspective.
  • FEV1 and DLCO <80% require further diagnostics using spiroergometry and determination of maximum oxygen uptake (VO2max)
    • If VO2max > 20ml/kg/BW (>75%), surgery up to pneumonectomy is possible from a lung function perspective.
    • If VO2max < 10ml/kg/BW (< 35%), surgery is contraindicated.

Especially in cases of VO2max 10-20ml/kg/BW or limiting cardiac preconditions, in addition to further diagnostics (e.g., perfusion scintigraphy, "lung segment counting"), an interdisciplinary individual case decision with experienced colleagues is essential.

• Shaving of the right thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Anastomotic insufficiency, bronchial fistula requiring intervention, possibly also re-operation
• Anastomotic stenosis requiring intervention, possibly re-operation
• Postoperative air fistula due to lesions of the lung parenchyma
• Postoperative lymph fistula with chylothorax
• Postoperative hemorrhage with possibly necessary re-operation
• Conversion to thoracotomy and possibly extension of the resection, approach depending on intraoperative findings
• Injury to adjacent structures, especially the trachea and main bronchi, large vessels, and the esophagus, necessitating appropriate extension of the procedure
• Damage to the phrenic nerve with diaphragmatic elevation on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paresis on the affected side
• Positioning injuries
• Cardiac arrhythmias

Alternative treatment: In case of oncological diagnosis, definitive radiochemotherapy

Intubation anesthesia with one-lung ventilation of the opposite side.

For standard positioning in minimally invasive thoracic surgical procedures, the extended lateral position is recommended.

• Bending of the operating table at the level of the scapula tip
• Horizontal alignment of the thoracic wall using slight anti-Trendelenburg positioning
• Stabilization of the position using padded side supports in the area of the abdomen and lumbar spine, as well as a U-shaped pillow between the legs. It may occasionally be helpful to use an additional shoulder support.

Finally, it is important to pad pressure-sensitive areas and place the head on a gel ring to avoid excessive bending of the cervical spine. The arm on the operating side is positioned laterally using an arm holder and should be placed below shoulder level to avoid potential obstruction during the subsequent operation.

The arrangement as shown in the picture of the surgeon and assistant ventrally and opposite the OR nursing staff was described by the Copenhagen working group led by Hendrik Hansen. Especially in uniportal VATS but also in 3-port VATS, optimal work can be performed here through the anterolateral minithoracotomy.

• Wound protection ring foil (wound retractor)
• Standard VATS instrumentation with curved instruments
  • An ultrasonic scalpel can be helpful for bloodless and thus clear dissection.
• Endoscopic stapling device
  • Staple cartridges with a curved tip assist in the gentle bypassing of smaller vessels.
  • In emphysematous lung tissue, staple line reinforcement is advisable before parenchyma transection.
• Titanium clip applicator

• Postoperative Analgesia

Due to the pain caused by the indwelling chest drain, a combination analgesia of a non-opioid analgesic (e.g., Metamizole) in combination with a low-dose opioid (e.g., Tilidine) is advisable. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Management of Acute Perioperative and Posttraumatic Pain.

• Medical Follow-up
  • X-ray control on the operating table
  • Chest drain with suction 20mmHg for approximately 2 days postoperatively, removal after X-ray control if secretion volume is under 250ml/24h and without evidence of an air fistula
  • Bronchoscopic anastomosis control on the 1st and 6th postoperative day.
• Thrombosis Prophylaxis

Standard thrombosis prophylaxis for 14 days with low molecular weight heparin subcutaneously, considering comorbidities, renal function, and laboratory control to exclude HIT. Link to the current guideline: Prophylaxis of Venous Thromboembolism (VTE)

• Mobilization

Full mobilization possible from the 1st postoperative day

• Physical Therapy

Mobilization, breathing exercises, and secretion mobilization

• Dietary Progression

Regular diet

• Bowel Regulation

Accompanying opioid analgesia

• Work Incapacity

Approximately 14 days, considering the type of work and patient situation