1. Video-Assisted Thoracic Surgery Lobectomy
Michael S. Mulligan, MD 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 17, Issue 2, Pages (June 2012)
DOI: /j.optechstcvs
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2. Figure 1
The first incision is made anteriorly at approximately the sixth intercostal space (working port). The other incisions are for the camera (mid-axillary line at approximately the eighth intercostal space) the retraction port (in the auscultatory triangle) and the access incision is created in the mid-axillary line at the level of the superior pulmonary vein for upper lobe resections and one space lower for middle and lower lobe resections.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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3. Figure 2
The exposure for lower lobe resections is enhanced by placing a diaphragmatic traction stitch in the central tendon and delivering it out through the camera port.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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4. Figure 3
Creation of lobar separation with partial completion of the fissures allows enhanced exposure of hilar structures with parenchymal retraction. LLL, left lower lobe; LUL, left upper lobe.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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5. Figure 4
If a nodule is present but a tissue diagnosis is not achieved, a simple wedge resection can be planned through a two-port approach. RUL, right upper lobe.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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6. Figure 5
This is generally achieved with two instruments passed through the anterior working port. When needed, retraction is added with side-by-side use of the clamp next to the camera.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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7. Figure 6
The lung is retracted posteriorly and the pleura is opened along the anterior hilum.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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8. Figure 7
The left superior pulmonary vein is circumferentially dissected and controlled in preparation for ligation and division.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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9. Figure 8
The stapler is passed from the auscultatory triangle port and the retraction on the vein anteriorly allows for safe stapling with protection of the pulmonary artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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10. Figure 9
The first branch of the pulmonary artery to the left upper lobe is circumferentially controlled, looped and prepared for stapling from the auscultatory triangle port. A, artery; LLL, left lower lobe; LUL, left upper lobe; V, vein.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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11. Figure 10
After ligation and division of the first two arterial branches, the bifurcation of the left mainstem bronchus to upper and lower lobes is cleared by removing fatty and lymphatic tissue from the saddle of this bifurcation. LLL, left lower lobe; LUL, left upper lobe; PA, pulmonary artery; V, vein.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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12. Figure 11
After circumferential control of the bronchus is achieved, the stapler is passed from the upper access incision to allow cooptation of the membranous airway to the cartilaginous airway as the stapler is fired. LLL, left lower lobe; LUL, left upper lobe; PA, pulmonary artery; V, vein.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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13. Figure 12
The superior trunk of the pulmonary artery to the right upper lobe is divided by passing the stapler through either the anterior working port or the auscultatory triangle port. PA, pulmonary artery; RUL, right upper lobe; V, vein.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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14. Figure 13
After division of the vascular supply to the right upper lobe, the bronchus is taken with a stapler passed from either the auscultatory triangle port or the anterior working port. RPA, right pulmonary artery; RUL, right upper lobe.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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15. Figure 14
Having divided the mid-lobe venous drainage, the middle lobe bronchus is circumferentially controlled and taken with a stapler through the access incision. PA, pulmonary artery; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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16. Figure 15
Having achieved control of the pulmonary artery branches to the lower lobe, they are divided with a vascular stapler passed through anterior working incision. Care must be taken to make sure the branches to the basilar segments as well as the superior segment are included in the staple line firing. LLL, left lower lobe; PA, pulmonary artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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