1. Troubleshooting Video-Assisted Thoracic Surgery Lobectomy
Todd L. Demmy, MD, Ted A. James, MD, Scott J. Swanson, MD, Robert J. McKenna, MD, Thomas A. D'Amico, MD 
The Annals of Thoracic Surgery 
Volume 79, Issue 5, Pages (May 2005)
DOI: /j.athoracsur

2. Fig 1
Video-assisted thoracic surgery lobectomy incision placement. The lines represent two different access incision options: the inferior facilitates dissection in the major fissure during lower lobe resections; the superior option allows optimal direct viewing of the superior pulmonary vein and apical pulmonary artery branches during upper lobectomies. Inset shows articulating endoscopic linear cutter essential for this technique. It is important to note that the function of each incision can change throughout the case (see Table 1). For instance, it is sometimes best to manipulate the tissue through the camera port and put the video camera through the access incision. It is important for the working incision to be very anterior and in line with the major fissure.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )

3. Fig 2
Video-assisted thoracic surgery lobectomy tools. Endoscopic instruments can be useful in large thoracic cavities; however, standard instruments are good choices because of their availability and familiar handling properties. The retractor shown is only used to spread the soft tissues of the chest wall without rib spreading. A Weitlaner retractor may also be used. A large blunt right-angle clamp is a favorite of the lead author. (a) Large right angle; (b) modified Babcock; (c) pediatric Tuffier; (d) extraction sac (5 × 8 inches).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )

4. Fig 3
Selected video-assisted thoracic surgery lobectomy maneuvers. For practicality, all the maneuvers are shown with the patient positioned in the left lateral decubitus position as if to undergo a right-sided procedure. The same maneuvers can be performed mirror-image for left-sided work. At least one example of an interior view is provided for each. (A) Medial viewing and inferior holding of lung to allow dissection through the access incision. Example shows dissection of the apical hilum. (B) Medial viewing and access holding of lung to allow stapling of hilar structures from below. Example shows division of the apical pulmonary artery trunk to the right upper lobe (upper lobe branch of vein divided and reflected away). (C) Standard viewing and use of working port to dissect and divide structures while lung is retracted through access incision. Example shows use of stapler to divide pulmonary artery to right lower lobe. (D) Standard viewing and use of working port to retract lung and access incision to dissect structures; this is commonly used to dissect the pulmonary artery in the major fissure. Example shows inferior pulmonary vein after the pulmonary ligament was divided by this maneuver. (E) Standard viewing and use of access incision to deliver stapler to divide fissures. Example shows division of the posterior fissure between the right lower lobe and the upper lobe.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )