World J Surg (2010) 34:616–620

DOI 10.1007/s00268-009-0340-8

Video-Assisted Thoracic Surgery (VATS) Lobectomy:

Focus on Technique
Raja M. Flores

Published online: 16 January 2010

Ó Société Internationale de Chirurgie 2010

Abstract Conclusions Standardized VATS lobectomy is feasible,

Background A clear definition of video-assisted thoracic expeditious, and safe. This standardized three-incision
surgery (VATS) lobectomy is lacking in the current peer- technique utilizing a 4-cm utility incision without rib
reviewed literature. Reported cases vary from four to six spreading may allow valid comparisons of conventional
incisions in number, 4.0 to 10.0 cm in length, and with and procedures in clinical trials.
without rib spreading; in addition, they include direct
visualization through a utility incision. Described is a
Introduction
complete standardized three-incision thoracoscopic tech-
nique that maximizes the benefits of minimally invasive
Video-assisted thoracoscopic surgery (VATS) lobectomy
surgery without compromising oncologic principles.
describes a technique of performing a minimally invasive
Methods Patients with clinically suspected stage I non-
lobectomy. However, there is no universally accepted stan-
small-cell lung cancer (NSCLC) were selected for VATS
dard definition. Yim et al. conducted a survey of minimally
lobectomy on the basis of thoracic computed tomography.
invasive thoracic surgeons in an effort to define their criteria
VATS lobectomies were performed using a standardized
for a VATS lobectomy [1]. The results varied greatly; the
three-incision technique: a 2-cm camera port, a 2-cm
numbers of incisions varied from three to five, the utility
posterior port, and a 4 cm utility incision without rib
incision ranged from 4 to 10 cm, and the avoidance of rib
spreading. Hilar structures were individually ligated, fis-
spreading was not standard. A number of surgeons perform
sures were completed, and lymph node dissection was
the procedure using direct visualization through the utility
performed entirely under thoracoscopic visualization.
incision, using the thoracoscope merely as a light source,
Results From May 2002 to December 2009, VATS
whereas others perform the procedure under total thoraco-
lobectomy was performed successfully in more than 600
scopic visualization. The ideal VATS lobectomy should
patients at our institution. There were no operative deaths,
maximize the benefits of minimally invasive surgery, thereby
and the median length of stay was 4 days.
minimizing chest wall trauma using the smallest and fewest
incisions possible without compromising standard surgical
oncologic principles. We have developed a standardized
This work was presented at the Eric Rose Festschrift of the John Jones approach at our institution among seven attending surgeons
Society of Columbia University.
and would like to standardize the approach universally to
R. M. Flores conduct multicenter clinical trials evaluating quality of life,
Department of Cardiothoracic Surgery, Cornell University survival, and the role of VATS in a multimodality setting.
Medical School, New York, NY, USA

R. M. Flores (&) Methods

Thoracic Service, Department of Surgery, Memorial Sloan-
Kettering Cancer Center, 1275 York Avenue, Room C-879,
New York, NY 10021, USA Patients were selected for VATS lobectomy on the basis of
e-mail: [email protected] clinical stage I non-small-cell lung cancer (NSCLC) by

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computed tomography (CT) and lack of nodal involvement A frequent pitfall in port placement for VATS lobec-
by positron emission tomography (PET). The technique is tomy is to place the utility incision at the anterior location
performed under total thoracoscopic visualization. Three of a possible posterolateral thoracotomy incision so that if
incisions are used: a 4-cm utility incision without rib conversion is required a separate incision is not made.
spreading, a camera port, and a retraction port that is later However, this assumption places the utility incision at too
used for chest tube placement. Dissection is carried out in low a position, thereby greatly increasing the likelihood of
an anterior-to-posterior fashion using standard thoracic an unsuccessful VATS lobectomy.
dissecting instruments through the utility incision. Hilar
structures are individually ligated, and an ipsilateral hilar Right upper lobectomy
and mediastinal lymph node evaluation (sampling or dis-
section) is performed. The superior pulmonary vein is dissected from the
overlying pleura via the access incision in the same
Operative technique manner as in an open lobectomy using long Metzenbaum
scissors and DeBakey forceps. A Harken clamp is passed
Patient positioning and port placement behind the superior pulmonary vein after clear identifi-
cation of the middle lobe vein. The superior pulmonary
The patient is placed in the maximally flexed lateral vein is then encircled with a monofilament tie and
decubitus position tilted slightly backward to prevent the retraced upwardly via the utility incision. An empty
hip from obstructing downward movement of the thora- sponge stick is then placed through the utility incision,
coscope. First, the camera port is placed at the eighth and the upper lobe is retracted posteriorly. An endovas-
interspace along the anterior axillary line for right-sided cular stapling device is placed through the posterior port
lesions and along the posterior axillary line for left-sided and, using the monofilament suture as a guide, is passed
lesions, thereby avoiding the apex of the heart. The pos- behind the superior pulmonary vein. Once the pulmonary
terior port is placed where the lower lobe edge touches the vein has been divided, the truncus arteriosus is visualized.
diaphragm (approximately at the eighth interspace). A Dissection is performed, and level 10 lymph nodes are
retractor is placed through the posterior port, and the upper removed. Once the entire artery is visualized, a Harken
lobe is retracted laterally to allow visualization of the clamp is passed, and a monofilament suture is placed
superior pulmonary vein. A utility incision (no larger than behind the artery and brought through the utility incision.
4 cm in length) is placed perpendicular to the anterior The endovascular stapler is passed though the posterior
axillary line directly over the superior pulmonary vein for port to transect the vessel. Transection of the truncus
upper lobectomies (approximately at the third or fourth artery branch exposes the right upper lobe bronchus.
interspace) and one interspace lower for middle and lower Dissection is performed to separate the ongoing pul-
lobectomies. The soft tissues of the utility incision are monary artery from the bronchus. A monofilament suture
separated by means of a Weitlaner retractor to facilitate is passed around the bronchus and retracted through the
passage of instruments in and out of the chest and to avoid utility incision. A universal 4.8-mm stapler is placed
loss of pneumothorax when suction is applied (Fig. 1). through the posterior port, and the right upper lobe
bronchus is transected. This exposes the recurrent (pos-
terior ascending) branch of the pulmonary artery, which
is transected in the same fashion through the posterior
port. Once all the structures to the upper lobe have been
divided, the fissure is assessed. A retractor placed through
the posterior port is used to retract the middle and lower
lobes inferiorly, and a retractor though the utility incision
retracts the upper lobe superiorly. Once the fissure is
exposed, universal 4.8-mm staplers are placed through the
utility incision to complete both minor and major fissures.
The lobe is then placed in a lap-sac and removed via the
utility incision (Table 1).
The surgical concept involving dissection of hilar
structures—passing a monofilament suture around the
structure and transection with a stapler—is similar for all
lobes. However, the sequence of transecting structures and
Fig. 1 Port placement the ports where staplers are passed differs.

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Table 1 Sequence of structure transection of right upper lobectomy Table 3 Sequence of structure transection of right middle lobectomy
Right upper lobectomy Stapler port Right middle lobectomy Stapler port

1. Superior vein Posterior 1. Middle vein Utility

2. Truncus artery Posterior 2. Bronchus Utility
3. Bronchus Posterior 3. Middle lobe arteries (1, 2) Utility
4. Recurrent artery Posterior 4. Fissures Utility
5. Fissures Utility

Left upper lobectomy

Right lower lobectomy The left upper lobe is retracted laterally, and the vein is
transected from the posterior port. The first apical branch
The lower lobe is retracted superiorly; the inferior pul- of the pulmonary artery is dissected, and further exposure
monary ligament is transected; and the level 9 lymph nodes is obtained by removing the level 10 nodes. The first apical
are removed. Once the entire inferior pulmonary vein has arterial branch is transected via the posterior port. The
been dissected, a stapler is placed via the utility incision to bifurcation of the left upper and lower lobe bronchi is
transect the vessel. The lower lobe bronchus is exposed identified, and the left upper lobe bronchus is transected
from its inferior aspect to its bifurcation with the middle from the posterior port by a universal stapler. An empty
lobe bronchus. The bronchus is left intact until the ongoing sponge stick is used to retract the stump of the bronchus
pulmonary artery is dissected medially and superiorly from laterally, which facilitates exposure of several branches on
the overlying fissure. After the pulmonary artery has been the pulmonary artery including the lingular artery. The
adequately exposed, the bronchus is transected with a 4.8- arteries are transected individually via the posterior port.
mm universal stapler placed through the utility incision. Occasionally, the lingular artery is best transected from the
The pulmonary artery is then transected followed by the utility incision. The left major fissure is more oblique than
fissure via the utility incision (Table 2). the right side and is best completed by passing a universal
stapler via the posterior port (Table 4).
Right middle lobectomy
Left lower lobectomy
The middle lobe is retracted laterally, and the pleura
overlying the middle lobe vein is incised. Once the vein is The lower lobe is retracted superiorly; the inferior pul-
dissected entirely, it is transected by an endovascular sta- monary ligament is divided; and level 9 lymph nodes are
pler placed via the utility incision, exposing the middle removed. Once the entire inferior pulmonary vein has been
lobe bronchus. After encircling the bronchus with a dissected, a stapler is placed via the utility incision to
monofilament suture, an endo-GIA 3.5 stapler is placed via transect the vessel. The lower lobe bronchus is exposed
the utility incision to transect the bronchus. An empty from its inferior aspect to its bifurcation with the upper
sponge stick is placed on the middle lobe bronchus for lobe bronchus. The bronchus is left intact until the ongoing
traction, exposing the first two branches on the middle lobe pulmonary artery is exposed medially and superiorly from
artery, which are then transected from the utility incision. the undersurface of the overlying fissure. After the pul-
On occasion, the angle is such that the middle lobe struc- monary artery has been adequately exposed, the bronchus
tures must be transected from the posterior port. The fis- is transected with a 4.8-mm universal stapler placed
sures are then completed by passing staplers via the utility through the utility incision. The pulmonary artery is tran-
incision (Table 3). sected via the utility incision, and the fissure is completed

Table 4 Sequence of structure transection of left upper lobectomy

Table 2 Sequence of structure transection of right lower lobectomy Left upper lobectomy Stapler port
Right lower lobectomy Stapler port
1. Superior vein Posterior
1. Inferior vein Utility 2. First apical arterial branch Posterior
2. Bronchus Utility 3. Bronchus Posterior
3. Ongoing artery Utility 4. Remaining arterial branches (3–5) Posterior
4. Fissure Utility 5. Fissures Posterior

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Table 5 Sequence of structure transection of left lower lobectomy left mainstem bronchus is visualized. Care must be taken
Left lower lobectomy Stapler port
not to injure the vagus nerve or the esophagus. Once the
inferior portion of the nodal chain is elevated, the nodal
1. Inferior vein Utility packet is grasped in its entirety, and dissection is continued
2. Bronchus Utility superiorly using electrocautery and endo clips until the
3. Ongoing artery Utility carina is clearly visualized. The nodal packet is then placed
4. Fissure Posterior in an endo-catch bag and removed via the utility incision.

Left-sided level 7 nodal dissection

via the posterior port. In cases with an extremely thick
incomplete fissure, the anterior fissure between the lingula Similar to the right side, the left lung is retracted medially,
and lower lobe should be completed prior to starting the and the posterior mediastinal pleura is divided using elec-
dissection to facilitate orientation and exposure (Table 5). trocautery. The key is first to identify the posterior portion
of the left lower lobe vein. The lung must be retracted with
a bit more force than on the right because the carina rests
Mediastinal nodal dissection behind the aorta and esophagus. After the left mainstem
bronchus is identified, a curved ring forceps is placed
Right level 2/4 nodal dissection between the left mainstem bronchus and esophagus and
opened widely. The same forceps is then placed through
Right level 2/4 nodal dissection is undertaken in the fol- the utility incision to grasp the nodal packet. It is retracted
lowing manner. Division of the azygous vein facilitates superiorly toward the carina. It is difficult to visualize the
exposure; however, this step is not essential. The lung is right mainstem bronchus with the left lower lobe in place,
retracted inferiorly, and a Harken clamp is used to dissect especially with the left lower lobe vein intact. This left-
behind the azygous vein. Once the vein is adequately sided subcarinal nodal dissection is significantly easier
mobilized, an endovascular stapler is placed through the during a left lower lobectomy because the dissection is
posterior port to transect the vein. A wide-spreading, facilitated by division of the left lower lobe vein.
curved ring forceps is placed through the posterior port.
The mediastinal pleura overlying the level 4 area is incised Level 5 and 6 nodal dissection
using electrocautery. The superior vena cava is dissected
away from the paratracheal tissues, allowing easy access to For level 5 and 6 nodal dissection, the pleura overlying the
the nodal area. The nodal tissue is dissected off the lateral aortopulmonary window is divided transversely; care must
wall of the superior vena cava up to the level of the right be taken to avoid injuring the vagus (left recurrent nerve) and
subclavian artery. The most inferior portion of the nodal the phrenic nerve. The superior edge of the pleura is retracted
packet is grasped with a ring forceps at the tracheobron- superiorly, exposing the underlying great vessels and lymph
chial angle (care must be taken not to injure the truncus nodes. A curved ring clamp grasps the lymph nodes as well
branch of the pulmonary artery). The packet is lifted as some surrounding fat; and sharp dissection and electro-
superiorly off the underlying pericardium, and electrocau- cautery are used to dissect the nodal tissues off the under-
tery and endo clips are used for control of blood vessels lying pulmonary artery for level 5 and the aorta for level 6.
and lymphatics. The entire packet is placed in an endo- The specimen is placed in a retrieval bag and removed.
catch bag and removed via the utility incision.
Level 8 and 9 nodal dissection
Right-sided level 7 nodal dissection
For level 8 and 9 nodal dissection, during the mobilization
For right-sided level 7 nodal dissection, the lung is of the pulmonary ligament an empty ring clamp is used to
retracted medially, and the posterior mediastinal pleura is grasp the level 9 or level 8 lymph nodes. The nodes are
divided using electrocautery. Identification of the posterior then retracted away from the mediastinum and easily
aspect of the inferior pulmonary vein marks the starting excised using electrocautery.
point of the dissection. At this point, the bronchus inter-
medius/right mainstem bronchus should be visible. An
empty ringed forceps is used to grasp the inferior portion of Results
the level 7 nodal packet and retract it superiorly. Sharp
dissection and electrocautery are used to dissect the nodal From May 2002 until December 2009, we have performed
packet off the posterior pericardium and laterally until the more than 600 successful VATS lobectomies. There were

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no operative deaths. The median length of stay was 4 days. The best way to determine the benefits of this approach
These results have been previously published and suggest is to conduct a prospective randomized controlled trial
patient benefit when compared to traditional thoracotomy comparing thoracotomy to VATS. A study with an 80%
[2]. power and an alpha of 0.5 to detect a 10% difference in
survival would require 385 patients. However, the feasi-
bility of conducting a trial of this nature is unclear. We
Discussion have standardized this procedure among several surgeons
at our institution and propose standardizing this procedure
Techniques to minimize the morbidity of standard thora- universally so multiinstitutional clinical trials can be
cotomy have evolved over the past decade and a half. conducted.
Standard posterolateral thoracotomy, which historically
involved division of the latissimus dorsi and serratus Acknowledgments The author thanks Robert McKenna for allow-
ing him to observe his operative technique.
anterior muscles, has been widely replaced by incisions
that spare the serratus anterior muscle and thoracotomies
that spare both the latissimus dorsi and serratus anterior References
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