PREOPERATIVE DIAGNOSIS: Right lower lobe and right upper lobe nodules.
POSTOPERATIVE DIAGNOSIS: Right lower lobe and right upper lobe bronchoalveolar carcinoma.
PROCEDURES PERFORMED:
1. Right VATS, right lower lobe wedge resection.
2. Right VATS, right upper lobe posterior segmentectomy.
3. Right VATS, completion segmentectomy.
4. Mediastinal lymph node sampling.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman who had an abdominal CT for abdominal complaints that incidentally noted a small lung nodule. On followup chest CT, this showed increased size of the nodule as well as a right upper lobe nodule. There was no suspicious mediastinal adenopathy. She underwent a PET scan that showed no evidence of mediastinal or distant spread but indicated uptake in the two lung nodules. We therefore recommended wedge biopsy with sublobar resection of both nodules if they were positive. We felt that right pneumonectomy should be avoided due to high morbidity and mortality risk, particularly in the setting of (if positive) two separate cancers, which might represent synchronous primary cancers but would also potentially represent metastatic disease. The patient understood the rationale and requested that we proceed with surgery.
Coumadin, which had been prescribed for thrombocytosis, was discontinued approximately seven days prior to surgery. She was initiated on a protocol of low molecular weight heparin, which was discontinued the night before surgery.
DESCRIPTION OF PROCEDURE: An epidural catheter was placed by the anesthesia service as was an arterial line and a central line due to difficult IV access. A Foley catheter was inserted. After the induction of general anesthesia, a double lumen endotracheal tube was inserted and its position was verified bronchoscopically. Fragmin at 5000 units was administered subcutaneously for DVT prophylaxis, and antibiotics were administered systemically. The patient was moved into the left lateral decubitus position and the right chest was prepped and draped.
Three 12 mm thoracoscopy ports were inserted; one in the auscultatory triangle, one in the eighth intercostal space at the mid axillary line, and one in the fifth intercostal space at the anterior axillary line. The right hemithorax was examined. There was a pleural abnormality corresponding to a suspicious lesion in the right lower lobe as well as a similar abnormal area in the right upper lobe. There were no other abnormalities.
The right lower lobe mass was resected with a generous wedge resection, achieved with firings of the thick tissue stapler. This was brought out through the chest wall with a specimen bag. The mass was palpated and was clearly suspicious for neoplasm. It was quite distant from the staple margin, over 1 cm to estimation grossly. This was sent for frozen section and returned bronchoalveolar carcinoma.
The right upper lobe mass was then resected with a nonanatomic right upper lobe posterior segmentectomy with multiple firings of the stapler. This was also brought out through a specimen bag. The mass was palpated and was also suspicious. It was close to the margin; although, we felt that it was grossly negative but near. On pathologic examination by frozen section, the mass was also a bronchoalveolar carcinoma and the measured margin was 5 mm.
In this setting, with two separate lesions, we felt that right pneumonectomy would offer little oncologic improvement while putting her at significantly higher morbidity and mortality as well as long-term pulmonary dysfunction. Accordingly, we decided to perform a completion segmentectomy by resecting the staple lines in order to gain a wider margin. Thus, the lower and upper staple lines were grasped and a new deeper staple line was placed. These were joined together from the right upper and right lower lobe into a single staple line posteriorly, creating a large Y-shaped specimen with a clean staple line.
We then performed a mediastinal lymph node sampling. The right paratracheal region was opened and examined. There were no suspicious lymph nodes. One small 4R lymph node was identified and was resected. The inferior pulmonary ligament had been taken down earlier for mobilization and it was carefully examined. There was one small nonsuspicious lymph node. In the paraesophageal region, one slightly enlarged lymph node was identified and resected. Finally, the mediastinal reflection posteriorly was taken down, and the subcarinal space was entered posterior to the bronchus intermedius. A level 7 lymph node was sampled. These were all sent for frozen section and were without evidence of malignancy.
Five milliliters of Tisseel was then applied to the staple lines. A 20 French straight chest tube was inserted. The lung was then reinflated. The right upper lobe and right middle lobe came up promptly. The right lower lobe still appeared atelectatic, and therefore, anesthesia service suctioned this area and performed bronchoscopy. We also witnessed the bronchoscopy, which demonstrated some narrowing of the basilar segments of the right lower lobe bronchus, but this could be traversed with the bronchoscope suggesting that it was primarily distortion rather than transection or stapling of the bronchus. Therefore, after suctioning it, we reattempted inflation, and the right lower lobe came up nicely. The chest tube was fixed to the skin with the heavy silk suture. The other two port sites were closed with 2-0 Vicryl followed by 4-0 Monocryl and the skin was sealed with Dermabond. The patient was subsequently extubated and brought to the post anesthesia care unit hemodynamically stable and breathing spontaneously. There were no intraoperative complications.
