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Page 4 of 9 Durand. Mini-invasive Surg 2019;3:35 I http://dx.doi.org/10.20517/2574-1225.2019.31

- Zone 2R 4R node harvest.
- Bag extraction.
- Chest tube placement and closing.

Arterial ligation was performed either by sewing 2 knots with linen 0 with the needle holder or by stapling
with white 35 mm endo stappler [mainly for anterior mediastinal artery in case of right upper lobectomy
(RUL)]. Venous ligation was performed either by sewing 1 knot with linen 0 doubled by a Vicryl 2/0 (22-mm
needle) 10-cm suture with the needle holder or by stapling with white 35 mm endo GIA. In the case of “manual”
ligation of vessels, the distal part was dissected as far as possible and the section was done by spatula
burning along the forceps and then distal vessel bipolar burn. Radical hilar and mediastinal node harvest
were performed during the procedure.

The assistant was holding a long suction device (Elefant® Coloplast Ltd UK) to ensure a bloodless field and
to avoid smoke inside the chest. The suction device was also used to stabilize the operating field by being
placed over one of the rolled gauzes. For each procedure, a frozen section analysis of the bronchus border
was performed to ensure the R0 margin. The specimen was placed after resection of the bronchus in an
Endobag® to prevent the chest contamination, and was extracted through the port access enlargement at
the end of the procedure.

A 24 French chest drain was left in the chest through the right-hand port and minor suction was applied
(minus 10 cm of water) after the patient’s extubation.

Sleeve lobectomy
TM
For the end-to-end anastomosis, V-Loc Covidien 3/0 180 (17-mm needle taper point, 15 cm length)
sutures were used. For each anastomosis, 2 half-continuous sutures were performed.

The principle of the anastomosis technique, referring to a sleeve RUL, is as follows. A vertical axis exposure
of the 2 borders was preferred. The posterior wall running suture started from outside the upper border,
forehand, 3 o’clock, clockwise. After the first way out from the lower border, usually backhand, the needle
was placed through the final loop of the wire to block the end of the running suture. The running suture
was continued, mainly backhand, until 9 o’clock outside the lower border with the tension of the suture
applied after each loop. Then, the anterior wall sewing was started with another V-Lock wire. The start
of this second suture was from the lower border outside 3 o’clock, forehand. As with the previous first
loop, the needle was placed through the final loop of the wire to block the end of the running suture after
emerging from the upper border outside. The running suture was then conducted anti-clockwise to 9 o’clock
outside the upper border, here again mainly backhand.

The airtightness was checked under water with mechanical insufflation before knotting the two wire ends,
to ensure a harmonious tension of the running sutures. Then, the final knot was done and the needles were
removed from the chest.

Regarding the lobe removal, exposure and gests were adapted. For a sleeve median lobectomy (ML), the
bronchial section was done through a fissure exposure after pulling back the lower lobe artery with a loop
(silicone 10-cm cut blue loop) to expose the intermediate bronchial trunk. The anastomosis was performed
after changing the exposure for a posterior view. Then, the 2 borders were naturally placed to avoid a twist
and the artery was hidden away from the sewing zone.

For inferior bilobectomy or lobectomy, the end anastomosis sleeve required a v-shaped cut of the distal
part of the bronchus. Then, separate single knots were placed, using violet Vicryl 2/0 (22-mm needle, 10-cm