Nonintubated thoracoscopic segmentectomy-left upper lobe trisegmentectomy.

Abstract

Enhanced computed tomography screening protocols have recently identified increasing numbers of small lung tumors in patients with high surgical risks (1). Consequently there has been increasing interest in minimally invasive surgical approaches, including thoracoscopic approaches, parenchyma-sparing resection, and less invasive anesthesia for management of lung tumors (2). The role of thoracoscopic segmentectomy is therefore increasingly reevaluated, not only as a traditional parenchyma-sparing procedure in high-risk patients with compromised medical conditions but also in patients with non-small cell lung cancer less than 2.0 cm (1). From 2009, we started a nonintubated thoracoscopic surgery program for patients who were reluctant or unsuitable to have a conventional intubated single lung ventilation during thoracic surgery (3). With a combination of target-controlled sedation and regional anesthesia—either by thoracic epidural anesthesia or intercostal nerve blocks with intrathoracic vagal blockade—the results of nonintubated thoracoscopic surgery are encouraging (2-5). In the current video, we demonstrate how a nonintubated technique was applied in thoracoscopic segmentectomy and mediastinal lymphadenectomy to treat a patient with early stage lung cancer (Video 1). Video 1 Nonintubated thoracoscopic segmentectomy—left upper lobe trisegmentectomy. Clinical vignette A 74-year-old man, who had undergone a total gastrectomy for gastric cancer in a different institution in 2003, was transferred to our hospital for management of an incidentally discovered left upper lobe lung nodule. Computed tomography-guided biopsy of the tumor revealed a primary pulmonary adenocarcinoma. Preoperative pulmonary function tests showed that he had a mild obstructive defect with forced expiratory volume in one second being 84.9% of predicted. Considering his age and reduced lung function, lingual-preserving left upper lobectomy (left upper lobe tri-segmentectomy) was planned instead of left upper lobectomy to preserve more lung parenchyma after surgery.