Why Two Incisions Are Sometimes Used During Bilobectomy
The question appears to misunderstand the surgical approach—bilobectomy typically uses a single thoracotomy incision, not two separate incisions. The confusion may arise from terminology around minimally invasive approaches that use multiple small ports rather than traditional incisions.
Standard Bilobectomy Approach
Bilobectomy is performed through a single thoracotomy incision, which provides access to remove two lobes of the lung (either right upper and middle lobes, or right middle and lower lobes) 1. This is classified as a standard major pulmonary resection that falls between lobectomy and pneumonectomy in terms of complexity and extent 1.
Surgical Access Considerations
For centrally located tumors or those with suspected/proven metastatic lymph nodes, thoracotomy (a single large incision) is the standard approach, depending on surgeon expertise 1.
The surgical approach depends on tumor size, location, and preoperative assessment, with the choice between open surgery or minimally invasive techniques based on surgeon experience 1.
Video-Assisted Thoracoscopic Surgery (VATS) Approaches
The reference to "two incisions" likely pertains to minimally invasive VATS techniques, which use multiple small ports rather than one large incision:
Biportal VATS Technique
Biportal complete VATS lobectomy can be performed through two small incisions (ports) instead of the traditional three to four ports, using a combination of conventional and endoscopic instruments 2.
The biportal approach requires optimization of exposure through a single utility incision for multiple instruments, with careful technique to introduce staplers without a third posterior port 2.
Single-Incision VATS
Single-incision VATS major pulmonary resection uses only one 3-5 cm incision in the fifth intercostal space at the anterior or posterior axillary line, depending on tumor location 3.
Single-incision VATS bilobectomy has been successfully performed with results similar to conventional VATS lobectomy, though some cases may require a second incision (7% in one series) 3.
Clinical Outcomes and Considerations
Morbidity and Mortality
Bilobectomy has intermediate operative mortality (approximately 4.2%) between lobectomy (2-4%) and pneumonectomy (6-8%) 1, 4.
Postoperative morbidity occurs in approximately 19% of bilobectomy patients, with complications including prolonged air leaks and pleural space problems 4.
Pleural Space Management
All patients demonstrate ipsilateral volume loss on postoperative chest radiographs after bilobectomy, with some developing asymptomatic hydropneumothoraces that typically resolve 4.
Pneumoperitoneum (injecting air under the diaphragm) after right middle and lower bilobectomy significantly reduces air leaks and pneumothoraces, decreasing median hospital stay from 6 to 4 days 5.
Chest Drain Placement
A single chest drain positioned mid-position is as effective as two classical drains (apical and basal) after bilobectomy, with the added benefit of reduced analgesia requirements and lower cost 6.
There are no significant differences in subcutaneous emphysema, residual pleural effusion, or need for additional drains between single and double drain approaches 6.