Port Positioning in Uniportal VATS for Right Middle Lobe Lobectomy
Optimal Port Location
For uniportal VATS right middle lobe lobectomy, position a single 3.5-4.5 cm incision in the 4th or 5th intercostal space at the anterior axillary line on the right side. 1
Technical Specifications
Incision Parameters
- Length: 3.5-4.5 cm is sufficient for instrument manipulation and specimen extraction 1
- Intercostal space: Either 4th or 5th intercostal space provides adequate access to middle lobe structures 1, 2
- Anatomic landmark: Anterior axillary line serves as the primary reference point 1
- Alternative approach: A 4 cm incision at the 5th intercostal space has been successfully used for major pulmonary resections 3
Surgeon Positioning and Instrument Approach
- Surgeon location: Stand at the abdominal side of the patient for optimal ergonomics 1
- Camera placement: Insert the 30-degree, high-definition, 10-mm thoracoscope through the posterior-anterior part of the incision 3
- Instrument insertion: Pass all surgical instruments through the anterior part of the utility incision 3
- Operative technique: Use endoscopic instruments exclusively without rib spreading 1, 3
Anatomic Considerations for Middle Lobe Access
Port Positioning Rationale
- The single anterior axillary line incision provides direct visualization of the middle lobe hilum and allows parallel instrumentation that mimics open surgical maneuvers 4
- This approach eliminates the unfavorable dihedral or torsional angles created by conventional triple-port triangulation 4
- The 4th-5th intercostal space level optimally aligns with middle lobe vascular and bronchial structures 1, 2
Wound Protection
- Apply a soft wound protector to the incision to facilitate instrument passage and protect tissues 2
- The protector should extend from the skin incision to the intercostal space 2
Special Considerations for COPD Patients
Surgical Approach Benefits
- VATS demonstrates superior outcomes in COPD patients compared to thoracotomy, with lower hospital mortality (8% vs 14%) and improved 5-year survival (48% vs 18%) 5
- Postoperative decline in FEV1 is significantly lower with VATS compared to open approaches in patients with compromised pulmonary function 5
- Patients with severe COPD may demonstrate a "lung volume reduction" effect, with smaller postoperative FEV1 decline than predicted 5
Feasibility in Severe Airflow Limitation
- Surgery can be performed safely even when baseline FEV1 is 26-45% predicted, with morbidity rates of 15-25% and mortality of 1-15% 5
- The uniportal approach minimizes intercostal nerve compression by avoiding trocar use, potentially reducing postoperative pain that impairs respiratory function 4
Pain Management Protocol
Regional Anesthesia (First-Line)
- Paravertebral block with continuous catheter infusion is the primary recommended technique for VATS procedures 6, 7
- Erector spinae plane (ESP) block serves as an equally effective alternative with potentially easier placement 6, 7
- Continuous infusion is superior to intermittent bolus techniques 6
Multimodal Systemic Analgesia
- Paracetamol: Administer pre-operatively or intra-operatively, continue at regular intervals postoperatively 6, 7
- NSAIDs or COX-2 inhibitors: Initiate pre-operatively unless contraindicated by renal impairment, heart failure, or bleeding risk 6, 7
- Opioids: Reserve exclusively for breakthrough pain rescue, not primary analgesia 6, 7
Pain Control Rationale
- Adequate analgesia directly prevents splinting, atelectasis, and impaired respiratory physiotherapy participation—critical concerns in COPD patients 6, 7
Critical Pitfalls to Avoid
Port Placement Errors
- Do not place the incision too posteriorly, as this compromises access to anterior hilar structures and middle lobe vessels 1, 2
- Avoid excessive incision length beyond 4.5 cm, which negates the minimally invasive benefits without improving exposure 1
Intraoperative Considerations
- Be prepared to extend the incision by 1 cm for specimen extraction if the middle lobe is bulky or the tumor is larger than anticipated 3
- Maintain readiness to convert to thoracotomy if adhesions prevent adequate visualization, though this occurs in approximately 20% of cases 8
Patient Selection
- Do not exclude patients based solely on severe COPD (FEV1 <40%), as VATS can be performed safely with appropriate patient selection and may provide lung volume reduction benefits 5
- Ensure adequate preoperative assessment including PPO FEV1 and PPO DLCO calculations, though surgery remains feasible even below traditional 40% thresholds 5
Alternative Cosmetic Approach
Transaxillary Modification
- A 4 cm incision at the fossa axillaris (armpit) parallel to skin folds, reaching the 3rd intercostal space along the anterior axillary line, provides superior cosmetic results 2
- This approach is technically feasible for right upper lobectomy and may be adapted for middle lobe resections in selected patients 2
- The transaxillary approach requires the same surgical sequence but offers better scar concealment 2