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J Thorac Cardiovasc Surg 2005;129:1454-1455
© 2005 The American Association for Thoracic Surgery

Brief Communication

Triangular retractor facilitates minimally invasive lobectomy

Todd L. Demmy, MD*, Chukwumere E. Nwogu, MD, Marc S. Sussman, MD

Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY.

Received for publication January 4, 2005; accepted for publication February 8, 2005.

* Address for reprints: Todd L. Demmy, MD, Roswell Park Cancer Institute, Elm & Carlton Sts, Buffalo, NY 14263 (Email: Todd.Demmy{at}roswellpark.org).

Video-assisted thoracic surgery (VATS) lobectomies are feasible, preferred at certain centers, and gaining in popularity.1 Yet some VATS maneuvers remain difficult or clumsy compared with open techniques, such as lifting the partially dissected lobe by hand away from the hilum to find remaining connections.

Technique

Diamond-flex triangular retractor system (Snowden-Pencer, Tucker, Ga) devices begin as flexible, snakelike, hollow, 5-mm metal tubes composed of small individual sections threaded over internal tension cables anchored to the tips. The individual tubular sections are cut obliquely so that when the internal metal cables are tightened, the retractors conform into triangular shapes. Typically, each retractor is inserted while loose and flexible though a 5-mm port and then conformed within the open abdominal cavity to retract the liver or other structures.

This tool controls nearly freed upper lobe lung specimens as well. After most of the incomplete fissure tissue and pulmonary vascular attachments have been divided, a Diamond-flex retractor can be passed through a working port and curled around the lung specimen. By using an anterior working port, the device will slide naturally along the anterior thoracic apex and then loop inferiorly around the base of the upper lobe. Then the retractor is conformed by tightening the screw in the handle with its tip in view so that it does not curl into delicate hilar structures. Given its relatively small diameter, additional tools can be passed through the same 10-mm working incision.

This instrument is manufactured in straight or angulated conformations of different lengths. We prefer a straight 60-mm device, but the best size is selected according to the thoracic cavity and lung size. Figure 1 demonstrates the control of the right upper lobe afforded by this method. In addition, a linear cutting stapler is depicted ready to complete the lobectomy by dividing the right upper lobe bronchus.


Figure 1
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  		Figure 1. Retractor control of the upper lobe.

 
Once the specimen has been freed from its attachments, extracting it can be difficult. This maneuver is facilitated by inserting the nylon sac (Lapsac; 5 x 8 in; Cook Group, Inc, Bloomington, Ind) through the access incision and controlling one portion of the sac externally. Additional points of fixation are needed to open the sac. Although this can be accomplished with instruments or sutures, the above retractor creates a base to yield a nice triangular opening. If needed, saline instillation or the retractor can help open the rest of the empty sac.

Once the opening is controlled, it is easy to place a grasping instrument through the same working port as the triangular retractor to push the isolated lobe into the specimen extraction sac. Once its lead point is inserted, another instrument placed through the access incision maintains the specimen’s forward progress so that the endoscopic grasper can gain a fresh hold on the tissue. With the cooperative use of these instruments, the lobe is inserted quickly. Figure 2 depicts the sac held open just after lung insertion.


Figure 2
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  		Figure 2. Control of the sac opening.

 
Discussion

Thoracic surgeons periodically reevaluate their interests in complex VATS operations as technology advances.2 Recent enhancements in video equipment aid exposure, and new specialized tools reduce operative times, making these cases more relevant to a busy surgical practice.

Upper lobe tissue often flops onto the hilum. This requires a lot of camera shifting and lung rolling to ensure complete dissection and thereby prevent inadvertent avulsion of an aberrant pulmonary artery branch. The described retraction method allows lifting the lung toward the lateral chest wall so that residual hilar connections can be viewed. Some authors advocate dividing the bronchus first to gain this exposure, but we prefer technology that allows us to approximate our traditional open methods.

Although introducing bulky lobes into specimen extraction sacs can be tedious, this technical modification reduced a variable 5- to 20-minute process into a routine step lasting 2 to 3 minutes. The study of other minimally invasive disciplines might yield additional useful instrument adaptations.

References

  1. Swanson SJ, Herndon J, D’Amico TA, Demmy TL, McKenna Jr R, Green M, et al. Results of CALGB 39802. feasibility of video-assisted thoracic surgery (VATS) lobectomy for early stage lung cancer [abstract]. Proc Am Soc Clin Oncol 2002;21:290a.
  2. Demmy TL, Curtis JJ, Boley TM, Walls JT, Nawarawong W, Schmaltz RA. Diagnostic and therapeutic thoracoscopy. lessons from the learning curve. Am J Surg 1993;166:696-700.[Medline]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
T. L. Demmy, C. E. Nwogu, and S. Yendamuri
Thoracoscopic Chest Wall Resection: What Is Its Role?
Ann. Thorac. Surg., June 1, 2010; 89(6): S2142 - S2145.
[Abstract] [Full Text] [PDF]

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