Extended thoracotomy for main pulmonary artery access: Two lung cancer cases

Abstract

This report details two cases of right upper-lobe lung cancer, of patients aged 62 and 56 years, requiring complex bronchoplasty and thoracoscopic surgeries. In both cases, owing to intraoperative complications, extended thoracotomies were performed to gain access to the right main pulmonary artery. The postoperative courses were uneventful, implying that this approach was safe. Uncomplicated postoperative recoveries underscore the need for adaptable surgical techniques, especially when traditional positioning fails. It emphasizes extending thoracotomy incisions for safer hilar structure access, offering insights for handling similar complex surgeries where standard methods falter.

Introduction

In thoracic surgery, cases requiring the encirclement of the main pulmonary artery, at times, necessitate an anterior approach, such as a sternotomy and hemiclamshell thoracotomy.^1,2 Conversely, bronchoplasty and thoracoscopic surgeries, including robot-assisted procedures, are typically performed in the lateral decubitus position.^3,4 However, intraoperative findings or accidental bleeding may necessitate proximal encircling of the main pulmonary artery, such as between the superior vena cava (SVC) and ascending aorta. In this case report, we present two challenging cases that necessitated extended thoracotomy to secure access to the right main pulmonary artery: one of a 62-year-old man with right upper-lobe lung cancer, and another of a 56-year-old man with suspected right upper-lobe lung cancer. This work has been reported as being in line with the SCARE criteria. ⁴

Case presentation

Case 1

A 62-year-old man exhibited a right hilar tumor on screening chest radiography. Surgery was indicated upon diagnosis of right upper-lobe lung cancer (cT3N1M0 stage IIIA) via endobronchial ultrasound-guided transbronchial fine-needle aspiration. The tumor that had invaded neighboring lymph nodes (10 and 11 s), was extensively connected to the bronchus of the right upper lobe, necessitating bronchoplasty (Figure 1(a)). Contrast-enhanced computed tomography with 3D reconstruction showed compression of A¹⁺³ and A² by the tumor (Figure 1(b)). No metastasis to N2 lymph nodes was identified, allowing radical resection without neoadjuvant therapy. The patient was positioned in the left lateral decubitus position for muscle-sparing thoracotomy. Compression by the tumor and gravitational effects made it challenging to encircle A¹⁺³ and A².

Figure 1.

Imaging findings in Case 1. (a) Initial chest computed tomography showing a tumor with lymph node involvement, extensively connected to the right upper-lobe branch. (b) Preoperative hilar vascular 3D image showing compression of A¹+A³ and A² by the tumor with preserved peripheral blood flow.

Moreover, sufficient control could not be established by mobilizing the SVC after dividing the azygos vein. Therefore, the thoracotomy was extended anteriorly to the level of the right internal thoracic artery, allowing for adequate SVC mobilization and subsequent encirclement of the right main pulmonary artery. The pulmonary artery was encircled distally from the bifurcation of A². The proximal and distal sides of the pulmonary artery were clamped, and A¹⁺³ and A² were divided. The bronchus of the right upper lobe was dissected using a deep-wedge technique, and bronchoplasty was performed without significant difficulty (Supplemental Video 1). Postoperative recovery was uneventful; however, chest drainage was monitored closely due to slightly increased output. The chest tube was removed on postoperative day 2, and the patient was discharged on postoperative day 9.

Case 2

A 56-year-old man had suspected right upper-lobe lung cancer (cT1aN0M0 stage IA1) based on screening chest radiography and computed tomography (Figure 2(a)). Diagnosis and treatment involved surgery through a left-down lateral decubitus position using three-port video-assisted thoracoscopic surgery. Intraoperative frozen sections confirmed the diagnosis of lung adenocarcinoma. Following the dissection of A³, accidental bleeding was noted while dividing A¹+recurrent A², necessitating thoracotomy (Figure 3(a) and (b)). However, the bifurcation of A¹+recurrent A² was proximal to the right main pulmonary artery trunk (Figure 2(b)), making it difficult to isolate and encircle the proximal region of the A¹+recurrent A² when the bleeding area was compressed. Consequently, an approach encircling the right main pulmonary artery was adopted. The thoracotomy was extended anteriorly to the level of the right internal thoracic artery, and the right main pulmonary artery was encircled between the SVC and ascending aorta (Figure 3(c)). After successfully controlling bleeding, A¹+recurrent A² was managed. The surgery proceeded uneventfully with successful right upper lobectomy and lymph node dissection. Postoperative recovery was smooth, with chest drain removal on the first postoperative day, and the patient was discharged on postoperative day 8.

Figure 2.

Imaging findings in Case 2. (a) Initial chest computed tomography showing a part-solid nodule in the right upper lobe. (b) Preoperative hilar vascular 3D image (posterior view) showing branching of A¹+recurrent A² centrally from the SVC.

Figure 3.

Intraoperative findings in Case 2.

Discussion

Surgeons should carefully plan and optimize procedures regarding positioning and approach before an operation. The utility of anterior thoracotomy in the supine position has been reported for the proximal management of the main pulmonary artery, whereas lateral decubitus positioning is typically preferred for bronchoplasty. Additionally, the lateral decubitus position is advantageous for SVC access. ⁵ Conventional thoracoscopic surgeries are commonly performed in the lateral decubitus position, and reports have suggested that anterior approaches may be disadvantageous for systematic lymph node dissection. ⁶ However, as demonstrated in the present cases, the tumor size and location or accidental bleeding can necessitate proximal encircling of the right main pulmonary artery, even in the lateral decubitus position.

Limited access to the standard thoracotomy approach for hilar structures (Figure 4(a)) can necessitate innovative solutions. In Case 1, although an anterior approach might have been chosen to prioritize access to the main pulmonary artery, a lateral thoracotomy in the lateral decubitus position was selected to facilitate bronchoplasty. This approach necessitated anterior mobilization of the SVC to reach the main pulmonary artery through the gap between the large tumor and the SVC. In Case 2, the procedure initially started in the lateral decubitus position as a standard thoracoscopic surgery. However, due to accidental bleeding and anatomical challenges in the pulmonary artery, access to the main pulmonary artery was achieved by navigating between the SVC and ascending aorta. Extending the thoracotomy incision anteriorly beyond the usual limits, up to the internal thoracic artery, was crucial to facilitate these maneuvers. This approach allowed for a broader angle of approach to the hilum, enabling the safer and more effective insertion of surgical instruments (Figure 4(b)). While experienced thoracic surgeons might be able to perform these adjustments instinctively, readily available knowledge is essential for handling emergencies. Our case report highlights important considerations for general thoracic surgeons, specifically when isolating and encircling the right main pulmonary artery in the lateral decubitus position, in cases where repositioning to the supine position is challenging due to accidental bleeding.

Figure 4.

Difference in approach angle to the pulmonary hilum. (a) Conventional and (b) extended thoracotomy approaches. Extending the incision edge forward allows for a wider approach to the hilum (hatched area) and safer insertion of instruments toward the right main PA (arrow).