Video-assisted thoracic surgery tunnel technique: an alternative fissureless approach for anatomical lung resections

We describe an alternative video-assisted thoracic surgery (VATS) fissureless pulmonary lobectomy technique. This involves opening the fissure completely and with staplers at an early stage of the procedure by making a tunnel between the bronchovascular structures and the lung parenchyma. To minimize air leak after anatomical lung resections, many surgeons use a “fissureless” VATS technique, using staplers to divide the hilar bronchovascular structures first and the main part of the parenchyma in the fissure last. Others try to find the artery by dissecting the parenchyma in the fissure. The advantage of the latter is clearance of N1 nodes and anatomical overview prior to division of bronchovascular structures. But, airleak can be induced when touching the parenchyma. The proposed alternative procedure tries to combine the advantages of both common techniques, i.e., reduce risk of airleak and obtain a good anatomical overview and N1 nodal clearance prior to division of the bronchovascular structures. To open the incomplete fissure first, with staplers, a tunnel dissection is started anterior between the triangle of pulmonary veins and the parenchyma. After identification of the pulmonary artery (PA), the anvil of a first stapler is placed on top of the artery and the anterior part of the fissure is divided. Dissection between artery and parenchyma is continued until the fissure is completely stapled. By making a tunnel between the bronchovascular structures and parenchyma from anteriorly to posteriorly, one can open the fissure completely with staplers at an early stage of an anatomical lung resection. This combines the advantages of both the “fissureless” hilum first technique and classic (open) fissure first dissection, i.e., minimal air leak and optimal anatomical overview before bronchovascular structures are divided, potentially avoiding inadvertent transections.