Bronchovascular sleeve resection of the right middle lobe in N1 lung cancer

Sleeve lobectomy is a useful procedure for avoiding pneumonectomy. However, bronchovascular sleeve resection of the right middle lobe is very rare. We describe a patient who underwent this procedure, along with illustrations and a surgical movie. The patient was a 76-year-old woman with a 4.5-cm squamous cell carcinoma in the right middle lobe, involving the interlobar pulmonary artery (PA) with bulky #11s lymph-node metastasis. Middle lobectomy with vascular reconstruction of the interlobar PA was planned. A posterior lateral thoracotomy was performed. After subcarinal lymph-node dissection, the upper lobe and intermedial bronchus were confirmed. From the ventral side, the superior pulmonary vein (PV) was dissected, preserving the upper lobe PV. The lower lobe PA was exposed at the level of the major fissure. The interlobar PA was not involved by the tumor, but the #11s lymph nodes showed wide extranodal invasion to the bronchus intermedius, requiring a long bronchial-sleeve resection. To obtain a better view to manipulate invaded bronchus, the interlobar PA was transected. The bronchus intermedius was cut off on the proximal side at the end of the upper lobe bronchus, including the underside of the bronchus to ensure an adequate surgical margin, and on the distal side along only the lower lobe bronchus inlet. An anastomosis was performed with interrupted 4-0 PDS sutures. After a sealing test, the interlobar PA was trimmed as the bronchus shortened and was anastomosed with a 5-0 Prolene running suture. The lower lobe was well expanded. No tissue interposition was used. The operation time was 307 minutes, and the blood loss was 200 g. Pathological examination confirmed complete resection. The postoperative course was uneventful. Even in patients with right middle lung cancer widely invading the bronchus intermedius, transaction and reconstruction of interlobar PA provides a good view and facilitates easy manipulation for sleeve resection.