{"doi":"10.1016/j.xjtc.2023.01.017","title":"Video Atlas: Fissureless video-assisted thoracoscopic surgery right lower lobectomy after induction chemotherapy","abstract":"Central MessageA fissureless approach to right lower lobectomy allows for careful delineation of anatomy and helps avoid air leaks. A fissureless approach to right lower lobectomy allows for careful delineation of anatomy and helps avoid air leaks. Video-assisted thoracoscopic surgery (VATS) is the predominant surgical approach for anatomic lung resection owing to its well-described perioperative benefits and potential long-term survival benefit over thoracotomy.1Taioli E. Lee D.-S. Lesser M. Flores R. Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis.Eur J Cardio Thorac Surg. 2013; 44: 591-597Crossref PubMed Scopus (110) Google Scholar However, as the number of incisions, choice of energy device, order of surgical steps, and many other variables are left to the discretion of individual surgeons, there is no standardized surgical technique for this procedure. Herein, we present our approach for VATS right lower lobectomy and mediastinal lymph node dissection. The patient in Videos 1 through 9 presented with clinical T2b N2 M0 squamous cell carcinoma in 2020. Positron emission tomography (PET) showed a 5-cm hypermetabolic right lower lobe (RLL) mass with an additional PET-avid right paratracheal focus. Fine-needle aspiration using endobronchial ultrasound was nondiagnostic at the 4R station, but biopsy of the subcarinal lymph nodes was positive for metastatic squamous cell carcinoma. No distant metastases were seen on PET or magnetic resonance imaging of the brain. The patient therefore underwent induction chemotherapy with carboplatin and gemcitabine for 4 cycles, which was well tolerated. Restaging imaging showed a partial response to chemotherapy, and the patient underwent surgical resection as planned. As shown in Videos 1 through 9, this patient was found to have a substantial amount of inflammation and fibrosis surrounding the mediastinal lymph nodes, which is typical of resections after neoadjuvant therapy. The technique shown in these videos is designed to be reproducible and can be consistently applied to any RLL resection, regardless of completeness of fissure or prior induction therapy. The Memorial Sloan Kettering Cancer Center Institutional Review Board approved the submission because this does not constitute human subjects research and the project does not involve identifiable patient information (IRB #16-1631, October 27, 2020). The patient gave informed written consent for the publication of the study data. The initial camera port was placed in the eighth interspace in the posterior axillary line using a 5-mm trocar. Carbon dioxide insufflation to 8 mm Hg was used initially to induce atelectasis of the right lung. The hemithorax was inspected for adhesions, pleural implants, and other unexpected findings. A 3- to 4-cm access incision was then made in the fourth interspace overlying the anterior axillary line, and a small wound protector (Applied Medical) was placed to retract the soft tissues overlying the incision. Carbon dioxide insufflation was stopped at this point. A 1.5-cm assistant incision was made posteriorly just inferior to the scapular edge. It is our practice to start all anatomic lung resections from a posterior approach. The lung was lifted cephalad and anterior using an atraumatic lung grasper from the anterior access incision, and an extended-tip Bovie cautery was used to open the inferior pulmonary ligament from the posterior port (Video 1, Figure 1). Any level-9 lymph nodes encountered were removed and sent for pathologic analysis. The lung was retracted anteriorly, and this line of prior dissection was extended cephalad up to the level of the carina (Video 2, Figure 2). After the pleura was opened, the bronchus intermedius (BI) was identified by visual inspection. A plane was then developed on the pericardium just cephalad to the superior border of the inferior pulmonary vein. This dissection was continued superiorly to ele","journal":"JTCVS Techniques","year":2023,"id":402819,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9549,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":253867,"name":"David R. Jones","orcid":"0000-0002-3318-0146","position":1,"is_corresponding":false},{"id":752438,"name":"Katherine Gray","orcid":"0000-0001-7669-7615","position":0,"is_corresponding":true}],"reference_count":12,"raw_metadata":null,"created_at":"2026-07-19T01:20:32.588152Z","pmid":"37096090","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}