Video description (Video 1)
A solid mass sized 2.5 cm × 2.5 cm × 2 cm was found at the apical segment of the right upper lobe. The mass invaded the junction where the azygos vein merges the superior vena cava. Multiple subcarinal, mediastinal, and hilar lymph nodes were found to be swollen.
Key surgical procedures
After the fissures in the right upper lung and the right hilar mediastinal pleura were separated, the right superior pulmonary vein and all the arterial branches were dissociated.
After the ligation and transection of the arterial branches in the posterior segment of right upper lung, the right superior pulmonary vein was transected using the same method.
The lymph nodes around the right upper lobe bronchus were removed, and the right upper lobe bronchus was then dissociated and transected.
Arteries at the apex and anterior segment of the right upper lung were dissociated, the azygos vein was transected, and the mediastinal pleura around the mass was released.
Under the mass, part of the side wall of the superior vena cava was excised by applying the GIA 60 stapler.
After the dissection of mediastinal lymph nodes and leakage test, the chest was closed.
For patients with tumors with invasion to the superior vena cava, the conventional management often requires cardiopulmonary bypass using artificial or autologous vascular grafts. The procedures are often complicated, with long operative time and severe surgical trauma. These surgeries cannot be performed under thoracoscope. However, along with the development of thoracoscope instruments and the improvement of surgical procedures, the above described operation can be applied for the treatment of mediastinal lung cancer with local invasion. It can achieve the same surgical effectiveness when reducing the surgical trauma. This operation is not too difficult and has been widely applied in our department in recent years. Young doctors often simply follow the way that they are trained and lack the spirit of innovation. For the patient described in our video, he might have received chemotherapy and thus missed the chance of surgery; or, he might have directly undergone open surgery. In contrast, a proactive thoracoscope-based surgical intervention would prolong his survival and meanwhile improve the clinical thinking of doctors.
Disclosure: The authors declare no conflict of interest.