EJCS：北大人民医院王俊等成功改良胸腔镜下肺叶袖式切除术

左肺下叶袖式切除、支气管重建术示意图：A图为左肺上叶支气管和左侧主支气管断端，B为用3-0可吸收缝合线间断缝合支气管后壁，C为用4-0不可吸收缝合线连续缝合支气管，D为用3-0可吸收缝合线间断缝合支气管前壁。

随着胸腔镜技术的日益成熟，胸腔镜辅助下可行的手术种类越来越多，难度越来越高，但镜下肺叶袖式切除、支气管重建术，肺动脉成型术等高难度手术仍鲜有报道。近日北京大学人民医院王俊等成功改良了胸腔镜下肺叶袖式切除、支气管重建术，使得该术式更加安全有效。该结果发表在2013年4月4日的欧洲心胸外科（European Journal of Cardio-Thoracic Surgery）杂志上。

该研究组2011年9月-2012年12月行胸腔镜辅助下肺叶袖式切除、支气管重建术15例，其中右肺上叶袖式切除术10例，右肺中、下叶袖式切除术1例，左肺下叶袖式切除术2例，左肺上叶袖式切除术2例，全组患者均为非小细胞肺癌，同期行纵膈淋巴结廓清术。全组手术均采用3孔式胸腔镜操作，其中操作孔选择在第4肋间腋前线，此操作孔邻近肺门，有利于肺门组织的游离和支气管吻合的操作。支气管吻合时采用连续缝合/间断缝合的混合式缝合法，使得吻合时间大大缩短，也有效的解决了间断缝合线头缠绕打结的现象。

对于右侧肺叶袖式切除术，该研究组保留了奇静脉，发现保留奇静脉对于吻合端的显露并没有太大影响。全组患者手术顺利，无中转开胸。平均手术时间165min，平均支气管吻合时间44min，术中平均失血量150ml。病理结果鳞癌14例，腺癌1例。全组患者术后恢复顺利，1例患者合并短暂性窦性心动过速，积极治疗后好转。胸引管平均拔除时间为5.4天，平均住院时间为7天。全组患者术后随访16个月，无肿瘤复发。

该研究结果表明：胸腔镜下肺叶袖式切除、支气管重建术是安全有效的。将操作孔设计在第4肋间腋前线更加方便支气管吻合的操作，而混合式缝合技术的应用使吻合更加安全、迅速。保留奇静脉并不影响支气管吻合断端的显露。而这些技术主要适用于肺癌直径＜3cm，生长于支气管腔内的肺癌患者。对于巨大肿瘤患者，仍是相对禁忌症

Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty: an improved operative technique.
OBJECTIVES
We summarize our experiences of video-assisted thoracoscopic surgery (VATS) sleeve lobectomy with bronchoplasty for non-small-cell lung cancer and discuss the indications and technical details of the operation.
METHODS
From September 2011 to December 2012, 15 patients underwent VATS sleeve lobectomy with bronchoplasty at our institution (right upper lobe 10, right middle and lower lobes 1, left lower lobe 2 and left upper lobe 2), with mediastinal lymphadenectomy. Three incisions were utilized. The utility incision was made at the fourth intercostal space, anterior axillary line. Simple continuous and simple interrupted suturing of the membranous and cartilaginous portions of the bronchus were performed for the anastomosis.
RESULTS
All procedures were uneventful, with a median operative time of 165 min, a median bronchial anastomosis time of 44 min and a median blood loss of 150 ml. There were no conversions to thoracotomy. There were 14 squamous carcinomas and 1 adenocarcinoma. All patients recovered well, and 1 experienced a minor complication. The median duration of chest tube drainage was 5.4 days, and the median length of hospital stay was 7 days. All patients were followed postoperatively for a range of 1-16 months without tumour recurrence.
CONCLUSIONS
VATS sleeve lobectomy with bronchoplasty is safe and effective. The utility incision placed at the fourth intercostal space, anterior axillary line, is convenient for the anastomosis, and the suturing technique is expeditious and secure. Preserving the azygos vein does not compromise exposure for the anastomosis. This technique is very suitable for centrally located lung cancers <3 cm in diameter, particularly when the cancers are located within the brachial lumen.