Bronchoplasty using continuous suture in complete monitor view: a suitable method of thoracoscopic sleeve lobectomy for non-small cell lung cancer
© Shao et al. 2016
Received: 23 January 2016
Accepted: 22 April 2016
Published: 30 April 2016
Our study aims to determine the value of bronchial anastomosis using complete continuous suture.
Six patients diagnosed with central lung carcinoma who were candidates for right-sided sleeve lobectomy and underwent sleeve resection of the right upper lobe by thoracoscopic surgical procedure.
The mean surgical time was 182 min (range, 110 to 260 min). The mean time of bronchial anastomosis was 49 min (range, 18 to 76 min). The mean bleeding was 110 mL (range, 50 to 260 mL). Median chest tube drainage was 305 mL (range, 200 to 600 mL). No perioperative deaths or major complications occurred. The postoperative bronchoscopy confirmed no stenosis. The mean follow-up time was 19.2 months (range, 7 to 34 months), and six patients were alive.
Bronchial anastomosis using complete continuous suture may be a suitable method in thoracoscopic sleeve lobectomy.
Thoracotomy is the traditional way to perform a bronchial sleeve lobectomy for non-small lung cancer (NSCLC), but it also can be performed by video-assisted thoracic surgery (VATS). The key point of thoracoscopic sleeve lobectomy is to finish bronchial anastomosis in the complete monitor view. The traditional interrupted suturing techniques emphasize on the security and less anastomotic site ischemia, while the continuous suturing techniques will result in less suture tangling and may be quicker. There is no evidence of which is the better between interrupted and continuous suturing in bronchial anastomosis. Since the first case was reported , we have performed six cases of NSCLC with bronchial anastomosis using complete continuous suture which we believe to be a suitable method in thoracoscopic sleeve lobectomy. The following section details our method.
Material and methods
Criteria for thoracoscopic sleeve lobectomy for primary lung carcinoma
Maximum tumor size 5 cm, location above the segment bronchi, necessary for sleeve lobectomy
No evidence of bronchi and vessel invasion, no direct invasion to the surrounding organs requiring reconstruction
No enlargement or calcification of mediastinal and hilar lymph nodes in CT and PET/CT
No heavy adhesion of pleural cavity, suitable for VATS
Patient and family agreed to procedure
Patient characteristics and histology
Tumor size (mm)
Pre-op pulmonary functional test
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee in our hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. Six of them underwent sleeve resection of the right upper lobe by thoracoscopic surgical procedure. We placed the patient in a left lateral decubitus position. A 1-cm port on the middle axillary line in the seventh intercostal space was the first port used primarily for thoracoscopy. The second and the third ports, 2 and 1.5 cm, respectively, on the anterior axillary line in the fourth intercostal space and the posterior axillary line in the ninth intercostal space, were used for manipulation of the lung.
Intraoperative and postoperative variables
Operating time (min)
Suturing time (min)
Hospital stay (day)
T2N0M0, IB, R0
T2N0M0, IB, R0
T2N1M0, IIB, R0
T2N2M0, IIIA, R0
T2N1M0, IIB, R0
T2N0M0, IB, R0
With improvements in thoracoscopic competency, greater exchange of knowledge and techniques, and advances in equipment, increasing number of medical centers are able to perform video-assisted thoracic surgery sleeve lobectomy and even double sleeve lobectomy for central lung cancer . Technically, the most important and difficult part of thoracoscopic sleeve lobectomy is to complete bronchial anastomosis in the monitor view. Interrupted suturing techniques have potential advantages of less anastomotic site ischemia and security, while continuous suturing techniques will result in less suture tangling and may be quicker. It seems impossible to have a meaningful comparison of clinical outcomes between the different anastomotic approaches for thoracoscopic sleeve lobectomy because of the relatively low case numbers .
Some of reports describe the VATS approach using interrupted sutures in anastomosis, especially in bronchus cartilage reconstruction [4, 5]. The end-to-end anastomosis can also be performed by complete continuous suture. Some authors believe that anastomosis with continuous sutures is thought to be useful for bronchoplasty in thoracoscopic surgical procedures . We think that the key point of sutures in bronchial anastomosis in VATS is to avoid tangling the ends of the untied ends. Since 2003, we have used continuous suture to complete both membranous bronchus and cartilage anastomosis at one time through thoracotomy. Consequently, as we accumulated experience, we were able to perform sleeve lobectomy with VATS. Complete continuous suture was an ideal way in thoracoscopic sleeve lobectomy with only one 3-0 prolene to avoid tangling the ends of the untied ends. With an endoscopic knot pusher, every suture could be pushed near the bronchus, it was quite clear to adjust for any size discrepancy between the proximal and distal airways with precise suture placement along the circumference of the anastomosis (Fig. 1). Besides, the tension could be carefully adjusted with a sliding knot-pushing instrument. Only by dragging the sutures tight, we can perform air leakage test, and tie the knots while placing the sutures to prevent them from tangling (Fig. 2). With the increasing number of cases, our techniques of continuous suture were more skillful. The time of operation and the time of the bronchial anastomosis were shortened.
VATS sleeve lobectomy becomes more popular with acceptable morbidity and mortality as well as short length of stays, and a viable choice for some patients with central lung cancer. We believe that complete continuous suture should be a suitable way in thoracoscopic sleeve lobectomy which can be convenient with a clear operative view.
Ethical approval statement
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee in our hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
We are very appreciative of Dr. Wan Mingyue for the pathological interpretation.
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