Novel thoracoscopic lymph node dissection techniques for left upper lobectomy with a fused fissure

: Currently, lobectomy with systematic lymph node dissection (LND) is the standard surgical procedure for early stage, non-small cell lung cancer (NSCLC). Several issues may arise when performing a lobectomy such as a fused fissure, especially during thoracoscopic surgery. In this case, performing hilar LND in a conventional manner may be difficult. Since both hilar and mediastinal LND are essential procedures during surgery for NSCLC, it is crucial to achieve both safe lobectomy and precise systematic LND in fused fissure cases. To address this difficult situation, we have developed the following three novel thoracoscopic techniques that focus on LND: (I) the “anterior fissure first technique”, (II) the “#4L-posterior first technique”, and (III) the “anterior #7 dissection technique”. First, the anterior fissure first technique enables the operator to view the entire hilar lymph node, similar to a situation with a complete fissure, and allows the hilar LND to proceed in a conventional manner. Second, when using the #4L-posterior first technique, the left lower paratracheal (#4L) LND is straightforward since the left recurrent laryngeal nerve (RLN) has already been dissected, and only the anterior area of #4L remains to be dissected. Finally, during the anterior #7 dissection technique, when performing the subcarinal (#7) LND, we do not dissect between the dorsal side of the trachea and esophagus. Consequently, the bronchial artery (BA) is preserved and postoperative ischemic change in the bronchial stumps is prevented. We believe that our techniques are oncologically appropriate and enable the safe and straightforward execution of precise thoracoscopic lobectomy and systematic LND, even in cases of fused fissures.