It is a case of right lung surgery with previous left pneumonectomy, which entails the resection to be least impairment to the respiratory function and least trauma as well. Uniportal VATS right anterior segmentectomy should be the optimal choice because of its complete removal of the tumor while maximally functional lung kept, and smallest intercostal incision left.
However, this procedure is very challenging in lung ventilation, isolation and maintenance throughout the operation. Except for the way we have successfully implemented, other options could be recommended. First, a single-lumen tracheal tube (SLT) could be intubated into the right bronchus intermedius, this could make use of the ventilation in the middle and lower lobes, yet it also would lead to the upper lobar inflation, unless a detachment of the SLT with the cuff deflated and the ventilator was made before the establishment of pneumothorax. Besides, the blood and sputum from the upper lobe would be a problem since the export would have been blocked by the SLT. Another approach is BB. BB can be served for the purpose of one lung ventilation and selective lobar blockade in VATS, and also its advantages in children and difficult airway placement are widely-accepted . As for this case, however, if BB were chosen, it should be placed into the right upper lobe bronchus, given the knowledge of the anatomical features, it would be more likely placed into some segmental bronchus of the right upper lobe, resulting in inflation in the right upper lobar; besides, even if by any chance, BB were suitably placed, it would have a great probability of being dispositioned given the thought of the short right upper lobe bronchus and the surgical intervention. Although DLT has rarely been taken in selective lobar blockade for lung resections , there was a precedent in partial sternotomy . Comparing to partial sternotomy, we believe that lung resection, as in this case segmentectomy is more challenging in ventilation, isolation and drainage. First, we have to make sure the bronchial cuff is intubated into the bronchus intermedius, and it can protect the middle and lower lobes from the upper lobe contamination when inflated, and the bronchial orifice should be above the middle lobe bronchial port to guarantee the ventilation in the middle and lower lobes. But the length of bronchus intermedius varies, and that length was only about 15 mm in this woman while the length of bronchial cuff and the tip included was about 30 mm, so we cut off the tip (about 10 mm without damage to the cuff) and made it clean and smooth without any possible damage to the human body. Still, our approach has some limitations too, the bronchial cuff of this modified DLT was meant to be positioned in the bronchus intermedius, however, the shorter, the easier to be dispositioned; also, skilled adapting and intubation technique, and the recognition of the bronchial anatomy are needed.
But putting the DLT in the expected position doesn’t guarantee a safe oxygenation, considering the middle and lower lobes only for ventilation. Although we assumed it would do, based on her preoperative arterial blood gas results and her daily exercise tolerance, still we asked for ECMO (extracorporeal membrane oxygenation) as an emergent plan in case of extreme low oxygenation. Our lung protective ventilation strategy was a combination of low Vt, high respiratory rate and a small PEEP. It’s been showed in a meta-analysis that in patients without ARDS (acute respiratory distress syndrome), lower Vt is associated with better outcomes, including fewer lung injuries and less pulmonary infection . However, Vt can’t be too low to cause small and distal airways earlier closing and alveoli collapsing, leading to atelectasis, decreased ventilation/perfusion (V/Q) and increased intrapulmonary shunt. It’s been demonstrated that a low Vt combined with an adequate PEEP could promote oxygenation, improve the desaturation status, and decrease the hypoxic lung injury .
In conclusion, we have succeeded in managing the ventilation in right middle and lower lobes and the upper lobar isolation by the adapted DLT, enlightening a new technique in selective lobar blockade, and the promotion of radical lung resection after previous pneumonectomy could be benefited.