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Sequence of interruption of pulmonary artery and vein in VATS lobectomy - Does it matter?
Khalid Amer1, Ali-Zamir Khan2.
1University Hospital Southampton, Southampton, United Kingdom, 2Medanta, The Medicity, Gurgaon - New Delhi, India.

OBJECTIVE: This study aims at comparing the survival of patients who had their
pulmonary vein stapled before the pulmonary artery during VATS Major Pulmonary Resection (VMPR) for Non Small Cell Lung Cancer (NSCLC), versus those who had the artery stapled before the vein. Ligating the vein first is claimed to reduce micrometastasis and tumour recurrence, at the expense of increased amount of blood retained in the lobe
METHODS: Retrospective analysis of consecutive patients undergoing first time VMPR
for NSCLC , assessed within 3 groups: (A) patients who had all major lobar
arteries stapled before lobar veins and Group (B) reversed sequence, vein
before arteries and (C) mixed group, e.g. arterial branch followed by vein then more arteries. Basic demographics were compared, as well as surgery required, operative time, drain dwell time, postoperative drainage, length of hospital stay, histology, conversion, intraoperative blood loss, need for blood transfusion, postoperative surgical and non-surgical events, readmission within 2 weeks, pattern of recurrence and overall survival
RESULTS: Between April 2005 and March 2010, operative details were complete in
155 patients. Artery first comprised 28 (17.4%), Vein first 105 (65.2%) and
Mixed 22 (13.7%). The vein was interrupted first in all middle lobectomies, as this was the natural anatomical order of dissection. Group A were followed up significantly longer than group B as it was historically the technique we started the VATS lobectomy programme with. Three years later we changed to vein first. There was a significant conversion rate between the three groups, favouring Mixed group, which represents taking the easy vessel that opens dissection and makes the next step easer. There was no survival benefit difference between groups
CONCLUSIONS: The sequence of vessel interruption in VATS lobectomy for NSCLC does not affect survival. It does not increase the level of difficulty of the operation, lobe congestion was not encountered, and there was no significant difference in recovery. Rate of conversion might be reduced if sequence of dissection is mixed, tackling easy vessel first.

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