Management of middle lobe veins during single-portal video-assisted thoracoscopic surgery lobectomy via the fifth intercostal approach (case series): why the subcarinal triangular right base angle is helpful

BACKGROUND: The fifth intercostal space is the preferred approach during uniportal video-assisted thoracoscopic surgery (VATS) lobectomy. However, managing the right middle lobe pulmonary vein (RML PV) through this approach is technically challenging for inexperienced surgeons. To facilitate the surgical procedure, we describe our surgical strategy for managing the middle lobe vein via the fifth intercostal space and define the approach [subcarinal triangular right base angle (SCT-RBA)] utilized to manage the middle lobe vein. CASE DESCRIPTION: Based on the characteristics of uniportal surgery, we designed a new method of managing middle lobar veins via the fifth intercostal approach, which also facilitates the dissection of the subcarinal lymph nodes. We described the short-term surgical outcomes of 7 patients who underwent single-port middle lobe resection from January 2021 to January 2022 in the Department of Thoracic Surgery, Ruijin Hospital North Campus, Shanghai Jiaotong University School of Medicine. No conversion and mortality were observed in 7 patients who underwent single-port VATS middle lobe resection. One patient had bronchial asthma and air leakage, which led to delayed drainage and hospitalization. There were no complications or delayed discharge reported among the other patients. CONCLUSIONS: Our initial results indicate that this new technique is a feasible strategy to manage the middle lobe veins and facilitate the dissection of subcarinal lymph nodes.