title: Thoracoscopic tunnel technique for anatomical lung resections: a 'fissure first, hilum last' approach with staplers in the fissureless patient.
abstract: OBJECTIVE
  To minimize air leak after anatomical lung resections, many video-assisted thoracic surgery (VATS) surgeons use a 'fissureless' technique, using staplers to divide the hilar bronchovascular structures first and the main part of the fissure last. We describe a cohort of 198 consecutive patients operated with an alternative fissureless technique, opening the fissure completely with staplers at an early stage of the VATS anatomical lung resection.
  
  
  METHODS
  To open the incomplete fissure first and with staplers, a tunnel dissection is started anterior between the triangle of pulmonary veins and the parenchyma. After identification of the pulmonary artery, the anvil of a first stapler is placed on top of the artery and the anterior part of the fissure is divided. Dissection between artery and parenchyma is continued until the fissure is completely stapled. From a prospectively managed single institution database, we retrieved 405 patients scheduled for VATS anatomical resection between October 2009 and December 2014. The patients were categorized in four consecutive periods: a learning curve with the first 50 cases of VATS lobectomy technique (LC), a period of consecutive 'hilum first, fissure last' (HF), a transition group (TG) during which both techniques were used and a period of consecutive 'fissure first, hilum last' (FF).
  
  
  RESULTS
  No significant differences in operating time, frequency of prolonged air leak or hospital stay were observed between HF (n = 45) and FF (n = 198). Chest tubes were removed earlier in the FF period (6.9 vs 5.2 days, P = 0.025). Excluding the learning curve, we found 2 patients (2.8%) operated 'hilum first' with an intraoperative complication that potentially could have been avoided by a 'fissure first' technique.
  
  
  CONCLUSIONS
  By making a tunnel between the bronchovascular structures and parenchyma from anteriorly to posteriorly, one can open the fissure completely with staplers at an early stage of an anatomical lung resection. This combines the advantages of both the 'fissureless' hilum first technique and classic (open) fissure first dissection, i.e. minimal air leak and optimal anatomical overview before bronchovascular structures are divided, potentially avoiding inadvertent transections. A cohort of 198 consecutive patients operated with this alternative fissureless technique demonstrates the feasibility and non-inferiority regarding hospital stay, chest tube duration, operation time and complications in comparison with the hilum first technique.
authors.affiliation: Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium herbert.decaluwe@uzleuven.be.
authors.forename: Herbert
authors.initials: H
authors.lastname: Decaluwe
authors.affiliation: Department of Thoracic Surgery, Hôpital Erasme, Université Libre de Bruxelles, Belgium.
authors.forename: Youri
authors.initials: Y
authors.lastname: Sokolow
authors.affiliation: Department of Thoracic and Vascular Surgery, University Hospital, Ghent, Belgium.
authors.forename: Frederic
authors.initials: F
authors.lastname: Deryck
authors.affiliation: Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.
authors.forename: Alessia
authors.initials: A
authors.lastname: Stanzi
authors.affiliation: Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.
authors.forename: Lieven
authors.initials: L
authors.lastname: Depypere
authors.affiliation: Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.
authors.forename: Johnny
authors.initials: J
authors.lastname: Moons
authors.affiliation: Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.
authors.forename: Dirk
authors.initials: D
authors.lastname: Van Raemdonck
authors.affiliation: Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.
authors.forename: Paul
authors.initials: P
authors.lastname: De Leyn
mesh_terms: D000368:Aged; D059925:Anatomic Landmarks; D001530:Belgium; D016208:Databases, Factual; D004210:Dissection; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D011651:Pulmonary Artery / Q000601:surgery; D013528:Surgical Staplers; D017792:Surgical Stapling / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome
keywords: Air leak; Fissure; Fissureless; Lobectomy; Stapler; Video-assisted thoracic surgery