About Dr. Chen Haiquan
Dr. Chen Haiquan is Chief of Thoracic Surgery at Fudan University Shanghai Cancer Center — one of China's highest-volume thoracic oncology programmes. He specialises in video-assisted thoracoscopic surgery (VATS) for lung cancer and complex mediastinal tumours, and has performed over 10,000 thoracic procedures across his career. Dr. Chen is a key opinion leader in minimally invasive lung surgery in China and has trained hundreds of thoracic surgeons in uniportal VATS technique. His practice integrates surgical precision with comprehensive oncological management — encompassing pathology, molecular profiling, and systemic therapy — to deliver whole-journey lung cancer care for international patients.
Case Overview
A 58-year-old architect with a 30 pack-year smoking history presented with a 3-month history of irritating dry cough and 1 week of blood-streaked sputum. Enhanced CT with three-dimensional reconstruction demonstrated a 2.5 x 2.0 cm soft tissue mass at the left upper lobe bronchial orifice, with 4L mediastinal lymph node enlargement. Bronchoscopy confirmed complete left upper lobe bronchial occlusion; biopsy established squamous cell carcinoma. PET-CT showed no distant metastasis. Clinical stage: cT2aN1M0 (Stage IIB) — central lung cancer. Conventional management would have required pneumonectomy, with its attendant cardiopulmonary morbidity and quality-of-life consequences. Dr. Chen Haiquan instead performed uniportal VATS sleeve lobectomy: left upper lobectomy with en bloc resection of the involved bronchial wall and left lower lobe bronchus-to-left main bronchus anastomosis — preserving the left lower lobe — through a single 3.5 cm incision, without chest drain or endotracheal intubation (tubeless technique). Operative time 180 minutes; blood loss 50 mL. R0 resection confirmed; 2 of 18 lymph nodes positive (pN1). Discharged on day 4. At 1-year follow-up, FEV1 had recovered to 90% of pre-operative baseline and the patient was hiking without limitation.
Patient Background
- Age / Sex: 58-year-old male
- Occupation: Architectural designer — high expectations for post-operative quality of life and cosmetic outcome
- Chief Complaint: Irritating dry cough for 3 months; blood-streaked sputum for 1 week
- Smoking History: 30 pack-years; ceased smoking 1 year prior to presentation
- Medical History: No significant comorbidities
- Pulmonary Function: FEV1 2.1 L (75% of predicted); DLCO normal — adequate reserve for lobectomy; pneumonectomy would have resulted in significant functional impairment
Diagnosis and Pre-operative Assessment
Enhanced CT with Three-Dimensional Reconstruction
- Primary lesion: Soft tissue mass 2.5 x 2.0 cm at the left upper lobe bronchial orifice — in close proximity to the left main bronchus and pulmonary artery branches
- Mediastinal nodes: Station 4L lymph node enlargement — suspicious for metastasis
- Key anatomical finding: Tumour located more than 1.5 cm from the carina — sleeve resection anatomically feasible
Bronchoscopy
- Complete occlusion of the left upper lobe bronchial orifice visualised
- Biopsy: squamous cell carcinoma confirmed
- Tumour involvement approximately 1.5 cm from the carina; carina itself uninvolved
PET-CT
- Left upper lobe mass: SUVmax 12.5
- Station 4L lymph node: SUVmax 4.2 — consistent with nodal metastasis
- No distant metastatic disease identified
Clinical Stage
- cT2aN1M0 — Stage IIB non-small cell lung cancer (central squamous cell carcinoma)
Clinical Decision Making
Central lung cancer at the bronchial orifice has historically mandated pneumonectomy — removal of the entire lung. Pneumonectomy carries substantial cardiopulmonary morbidity, a 5-year survival rate of only 30–40%, and permanent, severe reduction in quality of life.
Dr. Chen Haiquan's lung-preserving strategy: This patient has adequate pulmonary reserve, but pneumonectomy would devastate his quality of life. Because the tumour is located more than 1 cm from the carina, sleeve lobectomy is anatomically feasible: we resect the left upper lobe together with the involved bronchial wall, then anastomose the left lower lobe bronchus directly to the left main bronchus — preserving the entire left lower lobe. We will perform this through a single 3.5 cm uniportal VATS incision, without chest drain and without endotracheal intubation. The goal is R0 resection with maximum functional preservation and minimum physiological disruption.
Three technical challenges defined this case: the confined working space of uniportal VATS makes bronchial anastomosis technically demanding; simultaneous management of pulmonary artery branches carries haemorrhage risk; and complete systematic lymph node dissection must not be compromised by the minimally invasive approach.
Surgical Procedure
Approach: Uniportal VATS left upper sleeve lobectomy + systematic lymph node dissection
Incision: Left 4th intercostal space, anterior axillary line — 3.5 cm (no muscle division)
Operative time: 180 minutes
Estimated blood loss: 50 mL
Step 1 — Uniportal Access and Exploration
A soft wound protector was placed through the single intercostal incision — no rib spreading required, preserving thoracic wall integrity. Gravity-assisted left lower lobe retraction provided natural hilar exposure without additional instrumentation.
Step 2 — Pulmonary Artery First Strategy
Departing from the conventional bronchus-first sequence, Dr. Chen employed a pulmonary artery-first approach. Under three-dimensional magnified visualisation, the apicoposterior and anterior segmental arterial branches of the left upper lobe were individually dissected, clipped with Hem-o-lok, and divided using an ultrasonic scalpel.
Dr. Chen's operative note: Dividing the arterial supply first reduces tumour vascularity, clarifies the operative field, and — critically — eliminates the risk of haematogenous tumour dissemination from intraoperative tumour manipulation. It is an oncological principle, not merely a technical preference.
Step 3 — Bronchial Sleeve Resection and Anastomosis (Critical Step)
The left main bronchus and left lower lobe bronchus were divided, and the left upper lobe — containing the tumour and involved bronchial wall segment (approximately 1.5 cm) — was removed en bloc. Intraoperative frozen section of both bronchial margins confirmed negative resection margins before anastomosis was commenced.
Anastomosis was performed using 4-0 Prolene suture in a continuous full-thickness technique with interrupted reinforcing sutures, executed entirely through the single port using long-handled needle drivers. Following anastomosis completion, intravenous ICG was administered and near-infrared fluorescence imaging confirmed uniform anastomotic perfusion with no ischaemic segments.
Dr. Chen's operative note: ICG fluorescence is our intraoperative quality control for the anastomosis. A technically perfect suture line on a poorly perfused bronchus will still result in bronchopleural fistula. Fluorescence confirmation of anastomotic blood supply is the final step before we close — not optional.
Step 4 — Systematic Lymph Node Dissection
Stations 4L, 5/6, 7, 8, and 9 were systematically dissected; 18 lymph nodes retrieved in total. Dissection was completed without compromise to thoroughness despite the uniportal approach.
Step 5 — Tubeless Closure
In coordination with the anaesthesia team operating under deep neuromuscular blockade with laryngeal mask airway (no rigid endotracheal intubation), and with confirmed lung re-expansion and anastomotic integrity, no chest drain was placed. A single fine wound drain was positioned at the incision site only. The laryngeal mask was removed in the operating room.
Pathology and Post-operative Recovery
Final Pathology Report
- Histology: Moderately differentiated squamous cell carcinoma of the left upper lobe bronchus; tumour size 2.2 cm
- Resection margins: Bronchial and vascular margins both negative — R0 resection confirmed
- Lymph nodes: 2 of 18 positive — pN1 disease
- Molecular profiling: EGFR negative; ALK negative; PD-L1 TPS 60% (high expression)
Post-operative Course (ERAS Protocol)
- Recovery room: Laryngeal mask removed 30 minutes post-operatively; patient alert and comfortable; no sore throat
- Day 1: Independent ambulation; oral fluids; no subcutaneous emphysema
- Day 2: Fine wound drain removed (output less than 50 mL); regular diet resumed
- Day 4: Discharged home (conventional thoracotomy typically requires 7–10 days)
- Complications: No bronchopleural fistula; no cardiac arrhythmia; no air leak
Adjuvant Therapy and Follow-up
Given pN1 nodal disease and PD-L1 TPS of 60%, Dr. Chen recommended adjuvant pembrolizumab (PD-1 immune checkpoint inhibitor) combined with platinum-based chemotherapy for 4 cycles, consistent with current evidence for high PD-L1 expressing resected NSCLC.
- 1-year bronchoscopy: Anastomosis fully healed; no stricture; residual suture material only
- 1-year pulmonary function: FEV1 recovered to 90% of pre-operative baseline — a direct consequence of left lower lobe preservation
- 1-year clinical status: No cough; no dyspnoea; patient hiking at altitude without limitation
Expert Commentary — Dr. Chen Haiquan
1. Uniportal VATS: Precision, Not Just Minimalism
The uniportal approach is sometimes mischaracterised as a cosmetic modification of multiport VATS. It is not. The camera's wide-angle view through a single port provides superior visualisation of deep hilar structures compared with both open thoracotomy and multiport VATS. For sleeve resection — which demands precise suture placement in a confined anatomical space — the linear instrument trajectory of uniportal VATS is ergonomically advantageous. The technique requires rigorous training; I have trained several hundred surgeons in this approach. In experienced hands, it is safe, reproducible, and oncologically equivalent to open surgery.
2. Sleeve Lobectomy: The Lung-Preserving Standard for Central Cancer
Whenever a central tumour is located more than 1 cm from the carina, sleeve lobectomy should be the default — not pneumonectomy. Our institutional data demonstrate equivalent 5-year survival between sleeve lobectomy and pneumonectomy for Stage II central lung cancer, with dramatically superior quality of life in the sleeve group. The difference in FEV1 preservation — 90% versus 45% — translates directly into the patient's ability to work, exercise, and live without breathlessness. Sleeve resection is a technically demanding skill that every thoracic oncological surgeon must master.
3. Tubeless Surgery: The Logical Endpoint of ERAS
Eliminating endotracheal intubation and chest drain placement removes the two most significant sources of post-operative pain and physiological stress in thoracic surgery. The result — day 4 discharge after sleeve lobectomy — was unimaginable a decade ago. Tubeless VATS requires seamless coordination between surgery, anaesthesia, and nursing; it cannot be implemented unilaterally. For patients with adequate pulmonary reserve, we are progressively extending this approach toward 24–48 hour discharge protocols.
4. Whole-Journey Lung Cancer Management
Surgery is the beginning, not the end. This patient's PD-L1 TPS of 60% identified him as a strong candidate for adjuvant immunotherapy — a treatment decision that required integration of surgical, pathological, and molecular data. As thoracic surgeons at a dedicated cancer centre, we must understand medical oncology, pathology, and genomics to deliver optimal comprehensive care. The operation removes the tumour. The programme around the operation determines whether the patient is cured.
How CMCS Shanghai Coordinated This Case
China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through 1-year oncological follow-up. Our coordination included:
- Pre-arrival review of CT imaging and bronchoscopy reports; specialist referral to Dr. Chen Haiquan's thoracic surgery team at Fudan University Shanghai Cancer Center
- Arrangement of enhanced CT with three-dimensional bronchial reconstruction, PET-CT staging, pulmonary function testing, and bronchoscopic biopsy for complete pre-operative workup
- Bilingual interpretation during the surgical planning consultation, including detailed explanation of sleeve lobectomy versus pneumonectomy, uniportal VATS technique, tubeless anaesthesia, and realistic functional outcome expectations
- Molecular profiling coordination: EGFR, ALK, and PD-L1 testing with results translation and communication to the patient's home oncologist
- Surgical admission logistics: hospital registration, uniportal VATS suite scheduling, and accommodation support for accompanying family
- On-site medical interpretation throughout the hospitalisation, including ERAS protocol guidance, wound drain management, and early mobilisation support
- Post-discharge coordination of adjuvant pembrolizumab plus chemotherapy scheduling, cycle monitoring, and immune-related adverse event surveillance liaison with Dr. Chen's team
- 1-year surveillance coordination: bronchoscopy scheduling, pulmonary function testing, CT chest follow-up, and communication with the patient's home respiratory physician
For international patients facing a central lung cancer diagnosis — particularly those who have been advised that pneumonectomy is their only option, or who have been told that minimally invasive surgery is not feasible for their tumour location — the combination of uniportal VATS expertise, sleeve resection capability, and comprehensive molecular oncology at Shanghai's leading cancer centres represents a standard of care that may not be available in their home country. CMCS exists to connect patients with that expertise: ensuring every lung-preserving option is evaluated, every treatment decision is explained in their language, and every step from pre-operative staging to long-term oncological follow-up is coordinated with precision and care.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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