Fig. 4.

Intraoperative findings. a Thoracotomy incision: an incision was made posterior-laterally through the 4th intercostal space and extended anteriorly and upward, following the “Hook approach.” b Significant adhesions (arrow) were observed at the apical part of the left upper lobe. c Adhesions (arrowhead) between the left upper lobe (LUL) and the chest wall were too strong to separate, so we proceeded with the combined resection of the chest wall from the 1st to 4th ribs. LLL: left lower lobe. d Before performing a combined resection of the chest wall, we safely taped the left subclavian artery (Lt. SCA), vein (Lt. SCV), and brachial plexus