Table 1. Technical challenges and hurdles associated with VATS pneumonectomy.

Challenge	Solution
Concern regarding the possibility of stapler induced injury or stapler misfire when coming across and dividing main pulmonary artery with limited vascular control	Guiding stapler with red rubber “leader” facilitates safer passage across the main pulmonary artery
Safety of pulmonary artery dissection	Dissection onto the mainstem bronchus when performing mediastinoscopy/Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) will make vascular dissection easier/safer at time of VATS resection
Tissue coverage for the bronchial stump	Creation of a pericardial fat pad and/or pleural flap is safe Thoracoscopic intercostal muscle flap is also feasible
Getting proximal division point on the main stem bronchus, especially with a left pneumonectomy	Lung retraction instrumentation now allow for aggressive retraction for proximal division of the bronchus Use of Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) before resection
Technical consideration of retracting the whole lung when dividing the mainstem bronchus	A laparoscopic adjustable liver retractor (Snowden-Pencer Diamond-Flex) placed around the main stem bronchus allows for retraction of the entire lung (Figure 4)
Removing the specimen from the chest cavity	Larger 8 inch by 10 inch Nylon extraction sac
	Facilitates removal of the entire lung