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We very much appreciate the reviewer’s positive comments and constructive critiques (1), which were valuable in guiding development of our minimally invasive surgical methods. We have addressed all of the comments and provided our point-by-point responses below:
The surgical steps that we presented were performed using the S system, and we only have the S and Si systems in our hospital. We agree that the Xi or X system affords several significant advantages, and we will try the Xi or X system as soon as we have the upgraded systems in our hospital. In addition, we used CO2 insufflation in our surgeries with the Stryker Gas Insufflator.
We agree that a thorough complete thoracic lymphadenectomy should be performed. The International Association for the Study of Lung Cancer (IASLC) recommends that at least three mediastinal lymph node stations should be sampled and they include station 7 in all lung cancer patients, stations 5/6 in left upper lobe tumors, and station 9 in lower lobe tumors (2). We have described the steps of lymph node resection of stations 9, 7, 5/6, and 11, which are adequate for nodal staging.
We do prefer the sequence that we reported: division of the inferior pulmonary vein first followed by division of the bronchus and artery last. We believe that our sequence is easier, especially in patients with a fused fissure because it is difficult to divide the pulmonary artery first in these patients. In addition, the order of vein first followed by the artery conforms to oncologic principles (3). We agree that congestion is sometimes observed in the lung with this procedure. However, an experienced thoracic surgeon will be able to quickly divide the pulmonary artery after dividing the vein. Thus, we do not think early congestion in the lung is a problem.
We agree that “a left lower lobectomy” is a more accurate and clear description of the operation, and we made this change in our manuscript.
We would like to acknowledge David Tian, Senior Editor of AME Publishing Company, for editing support.
Provenance: This is an invited article commissioned by Section Editor Jianfei Shen, MD (Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Taizhou, China).
Conflicts of Interest: The authors have no conflicts of interest to declare.