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Surgical videos on WeBSurg
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English - 20'00''
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| 00'18'' | Case presentation
Hello, I’m Dr Steve Rothenberg and today we are bringing you the second in the series of 3 live web broadcasts on pediatric surgical procedures. This is sponsored by Karl Storz and Network 1. Today we are going to do a thoracoscopic lobectomy for a congenital cystic adenomatoid malformation of the lung. This is a 9-month-old patient who had a prenatal diagnosis of a CAM and has been followed with serial CT-scans. As the lesion has progressed in size, we have elected to go ahead with thoracoscopic resection at this time. So I am going to turn it over to Dr. Blingman at this time and I am going to go ahead and head over to the patient and we’ll get started. |
| 00'59'' | Trocar placement
You see the port placement. The child’s chest is at the right-hand side of your screen with the back to the left and we are standing at the child’s front facing his back. The most difficult part of this procedure is the operation that occurs in the major fissure so I try to position my instruments to have the best advantageous approach to that. |
| 01'25'' | Start of procedure
Sorry we are still looking at the outside but here again you can see my left hand, my right hand, you can see some of the cyst that are showing up in the lung, this is probably a variation of a type 2 or type 3 CAM with smaller cysts, here are some as well. Now we are going to go ahead just to get orientated, we are going to take the inferior pulmonary ligament and for these procedures I really like using a device called the Ligasure which is a variation on bipolar technology, which is an extremely good sealing device. What it does is it collapses the tissues and seals them; it’s a smart instrument so it goes till we get a sound tone telling us that it’s sealed. I like this instrument because it’s a good dissector, you see it’s a 5mm instrument but it has a relatively nice dissecting tool so I don’t have to switch out instruments, and also the curve of the instrument makes it an excellent dissector. When I actually take the pulmonary vessels I want to be able to seal them and then what I usually do is make two seals and then I’ll divide between those seals so that if per chance a seal doesn’t take, I have the opportunity to recover and do something else. You see the instrument just cooks until it tells you that it has a seal, and sometimes in thinner tissues like this, you will get a fall tone because the tissue is really too thin and there is not much to seal. Here you see the inferior pulmonary vein there, and I like to dissect this out first so that I have easy access to it if I need to take it. My personal preference in these cases is to take the vein last so that the lung doesn’t get congested. We are going to roll the lung over a little bit and try to free up the posterior aspect of it. You can see the aorta very nicely there. I also think that when you do these operations in infants, the compensatory expansion of the remaining lobes really works quite well and these children really have no respiratory deficit and I still think this is a question of whether or not there is a risk of cancer later and so I am reluctant to leave what might be abnormal tissue. Here we are using the Ligasure to help complete the incomplete fissure and it’s actually a very good device for sealing lung in small sections like this. You can kind of get an idea of where we are going. We are going to use it to help us dissect up on into the major portion of the fissure. You can see we are going up across lung parenchyma now and again we are using just the same instruments. The goal here is to expose the pulmonary artery, it’s one of the key things about this procedure, it’s very important to have a good sense of what the anatomy is in the chest because you can’t always see it and you want to know what structures you are coming up to. What we are trying to do right now is just expose the pulmonary artery as it comes through the major fissure. A lower lobectomy is easier to perform because basically you get to take everything that heads south of the major fissure. |
| 05'12'' | Vascular and bronchus dissections
Here you can see the pulmonary artery coming into view right there. You can see there is some char building up on the instrument and we’ll clean it soon because that is a problem, sometimes you have to be careful that there is not sticking and you can see this is just sealing the tissues but in these thinner tissues it will actually divide it. When we come to the vessels, we will actively divide them after we have sealed them. Are you using standard 3mm instruments? That’s a good point, in this child we are using 3mm instruments, these again are the ClickLine®, these are short-shafted instruments so that they are about 18 to 20cm in length, so they are much more ergonomic then the standard length 5mm instruments. Unfortunately the Ligasure is still just available in a 5mm version, hopefully they will soon get us a 3mm version. Now you can see that we have really opened up that fissure nicely, here you can see the lingular branch of the pulmonary artery coming up here, so we want to make sure that we preserve that. We are going to dissect down into the lower lobe so that we don’t injure that vessel. It is just important to take your time here and be very methodical. I’ll dissect into the lung a little bit to get some length on those vessels as they go into the lower lobe. If you need to, you can put in a fourth port to help retract the lung. Here we have the lung retracted with some gentle CO2 insufflation. We have set the pressure just at 4. We have a mainstem intubation so that’s really what is causing most of the claps here, this is not a double endoluminal tracheal tube here we do get some overflow of ventilation and so the CO2 allows us to keep good compression on the lung while we are operating. The babies will tolerate pressures up to 8 or even 10 for short periods of time. Often what you need to do initially to get the lung collapsed is use a higher pressure and then once you have the lung collapse especially in a newborn you can back off because until you actively try to ventilate the lung it stays fairly collapsed. That is a technique we use a lot when we do TEF repairs because in those cases it’s very difficult to get a left mainstem intubation and so rather than wasting time trying to do that. On the left part of your screen, you are seeing the upper lobe, on the right part you are seeing the lower lobe, we have opened up the major fissure and I am dissecting out the branches of the pulmonary artery as it goes to the lower lobe. Here you see the apical branch right there. |
| 08'43'' | Exposure of pulmonary artery
I think that the most important thing is to preserve the vessel to the upper lobes, you don’t want to do anything to compromise that. By going down into the lung you can get the vessels when they are a little bit smaller after the branch rather then taking the full branch of the pulmonary artery as it comes below, you can do that, and it’s not a wrong thing to do, it’s just especially using a device like the Ligasure I think it’s a little bit safer. Here you see that there is a little tissue back there. I think you can use the same techniques that you use in open surgery. Now I think that we have enough of the vessel that we can safely seal it, so we are going to seal near its take off up here. I’ll go ahead and apply the Ligasure, in this case the vessel is small enough that our seal is just about going to divide the vessel for us. You see another branch back there. Try to get a little lower seal there. We have completed the fissure posteriorly and you can see those large nodes which are not normal and they have to do with his CAM. Here you see the next branch. You can see how nice this 3mm dissector works in here, this is a very comfortable operating position for me. Here we see again the branching points, beautiful anatomy. You can see that the benefit is that it’s a difficult space to tie in because it’s small. The concern about using clips is that they too might come off during the dissection so I think this particular instrument is particularly well-suited for these cases, especially in the smaller babies. You can see how fine electrocautery is, and we are just trying to mobilise the vessels a little bit, give us a little bit more room. You need to know what’s there so that you don’t miss one but I sort of take what nature gives me. You can see that seal and now I am going to cut right in the middle of it. These are abnormal nodes, that’s not a normal node for a normal 8-month-old infant. I am just cleaning up the bronchus, you really have two options here: you can go ahead and divide the bronchus and generally in babies what I do is I divide it and saw it close. Look at that node, it’s obstructing our view, we are going to need to get it out of the way. One thing that’s very important and that I did before we went live is to look and make sure there is no systemic vessel coming directly off the aorta because that is clearly not something you want to miss. |
| 12'56'' | Exposure of pulmonary vein
Now we are going to start our dissection on the pulmonary vein. What I am doing is I am retracting the lung superiorly and posteriorly, kind of holding it up to put the vein on a stretch, again if you are having trouble you can put in another port so that your assistant can help you; I am just holding it for myself. If you want to get even better exposure, you can divide the bronchus, I try to wait to do that so we don’t have the air leak until the very end. Again I am retracting the lung superiorly with my left hand, putting the pulmonary vein on a stretch, that is showing these vessels quite nicely. Of course we have all the usual safety measures here, including blood available in the room, full open set available for use if we need it. For lobectomies and PDA ligations I will always have blood available. I will have an opportunity to get in there and re-apply the sealer or some other technology. There is the last branch of the inferior pulmonary vein to lower lobe, again we could have gone right across the stump and taken this, the Ligasure is certified to take vessels up to about 8mm in size, I generally try not to push it quite that far but you can. Now we see the last branches. We are going to flip the lung back down, there again you can tell somebody where some of the abnormal lung is. Now if we have done our homework right, there is the bronchus, there is a bit of attachment here with the possibility that there is a vessel left in there, I don’t think so but we are going to go ahead and come across this. You can see the division of the bronchus as it goes to the apical segment and the lower lobe segment. |
| 15'23'' | Exposure and division of bronchus
I think it would be a bit of stretch to try and get our stapler in there. I am going to go ahead and divide this sharply. The other thing I don’t like about using staplers in babies is that I think it’s too easy to compromise the bronchus to the other lobes, because the stapler is so wide. There is often some bronchial branches that will bleed. There are no bubbles around the bronchial stumps. This is basically the lobectomy; that’s the port that I use with the Ligasure in and work in the fissure, I will enlarge that to about 1cm and then I will tear this lung out. |
| 16'20'' | Bronchus suturing
We have done reverse bronchoscopy before, but it is kind of a drastic technique. So we are just going to put a few simple stitches in and test for an air leak again. You get a nice look at the bronchus, look at the beautiful view we have, easy to release, and I use the reverse C technique of lying down square nuts! Because of its memory, it is a little tough to suture with but again I think it’s the best choice in these cases. I know that if the baby is not doing well then they will tell me and that I can make adjustments for that but otherwise I am not concerned about the baby’s condition and that is a huge relief. If you are going to do these procedures, then you need to have that kind of relationship and understanding with the anesthesiologist. Now I go to the 5 mm step-port. TEF needle is also a good choice and the RV2 is just a little bit smaller and also works well in even smaller babies. How do you check for an air leak, what pressures and how do you do it? It is a little more difficult thoracoscopically to be honest with you, we will pour a little saline in there and have Dr. Clark at the end of the procedure pull back the endotracheal tube and inflate the lung and I want to visualize the lower lobe inflating to make sure I haven’t compromised anything. The only problem is that it can get in the way when you are suturing as it probably will a little bit with this position. Have you ever tried to use just an endoloop on the bronchus? I haven’t, it’s not a bad idea but my concern would be that you wouldn’t get enough compression. Everybody knows I use endoloops on the lung to do lung biopsies in babies, it might work, I would just worry about it releasing prematurely. Have you ever just morcellized the specimen to get it out through a smaller hole? I basically do, I think we are going to keep the broadcast going so I’ll show you, this is probably the most difficult part of the operation. Especially since we saw the enlarged nodes, it’s hard to know if there has been any significant infection or anything else going on and you don’t want to release a lot of pus into the wound, I will generally not cut the lung up before but what I do, I’ll show you. You can see the field is perfectly dry, you have nice stump closure, we will come back and inflate it in a minute. We are going to make our incision a little bit bigger, and in fact by using that lower rib space, you can get out even slightly larger specimens that you wouldn’t want to morcellize for pathology. |
| 20'08'' | Specimen extraction
I am spreading in the direction of the rib space. If I thought this was a specimen I should be really worried about contamination, then I would cut a finger off a surgeon’s glove or something along that line. Here is our inferior pulmonary vein, here is our bronchial stump, here is our pulmonary artery with some goo. I am very comfortable with that closure, and we will put a chest tube in and before we wake the baby up, we will try to get a look at it, we may not be able to. We have no blood. That’s it. |
| 21'00'' | End of procedure
I would also like to thank you all for tuning in, I’d particularly like to thank Karl Storz who has sponsored these educational events and this is the second in the series of three live web broadcasts we are doing and we will try to do a fourth one in an emerging case, most likely a tracheo-esophageal fistula repair. We certainly couldn’t do this without Karl Storz’s support, I’d like to thank Dr. Blingman, my moderator and Dr. Rendal Clark, my anaesthesiologist and Lee Handy, my assistant, thank you. |
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