We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

Thoracic surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.


Filter by
Publication date
Type
Category
Right upper lobectomy: how I do it?
The anterior approach to right upper lobectomies is the most standard one, although it is not always the easiest one. As stressed by Dr. Baste, anterior dissection of the hilum can be hazardous and requires attention. Based on demonstrative pictures and videos, Dr. Baste outlines the global preoperative and intraoperative approach used routinely at Rouen’s Teaching Hospital. The description of the technique is mainly inspired from the Danish team (Hansen et al., Surgical Endoscopy). Surgical safety is one of the key objectives of this approach with preventative methods and intraoperative management techniques in case of injury. Preoperatively, CT-scan analysis is highlighted and patient set-up is described.
The intraoperative step is also described meticulously, and notably the D-zone, which represents the most dangerous zone during the resection.
JM Baste
Lecture
2 years ago
905 views
85 likes
0 comments
13:30
Right upper lobectomy: how I do it?
The anterior approach to right upper lobectomies is the most standard one, although it is not always the easiest one. As stressed by Dr. Baste, anterior dissection of the hilum can be hazardous and requires attention. Based on demonstrative pictures and videos, Dr. Baste outlines the global preoperative and intraoperative approach used routinely at Rouen’s Teaching Hospital. The description of the technique is mainly inspired from the Danish team (Hansen et al., Surgical Endoscopy). Surgical safety is one of the key objectives of this approach with preventative methods and intraoperative management techniques in case of injury. Preoperatively, CT-scan analysis is highlighted and patient set-up is described.
The intraoperative step is also described meticulously, and notably the D-zone, which represents the most dangerous zone during the resection.
Alternative fissureless technique: VATS ‘tunnel’ and ‘fissure first’ technique with staplers
Over the last years, the fissureless technique for thoracoscopic major pulmonary resections has become very popular. In this technique, the surgeon does not care about the fissure and its contents and staples it “en bloc” at completion of the lobectomy. The main advantage is its relative ease and rapidity. However, some anatomical variations make this technique hazardous and some surgeons do prefer a “fissure-based” technique with first dissection of vascular elements in the fissure. When the fissure is fused, this technique is difficult and can lead to troublesome oozing and postoperative air leaks. In these cases, the “tunnel technique”, which is presented here by Dr. Decaluwe, is very helpful.
H Decaluwe
Lecture
2 years ago
629 views
40 likes
0 comments
15:00
Alternative fissureless technique: VATS ‘tunnel’ and ‘fissure first’ technique with staplers
Over the last years, the fissureless technique for thoracoscopic major pulmonary resections has become very popular. In this technique, the surgeon does not care about the fissure and its contents and staples it “en bloc” at completion of the lobectomy. The main advantage is its relative ease and rapidity. However, some anatomical variations make this technique hazardous and some surgeons do prefer a “fissure-based” technique with first dissection of vascular elements in the fissure. When the fissure is fused, this technique is difficult and can lead to troublesome oozing and postoperative air leaks. In these cases, the “tunnel technique”, which is presented here by Dr. Decaluwe, is very helpful.
Complex robotic resection of a large middle mediastinal thymoma
A 62-year-old man had an asymptomatic middle mediastinal tumor with a 4.5cm diameter, opposite to the superior vena cava and the azygos vein in the Barety’s space, which was discovered on thoracic CT-scan performed during an urothelial tumor follow-up.
Past history includes an urothelial carcinoma grade I treated with transurethral cystectomy, an ischemic cardiopathy with a single medical treatment, a prostate hypertrophy, and a sigmoid diverticulosis.
After a multidisciplinary review of the case, a mediastinoscopy was performed. It demonstrated the presence of a thymoma.
The patient was well informed of the operative risks and of the possibility of conversion, but thanks to our experience and national recommendations, we were able to perform a radical robotic assisted thymectomy.
The operation took during 3 hours with less than 100cc of bleeding.
The postoperative course was uneventful and the patient was discharged on postoperative day 3.
Histopathological analysis showed a type AB thymoma according to the OMS 2015 classification. The staging was IIb according to Masaoka. No adjuvant radiotherapy was indicated.
A Boutin, M Sarsam, M Lair, N Piton, C Peillon, JM Baste
Surgical intervention
2 years ago
584 views
64 likes
0 comments
07:38
Complex robotic resection of a large middle mediastinal thymoma
A 62-year-old man had an asymptomatic middle mediastinal tumor with a 4.5cm diameter, opposite to the superior vena cava and the azygos vein in the Barety’s space, which was discovered on thoracic CT-scan performed during an urothelial tumor follow-up.
Past history includes an urothelial carcinoma grade I treated with transurethral cystectomy, an ischemic cardiopathy with a single medical treatment, a prostate hypertrophy, and a sigmoid diverticulosis.
After a multidisciplinary review of the case, a mediastinoscopy was performed. It demonstrated the presence of a thymoma.
The patient was well informed of the operative risks and of the possibility of conversion, but thanks to our experience and national recommendations, we were able to perform a radical robotic assisted thymectomy.
The operation took during 3 hours with less than 100cc of bleeding.
The postoperative course was uneventful and the patient was discharged on postoperative day 3.
Histopathological analysis showed a type AB thymoma according to the OMS 2015 classification. The staging was IIb according to Masaoka. No adjuvant radiotherapy was indicated.
Bronchoscopy for thoracic surgeons
The idea of this lecture originated from the fact that there is very little teaching material which described bronchoscopy as practiced by the thoracic surgeon. Chest physicians (pulmonologists) perform flexible bronchoscopy on a sedated patient, and they get up-side-down views to that obtained by the surgeons. Bronchoscopy at our department is performed under general anaesthesia, usually in the anaesthetic room just before the operation. We introduce a rigid bronchoscope first, and then a flexible fibre optic 5mm bronchoscope through the rigid scope into the trachea. This arrangement enables precise diagnosis due to excellent vision, with the ability to transform the procedure into a therapeutic session, for example, to take large biopsies, and decide to laser a lesion or to put in a central airway stent. Controlled breathing makes it safer to control significant bleeding during the procedure, and it is understandable that chest physicians shy away from biopsying carcinoid tumours.
The video is divided into 6 chapters. Chapter one deals with the identification of the bronchopulmonary segments and a bit of history about the two systems of nomenclature. It describes in a simplified way the effects of the heart growing in the left chest and the results of fusion, rotation and delayed branching of bronchi. Chapter 2 deals with normal bronchoscopy and anatomy of trachea, main bronchi, and segmental bronchi. Chapter 3 deals with abnormalities of the upper airways and trachea. Chapter 4 deals with abnormalities of the right bronchial tree, and chapter 5 deals with abnormalities of the left bronchial tree. The emphasis is on surgical pathology, assessment of airway for resection and decision-making. The viewer is encouraged to take the test on chapter 6 to bolster his/her knowledge of the anatomy of the airways.

1. Objectives:
a. To identify the bronchopulmonary segments in a logical and easy way to recall.
b. To understand the embryological changes resulting from heart growing into left chest.
c. To state what the operator should look for, what is normal and what is abnormal.
d. To help decision-making at operation and in the perioperative period.

2. For whom is this video made:
a. Consultants and trainees in the specialty of cardiothoracic surgery, including paediatric thoracic surgeons.
b. Thoracic and general anaesthetists who are involved with single lung ventilation.
c. Chest physicians who perform bronchoscopy, to understand views and capabilities of flexible over rigid bronchoscopy, and to have a gist of what goes on the mind of a thoracic surgeon when performing bronchoscopy.
d. Intensivists who might perform bronchoscopy via an endotracheal tube for a ventilated patient in the intensive care unit (ICU).
e. Medical students interested in the detailed anatomy of the central airways.

3. What this video is not intended to do:
a. This is not a compendium of abnormalities and pathologies revealed by bronchoscopy.
K Amer
Lecture
2 years ago
893 views
39 likes
0 comments
59:32
Bronchoscopy for thoracic surgeons
The idea of this lecture originated from the fact that there is very little teaching material which described bronchoscopy as practiced by the thoracic surgeon. Chest physicians (pulmonologists) perform flexible bronchoscopy on a sedated patient, and they get up-side-down views to that obtained by the surgeons. Bronchoscopy at our department is performed under general anaesthesia, usually in the anaesthetic room just before the operation. We introduce a rigid bronchoscope first, and then a flexible fibre optic 5mm bronchoscope through the rigid scope into the trachea. This arrangement enables precise diagnosis due to excellent vision, with the ability to transform the procedure into a therapeutic session, for example, to take large biopsies, and decide to laser a lesion or to put in a central airway stent. Controlled breathing makes it safer to control significant bleeding during the procedure, and it is understandable that chest physicians shy away from biopsying carcinoid tumours.
The video is divided into 6 chapters. Chapter one deals with the identification of the bronchopulmonary segments and a bit of history about the two systems of nomenclature. It describes in a simplified way the effects of the heart growing in the left chest and the results of fusion, rotation and delayed branching of bronchi. Chapter 2 deals with normal bronchoscopy and anatomy of trachea, main bronchi, and segmental bronchi. Chapter 3 deals with abnormalities of the upper airways and trachea. Chapter 4 deals with abnormalities of the right bronchial tree, and chapter 5 deals with abnormalities of the left bronchial tree. The emphasis is on surgical pathology, assessment of airway for resection and decision-making. The viewer is encouraged to take the test on chapter 6 to bolster his/her knowledge of the anatomy of the airways.

1. Objectives:
a. To identify the bronchopulmonary segments in a logical and easy way to recall.
b. To understand the embryological changes resulting from heart growing into left chest.
c. To state what the operator should look for, what is normal and what is abnormal.
d. To help decision-making at operation and in the perioperative period.

2. For whom is this video made:
a. Consultants and trainees in the specialty of cardiothoracic surgery, including paediatric thoracic surgeons.
b. Thoracic and general anaesthetists who are involved with single lung ventilation.
c. Chest physicians who perform bronchoscopy, to understand views and capabilities of flexible over rigid bronchoscopy, and to have a gist of what goes on the mind of a thoracic surgeon when performing bronchoscopy.
d. Intensivists who might perform bronchoscopy via an endotracheal tube for a ventilated patient in the intensive care unit (ICU).
e. Medical students interested in the detailed anatomy of the central airways.

3. What this video is not intended to do:
a. This is not a compendium of abnormalities and pathologies revealed by bronchoscopy.
Full thoracoscopic left 6 segmentectomy for invasive pulmonary aspergillosis (IPA)
This video summarizes the main steps of a thoracoscopic left S6 segmentectomy whose indication was a high suspicion of invasive pulmonary aspergillosis (IPA) in a female patient presenting with an acute myeloid leukemia. IPA was resistant to antifungal therapy. A resection was rapidly required as an allogenic bone marrow transplantation was pending.
A full thoracoscopic technique, i.e., with access incision, was used. As for all anatomical segmentectomies performed in our department, a tridimensional reconstruction was carried out preoperatively. A high-definition camera system, a deflectable scope, as well as dedicated thoracoscopic instruments were used.
D Gossot, A Seguin-Givelet, E Brian, M Grigoroiu, D Mayeur, J Lutz
Surgical intervention
2 years ago
712 views
40 likes
0 comments
08:39
Full thoracoscopic left 6 segmentectomy for invasive pulmonary aspergillosis (IPA)
This video summarizes the main steps of a thoracoscopic left S6 segmentectomy whose indication was a high suspicion of invasive pulmonary aspergillosis (IPA) in a female patient presenting with an acute myeloid leukemia. IPA was resistant to antifungal therapy. A resection was rapidly required as an allogenic bone marrow transplantation was pending.
A full thoracoscopic technique, i.e., with access incision, was used. As for all anatomical segmentectomies performed in our department, a tridimensional reconstruction was carried out preoperatively. A high-definition camera system, a deflectable scope, as well as dedicated thoracoscopic instruments were used.
Uniportal video-assisted thoracoscopic left lower lobectomy and lingular segmentectomy for bronchiectasis
As thoracoscopic surgical techniques are getting increasingly advanced, some thoracic surgeons are dissatisfied with the use of 3 or 4 ports to perform lobectomy. They start to try biportal or uniportal lobectomy in order to make it increasingly less invasive. As compared to 3-portal VATS lobectomy, the literature showed that uniportal VATS lobectomies have even more decreased postoperative pain, without significantly lengthening operative time, increasing blood loss or complications. After acquiring uniportal VATS techniques by adjusting the angle of view, by reorganizing the positions of the instruments, and by updating the anatomical concepts and dissecting process, lobectomy, and even composite-lobe resection, can be managed as a regular procedure.
We present the case of a 52-year-old man with a left lower lobe and lingular segment bronchiectasis. The patient underwent a left lower lobectomy and lingular segmentectomy using a uniportal video-assisted thoracoscopic approach.
J He, DJ Ma
Surgical intervention
2 years ago
895 views
31 likes
0 comments
09:45
Uniportal video-assisted thoracoscopic left lower lobectomy and lingular segmentectomy for bronchiectasis
As thoracoscopic surgical techniques are getting increasingly advanced, some thoracic surgeons are dissatisfied with the use of 3 or 4 ports to perform lobectomy. They start to try biportal or uniportal lobectomy in order to make it increasingly less invasive. As compared to 3-portal VATS lobectomy, the literature showed that uniportal VATS lobectomies have even more decreased postoperative pain, without significantly lengthening operative time, increasing blood loss or complications. After acquiring uniportal VATS techniques by adjusting the angle of view, by reorganizing the positions of the instruments, and by updating the anatomical concepts and dissecting process, lobectomy, and even composite-lobe resection, can be managed as a regular procedure.
We present the case of a 52-year-old man with a left lower lobe and lingular segment bronchiectasis. The patient underwent a left lower lobectomy and lingular segmentectomy using a uniportal video-assisted thoracoscopic approach.
VATS right upper lobectomy with en bloc chest wall resection
The optimal treatment of lung cancer invading the chest wall is complete surgical resection via lobectomy and en bloc chest wall resection, which has a 40 to 50% 5-year survival when there is no lymph node involvement.
VATS lobectomy is currently preferred as a standard approach in selected cases for pulmonary resections, especially for early stage non-small cell lung cancer with acceptable safety, successful surgical outcomes, and oncological efficacy. With recent advances in both equipment and technique, VATS is being applied to more complex conditions by some experienced thoracic surgeons.
We present the case of a 68-year-old man with pulmonary squamous cells carcinoma of the right upper lobe invading chest wall on the level of posterolateral part of the 3rd and 4th ribs. Right upper lobectomy with en bloc chest wall resection was finally performed by VATS.
M Gonzalez, JY Perentes, T Krueger
Surgical intervention
2 years ago
929 views
39 likes
1 comment
12:29
VATS right upper lobectomy with en bloc chest wall resection
The optimal treatment of lung cancer invading the chest wall is complete surgical resection via lobectomy and en bloc chest wall resection, which has a 40 to 50% 5-year survival when there is no lymph node involvement.
VATS lobectomy is currently preferred as a standard approach in selected cases for pulmonary resections, especially for early stage non-small cell lung cancer with acceptable safety, successful surgical outcomes, and oncological efficacy. With recent advances in both equipment and technique, VATS is being applied to more complex conditions by some experienced thoracic surgeons.
We present the case of a 68-year-old man with pulmonary squamous cells carcinoma of the right upper lobe invading chest wall on the level of posterolateral part of the 3rd and 4th ribs. Right upper lobectomy with en bloc chest wall resection was finally performed by VATS.
Robotic assisted thoracoscopic lingulectomy
A 67-year-old otherwise healthy woman presented to her primary care physician with complaints of dyspnea. Her primary care physician obtained a chest X-ray, which revealed a left upper lobe abnormality. A follow-up chest CT revealed a 16mm left upper lobe mass concerning for malignancy in the lingula. A bronchoscopy with brushings was performed and pathology was positive for a well-differentiated adenocarcinoma. As part of a clinical staging, a PET-CT was obtained and demonstrated no FDG avid disease in the thorax or elsewhere. Pulmonary function tests revealed an FEV1 of 2.28 L (122% predicted) and DLCO of 19.05 (112% predicted). The therapeutic objectives were to perform an oncologically sound anatomic lung resection and lymph node dissection for the patients early stage biopsy proven lung cancer. The robotic platform was used in this case and we aimed to demonstrate our approach to a robotic assisted thoracoscopic lingulectomy for lung cancer.
HJ Feldman, M Kent, J Wilson
Surgical intervention
2 years ago
387 views
16 likes
0 comments
10:55
Robotic assisted thoracoscopic lingulectomy
A 67-year-old otherwise healthy woman presented to her primary care physician with complaints of dyspnea. Her primary care physician obtained a chest X-ray, which revealed a left upper lobe abnormality. A follow-up chest CT revealed a 16mm left upper lobe mass concerning for malignancy in the lingula. A bronchoscopy with brushings was performed and pathology was positive for a well-differentiated adenocarcinoma. As part of a clinical staging, a PET-CT was obtained and demonstrated no FDG avid disease in the thorax or elsewhere. Pulmonary function tests revealed an FEV1 of 2.28 L (122% predicted) and DLCO of 19.05 (112% predicted). The therapeutic objectives were to perform an oncologically sound anatomic lung resection and lymph node dissection for the patients early stage biopsy proven lung cancer. The robotic platform was used in this case and we aimed to demonstrate our approach to a robotic assisted thoracoscopic lingulectomy for lung cancer.
Right upper lobectomy for large apical tuberculosis cavity using videothoracoscopy: focus on the use of curved endoscopic instruments
A 36-year-old patient was treated for tuberculosis for two years in Georgia. However, treatment failed. After a 3-month treatment in France, CT-scan showed a persistent tuberculous cavity in the right upper lobe, which seemed totally destroyed, associated with bilateral opacities. The patient was still multi-bacillary. A right upper lobectomy by videothoracoscopy was performed. Dissection of the right upper lobe, fully retracted on the apex, was facilitated by the use of an ENSEAL® G2 articulating tissue sealer (Ethicon Endosurgery), a curved vacuum, and the ENDOEYE FLEX 3D (Olympus) articulated camera. The ENSEAL® articulated bipolar forceps facilitated the perpendicular approach to the superior lobar vessels, which were all sheathed by inflamed tissues, and improved dissection of retractile adhesions to the pulmonary apex and mediastinum. It made the handling of hemorrhagic tissue easier. The 3D camera allowed an accurate visualization of these complex anatomical relationships. Drains were removed on postoperative day 6. The BK sputum was negative postoperatively and at 5 months. CT-scan at 2 months is satisfactory with a regression of bilateral opacities. Videothoracoscopy using articulated endoscopic instruments is a relevant technique for the resection of tuberculous lesions, even when lesions are large and retractile.
L Haddad, J Melki, P Rinieri, C Peillon, JM Baste
Surgical intervention
3 years ago
912 views
36 likes
0 comments
07:35
Right upper lobectomy for large apical tuberculosis cavity using videothoracoscopy: focus on the use of curved endoscopic instruments
A 36-year-old patient was treated for tuberculosis for two years in Georgia. However, treatment failed. After a 3-month treatment in France, CT-scan showed a persistent tuberculous cavity in the right upper lobe, which seemed totally destroyed, associated with bilateral opacities. The patient was still multi-bacillary. A right upper lobectomy by videothoracoscopy was performed. Dissection of the right upper lobe, fully retracted on the apex, was facilitated by the use of an ENSEAL® G2 articulating tissue sealer (Ethicon Endosurgery), a curved vacuum, and the ENDOEYE FLEX 3D (Olympus) articulated camera. The ENSEAL® articulated bipolar forceps facilitated the perpendicular approach to the superior lobar vessels, which were all sheathed by inflamed tissues, and improved dissection of retractile adhesions to the pulmonary apex and mediastinum. It made the handling of hemorrhagic tissue easier. The 3D camera allowed an accurate visualization of these complex anatomical relationships. Drains were removed on postoperative day 6. The BK sputum was negative postoperatively and at 5 months. CT-scan at 2 months is satisfactory with a regression of bilateral opacities. Videothoracoscopy using articulated endoscopic instruments is a relevant technique for the resection of tuberculous lesions, even when lesions are large and retractile.
Complex left upper lobectomy with lymphadenectomy using a full endoscopic robotic technique
This is the case of a 72-year-old woman, followed up for chronic lymphocytic leukemia treated with chemotherapy.
During her follow-up, a nodule in the left upper lobe as well as multiple bulky lymph nodes were discovered.
The multidisciplinary meeting proposed a wedge resection more or less associated with a lobectomy depending on the results of frozen section.
The difficulty of this procedure lies in bulky lymph nodes around the pulmonary artery.
Due to the complexity of the case, we prefer to use a RATS approach rather than a VATS approach, as it allows for a sharp dissection using a bipolar Maryland forceps.
JM Baste, B Bottet, C Peillon
Surgical intervention
3 years ago
903 views
13 likes
0 comments
08:52
Complex left upper lobectomy with lymphadenectomy using a full endoscopic robotic technique
This is the case of a 72-year-old woman, followed up for chronic lymphocytic leukemia treated with chemotherapy.
During her follow-up, a nodule in the left upper lobe as well as multiple bulky lymph nodes were discovered.
The multidisciplinary meeting proposed a wedge resection more or less associated with a lobectomy depending on the results of frozen section.
The difficulty of this procedure lies in bulky lymph nodes around the pulmonary artery.
Due to the complexity of the case, we prefer to use a RATS approach rather than a VATS approach, as it allows for a sharp dissection using a bipolar Maryland forceps.
Robotic assisted resection of a complex thymoma
Our objective is to demonstrate the management of a very complex mediastinal tumor. To do so, a minimally invasive resection is used, highlighting the benefit of a robotic approach.
The present case is that of a 64-year-old patient diagnosed with an anterior mediastinal mass discovered during myasthenia assessment with positive antibodies.
The tumor was in contact with the aorta, pulmonary artery, and the innominate vein with probable pericardial invasion.
Given such a complex localization, the challenge was to propose a radical resection using minimally invasive surgery with robotic assistance.
As compared to a VATS approach, a robotic approach provides a better view and instruments to achieve complete resection in complex mediastinal tumor. What is important to first control on the CT-scan is the size of the tumor as compared to the thoracic cavity’s size which will allow robotic surgery with a good operative field.
Pericardial resection associated with a lateral plasty of the innominate vein were required to achieved complete R0 resection. The entire resection was performed using a bipolar forceps.
The postoperative course was uneventful. The patient is discharged on postopeartive day 3. The phrenic nerve was preserved.
Pathological analysis of the operative specimen is evocative of a B1 thymoma classified IIb on the Masaoka staging system with complete R0 resection (margins were clear).
The entire file was discussed at the Rhythmic meeting, which is the national meeting for thymoma tumor management held every two weeks. A simple survey was put forward without any adjuvant radiotherapy.
JM Baste, E Roussel, L Haddad, C Peillon
Surgical intervention
3 years ago
1115 views
26 likes
0 comments
07:19
Robotic assisted resection of a complex thymoma
Our objective is to demonstrate the management of a very complex mediastinal tumor. To do so, a minimally invasive resection is used, highlighting the benefit of a robotic approach.
The present case is that of a 64-year-old patient diagnosed with an anterior mediastinal mass discovered during myasthenia assessment with positive antibodies.
The tumor was in contact with the aorta, pulmonary artery, and the innominate vein with probable pericardial invasion.
Given such a complex localization, the challenge was to propose a radical resection using minimally invasive surgery with robotic assistance.
As compared to a VATS approach, a robotic approach provides a better view and instruments to achieve complete resection in complex mediastinal tumor. What is important to first control on the CT-scan is the size of the tumor as compared to the thoracic cavity’s size which will allow robotic surgery with a good operative field.
Pericardial resection associated with a lateral plasty of the innominate vein were required to achieved complete R0 resection. The entire resection was performed using a bipolar forceps.
The postoperative course was uneventful. The patient is discharged on postopeartive day 3. The phrenic nerve was preserved.
Pathological analysis of the operative specimen is evocative of a B1 thymoma classified IIb on the Masaoka staging system with complete R0 resection (margins were clear).
The entire file was discussed at the Rhythmic meeting, which is the national meeting for thymoma tumor management held every two weeks. A simple survey was put forward without any adjuvant radiotherapy.
Robot-assisted thoracoscopic right superior lobectomy with conversion for controlled bleeding: a complex case
As the technique and the indications of robotic video-assisted lung resections have evolved, surgeons have had to face numerous pitfalls. One in particular is the vascular tear, which urge the operator to convert to thoracotomy. The decision as to when and how to convert to thoracotomy is always difficult to make. This video illustrates a complex case of robotic right upper lobectomy which required thoracotomy for controlled bleeding.
This is the case of a 47-year-old woman with a past medical history of severe chronic obstructive pulmonary disease, active smoking, alcoholic liver cirrhosis, but no history of tuberculosis. She presented with a 3-month history of a right upper lobar mass detected on chest X-ray which evolved despite antibiotic treatment. Work-up including a PET-scan evoked a suspicion of malignancy.

While finishing the lobectomy, we had to face a difficult dissection of the posterior part of the oblique fissure with a tricky control of the dorsal artery. Trying to open the fissure with the endostapler, we tore the arterial branch and applied an immediate control by means of a double Cadiere grasper. When bleeding was finally controlled, we decided to convert for safety reasons. We proceeded without undocking the last robotic arm, clamping the artery until control was achieved using thoracotomy instruments. It allowed us to manage this situation with no rush and stress.
There are two types of bleeding: controlled and uncontrolled. In our experience of RATS lobectomy and by reviewing our complications, we feel that there are several advantages to this technique: first, small instruments make small injuries which can be controlled by robotic instrument. Secondly, passive locking of the robotic arm provides sufficient time for the surgical team to prepare conversion.
JM Baste, N Bayard, C Peillon
Surgical intervention
3 years ago
913 views
35 likes
0 comments
08:59
Robot-assisted thoracoscopic right superior lobectomy with conversion for controlled bleeding: a complex case
As the technique and the indications of robotic video-assisted lung resections have evolved, surgeons have had to face numerous pitfalls. One in particular is the vascular tear, which urge the operator to convert to thoracotomy. The decision as to when and how to convert to thoracotomy is always difficult to make. This video illustrates a complex case of robotic right upper lobectomy which required thoracotomy for controlled bleeding.
This is the case of a 47-year-old woman with a past medical history of severe chronic obstructive pulmonary disease, active smoking, alcoholic liver cirrhosis, but no history of tuberculosis. She presented with a 3-month history of a right upper lobar mass detected on chest X-ray which evolved despite antibiotic treatment. Work-up including a PET-scan evoked a suspicion of malignancy.

While finishing the lobectomy, we had to face a difficult dissection of the posterior part of the oblique fissure with a tricky control of the dorsal artery. Trying to open the fissure with the endostapler, we tore the arterial branch and applied an immediate control by means of a double Cadiere grasper. When bleeding was finally controlled, we decided to convert for safety reasons. We proceeded without undocking the last robotic arm, clamping the artery until control was achieved using thoracotomy instruments. It allowed us to manage this situation with no rush and stress.
There are two types of bleeding: controlled and uncontrolled. In our experience of RATS lobectomy and by reviewing our complications, we feel that there are several advantages to this technique: first, small instruments make small injuries which can be controlled by robotic instrument. Secondly, passive locking of the robotic arm provides sufficient time for the surgical team to prepare conversion.
Safety in complex VATS lobectomy: how to secure your procedure
Objective
As surgical teams performing video-assisted thoracoscopic (VATS) lobectomy procedures improve in technicality, surgeons have to face more complex cases which could not be handled without an open thoracotomy before. Consequently, unexpected events occur and safety measures must be implemented in order to prevent whatever could be prevented. Clinical videos have become a very powerful tool that allow surgeons from the world over to share their experience on the matter.

Methods
In this video, routine safety procedures used in our center are illustrated. The case presented is that of a 52-year-old woman with a clinical stage IIIA (T3N1M0) mass at the left upper lobe. CT-scan showed a close relationship between the tumor and the first upper lobar branch. In many centers, this would often contraindicate a minimally invasive approach.

Results
A preoperative assessment is crucial in order to anticipate the anatomy of the area. CT-scan reconstruction is of great importance whenever the surgeon requires it. The procedure is begun with an extended safety checklist including the availability of conversion instruments and a second suction line as major ‘’go/no go’’ factors. The anterior approach of the hilum allows for a control of both arterial and venous structures using vessel loops.

Conclusions
Our technique allows to routinely perform safe and reproducible complex cases of VATS lobectomy.
JM Baste, N Bayard, R Levy, C Peillon
Surgical intervention
3 years ago
1021 views
23 likes
0 comments
10:27
Safety in complex VATS lobectomy: how to secure your procedure
Objective
As surgical teams performing video-assisted thoracoscopic (VATS) lobectomy procedures improve in technicality, surgeons have to face more complex cases which could not be handled without an open thoracotomy before. Consequently, unexpected events occur and safety measures must be implemented in order to prevent whatever could be prevented. Clinical videos have become a very powerful tool that allow surgeons from the world over to share their experience on the matter.

Methods
In this video, routine safety procedures used in our center are illustrated. The case presented is that of a 52-year-old woman with a clinical stage IIIA (T3N1M0) mass at the left upper lobe. CT-scan showed a close relationship between the tumor and the first upper lobar branch. In many centers, this would often contraindicate a minimally invasive approach.

Results
A preoperative assessment is crucial in order to anticipate the anatomy of the area. CT-scan reconstruction is of great importance whenever the surgeon requires it. The procedure is begun with an extended safety checklist including the availability of conversion instruments and a second suction line as major ‘’go/no go’’ factors. The anterior approach of the hilum allows for a control of both arterial and venous structures using vessel loops.

Conclusions
Our technique allows to routinely perform safe and reproducible complex cases of VATS lobectomy.
Complex left upper lobectomy with lymphadenectomy by robotic assisted thoracoscopy (CPRL-3) for cT2N2 non-small-cell lung carcinoma (NSCLC)
This video demonstrates a left upper lobectomy for the management of a proximal cT2N2M0 lung tumor. It is usually considered a contraindication of minimally invasive surgery. Our aim is to show the feasibility and the safety of the procedure. Robotic surgery will allow for more minimally invasive indications.
The tumor lies proximally to the left trunk of the pulmonary artery which could be a contraindication to a minimally invasive surgery. A CT-scan combined with a 3D reconstruction helps to rule out the existence of pulmonary artery invasion. Hilar adenopathies as well as adenopathies of the aortopulmonary window present a hypermetabolism on PET-scan. No neoadjuvant chemotherapy is performed since a R0 surgery is potentially feasible immediately and can be associated with a full lymphadenectomy.
This video presents our technique of robotically assisted left upper lobectomy combined with a lymph node dissection. We have attempted to standardize our lung resection technique using 6 areas of dissection to gain in efficacy and save time. The first operative step is to free the triangular ligament and to sample potential lymph nodes (station No. 9). A hilar lymphadenectomy (lymph node station No. 10) is then performed using a posterior approach first followed by a subcarinal approach (lymph node #7, by skeletonizing the pulmonary artery and the left main bronchus. The third step of the procedure is to dissect the fissure to skeletonize the pulmonary artery and its lingular branches as well as branches of the posterior fissure, dissection of lymph node stations No. 11 is performed simultaneously. The elements of the hilum are then approached using an anterior approach. The superior pulmonary vein is dissected. The roof of the hilum is then freed. The left upper bronchus is divided last. Dissection of lymph node station No. 5 completes the procedure with preservation of the left recurrent nerve
Abbreviation:
CPRL-3: complete portal robotic lobectomy using 3 arms
J Cahais, JM Baste, C Peillon
Surgical intervention
3 years ago
680 views
18 likes
0 comments
11:07
Complex left upper lobectomy with lymphadenectomy by robotic assisted thoracoscopy (CPRL-3) for cT2N2 non-small-cell lung carcinoma (NSCLC)
This video demonstrates a left upper lobectomy for the management of a proximal cT2N2M0 lung tumor. It is usually considered a contraindication of minimally invasive surgery. Our aim is to show the feasibility and the safety of the procedure. Robotic surgery will allow for more minimally invasive indications.
The tumor lies proximally to the left trunk of the pulmonary artery which could be a contraindication to a minimally invasive surgery. A CT-scan combined with a 3D reconstruction helps to rule out the existence of pulmonary artery invasion. Hilar adenopathies as well as adenopathies of the aortopulmonary window present a hypermetabolism on PET-scan. No neoadjuvant chemotherapy is performed since a R0 surgery is potentially feasible immediately and can be associated with a full lymphadenectomy.
This video presents our technique of robotically assisted left upper lobectomy combined with a lymph node dissection. We have attempted to standardize our lung resection technique using 6 areas of dissection to gain in efficacy and save time. The first operative step is to free the triangular ligament and to sample potential lymph nodes (station No. 9). A hilar lymphadenectomy (lymph node station No. 10) is then performed using a posterior approach first followed by a subcarinal approach (lymph node #7, by skeletonizing the pulmonary artery and the left main bronchus. The third step of the procedure is to dissect the fissure to skeletonize the pulmonary artery and its lingular branches as well as branches of the posterior fissure, dissection of lymph node stations No. 11 is performed simultaneously. The elements of the hilum are then approached using an anterior approach. The superior pulmonary vein is dissected. The roof of the hilum is then freed. The left upper bronchus is divided last. Dissection of lymph node station No. 5 completes the procedure with preservation of the left recurrent nerve
Abbreviation:
CPRL-3: complete portal robotic lobectomy using 3 arms
Video-assisted thoracoscopic (VATS) lobectomy: left lower lobe
Standard treatment of early-stage non-small cell lung cancer (NSCLC) involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterior lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include the following:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be performed with lower morbidity and an equivalent or better oncologic outcome to traditional open surgery. We present a VATS lobectomy for a carcinoid tumor of the left lower lobe in a 42-year-old patient. The video lays emphasis on the steps of lobe resection; mediastinal lymph node dissection was performed but is not shown.
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens for their continued support.
G Rakovich
Surgical intervention
3 years ago
534 views
83 likes
0 comments
08:05
Video-assisted thoracoscopic (VATS) lobectomy: left lower lobe
Standard treatment of early-stage non-small cell lung cancer (NSCLC) involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterior lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include the following:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be performed with lower morbidity and an equivalent or better oncologic outcome to traditional open surgery. We present a VATS lobectomy for a carcinoid tumor of the left lower lobe in a 42-year-old patient. The video lays emphasis on the steps of lobe resection; mediastinal lymph node dissection was performed but is not shown.
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens for their continued support.
Video-assisted thoracoscopic surgery (VATS): Right middle lobectomy and complete mediastinal lymphadenectomy
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is actually preferred over a thoracotomy in experienced centers.
Potential advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital length of stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 63-year-old woman with clinical cT2 cN0 lung adenocarcinoma of the middle lobe. The patient underwent right middle lobectomy with complete mediastinal lymph node dissection using an anterior three-port thoracoscopic approach.
M Gonzalez, T Krueger, JY Perentes
Surgical intervention
3 years ago
1632 views
41 likes
0 comments
10:42
Video-assisted thoracoscopic surgery (VATS): Right middle lobectomy and complete mediastinal lymphadenectomy
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is actually preferred over a thoracotomy in experienced centers.
Potential advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital length of stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 63-year-old woman with clinical cT2 cN0 lung adenocarcinoma of the middle lobe. The patient underwent right middle lobectomy with complete mediastinal lymph node dissection using an anterior three-port thoracoscopic approach.
Thoracoscopic middle lobectomy with sleeve resection for bulky carcinoid tumor
We report the case of a 35-year-old female patient presenting with hemoptysis from a bulky carcinoid tumor of the middle lobe protruding in the truncus intermedius.
A middle lobectomy with sleeve resection was performed, using a full thoracoscopic approach, i.e. without utility incision. Resection margins were free. The final pathologic examination confirmed a typical pT1bN0carcinoid tumor.
The patient was discharged on postoperative day 4, after an uneventful postoperative course.
The main steps of the procedure are described. The slightly hemorrhagic atmosphere of the operation is due to vascular compression from the tumor.
D Gossot, M Grigoroiu, E Brian
Surgical intervention
4 years ago
779 views
13 likes
0 comments
09:22
Thoracoscopic middle lobectomy with sleeve resection for bulky carcinoid tumor
We report the case of a 35-year-old female patient presenting with hemoptysis from a bulky carcinoid tumor of the middle lobe protruding in the truncus intermedius.
A middle lobectomy with sleeve resection was performed, using a full thoracoscopic approach, i.e. without utility incision. Resection margins were free. The final pathologic examination confirmed a typical pT1bN0carcinoid tumor.
The patient was discharged on postoperative day 4, after an uneventful postoperative course.
The main steps of the procedure are described. The slightly hemorrhagic atmosphere of the operation is due to vascular compression from the tumor.
Video-assisted thoracoscopic (VATS) lobectomy: middle lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterolateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions (Although we favor a fully thoracoscopic technique for all our cases, some centers may use a 4 to 5cm “working incision” near the axilla);
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for an adenocarcinoma of the middle lobe in a 67-year-old patient (the video emphasizes the steps of lobe resection - mediastinal lymph node dissection was effected but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their unfaltering dedication and continued support.
DD Masckauchan, G Rakovich
Surgical intervention
4 years ago
360 views
42 likes
0 comments
08:49
Video-assisted thoracoscopic (VATS) lobectomy: middle lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterolateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions (Although we favor a fully thoracoscopic technique for all our cases, some centers may use a 4 to 5cm “working incision” near the axilla);
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for an adenocarcinoma of the middle lobe in a 67-year-old patient (the video emphasizes the steps of lobe resection - mediastinal lymph node dissection was effected but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their unfaltering dedication and continued support.
Robot-assisted left upper lobectomy for T1N0M0 adenocarcinoma
This is the case of a robotic left upper lobectomy with lymphadenectomy in a woman aged 52 who has had 9 children and who was a regular smoker (50 packs per year). She is presenting with an isolated cT1N0M0 adenocarcinoma in the left upper pulmonary lobe. PET-scan was positive for the lesion without any other pathological finding in the mediastinum or far metastasis. Histology was obtained by CT-guided transthoracic needle aspiration biopsy.
This minimally invasive technique, assisted by the da Vinci® robotic surgical system, is sure, comfortable, and efficient to perform a pulmonary lobectomy with lymphadenectomy in the early stages of lung cancer.
3D vision and the accuracy of dissection appear to be better than in conventional VATS.
As in VATS lobectomy, hospital stay is reduced to 3-4 days and postoperative pain appears to be more acceptable.
N Santelmo, F Antonacci, G Massard
Surgical intervention
4 years ago
481 views
6 likes
0 comments
11:59
Robot-assisted left upper lobectomy for T1N0M0 adenocarcinoma
This is the case of a robotic left upper lobectomy with lymphadenectomy in a woman aged 52 who has had 9 children and who was a regular smoker (50 packs per year). She is presenting with an isolated cT1N0M0 adenocarcinoma in the left upper pulmonary lobe. PET-scan was positive for the lesion without any other pathological finding in the mediastinum or far metastasis. Histology was obtained by CT-guided transthoracic needle aspiration biopsy.
This minimally invasive technique, assisted by the da Vinci® robotic surgical system, is sure, comfortable, and efficient to perform a pulmonary lobectomy with lymphadenectomy in the early stages of lung cancer.
3D vision and the accuracy of dissection appear to be better than in conventional VATS.
As in VATS lobectomy, hospital stay is reduced to 3-4 days and postoperative pain appears to be more acceptable.
Video-assisted thoracoscopic surgery (VATS): left upper lobectomy and complete lymphadenectomy by fissureless anterior approach
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is currently preferred over a thoracotomy in experienced centers.
Possible advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 58-year-old woman with suspicion of peripheral pulmonary cT1 cN0 cancer who initially underwent wedge resection by VATS of the lesion with preoperative localization using a CT-guided hook wire. Frozen section revealed the presence of squamous cell carcinoma, and completion lobectomy with complete mediastinal lymph node dissection was finally performed by VATS.
M Gonzalez, JY Perentes, T Krueger
Surgical intervention
4 years ago
1573 views
34 likes
0 comments
10:43
Video-assisted thoracoscopic surgery (VATS): left upper lobectomy and complete lymphadenectomy by fissureless anterior approach
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is currently preferred over a thoracotomy in experienced centers.
Possible advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 58-year-old woman with suspicion of peripheral pulmonary cT1 cN0 cancer who initially underwent wedge resection by VATS of the lesion with preoperative localization using a CT-guided hook wire. Frozen section revealed the presence of squamous cell carcinoma, and completion lobectomy with complete mediastinal lymph node dissection was finally performed by VATS.
Video-assisted thoracic surgery (VATS): middle lower bilobectomy with lymph nodes dissection for carcinoid tumor
Objective
Carcinoid tumors represent less than 5% of the bronchopulmonary cancers [1], but often concern young people. A lung-sparing anatomical resection is often preferred if possible [2]. However, an uneasy intrabronchial localization mandates a major resection such as bilobectomy and/or sometimes pneumonectomy for complete resection as it is the aim of carcinoid tumor treatment. This can be achieved using a minimally invasive approach [3, 4].
Case presentation
This is the case of a 34-year-old woman suffering from recurrent right pneumopathy, without any other medical history. A mass in the middle lobe bronchus with partial obstruction of the intermedius bronchus was found on CT-scan. Bronchoscopy found the extension of a strawberry-like tumor until segment 6 bronchus. Histopathology confirmed the presence of a carcinoid tumor. A radical excision with middle lower bilobectomy by VATS was decided upon rather than middle lobe sleeve lobectomy in order to ensure complete resection.
Results
There was no postoperative complication and the patient was discharged on postoperative day 5. The operative specimen contained the tumor. Vascular and bronchial resections were free. Histopathology confirmed a typical pT1N0 carcinoid tumor.
Conclusion
Complete middle lower bilobectomy can be performed using a VATS approach. This therapeutic option seems worthwhile in young people because of low postoperative morbidity and fast recovery for active people.

Bibliographic references
1. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119:1647-51.
2. Schrevens L, Vansteenkiste J, Deneffe G, De Leyn P, Verbeken E, Vandenberghe T, Demedts M. Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience. Lung Cancer 2004;43:39-45.
3. Hansen HJ, Petersen RH, Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Lung Cancer 2011;71,25(4):1263-9.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothoracic Surg 2003;23:397-402.
JM Baste, P Rinieri, A Sebestyen
Surgical intervention
4 years ago
1154 views
18 likes
0 comments
07:26
Video-assisted thoracic surgery (VATS): middle lower bilobectomy with lymph nodes dissection for carcinoid tumor
Objective
Carcinoid tumors represent less than 5% of the bronchopulmonary cancers [1], but often concern young people. A lung-sparing anatomical resection is often preferred if possible [2]. However, an uneasy intrabronchial localization mandates a major resection such as bilobectomy and/or sometimes pneumonectomy for complete resection as it is the aim of carcinoid tumor treatment. This can be achieved using a minimally invasive approach [3, 4].
Case presentation
This is the case of a 34-year-old woman suffering from recurrent right pneumopathy, without any other medical history. A mass in the middle lobe bronchus with partial obstruction of the intermedius bronchus was found on CT-scan. Bronchoscopy found the extension of a strawberry-like tumor until segment 6 bronchus. Histopathology confirmed the presence of a carcinoid tumor. A radical excision with middle lower bilobectomy by VATS was decided upon rather than middle lobe sleeve lobectomy in order to ensure complete resection.
Results
There was no postoperative complication and the patient was discharged on postoperative day 5. The operative specimen contained the tumor. Vascular and bronchial resections were free. Histopathology confirmed a typical pT1N0 carcinoid tumor.
Conclusion
Complete middle lower bilobectomy can be performed using a VATS approach. This therapeutic option seems worthwhile in young people because of low postoperative morbidity and fast recovery for active people.

Bibliographic references
1. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119:1647-51.
2. Schrevens L, Vansteenkiste J, Deneffe G, De Leyn P, Verbeken E, Vandenberghe T, Demedts M. Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience. Lung Cancer 2004;43:39-45.
3. Hansen HJ, Petersen RH, Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Lung Cancer 2011;71,25(4):1263-9.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothoracic Surg 2003;23:397-402.
Thoracoscopic management of empyema
From the mid-1990s, thoracoscopic treatment of empyemas has gained a wide acceptance. Potential advantages of video-assisted thoracoscopic surgery (VATS) include improved visualization, less surgical trauma and improved quality of life. VATS was initially used in early stage empyema to debride purulent collections and resect fibrin septae that failed to resolve with antibiotics and chest tube drainage (with or without fibrinolytic therapy).
The goals of the thoracoscopic treatment of empyema are as follows: 1) the debridement of purulent collections and fibrin, 2) the evacuation of necrotic material, 3) the breakdown of loculations, 4) to obtain adequate lung re-expansion, and 5) optimal chest tube placement for drainage.
Several reports have demonstrated that VATS debridement is a valid treatment option for stage II empyema, which allows an appropriate control of infection and a complete restoration of pulmonary function in early stage empyemas. Formal exclusion criteria for a primary VATS approach are suspicion of lung abscess, bronchopleural fistula, tumor at initial work-up or the need of muscle flaps with or without thoracoplasty. Presumed stage III empyema with pleural thickening and signs of restriction on CT-scan no longer are formal contraindications, but the conversion rate to decortications via thoracotomy is higher.
M Gonzalez, JY Perentes, T Krueger
Surgical intervention
4 years ago
2851 views
104 likes
1 comment
07:09
Thoracoscopic management of empyema
From the mid-1990s, thoracoscopic treatment of empyemas has gained a wide acceptance. Potential advantages of video-assisted thoracoscopic surgery (VATS) include improved visualization, less surgical trauma and improved quality of life. VATS was initially used in early stage empyema to debride purulent collections and resect fibrin septae that failed to resolve with antibiotics and chest tube drainage (with or without fibrinolytic therapy).
The goals of the thoracoscopic treatment of empyema are as follows: 1) the debridement of purulent collections and fibrin, 2) the evacuation of necrotic material, 3) the breakdown of loculations, 4) to obtain adequate lung re-expansion, and 5) optimal chest tube placement for drainage.
Several reports have demonstrated that VATS debridement is a valid treatment option for stage II empyema, which allows an appropriate control of infection and a complete restoration of pulmonary function in early stage empyemas. Formal exclusion criteria for a primary VATS approach are suspicion of lung abscess, bronchopleural fistula, tumor at initial work-up or the need of muscle flaps with or without thoracoplasty. Presumed stage III empyema with pleural thickening and signs of restriction on CT-scan no longer are formal contraindications, but the conversion rate to decortications via thoracotomy is higher.
Full endoscopic robot-assisted trisegmentectomy of the pulmonary left upper lobe for diagnosis and treatment
Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.
JM Baste, M Renaux-Petel, C Peillon
Surgical intervention
5 years ago
1093 views
6 likes
0 comments
11:42
Full endoscopic robot-assisted trisegmentectomy of the pulmonary left upper lobe for diagnosis and treatment
Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.
Thoracoscopic resection of an esophageal leiomyoma
Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign tumors are leiomyomas. They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus. They have extremely small potential for malignant degeneration. Surgical excision is recommended for symptomatic great lesions. The video demonstrates the thoracoscopic resection of a leiomyoma on the upper thoracic third of the esophagus with the patient in a prone position, which brings an excellent exposure of the operative field and decreases lung injuries as we do not use any retractor.
J Torres Bermúdez, FC Becerra García, J Lopez Espejo, JL Martín, G Sánchez de la Villa
Surgical intervention
5 years ago
2074 views
18 likes
0 comments
07:22
Thoracoscopic resection of an esophageal leiomyoma
Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign tumors are leiomyomas. They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus. They have extremely small potential for malignant degeneration. Surgical excision is recommended for symptomatic great lesions. The video demonstrates the thoracoscopic resection of a leiomyoma on the upper thoracic third of the esophagus with the patient in a prone position, which brings an excellent exposure of the operative field and decreases lung injuries as we do not use any retractor.
Full endoscopic robotic assisted upper left lung lobectomy for a suspicious lesion
Objective:
To present a complete endoscopic approach for thoracic resection using the Da Vinci™ robotic device (Ninan M, MR Dylewski. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2).
Methods:
A 62-year-old man was a former smoker with an accumulated dose of 70 packs of cigarettes a year and had a history of rheumatic polyarthritis under immunotherapy. He presented a deterioration of his overall health condition and a CT-scan was performed. The CT-scan showed a ground-glass opacity (GGO) in the left upper lobe. Functional respiratory tests were the following: FEV1 51% and DLCO 65%, and the patient completed 4 floors at the stair-climbing test. An upper left lobectomy using a Da Vinci™ robotic system was performed with a high level of safety.
Results: The postoperative course was uneventful. Pathological findings confirmed the diagnosis of a benign granuloma. Our patient has not shown any incidence during a one-month follow-up and his physician reintroduced his immunosuppressive treatment.
Conclusion: Complete and precise lobectomy can be performed safely by means of the Da Vinci™ robotic system with low morbidity.
JM Baste, V Díaz-Ravetllat, C Peillon
Surgical intervention
5 years ago
1217 views
17 likes
0 comments
07:10
Full endoscopic robotic assisted upper left lung lobectomy for a suspicious lesion
Objective:
To present a complete endoscopic approach for thoracic resection using the Da Vinci™ robotic device (Ninan M, MR Dylewski. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2).
Methods:
A 62-year-old man was a former smoker with an accumulated dose of 70 packs of cigarettes a year and had a history of rheumatic polyarthritis under immunotherapy. He presented a deterioration of his overall health condition and a CT-scan was performed. The CT-scan showed a ground-glass opacity (GGO) in the left upper lobe. Functional respiratory tests were the following: FEV1 51% and DLCO 65%, and the patient completed 4 floors at the stair-climbing test. An upper left lobectomy using a Da Vinci™ robotic system was performed with a high level of safety.
Results: The postoperative course was uneventful. Pathological findings confirmed the diagnosis of a benign granuloma. Our patient has not shown any incidence during a one-month follow-up and his physician reintroduced his immunosuppressive treatment.
Conclusion: Complete and precise lobectomy can be performed safely by means of the Da Vinci™ robotic system with low morbidity.
Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

Symptoms are generalized to her four arms. Anti-acetylcholine antibodies and the therapeutic test of Mestinon® (Pyridostigmine) are positive.
In recent months, her symptoms worsened with the onset of swallowing disorders.

Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia.
Thymectomy is indicated. To do so, a left thoracoscopy is performed and assisted by means of the Da Vinci™ robot.

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy, which is the standard technique. When compared to thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements, and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
N Santelmo, A Olland
Surgical intervention
5 years ago
1774 views
23 likes
0 comments
11:26
Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

Symptoms are generalized to her four arms. Anti-acetylcholine antibodies and the therapeutic test of Mestinon® (Pyridostigmine) are positive.
In recent months, her symptoms worsened with the onset of swallowing disorders.

Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia.
Thymectomy is indicated. To do so, a left thoracoscopy is performed and assisted by means of the Da Vinci™ robot.

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy, which is the standard technique. When compared to thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements, and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
Middle lobectomy for a typical carcinoid tumor using 4 robotic arms
We present the case of a 78-year-old woman with a typical carcinoid tumor of the middle lobe of the lung. Bronchoscopy was carried out. A tumor lying in the deep segment of the middle lobe bronchus was identified by biopsy as a typical carcinoid tumor. We decided to perform middle lobectomy using a four-arm robotic assistance as it allows for a minimally invasive surgery.

The patient is intubated with a double lumen tracheal tube. The patient is placed in a left-sided decubitus with the right arm hanging. Anesthesiologists and mechanical ventilation need to be placed on the patient’s right side. This will provide sufficient room to approach the robot on the left side with a 30-degree angulation to the patient’s head.

The robotic procedure was uneventful and was fully carried out. Chest tube drainage was removed on postoperative day 2 and the patient was discharged on postoperative day 7.
N Santelmo, A Olland
Surgical intervention
5 years ago
1863 views
4 likes
0 comments
14:03
Middle lobectomy for a typical carcinoid tumor using 4 robotic arms
We present the case of a 78-year-old woman with a typical carcinoid tumor of the middle lobe of the lung. Bronchoscopy was carried out. A tumor lying in the deep segment of the middle lobe bronchus was identified by biopsy as a typical carcinoid tumor. We decided to perform middle lobectomy using a four-arm robotic assistance as it allows for a minimally invasive surgery.

The patient is intubated with a double lumen tracheal tube. The patient is placed in a left-sided decubitus with the right arm hanging. Anesthesiologists and mechanical ventilation need to be placed on the patient’s right side. This will provide sufficient room to approach the robot on the left side with a 30-degree angulation to the patient’s head.

The robotic procedure was uneventful and was fully carried out. Chest tube drainage was removed on postoperative day 2 and the patient was discharged on postoperative day 7.
Technique for endoscopic resection of obstructive endobronchial malignancy
Invasion of the tracheo-bronchial tree by a malignant pulmonary lesion is the most frequent cause of bronchial obstruction in the adult. Malignant obstruction of major airways may require endoscopic resection for rapid palliation of dyspnea and obstructive pneumonitis.
Patients should be evaluated with flexible bronchoscopy and computed tomography of the chest to assess the anatomy of the obstruction and demonstrate patent airway distally. This criterion is critical for optimal selection.
Resection is carried out in the operating room under general anesthesia. It is important to emphasize that close collaboration between the surgical and anesthesia teams is essential at all times, as they are sharing responsibility for the airway. We use rigid bronchoscopy for piecemeal extraction of the lesion. Since moderate bleeding may be encountered, the clinician should be familiar with hemostatic manoeuvres including dabbing raw bronchial surfaces using the rigid bronchoscope, the use of epinephrine soaked pledgets, and irrigation using epinephrine solution. Hemostasis may also be accomplished using energy sources delivered through a flexible bronchoscope, including electrocautery, argon beam, and Nd:YAG laser. All energy sources should be used with caution within the airway to minimize the risk of complications.
Depending on the individual patient, endobronchial resection may be combined with airway stenting and/or postoperative chemoradiotherapy. In carefully selected patients, this will result in adequate palliation of symptoms.
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
G Rakovich
Surgical intervention
5 years ago
828 views
8 likes
0 comments
04:07
Technique for endoscopic resection of obstructive endobronchial malignancy
Invasion of the tracheo-bronchial tree by a malignant pulmonary lesion is the most frequent cause of bronchial obstruction in the adult. Malignant obstruction of major airways may require endoscopic resection for rapid palliation of dyspnea and obstructive pneumonitis.
Patients should be evaluated with flexible bronchoscopy and computed tomography of the chest to assess the anatomy of the obstruction and demonstrate patent airway distally. This criterion is critical for optimal selection.
Resection is carried out in the operating room under general anesthesia. It is important to emphasize that close collaboration between the surgical and anesthesia teams is essential at all times, as they are sharing responsibility for the airway. We use rigid bronchoscopy for piecemeal extraction of the lesion. Since moderate bleeding may be encountered, the clinician should be familiar with hemostatic manoeuvres including dabbing raw bronchial surfaces using the rigid bronchoscope, the use of epinephrine soaked pledgets, and irrigation using epinephrine solution. Hemostasis may also be accomplished using energy sources delivered through a flexible bronchoscope, including electrocautery, argon beam, and Nd:YAG laser. All energy sources should be used with caution within the airway to minimize the risk of complications.
Depending on the individual patient, endobronchial resection may be combined with airway stenting and/or postoperative chemoradiotherapy. In carefully selected patients, this will result in adequate palliation of symptoms.
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
Video-assisted thoracoscopic (VATS) lobectomy: left upper lobe
Standard treatment of early stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterior lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.

Key aspects of the procedure include:
Proper patient positioning:
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air-leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.

The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for an adenocarcinoma of the left upper lobe in a 66-year-old patient (the video emphasizes the steps of lobe resection – complete mediastinal lymph node dissection was effected but is not shown).

Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
G Rakovich
Surgical intervention
5 years ago
3297 views
20 likes
0 comments
10:02
Video-assisted thoracoscopic (VATS) lobectomy: left upper lobe
Standard treatment of early stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterior lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.

Key aspects of the procedure include:
Proper patient positioning:
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air-leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.

The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for an adenocarcinoma of the left upper lobe in a 66-year-old patient (the video emphasizes the steps of lobe resection – complete mediastinal lymph node dissection was effected but is not shown).

Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
Video-assisted thoracic surgery (VATS): right lower lobectomy with complete node clearance using an anterior approach
This video presents the management of a suspicious peripheral pulmonary tumor located in the right lower lobe (RLL), classified cT3N0M0 after preoperative staging (positive PET-scan with positive pathology). This case has been presented in a thoracic oncology multidisciplinary meeting, which validated a first-line surgical treatment by lobectomy and radical mediastinal lymph node resection.
The video demonstrates the videothoracoscopic anterior approach, initially described by McKenna and modified by Hansen. This anterior approach seems easier to reproduce and generally simpler than a videothoracoscopic posterior approach for many reasons: no dissection of the fissure, which is an unpredictable technique depending on the patient, use of a 5cm pleurotomy allowing for an easy access for curved instruments, and a very quick conversion, should it be needed; this last safety measure is fundamental.
Videothoracoscopic surgery is poorly developed in France although it is becoming a standard procedure in some major reference centers in thoracic surgery. This procedure offers many advantages: early rehabilitation linked to lesser postoperative pain, a rapid return to regular daily activities, an earlier onset for any potential adjuvant therapy.
It is important to be familiar with the anterior approach because it presents very different anatomical features as compared with the conventional posterior approach by thoracotomy. The emergence of reference centers should make training for this complex surgery possible, and it will probably become a therapeutic standard for cancer treatment, along with other specialities.
This video shows many tips to deal with fissure and pulmonary artery.
JM Baste, C Peillon
Surgical intervention
6 years ago
3663 views
27 likes
0 comments
10:24
Video-assisted thoracic surgery (VATS): right lower lobectomy with complete node clearance using an anterior approach
This video presents the management of a suspicious peripheral pulmonary tumor located in the right lower lobe (RLL), classified cT3N0M0 after preoperative staging (positive PET-scan with positive pathology). This case has been presented in a thoracic oncology multidisciplinary meeting, which validated a first-line surgical treatment by lobectomy and radical mediastinal lymph node resection.
The video demonstrates the videothoracoscopic anterior approach, initially described by McKenna and modified by Hansen. This anterior approach seems easier to reproduce and generally simpler than a videothoracoscopic posterior approach for many reasons: no dissection of the fissure, which is an unpredictable technique depending on the patient, use of a 5cm pleurotomy allowing for an easy access for curved instruments, and a very quick conversion, should it be needed; this last safety measure is fundamental.
Videothoracoscopic surgery is poorly developed in France although it is becoming a standard procedure in some major reference centers in thoracic surgery. This procedure offers many advantages: early rehabilitation linked to lesser postoperative pain, a rapid return to regular daily activities, an earlier onset for any potential adjuvant therapy.
It is important to be familiar with the anterior approach because it presents very different anatomical features as compared with the conventional posterior approach by thoracotomy. The emergence of reference centers should make training for this complex surgery possible, and it will probably become a therapeutic standard for cancer treatment, along with other specialities.
This video shows many tips to deal with fissure and pulmonary artery.
Robotic thymectomy for autoimmune myasthenia gravis
We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.
N Santelmo, S Renaud, J Marescaux
Surgical intervention
6 years ago
1866 views
18 likes
0 comments
12:14
Robotic thymectomy for autoimmune myasthenia gravis
We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.
Endoscopic resection of an endobronchial hamartoma
Invasion of the tracheo-bronchial tree by a malignant pulmonary lesion is the most frequent cause of bronchial obstruction in the adult. However, benign lesions, although rare, may also occur.
Hamartoma is amongst the most frequent benign endobronchial tumors. In many cases, these tumors are amenable to endoscopic treatment (either resection or laser ablation), thus sparing the patient the potential morbidity of a thoracotomy and bronchial or parenchymal resection.
We present a case of bronchoscopic resection of a hamartoma obstructing the left lower lobe bronchus in a 58-year-old patient who had presented with cough and post-obstructive pneumonia.
Key aspects of the procedure include:
- Optimal pre-operative evaluation with flexible bronchoscopy and computed tomography of the chest.
- Close collaboration between the surgical and anesthesia teams who are sharing responsibility for the airway.
- Careful use of energy sources within the airway.
- Adequate precautions in case of an unexpected major endobronchial bleed.
The prognosis of completely resected benign tumors is excellent.
Acknowledgment: we would like to thank Nathalie Leroux RN and Mélodie Leclerc RN for their continued support.
G Rakovich, D Ouellette, G Beauchamp
Surgical intervention
6 years ago
1394 views
12 likes
1 comment
03:33
Endoscopic resection of an endobronchial hamartoma
Invasion of the tracheo-bronchial tree by a malignant pulmonary lesion is the most frequent cause of bronchial obstruction in the adult. However, benign lesions, although rare, may also occur.
Hamartoma is amongst the most frequent benign endobronchial tumors. In many cases, these tumors are amenable to endoscopic treatment (either resection or laser ablation), thus sparing the patient the potential morbidity of a thoracotomy and bronchial or parenchymal resection.
We present a case of bronchoscopic resection of a hamartoma obstructing the left lower lobe bronchus in a 58-year-old patient who had presented with cough and post-obstructive pneumonia.
Key aspects of the procedure include:
- Optimal pre-operative evaluation with flexible bronchoscopy and computed tomography of the chest.
- Close collaboration between the surgical and anesthesia teams who are sharing responsibility for the airway.
- Careful use of energy sources within the airway.
- Adequate precautions in case of an unexpected major endobronchial bleed.
The prognosis of completely resected benign tumors is excellent.
Acknowledgment: we would like to thank Nathalie Leroux RN and Mélodie Leclerc RN for their continued support.
Completely thoracoscopic segmentectomy: apical segment, right upper lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. In patients with compromised lung function, anatomic segmentectomy may be an acceptable alternative to lobectomy. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with disturbed respiratory mechanics in the postoperative period, as well as chronic postoperative pain which may become incapacitating in 5% of patients.
One of the major potential advantages of thoracoscopic approaches is decreasing the incidence of post-thoracotomy pain.
Key aspects of thoracoscopic segmentectomy include:
Proper patient positioning.
Access to the pleural cavity and appropriate positioning of operating incisions.
Careful dissection of segmental branches of the pulmonary artery and bronchus.
Division of blood vessels and bronchus using endoscopic staplers.
Division of lung parenchyma along intersegmental planes.

The thoracoscopic approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present a completely thoracoscopic resection of the apical segment of the right upper lobe for a small T1 adenocarcinoma in a 78-year-old patient. The video emphasizes the steps of segmental resection —mediastinal lymph node dissection was effected but is not shown.

Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Martin RN, and Mélodie Leclerc RN for their continued support. Additionally, the figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
G Rakovich, J Forcillo, D Ouellette, G Beauchamp
Surgical intervention
7 years ago
577 views
22 likes
0 comments
09:44
Completely thoracoscopic segmentectomy: apical segment, right upper lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. In patients with compromised lung function, anatomic segmentectomy may be an acceptable alternative to lobectomy. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with disturbed respiratory mechanics in the postoperative period, as well as chronic postoperative pain which may become incapacitating in 5% of patients.
One of the major potential advantages of thoracoscopic approaches is decreasing the incidence of post-thoracotomy pain.
Key aspects of thoracoscopic segmentectomy include:
Proper patient positioning.
Access to the pleural cavity and appropriate positioning of operating incisions.
Careful dissection of segmental branches of the pulmonary artery and bronchus.
Division of blood vessels and bronchus using endoscopic staplers.
Division of lung parenchyma along intersegmental planes.

The thoracoscopic approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present a completely thoracoscopic resection of the apical segment of the right upper lobe for a small T1 adenocarcinoma in a 78-year-old patient. The video emphasizes the steps of segmental resection —mediastinal lymph node dissection was effected but is not shown.

Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Martin RN, and Mélodie Leclerc RN for their continued support. Additionally, the figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
Video-assisted thoracoscopic (VATS) lobectomy: right upper lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via posterolateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.

One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.

Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.

The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for neuro-endocrine carcinoma of the right upper lobe in a 71-year-old patient (the video emphasizes the steps of lobe resection —mediastinal lymph node dissection was effected, but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Martin RN, and Mélodie Leclerc RN for their continued support.
*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
G Rakovich, D Ouellette, G Beauchamp
Surgical intervention
7 years ago
556 views
93 likes
0 comments
08:01
Video-assisted thoracoscopic (VATS) lobectomy: right upper lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via posterolateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.

One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.

Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.

The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for neuro-endocrine carcinoma of the right upper lobe in a 71-year-old patient (the video emphasizes the steps of lobe resection —mediastinal lymph node dissection was effected, but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Martin RN, and Mélodie Leclerc RN for their continued support.
*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
Video-assisted thoracoscopic (VATS) lobectomy: right lower lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air-leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for adenocarcinoma of the right lower lobe in a 78-year-old patient (the video emphasizes the steps of lobe resection - mediastinal lymph node dissection was effected but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Girard RN, and Mélodie Leclerc RN for their continued support.

*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
G Rakovich, D Ouellette, G Beauchamp
Surgical intervention
7 years ago
823 views
39 likes
1 comment
09:56
Video-assisted thoracoscopic (VATS) lobectomy: right lower lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air-leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for adenocarcinoma of the right lower lobe in a 78-year-old patient (the video emphasizes the steps of lobe resection - mediastinal lymph node dissection was effected but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Girard RN, and Mélodie Leclerc RN for their continued support.

*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
Thoracoscopic left superior segmentectomy for primary lung adenocarcinoma
This 59-old male patient, smoker, has a previous history of thymoma that was operated upon 15 years ago by sternotomy. He presented with a large nodule in the superior segment of the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma TTF1+. 18-FDG scintigraphy showed a significant and isolated fixation. Because of the impaired respiratory function, a limited resection was decided upon, i.e, a resection of the superior segment of the left lower lobe with radical lymph node dissection.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
8 years ago
2221 views
14 likes
0 comments
07:01
Thoracoscopic left superior segmentectomy for primary lung adenocarcinoma
This 59-old male patient, smoker, has a previous history of thymoma that was operated upon 15 years ago by sternotomy. He presented with a large nodule in the superior segment of the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma TTF1+. 18-FDG scintigraphy showed a significant and isolated fixation. Because of the impaired respiratory function, a limited resection was decided upon, i.e, a resection of the superior segment of the left lower lobe with radical lymph node dissection.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
Endoscopic mediastinal lymph node dissection for stage I lung carcinoma
In this video, we will focus on mediastinal lymph node dissection as defined by the American College of Surgeons Oncology Group, i.e.: for right-sided tumors: removal of all lymphatic tissue bounded by the right upper bronchus, the right subclavian artery, the superior vena cava and the trachea (stations 2R and 4R); for left-sided tumors: removal of all lymphatic tissue bounded by the phrenic nerve, the vagus nerve and the top of the aortic arch (stations 5 and 6); and for both sides, removal of lymph nodes from stations 7, 8, 9, 10 and 11.
A perfect vision is necessary during mediastinal lymph node dissection. An oblique viewing 30 degree scope or a deflectable thoracoscope is almost essential to avoid the drawbacks linked to tangential vision, as it frequently occurs with a low inserted scope.
During open or video-assisted lymphadenectomy, it is usual to control small vessels by a combination of clipping and transection. This is time-consuming and it can be replaced by either bipolar cautery or ultrasonic shears or a vessel-sealing device, which both allow coagulating and transecting with a single tool.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
8 years ago
3078 views
17 likes
0 comments
09:36
Endoscopic mediastinal lymph node dissection for stage I lung carcinoma
In this video, we will focus on mediastinal lymph node dissection as defined by the American College of Surgeons Oncology Group, i.e.: for right-sided tumors: removal of all lymphatic tissue bounded by the right upper bronchus, the right subclavian artery, the superior vena cava and the trachea (stations 2R and 4R); for left-sided tumors: removal of all lymphatic tissue bounded by the phrenic nerve, the vagus nerve and the top of the aortic arch (stations 5 and 6); and for both sides, removal of lymph nodes from stations 7, 8, 9, 10 and 11.
A perfect vision is necessary during mediastinal lymph node dissection. An oblique viewing 30 degree scope or a deflectable thoracoscope is almost essential to avoid the drawbacks linked to tangential vision, as it frequently occurs with a low inserted scope.
During open or video-assisted lymphadenectomy, it is usual to control small vessels by a combination of clipping and transection. This is time-consuming and it can be replaced by either bipolar cautery or ultrasonic shears or a vessel-sealing device, which both allow coagulating and transecting with a single tool.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
Totally endoscopic right basilar segmentectomy for stage I lung carcinoma
Pulmonary segmentectomy was originally introduced nearly 70 years ago for the treatment of benign lung conditions. Later, Jensik and colleagues as well as Peters independently suggested that anatomic pulmonary segmentectomy could be effectively applied to small primary lung cancers when good margins were achievable. Today, this is possible thanks to recognition of early lung cancer by high-resolution computed tomography scan. Futhermore, lung-sparing procedures are advocated in those with small, early-stage primary lung cancers so that additional resections for bilateral synchronous or metachronous primaries are facilitated.
Several advantages to endoscopic procedures relative to open procedures have been identified and include decreased postoperative pain, shortened chest tube duration and length of stay, faster return to preoperative activity levels, preserved pulmonary function, and decreased inflammatory response.
This video demonstrates the main steps of a totally endoscopic right basilar segmentectomy for stage I lung carcinoma.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
9 years ago
1804 views
25 likes
1 comment
04:14
Totally endoscopic right basilar segmentectomy for stage I lung carcinoma
Pulmonary segmentectomy was originally introduced nearly 70 years ago for the treatment of benign lung conditions. Later, Jensik and colleagues as well as Peters independently suggested that anatomic pulmonary segmentectomy could be effectively applied to small primary lung cancers when good margins were achievable. Today, this is possible thanks to recognition of early lung cancer by high-resolution computed tomography scan. Futhermore, lung-sparing procedures are advocated in those with small, early-stage primary lung cancers so that additional resections for bilateral synchronous or metachronous primaries are facilitated.
Several advantages to endoscopic procedures relative to open procedures have been identified and include decreased postoperative pain, shortened chest tube duration and length of stay, faster return to preoperative activity levels, preserved pulmonary function, and decreased inflammatory response.
This video demonstrates the main steps of a totally endoscopic right basilar segmentectomy for stage I lung carcinoma.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
Totally endoscopic right apico-posterior segmentectomy for stage I lung carcinoma
This is the case of a 56-year-old male patient presenting with stage I (cT1N0) adenocarcinoma of the posterior segment of the right upper pulmonary lobe.
In this case, we will perform a totally endoscopic segmentectomy, namely only video display and endoscopic instrumentation without utility incision. A 3cm incision is made at completion of the segmentectomy by enlarging one of the ports for specimen extraction.
In this video, only the main steps of the pulmonary resection will be demonstrated. The lymphadenectomy will be shown in another video.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
9 years ago
1515 views
21 likes
0 comments
06:08
Totally endoscopic right apico-posterior segmentectomy for stage I lung carcinoma
This is the case of a 56-year-old male patient presenting with stage I (cT1N0) adenocarcinoma of the posterior segment of the right upper pulmonary lobe.
In this case, we will perform a totally endoscopic segmentectomy, namely only video display and endoscopic instrumentation without utility incision. A 3cm incision is made at completion of the segmentectomy by enlarging one of the ports for specimen extraction.
In this video, only the main steps of the pulmonary resection will be demonstrated. The lymphadenectomy will be shown in another video.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1