RLL 2020 3 mo old

This video demonstrates a thoracoscopic right lower lobectomy and a 3 month old who had a CPAM diagnosed prenatally. The patient is placed in a left lateral decubitus position with the right chest being prepped and draped in a standard fashion. The surgeon and the assistant stand at the patient's front with the monitor at the patient's back. The initial trochar is placed in the mid-axillary line in approximately the 6th intercostal space to overlook the major fissure. The right and left hand operating ports are placed in the anterior axillary line and approximately the 5th and 8th intercostal spaces respectively. The left-hand port is later changed to a 5 millimeter to accommodate the stapler. The initial step is to take down the inferior pulmonary ligament and ensure there is not a systemic vessel or a hybrid lesion. Then the major fissure is examined. In this case, the fissure is incomplete anteriorly, although the vessels can be seen coursing through the fissure more posteriorly. In this case, we complete the fissure anteriorly to better expose the pulmonary artery as it passes through the major fissure. We use a 3 millimeter vessel sealer to seal the tissue and then divide sharply between it. This technique is both hemostatic. As well as Preventing air leaks in the divided tissue. When the tissue is too thick, a sequential pattern is performed, as here you see, first we seal tissue anteriorly and then posteriorly, almost going through this as though you were doing a segmental resection in the liver. Again, one or two applications of the sealer can be made, and then the tissue can be divided either between the seals or in the center of the seal, gradually separating the lower lobe from the middle lobe. The section is continued posteriorly exposing the Pulmonary arteries as it transverses through the major fissure. We start to begin to get a good view of the pulmonary artery to the lower lobe. Posteriorly, care must be taken to avoid injury to the apical or superior segmental branch, which usually comes off towards the posterior aspect of the fissure. This vessel usually is. Identified and separated and taken separately from the main trunk to the rest of the lower lobe. Again, blunt dissection can be performed relatively aggressively once the anterior wall of the pulmonary vein is identified, as all tissue anterior to that can now be deemed safe for sealing and division. You perform the entire dissection using the 3 millimeter vessel sealer and only change instruments when it is necessary to divide tissue between seals. Now with the fissure complete, we clearly see the apical segment vessel going to the lower lobe. This vessel is then dissected out. Sealed approximately. And then distally and divided between the seals. Ideally, the seals will be 3 to 5. Millimeters apart. And you can see the white bubble of the vessel between the two transparent seals. When seen like this, that seals are considered safe. We now divide the vessel partway to visualize the lumen, and once we see the lumen and that there is no bleeding, we can continue to divide the vessel the rest of the way. This ensures that we do not lose control of the vessel should there be a leak from either seal. Even in this young child, there are already significantly enlarged lymph nodes which can obscure the dissection and make it hard to identify all the branches of the artery. These must be dissected out of the way as necessary. With the majority of the artery and roof, we finish the last parts of the incomplete fissure anteriorly, fully separating. The lower and middle lobes. We can now see all of the basal segments as they traverse down to the lower lobe. The anterior basal segment is clear anteriorly, and we are working to separate this from the middle lobe. Depending on the size of the child and the size of the vessels, the basal segment can be taken as an entire trunk or can be done separately as in this case. This child is a bit larger, almost 6 kg. We have elected to take the vessels after their branching point. For safety. The smaller vessels are easy, easier to seal and also provide some backup. Should there be a problem, we can still grab the basal trunk to stop any bleeding. Here we are taking the posterior basal. Trunk branch. Sealing it proximally and distally and then dividing it. Again, the vessel is divided partway. To ensure that the seals are competent. Before completely dividing the vessel. The lumen is seen. There's no bleeding and the division of the vessel is completed. This should be the medial basal trunk. It is approached in the same way. You can see that even this vessel is branching. Uh, just as it enters the parenchyma. In this case, to get extra length, we will flip the tips of the sealer. So that we use the curve of the. Sealer to our advantage gaining more length between the two seals. If there is any question that the 2nd seal has disrupted the 1st seal. Then the vessel can be resealed on the proximal seal. However, in this case, both seals are clear and transparent and therefore safe. Here we are dividing the vessel, but that you can see there is a small posterior branch which was not noticed. But it is safely sealed. This is one of the lateral basal trunks. Again, this is a larger vessel, but still smaller than the 5 millimeter. Which is the upper limit. Of a vessel which can be taken with a 3 millimeter sealer. Proximal seal first is made first, but here you can see the distal seal causes disruption of the proximal seal because of the large size of the vessel and the fact that the seals are too close. For that reason, the proximal seal is redone. We then cut between the seals again, seeing the lumen of the vessel. There is no active bleeding. This time, as we divide the vessel, there is a small branching vessel just behind it. Which was not sealed. In mobilizing this, a small rent was made in that vessel. However, because we have complete control. And limited bleeding, we were able to just reintroduce the seal. And seal a cross. The major vessel this time including the small posterior vessel. And for safety, a single seal is made on that vessel as well. This can now be divided safely. This again shows the importance of this technique of sealing proximally and distally to ensure that there is good hemostasis and not allowing the vessels to retract. And finally, the anterior basal segmental vessel. Is mobilized. Sealed approximately. And then distally. Again Resealing the proximal. Seal to ensure it is. Completely secure And then dividing between the seals sharply. This technique has been used in over 500 thoroscopic lobectomies with excellent results. And without The occurrence of uncontrolled bleeding. Once the artery is divided. It now gives exposure to the Bronchuss to the lower lobe. Again, we first mobilize and take the apical or superior segmental bronchus to the lower lobe. You can't see that there is a pulmonary vein going to this segment posteriorly, and care needs to be taken not to injure that during this dissection. However, this plane is readily. Available And can be dissected safely. We dissected through the left hand or lower port because this is the port we will enlarge for the 5 millimeter stapler. Prior to stapling, we always crush the bronchus. In order to help compress the tissue to enable. The 5 millimeter stapler, which holds 2 millimeter staples. The stapler is then applied and closed for a count of 20. Once that is reached, the stapler is fired. And as you can see, the staples create an excellent staple line with complete compression. Of the bronchus in complete closure. With the. apical segment bronchus divided. This now exposes the trunk to the lower lobe. In general, we take the bronchus to the basal segments at this main takeoff and not further as we did the vessels. This time we insert a 3 millimeter bowel clamp to crush the bronchus, as this tissue is thicker than the single segment we took before. We also try to make sure we do not cross. Over the previous staple line. As this can sometimes disrupt smaller these smaller staples. Where you can see there is some tissue posteriorly. And we dissect this off, creating a large window for placement in the stapl and to ensure that we are not injuring the bronchus to the middle lobe. The bronchus can be pulled into the jaws of the stapler, which is somewhat limited by the vertebral column. And it's enclosed. Again, it is left for a count of 20 then the stapler is fired, and an excellent division is obtained. With this done, only the inferior pulmonary vein remains. In general, we will take this as a solid trunk, but it is important to dissect high enough up on the vein to ensure that when applying the stapler. Good proximal control can be obtained. The lung is flipped anteriorly and down to help take down the pleural reflection overlying the vein posteriorly. Occasionally it is necessary to take one or two small branches to gain adequate length on the trunk of the vein to apply the stapler. If the vein branches more approximately. Then I would simply dissect into the lung and get it at a Segmental level using the sealer rather than the stapler. Again, here we're dissecting some of the superior tissue in order to gain length on the vein. To allow for use of the staple. There is a small branching vein in this, and it is sealed. Approximately And then again distally. And divided. Once this tissue is divided. A good length of the. Inferior pulmonary vein trunk is now available. And we are able to apply the stapler and still have proximal control. It is critical that if you use this taper on the inferior pulmonary vein trunk that you have proximal control in case there is a misfire. As this will allow you to further secure the vein. And eliminate the risk. Of uncontrolled bleeding. We have never had this problem using the stapler, but I think it is imperative that this precaution be taken, as if there were a problem, the vein could conceivably retract to the point where control could not be gotten thoracoscopically. Where you see the stapler in place. And now The sealer or another a traumatic instrument is placed approximately while the stapler is fired to ensure that there is a secure staple on. The specimen is then brought out through the lower 5 millimeter trochar site in a piecemeal fashion.