Steven Rothenberg

1318 statements · 16 topics · summaries given as host listed separately

Congenital Lung Lesions (CPAM) · guest expert Fetal Surgery · guest expert Pectus Excavatum · guest expert Sarcoma (Ewing/Rhabdo) · guest expert Single Ventricle / HLHS · guest expert

Featured statements

It's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed and I believe that's because as the vessel, the nature of the vessel changes, that the clip no longer has secure footing, that the the vessel sort of necrosis a bit and the clip falls off

quote · Congenital Lung Lesions (CPAM)

You really want to maximize the downside. And so. Um, the way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.

quote · Congenital Lung Lesions (CPAM)

I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.

quote · Congenital Pulmonary Airway Malformation

The way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.

quote · Congenital Pulmonary Airway Malformation

I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.

quote · Fetal Surgery

quote · Single Ventricle / HLHS

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Steven's statements about Congenital Lung Lesions (CPAM) 429 statements

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Congenital Cystic Lung Lesions: Update Course 2014

Statement Fetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids. Open

Quotation I find that more and more are being, being obtained, but they really don't change what I do at all. Open

Statement Approximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management. Open

Quotation Oh, absolutely not. It's so much easier. Open

Quotation There's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier. Open

Statement Operative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data. Open

Quotation There's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier. Open

Statement Asymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery. Open

Quotation The difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult. Open

Quotation I will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult. Open

Statement A 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery. Open

Statement Even in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult. Open

Quotation You will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with. Open

Statement At 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor. Open

Statement Anatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease. Open

Statement One child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up. Open

Statement In a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma. Open

Statement Neoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer. Open

Statement Columbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature. Open

Statement 30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life. Open

Statement Once congenital cystic lung lesions become infected, they are much more difficult to resect surgically. Open

Statement All thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity. Open

Quotation I think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy. Open

Statement Long-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability. Open

Statement Morsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance. Open

Quotation The hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids. Open

Statement All three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age. Open

Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012

Statement For a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low. Open

Quotation I don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again. Open

Statement Performing apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis. Open

Neonatal Lung Lesions with Dr. Steven Rothenberg

Statement Serial prenatal ultrasounds are the best way to watch the development of cystic lung lesions; they are noninvasive and can be done quickly every couple of weeks. Open

Statement Fetal MRI provides little benefit for lung lesions; it does not change the plan or give much more definition than ultrasound. Open

Statement Anywhere from 6 to 40% of prenatally detected lung lesions will regress with time, and in some cases appear to completely disappear. Open

Statement CHOP performs open fetal surgery for lung lesions less than once every couple of years; it is extremely rare. Open

Statement Fetal thoracentesis or thoracoamniotic shunt placement is done only if the fetus shows significant distress and evidence of hydrops, when mortality rate goes up significantly. Open

Statement A cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and indicates cases more prone to need fetal intervention. Open

Statement When removing lung lesions, it is not uncommon to see a hybrid lesion on pathology, suggesting these represent a spectrum rather than distinct entities. Open

Statement Intralobar sequestration is within the parenchyma of the lung and shares a common pleura with that lobe, usually the lower lobe. Open

Statement Extralobar sequestration generally has its own pleural lining and is either completely separate or 90% separate from the lobe. Open

Statement Sequestrations are classified by having a systemic artery coming into them, generally right off the aorta, either from the thoracic aorta or through the diaphragm from the abdominal aorta. Open

Statement CT scan at 4 to 6 weeks of age is performed to fully evaluate the lesion; waiting this period reduces atelectasis during the study and allows outpatient scanning, sometimes without general anesthetic. Open

Quotation I think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right. Open

Quotation I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected. Open

Statement Dr. Rothenberg has seen multiple children who had normal chest X-ray at birth but later presented at 9 months to 6-7 years with pneumonia and were found to have an infected CPAM. Open

Statement A plain chest X-ray or ultrasound are not adequate to ensure there is absolutely no lung lesion present; CT scan is required. Open

Statement Depending on the series, 20-40% of untreated lung lesions will develop a significant infection at some point. Open

Quotation The incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant. Open

Statement The incidence of malignancy in Dr. Rothenberg's series of lung lesions is over 1%, which he does not consider insignificant. Open

Statement Dr. Rothenberg prefers to operate by 3 months of age to avoid infection before surgery, because the surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth. Open

Quotation I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection Open

Statement Even in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes in the fissures and peribronchial spaces, and inflammation in the fissure, suggesting low-grade infections. Open

Statement In Dr. Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were all shorter in patients under 5 kg compared to those under 10 kg. Open

Statement Most children undergoing early lobectomy are discharged within 48 hours, and by one month post-op on chest X-ray, you cannot tell they had surgery; the remaining lung undergoes compensatory growth. Open

Quotation The key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room Open

Statement Blood is typed and crossed for all lobectomy cases; if bleeding occurs, it can be significant and blood should be available. Open

Statement Most asymptomatic children on room air will tolerate single-lung ventilation without problem. Open

Statement Single-lung ventilation is obtained by mainstem intubation of the contralateral bronchus (e.g., left mainstem for right lower lobe resection). Open

Statement Bronchial blockers are difficult to place and add extra time to the procedure; mainstem intubation is preferred and can often be done blindly with positioning. Open

Statement After lung collapse, all babies will initially desaturate (low 90s to high 80s) for a few minutes due to continued shunting to the collapsed lung; saturations come up once shunting stops. Open

Statement Anesthesiologists should use lower peak ventilatory pressures to avoid overcoming the pneumothorax or mainstem intubation; if ventilation needs to increase, increase rate rather than pressure. Open

Statement End-tidal CO2 in the mid-40s during thoracoscopic lobectomy is not a problem and does not cause significant acidosis or deleterious effects. Open

Statement For lobectomies, the patient is positioned in pure lateral decubitus with the surgeon and assistant standing at the patient's front (toward the nipple), which provides more room from the front of the chest toward the hilum than standing at the back. Open

Statement The camera port is placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula (not posterior), to allow working from front to back without paradoxical instrument orientation. Open

Statement A 4mm 30-degree scope (about 20cm length) provides a more wide-angle view comparable to a 5mm scope; short scopes allow the surgeon to get close to the patient without the assistant getting in the way. Open

Statement Low-profile reusable 3mm ports with small heads are essential in the small space of an infant chest to prevent instruments from banging against each other. Open

Statement The technique for vessel control is to make two separate seals on the vessel at least 4-5mm apart using a 3mm vessel sealer, then cut partway between the seals to check for bleeding before complete division. Open

Quotation You really want to maximize the downside. And so. Um, the way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe. Open

Statement Cutting only partway through a sealed vessel allows recovery if bleeding occurs; complete division without checking loses vascular control. Open

Quotation I think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble Open

Statement Using energy devices that seal and cut simultaneously (like Harmonic) is a mistake and sets the surgeon up for trouble; if the device fails, recovery is not possible. Open

Statement Dr. Rothenberg had a case where using a seal-and-cut device in another country resulted in failure to seal, bleeding, and conversion to open surgery. Open

Statement For left lower lobectomy, the first step is to take down the inferior pulmonary ligament to check for a systemic vessel and expose the inferior pulmonary vein. Open

Statement When the fissure is incomplete, complete it layer by layer using vessel-sealing technology, working anteriorly to posteriorly until the pulmonary artery is exposed. Open

Statement In a lower lobe, the main pulmonary artery trunk bifurcates into four branches to the basal segments, with a superior segmental branch coming off higher and more posteriorly. Open

Statement The bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery. Open

Statement For larger vessels with good trunk length, a 5mm stapler can be used on the main trunk instead of isolating four separate basal segment branches, provided proximal control with a clamp is maintained during stapler firing. Open

Statement When dissecting behind the bronchus to reach the pulmonary vein, stay hard on the backside of the bronchus and be aware the pulmonary vein is immediately behind it. Open

Quotation Never take the pulmonary vein trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. Open

Statement Never take the pulmonary vein trunk near the pericardium; if the device fails, the vessel will retract into the pericardium and the child will bleed to death before anything can be done. Ensure enough length away from the pericardium for proximal control. Open

Statement For right lower lobectomy, the technique is the same as left lower lobe but with hands switched; be careful that branches to the middle lobe come off just above the lower lobe artery and can be damaged if dissection migrates too far cephalad. Open

Statement For left upper lobectomy, the camera port is placed in the 5th intercostal space and working ports may be moved up one space; the lung apex is retracted inferiorly to expose the pulmonary artery as it enters the upper lobe near the apex. Open

Statement The lingula is almost always taken with an upper lobectomy on the left; on the right, the middle lobe is usually preserved but the technique for isolating the vein is the same. Open

Statement For right middle lobe resection, complete the minor fissure first; the pulmonary artery enters at the posterior aspect and bifurcates into upper and lower branches. Open

Statement If the lung has large cysts limiting space and manipulation, use the sealing device to pop the cysts and decompress them at the beginning of the procedure (a lung reduction technique). Open

Statement Extralobar sequestrations can have up to 6 systemic vessels; Dr. Rothenberg's largest vessel was almost 15mm in diameter. Open

Statement For sequestration vessels, apply clips proximally and distally with enough length to cut partway between them; alternatively, use vessel sealing with the same partial-cut technique, or use a 5mm stapler for very large vessels (e.g., 15mm). Open

Quotation It's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed and I believe that's because as the vessel, the nature of the vessel changes, that the clip no longer has secure footing, that the the vessel sort of necrosis a bit and the clip falls off Open

Statement Never use sealing technology and clips on the same vessel; as the vessel changes with sealing, the clip can lose secure footing and fall off, causing delayed bleeding. Open

Statement Extralobar sequestrations become infected and can cause problems; embolization requires general anesthetic and significant arterial intervention, whereas thoracoscopic removal has almost no morbidity with no chest tube and next-day discharge. Open

Statement Dr. Rothenberg has changed his practice to consider segmentectomy in select cases where CT scan shows disease confined to a single segment (easiest for superior segment of lower lobe or lingula) and anatomy is favorable; these patients are being followed but it is not yet widely recommended. Open

Statement A chest tube is always left overnight after formal lobectomy; if no air leak or significant drainage in the morning, the tube is pulled, chest X-ray is checked in 2 hours, and the child is discharged that afternoon if the family lives in town. Open

Statement Average length of stay for lobectomy in patients who come in the morning is about 2.5 days, and slightly shorter for patients under 5 kg. Open

Thoracoscopic Right Lower Lobe Cystic Lesion Excision: Update Course 2014

Statement The patient is a 3-month-old, 5 kg infant undergoing thoracoscopic right lower lobectomy for a cystic lesion with an unseen sequestration. Open

Statement Three-millimeter instruments are used for the procedure, and space is not an issue in a 3-month-old infant. Open

Statement At 3 months of age, enlarged lymph nodes are already visible in the major fissure. Open

Statement In asymptomatic children aged 9 months to 1 year, lymph nodes are often massive and inflammation in the fissure is extensive, making the operation more difficult. Open

Statement The operation with a fellow assisting took approximately 90 minutes. Open

Statement A 3 mm sealer can safely take vessels up to 5 mm in diameter. Open

Statement When asymptomatic children are operated on around 1 year of age, dissection becomes much tougher due to inflammation, even in children who have never had a cold or chest infection. Open

Statement At 3 months of age, clips can be safely used at the segmental level. Open

Statement The specimen is morcellated through the trocar site and removed piecemeal because it is difficult to use a bag with a large specimen in a small infant. Open

Statement If cystic disease is seen in the lower part of the upper lobe, an anatomic segmental resection should be performed. Open

Statement One child who had a segmental resection that appeared limited to an anatomic segment on CT and at surgery has shown evidence of recurrent cystic disease. Open

Statement One child with no fissure (one giant lobe) required a bi-segmental resection and subsequently developed recurrent cystic disease because an anatomic resection could not be performed. Open

Statement The chest tube was removed on postoperative day 2 and could have been removed on postoperative day 1; the child went home on postoperative day 3. Open

Statement Pathology showed lung tissue with CPAM type 1 and type 2 changes with exuberant neoplastic mucinous proliferations; bronchial margin was negative. This is a finding not previously reported by the speaker. Open

Statement In a personal series of over 300 lobectomies for cystic lung disease, the speaker has identified two pulmonary blastomas and one adenocarcinoma. Open

Statement The neoplastic mucinous proliferations may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer. Open

Statement At Columbia, pathologists reviewing cases have found four others with exuberant neoplastic mucinous proliferations. Open

Statement The literature shows that 30–40% of children with cystic lung disease will have a significant pulmonary infection at some point during their life. Open

Statement Once cystic lesions become infected, they are much more difficult to resect. Open

Statement All lobectomies for cystic lung disease should be done thoracoscopically, and if a center cannot perform them thoracoscopically, patients should be referred to a center that can. Open

Statement Good long-term pulmonary function studies are needed to document that if a lobe is removed in infancy, the rest of the lung will grow and compensate without significant disability. Open

Statement In the speaker's personal series, the incidence of malignancy is almost 2%, certainly 1%, but may be 2%. Open

Statement Hematologist-oncologists have stated that morcellating the specimen does not upgrade the tumor, does not change treatment, and no patient has received chemotherapy, but these children are being watched. Open

Statement It is difficult to place a large specimen in a bag in young infants undergoing early lobectomy. Open

Statement Three tumors in 300 cases represents a 1% incidence of cancer. Open

Statement The three malignancies (blastomas and adenocarcinoma) were all diagnosed at 1 year of age. Open

Neonatal Lung Lesions with Dr. Steven Rothenberg

Statement Serial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks. Open

Statement Fetal MRI for lung lesions provides little additional benefit and does not change the management plan. Open

Statement Anywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear. Open

Statement Fetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years. Open

Statement Fetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality. Open

Statement Steroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated. Open

Statement A cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention. Open

Statement Congenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology. Open

Statement Sequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining. Open

Statement If a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks. Open

Statement A chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required. Open

Quotation Some of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that. Open

Statement Some children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM. Open

Quotation I feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy. Open

Statement Depending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point. Open

Statement The incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant. Open

Quotation The incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant. Open

Statement Rothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth. Open

Quotation I like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier. Open

Statement Even in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection. Open

Statement In Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg. Open

Quotation The hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients. Open

Statement Most infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery. Open

Statement The key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work. Open

Statement Blood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant. Open

Quotation I do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available. Open

Statement Most asymptomatic children on room air tolerate single-lung ventilation without problem. Open

Quotation Most kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem. Open

Statement Most asymptomatic children on room air tolerate single-lung ventilation without problem. Open

Statement Single-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided. Open

Statement After lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops. Open

Quotation Once you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up. Open

Statement After lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops. Open

Statement Anesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung. Open

Statement End-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy. Open

Statement The surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back. Open

Statement The camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles. Open

Statement A fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children. Open

Statement Rothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference. Open

Statement Low-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space. Open

Statement A 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter. Open

Statement The dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division. Open

Quotation The thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything. Open

Statement Vascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage. Open

Quotation The way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe. Open

Quotation You only lose control once you've completely divided the vessel. Open

Statement Clips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping. Open

Quotation I think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble. Open

Statement Using energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding. Open

Quotation I think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover. Open

Quotation My, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible. Open

Statement Rothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open. Open

Quotation In fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open. Open

Statement Rothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open. Open

Statement The first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein. Open

Statement The ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery. Open

Quotation The ease of the operation really depends on how complete the fissure is. Open

Statement The ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery. Open

Quotation The ease of the operation really depends on how complete the fissure is. Open

Statement In a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly. Open

Statement The bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery. Open

Statement If the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control. Open

Statement When using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds. Open

Quotation When I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time. Open

Statement Rothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically. Open

Quotation When I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time. Open

Statement After dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus. Open

Quotation The key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there. Open

Statement In children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice. Open

Statement After dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium. Open

Quotation The key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. Open

Statement If a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control. Open

Statement Right lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery. Open

Statement For left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first. Open

Statement After taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein. Open

Statement In left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved. Open

Statement Working through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus. Open

Statement For right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches. Open

Quotation If you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them. Open

Statement If the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure. Open

Statement Extralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter. Open

Statement For sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm). Open

Statement Never use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding. Open

Quotation The one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed. Open

Statement Never use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding. Open

Statement Systemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical. Open

Statement Extralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated. Open

Quotation I worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems. Open

Quotation I believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day. Open

Quotation I think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me. Open

Statement Rothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up. Open

Statement A chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon. Open

Statement Average length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg. Open

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Statement Single lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures. Open

Statement For thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox. Open

Statement When completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery. Open

Quotation Vascular control in these cases is everything. Open

Statement Vascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division. Open

Quotation Vascular control in these cases is everything. Open

Statement The bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy. Open

Statement When dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it. Open

Quotation You cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything. Open

Statement Do not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control. Open

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