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Thoracoscopic Left Lower Lobectomy Technique by Dr. Steven Rothenberg: How I...
With Dr. Steven Rothenberg · hosted by Dr. Todd Ponsky
Chapter 1 of 8 · Fundamentals
Series introduction
Introduction to How I Do It Series
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The procedure uses 3mm sealer and 5mm stapler instruments for thoracoscopic left lower lobectomy in an infant with CPAM.
The surgeon and assistant stand at the patient's front with the patient in full lateral decubitus position, with monitors behind the patient for inline viewing during delicate portions.
Right mainstem intubation is used to obtain left lung collapse.
The camera port is placed anterior to the tip of the scapula in approximately the 5th intercostal space in the posterior axillary line.
Operating ports are placed in the anterior axillary line, with the right hand port just above the diaphragm, initially 3mm and later upsized to 5mm for the stapler.
In lower lobectomies, surgeons should always look for a systemic artery even if not identified on CT scan, as hybrid sequestration-CPAM lesions are not unusual and large vessels are occasionally missed.
The seal-and-tear technique (grasping tissue, sealing, then tearing gently upward) eliminates the need for sharp dissection when mobilizing the inferior pulmonary ligament.
It is important to identify the branch going to the lingula so it can be preserved during lower lobectomy.
In cases where the fissure is incomplete, lung parenchyma is gone through a layer at a time to expose the pulmonary artery.
The superior segmental artery of the left lower lobe usually comes off separately from the basal trunk and is best isolated alone.
When sealing thicker tissue, two separate seals should be made and the cut made between them rather than cutting in the center of a single seal.
The double-seal technique (proximal and distal seals 3-4mm apart, only partially dividing initially) ensures that if the seal is incomplete or there is bleeding, the surgeon still has control of the vessel before the ends separate and retract.
Even in asymptomatic CPAM patients, enlarged inflamed lymph nodes are often seen due to chronic inflammation secondary to the CPAM.
In a patient one year of age with CPAM, it is not unusual to have the fissure obliterated by inflammation and enlarged lymph nodes even though the patient has been completely asymptomatic.
The bronchus to the lower lobe lies just below the main arterial trunk to the basal segments and can be used as a tactile landmark during vessel dissection.
Taking the superior segmental artery first before the main trunk gives more length on the main trunk for safe ligation, sealing, and division.
The 5mm stapler is used for the main arterial trunk after upsizing the right hand trocar from 3mm to 5mm.
After placing the stapler, the surgeon should compress and wait for a count of 10 seconds to allow the staples to completely form.
In thoracoscopic lobectomy, it is often easier to take the bronchus first (rather than the traditional open surgery sequence of artery-vein-bronchus), which leaves the pulmonary vein well exposed.
It is important to remember that the vein lies just behind the bronchus during dissection to ensure no branches of the vein are injured.
In children over 2-3 months of age, separating the superior segmental bronchus from the basal segmental bronchi is preferable because of bronchial size, to ensure adequate division and seal using the stapler.
Compressing the bronchus before stapling aids in the formation of the staples.
The 5mm stapler works well in children under 10kg; in larger children the bronchi may be too large for the 5mm stapler and must be evaluated case by case.
This minimally edited procedure took 45 minutes in real time.
The patient had a chest tube in just overnight, it was removed on the first postoperative day, and she was discharged later that evening.
The pathology came back consistent with type 2 CPAM.
Taking the superior branch of the inferior pulmonary vein first gains more length on the main trunk, allowing safe use of the stapler.
The sealer works extremely well on lung tissue and has been used to complete incomplete fissures and perform segmental resections with no problems with bleeding or air leak.
When going through a great deal of tissue with the sealer, it is important to clean the jaws and remove char that may build up.
When stapling the main venous trunk, the staple line must be well away from the base of the vein and well away from the pericardium (at least 2cm), and the surgeon should grasp the trunk proximal to the stapler in case of leak or problem.