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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
3 years ago
853 views
65 likes
1 comment
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.
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
3 years ago
1257 views
92 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
3 years ago
786 views
43 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.
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
3 years ago
1074 views
42 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
3 years ago
884 views
42 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.
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
4 years ago
1255 views
42 likes
0 comments
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
4 years ago
473 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.
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
4 years ago
1102 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.
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
4 years ago
998 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
4 years ago
1002 views
14 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
4 years ago
1180 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
4 years ago
1028 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
4 years ago
1168 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.