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Full endoscopic robot-assisted trisegmentectomy of the pulmonary left upper lobe for diagnosis and treatment
Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.
JM Baste, M Renaux-Petel, C Peillon
Surgical intervention
6 years ago
1122 views
6 likes
0 comments
11:42
Full endoscopic robot-assisted trisegmentectomy of the pulmonary left upper lobe for diagnosis and treatment
Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.
Thoracoscopic resection of an esophageal leiomyoma
Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign tumors are leiomyomas. They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus. They have extremely small potential for malignant degeneration. Surgical excision is recommended for symptomatic great lesions. The video demonstrates the thoracoscopic resection of a leiomyoma on the upper thoracic third of the esophagus with the patient in a prone position, which brings an excellent exposure of the operative field and decreases lung injuries as we do not use any retractor.
J Torres Bermúdez, FC Becerra García, J Lopez Espejo, JL Martín, G Sánchez de la Villa
Surgical intervention
6 years ago
2169 views
18 likes
0 comments
07:22
Thoracoscopic resection of an esophageal leiomyoma
Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign tumors are leiomyomas. They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus. They have extremely small potential for malignant degeneration. Surgical excision is recommended for symptomatic great lesions. The video demonstrates the thoracoscopic resection of a leiomyoma on the upper thoracic third of the esophagus with the patient in a prone position, which brings an excellent exposure of the operative field and decreases lung injuries as we do not use any retractor.
Full endoscopic robotic assisted upper left lung lobectomy for a suspicious lesion
Objective:
To present a complete endoscopic approach for thoracic resection using the Da Vinci™ robotic device (Ninan M, MR Dylewski. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2).
Methods:
A 62-year-old man was a former smoker with an accumulated dose of 70 packs of cigarettes a year and had a history of rheumatic polyarthritis under immunotherapy. He presented a deterioration of his overall health condition and a CT-scan was performed. The CT-scan showed a ground-glass opacity (GGO) in the left upper lobe. Functional respiratory tests were the following: FEV1 51% and DLCO 65%, and the patient completed 4 floors at the stair-climbing test. An upper left lobectomy using a Da Vinci™ robotic system was performed with a high level of safety.
Results: The postoperative course was uneventful. Pathological findings confirmed the diagnosis of a benign granuloma. Our patient has not shown any incidence during a one-month follow-up and his physician reintroduced his immunosuppressive treatment.
Conclusion: Complete and precise lobectomy can be performed safely by means of the Da Vinci™ robotic system with low morbidity.
JM Baste, V Díaz-Ravetllat, C Peillon
Surgical intervention
6 years ago
1255 views
17 likes
0 comments
07:10
Full endoscopic robotic assisted upper left lung lobectomy for a suspicious lesion
Objective:
To present a complete endoscopic approach for thoracic resection using the Da Vinci™ robotic device (Ninan M, MR Dylewski. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2).
Methods:
A 62-year-old man was a former smoker with an accumulated dose of 70 packs of cigarettes a year and had a history of rheumatic polyarthritis under immunotherapy. He presented a deterioration of his overall health condition and a CT-scan was performed. The CT-scan showed a ground-glass opacity (GGO) in the left upper lobe. Functional respiratory tests were the following: FEV1 51% and DLCO 65%, and the patient completed 4 floors at the stair-climbing test. An upper left lobectomy using a Da Vinci™ robotic system was performed with a high level of safety.
Results: The postoperative course was uneventful. Pathological findings confirmed the diagnosis of a benign granuloma. Our patient has not shown any incidence during a one-month follow-up and his physician reintroduced his immunosuppressive treatment.
Conclusion: Complete and precise lobectomy can be performed safely by means of the Da Vinci™ robotic system with low morbidity.
Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

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

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

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy, which is the standard technique. When compared to thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements, and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
N Santelmo, A Olland
Surgical intervention
6 years ago
1824 views
23 likes
0 comments
11:26
Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

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

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

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

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

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

The robotic procedure was uneventful and was fully carried out. Chest tube drainage was removed on postoperative day 2 and the patient was discharged on postoperative day 7.
N Santelmo, A Olland
Surgical intervention
6 years ago
1895 views
4 likes
0 comments
14:03
Middle lobectomy for a typical carcinoid tumor using 4 robotic arms
We present the case of a 78-year-old woman with a typical carcinoid tumor of the middle lobe of the lung. Bronchoscopy was carried out. A tumor lying in the deep segment of the middle lobe bronchus was identified by biopsy as a typical carcinoid tumor. We decided to perform middle lobectomy using a four-arm robotic assistance as it allows for a minimally invasive surgery.

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

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

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

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

Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
G Rakovich
Surgical intervention
6 years ago
3411 views
20 likes
0 comments
10:02
Video-assisted thoracoscopic (VATS) lobectomy: left upper lobe
Standard treatment of early stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via a posterior lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.

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

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

Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
Video-assisted thoracic surgery (VATS): right lower lobectomy with complete node clearance using an anterior approach
This video presents the management of a suspicious peripheral pulmonary tumor located in the right lower lobe (RLL), classified cT3N0M0 after preoperative staging (positive PET-scan with positive pathology). This case has been presented in a thoracic oncology multidisciplinary meeting, which validated a first-line surgical treatment by lobectomy and radical mediastinal lymph node resection.
The video demonstrates the videothoracoscopic anterior approach, initially described by McKenna and modified by Hansen. This anterior approach seems easier to reproduce and generally simpler than a videothoracoscopic posterior approach for many reasons: no dissection of the fissure, which is an unpredictable technique depending on the patient, use of a 5cm pleurotomy allowing for an easy access for curved instruments, and a very quick conversion, should it be needed; this last safety measure is fundamental.
Videothoracoscopic surgery is poorly developed in France although it is becoming a standard procedure in some major reference centers in thoracic surgery. This procedure offers many advantages: early rehabilitation linked to lesser postoperative pain, a rapid return to regular daily activities, an earlier onset for any potential adjuvant therapy.
It is important to be familiar with the anterior approach because it presents very different anatomical features as compared with the conventional posterior approach by thoracotomy. The emergence of reference centers should make training for this complex surgery possible, and it will probably become a therapeutic standard for cancer treatment, along with other specialities.
This video shows many tips to deal with fissure and pulmonary artery.
JM Baste, C Peillon
Surgical intervention
7 years ago
3782 views
27 likes
0 comments
10:24
Video-assisted thoracic surgery (VATS): right lower lobectomy with complete node clearance using an anterior approach
This video presents the management of a suspicious peripheral pulmonary tumor located in the right lower lobe (RLL), classified cT3N0M0 after preoperative staging (positive PET-scan with positive pathology). This case has been presented in a thoracic oncology multidisciplinary meeting, which validated a first-line surgical treatment by lobectomy and radical mediastinal lymph node resection.
The video demonstrates the videothoracoscopic anterior approach, initially described by McKenna and modified by Hansen. This anterior approach seems easier to reproduce and generally simpler than a videothoracoscopic posterior approach for many reasons: no dissection of the fissure, which is an unpredictable technique depending on the patient, use of a 5cm pleurotomy allowing for an easy access for curved instruments, and a very quick conversion, should it be needed; this last safety measure is fundamental.
Videothoracoscopic surgery is poorly developed in France although it is becoming a standard procedure in some major reference centers in thoracic surgery. This procedure offers many advantages: early rehabilitation linked to lesser postoperative pain, a rapid return to regular daily activities, an earlier onset for any potential adjuvant therapy.
It is important to be familiar with the anterior approach because it presents very different anatomical features as compared with the conventional posterior approach by thoracotomy. The emergence of reference centers should make training for this complex surgery possible, and it will probably become a therapeutic standard for cancer treatment, along with other specialities.
This video shows many tips to deal with fissure and pulmonary artery.
Robotic thymectomy for autoimmune myasthenia gravis
We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.
N Santelmo, S Renaud, J Marescaux
Surgical intervention
7 years ago
1926 views
18 likes
0 comments
12:14
Robotic thymectomy for autoimmune myasthenia gravis
We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.
Endoscopic resection of an endobronchial hamartoma
Invasion of the tracheo-bronchial tree by a malignant pulmonary lesion is the most frequent cause of bronchial obstruction in the adult. However, benign lesions, although rare, may also occur.
Hamartoma is amongst the most frequent benign endobronchial tumors. In many cases, these tumors are amenable to endoscopic treatment (either resection or laser ablation), thus sparing the patient the potential morbidity of a thoracotomy and bronchial or parenchymal resection.
We present a case of bronchoscopic resection of a hamartoma obstructing the left lower lobe bronchus in a 58-year-old patient who had presented with cough and post-obstructive pneumonia.
Key aspects of the procedure include:
- Optimal pre-operative evaluation with flexible bronchoscopy and computed tomography of the chest.
- Close collaboration between the surgical and anesthesia teams who are sharing responsibility for the airway.
- Careful use of energy sources within the airway.
- Adequate precautions in case of an unexpected major endobronchial bleed.
The prognosis of completely resected benign tumors is excellent.
Acknowledgment: we would like to thank Nathalie Leroux RN and Mélodie Leclerc RN for their continued support.
G Rakovich, D Ouellette, G Beauchamp
Surgical intervention
7 years ago
1409 views
12 likes
0 comments
03:33
Endoscopic resection of an endobronchial hamartoma
Invasion of the tracheo-bronchial tree by a malignant pulmonary lesion is the most frequent cause of bronchial obstruction in the adult. However, benign lesions, although rare, may also occur.
Hamartoma is amongst the most frequent benign endobronchial tumors. In many cases, these tumors are amenable to endoscopic treatment (either resection or laser ablation), thus sparing the patient the potential morbidity of a thoracotomy and bronchial or parenchymal resection.
We present a case of bronchoscopic resection of a hamartoma obstructing the left lower lobe bronchus in a 58-year-old patient who had presented with cough and post-obstructive pneumonia.
Key aspects of the procedure include:
- Optimal pre-operative evaluation with flexible bronchoscopy and computed tomography of the chest.
- Close collaboration between the surgical and anesthesia teams who are sharing responsibility for the airway.
- Careful use of energy sources within the airway.
- Adequate precautions in case of an unexpected major endobronchial bleed.
The prognosis of completely resected benign tumors is excellent.
Acknowledgment: we would like to thank Nathalie Leroux RN and Mélodie Leclerc RN for their continued support.
Completely thoracoscopic segmentectomy: apical segment, right upper lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. In patients with compromised lung function, anatomic segmentectomy may be an acceptable alternative to lobectomy. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with disturbed respiratory mechanics in the postoperative period, as well as chronic postoperative pain which may become incapacitating in 5% of patients.
One of the major potential advantages of thoracoscopic approaches is decreasing the incidence of post-thoracotomy pain.
Key aspects of thoracoscopic segmentectomy include:
Proper patient positioning.
Access to the pleural cavity and appropriate positioning of operating incisions.
Careful dissection of segmental branches of the pulmonary artery and bronchus.
Division of blood vessels and bronchus using endoscopic staplers.
Division of lung parenchyma along intersegmental planes.

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

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

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

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

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

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

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

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

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

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

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

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

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
9 years ago
2269 views
14 likes
0 comments
07:01
Thoracoscopic left superior segmentectomy for primary lung adenocarcinoma
This 59-old male patient, smoker, has a previous history of thymoma that was operated upon 15 years ago by sternotomy. He presented with a large nodule in the superior segment of the left lower lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma TTF1+. 18-FDG scintigraphy showed a significant and isolated fixation. Because of the impaired respiratory function, a limited resection was decided upon, i.e, a resection of the superior segment of the left lower lobe with radical lymph node dissection.

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

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
9 years ago
3134 views
17 likes
0 comments
09:36
Endoscopic mediastinal lymph node dissection for stage I lung carcinoma
In this video, we will focus on mediastinal lymph node dissection as defined by the American College of Surgeons Oncology Group, i.e.: for right-sided tumors: removal of all lymphatic tissue bounded by the right upper bronchus, the right subclavian artery, the superior vena cava and the trachea (stations 2R and 4R); for left-sided tumors: removal of all lymphatic tissue bounded by the phrenic nerve, the vagus nerve and the top of the aortic arch (stations 5 and 6); and for both sides, removal of lymph nodes from stations 7, 8, 9, 10 and 11.
A perfect vision is necessary during mediastinal lymph node dissection. An oblique viewing 30 degree scope or a deflectable thoracoscope is almost essential to avoid the drawbacks linked to tangential vision, as it frequently occurs with a low inserted scope.
During open or video-assisted lymphadenectomy, it is usual to control small vessels by a combination of clipping and transection. This is time-consuming and it can be replaced by either bipolar cautery or ultrasonic shears or a vessel-sealing device, which both allow coagulating and transecting with a single tool.

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

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
10 years ago
1847 views
25 likes
0 comments
04:14
Totally endoscopic right basilar segmentectomy for stage I lung carcinoma
Pulmonary segmentectomy was originally introduced nearly 70 years ago for the treatment of benign lung conditions. Later, Jensik and colleagues as well as Peters independently suggested that anatomic pulmonary segmentectomy could be effectively applied to small primary lung cancers when good margins were achievable. Today, this is possible thanks to recognition of early lung cancer by high-resolution computed tomography scan. Futhermore, lung-sparing procedures are advocated in those with small, early-stage primary lung cancers so that additional resections for bilateral synchronous or metachronous primaries are facilitated.
Several advantages to endoscopic procedures relative to open procedures have been identified and include decreased postoperative pain, shortened chest tube duration and length of stay, faster return to preoperative activity levels, preserved pulmonary function, and decreased inflammatory response.
This video demonstrates the main steps of a totally endoscopic right basilar segmentectomy for stage I lung carcinoma.

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

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
10 years ago
1566 views
22 likes
0 comments
06:08
Totally endoscopic right apico-posterior segmentectomy for stage I lung carcinoma
This is the case of a 56-year-old male patient presenting with stage I (cT1N0) adenocarcinoma of the posterior segment of the right upper pulmonary lobe.
In this case, we will perform a totally endoscopic segmentectomy, namely only video display and endoscopic instrumentation without utility incision. A 3cm incision is made at completion of the segmentectomy by enlarging one of the ports for specimen extraction.
In this video, only the main steps of the pulmonary resection will be demonstrated. The lymphadenectomy will be shown in another video.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
Full thoracoscopic lingulectomy
This video illustrates the case of a 54-year-old female patient presenting with a 2cm tumor of the lingula. Percutaneous biopsy under CT-scan guidance revealed a carcinoid tumor. Imaging and DOPA PET scan did not demonstrate any other localization of the disease.

The patient was treated with a lingulectomy and lymphadenectomy performed via a totally endoscopic approach. The specimen was retrieved through one of the port that was enlarged at the end of the procedure. She was discharged 4 days later. Pathological examination confirmed the carcinoid tumor. All 18 removed lymph nodes were benign.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
11 years ago
542 views
21 likes
0 comments
05:14
Full thoracoscopic lingulectomy
This video illustrates the case of a 54-year-old female patient presenting with a 2cm tumor of the lingula. Percutaneous biopsy under CT-scan guidance revealed a carcinoid tumor. Imaging and DOPA PET scan did not demonstrate any other localization of the disease.

The patient was treated with a lingulectomy and lymphadenectomy performed via a totally endoscopic approach. The specimen was retrieved through one of the port that was enlarged at the end of the procedure. She was discharged 4 days later. Pathological examination confirmed the carcinoid tumor. All 18 removed lymph nodes were benign.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
Thoracoscopic approach to pericardial effusions
The description of the Thoracoscopic approach to pericardial effusions covers all aspects of the surgical procedure used for the management of (description de la pathologie en cause).
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: Introduction, Anatomy, Indications, Preop period, Operating room set-up, Trocar placement, Instruments, Access/pericardium, Puncture/pericardium, Pericardial opening, Pericardial exploration, Drainage, Complications, Postop period, Reference.
Consequently, this operating technique is well standardized for the management of this condition.
D Gossot
Operative technique
17 years ago
1614 views
51 likes
0 comments
Thoracoscopic approach to pericardial effusions
The description of the Thoracoscopic approach to pericardial effusions covers all aspects of the surgical procedure used for the management of (description de la pathologie en cause).
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: Introduction, Anatomy, Indications, Preop period, Operating room set-up, Trocar placement, Instruments, Access/pericardium, Puncture/pericardium, Pericardial opening, Pericardial exploration, Drainage, Complications, Postop period, Reference.
Consequently, this operating technique is well standardized for the management of this condition.