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Incidental finding of a voluminous bronchogenic cyst in a 13-year-old child
This rare case of a giant bronchogenic cyst in the lower right hemithorax allows to provide the following tips: patient positioning and port placement should allow for a 180-degree reversal of the screen and free movement of the surgical team; use of a LigaSure™ vessel-sealing device used as a dissection instrument in lung surgery is helpful but does not guarantee perfect aerostasis, which should be controlled by taking enough time at the end of the procedure when reventilating an excluded lobe intraoperatively; along with low intrathoracic carbon dioxide insufflation, the use of a blocker in pediatric thoracoscopic surgery is an unconditional factor, which contributes to a satisfactory operating field.
F Becmeur, L Donato
Surgical intervention
1 year ago
843 views
0 likes
0 comments
05:31
Incidental finding of a voluminous bronchogenic cyst in a 13-year-old child
This rare case of a giant bronchogenic cyst in the lower right hemithorax allows to provide the following tips: patient positioning and port placement should allow for a 180-degree reversal of the screen and free movement of the surgical team; use of a LigaSure™ vessel-sealing device used as a dissection instrument in lung surgery is helpful but does not guarantee perfect aerostasis, which should be controlled by taking enough time at the end of the procedure when reventilating an excluded lobe intraoperatively; along with low intrathoracic carbon dioxide insufflation, the use of a blocker in pediatric thoracoscopic surgery is an unconditional factor, which contributes to a satisfactory operating field.
Thoracoscopic treatment of pulmonary hydatid cyst in children
Introduction: The hydatid cyst is an anthropozoonosis caused by the development of the Echinococcus granulosus tapeworm larva in humans. It is endemic in the Mediterranean, South America, Middle East, Australia, New Zealand, and India. Lung localization is ranked second in order of frequency for all age groups after liver localization.
Treatment is mainly surgical and consists in the resection of the protruding dome after cyst puncture, suction, and sterilization using a Scolicide solution followed by proligerous membrane extraction and bronchial fistulas obstruction. This surgery can be performed through a thoracotomy or a thoracoscopy.
We report the highlights of a thoracoscopic surgical management of a bilateral pulmonary hydatid cyst in a 6-year-old boy. The cyst was discovered following exploration for chest pain associated with a dry cough, as demonstrated by chest CT-scan findings and confirmed by serum chemistries positive for pulmonary hydatid cyst.
Materials and methods: The patient was first operated on for his two hydatid cysts of the right lung, followed by another left-side intervention a month later. Intubation was selective and was performed with a standard intubation cannula.
The patient was placed in a strict lateral decubitus position.
Four ports (10, 5, 5, and 5mm in size) were used for the right lung and three ports (10, 5, and 5mm) were used for the left lung, making sure to respect the rule of triangulation.
After partial filling of the pleural cavity with a 10% hypertonic saline solution, the surgical principles of the thoracoscopic treatment of pulmonary hydatid cysts are performed as follows: puncture of the cyst at its dome using a Veress needle, suction, and sterilization with a 10% hypertonic saline solution for 15 minutes; resection of the protruding dome; extraction of the proligerous membrane through an Endobag®; closure of bronchial fistulas by means of intracorporeal stitches; no padding necessary; double chest drainage (anterior and posterior).
Results: Immediate postoperative outcomes were uneventful. Paracetamol was sufficient to manage postoperative pain in the first 24 hours. Chest drains were removed on postoperative day 3, and the patient was discharged on postoperative day 4.
After 5 years, late postoperative outcomes were extremely favorable clinically, radiologically, and cosmetically speaking.
Conclusion: The thoracoscopic approach to the management of pulmonary hydatid cysts is feasible. It completely changed the postoperative evolution of thoracotomy, which causes pain and parietal sequelae in children.
AM Benaired
Surgical intervention
1 year ago
1172 views
142 likes
0 comments
04:03
Thoracoscopic treatment of pulmonary hydatid cyst in children
Introduction: The hydatid cyst is an anthropozoonosis caused by the development of the Echinococcus granulosus tapeworm larva in humans. It is endemic in the Mediterranean, South America, Middle East, Australia, New Zealand, and India. Lung localization is ranked second in order of frequency for all age groups after liver localization.
Treatment is mainly surgical and consists in the resection of the protruding dome after cyst puncture, suction, and sterilization using a Scolicide solution followed by proligerous membrane extraction and bronchial fistulas obstruction. This surgery can be performed through a thoracotomy or a thoracoscopy.
We report the highlights of a thoracoscopic surgical management of a bilateral pulmonary hydatid cyst in a 6-year-old boy. The cyst was discovered following exploration for chest pain associated with a dry cough, as demonstrated by chest CT-scan findings and confirmed by serum chemistries positive for pulmonary hydatid cyst.
Materials and methods: The patient was first operated on for his two hydatid cysts of the right lung, followed by another left-side intervention a month later. Intubation was selective and was performed with a standard intubation cannula.
The patient was placed in a strict lateral decubitus position.
Four ports (10, 5, 5, and 5mm in size) were used for the right lung and three ports (10, 5, and 5mm) were used for the left lung, making sure to respect the rule of triangulation.
After partial filling of the pleural cavity with a 10% hypertonic saline solution, the surgical principles of the thoracoscopic treatment of pulmonary hydatid cysts are performed as follows: puncture of the cyst at its dome using a Veress needle, suction, and sterilization with a 10% hypertonic saline solution for 15 minutes; resection of the protruding dome; extraction of the proligerous membrane through an Endobag®; closure of bronchial fistulas by means of intracorporeal stitches; no padding necessary; double chest drainage (anterior and posterior).
Results: Immediate postoperative outcomes were uneventful. Paracetamol was sufficient to manage postoperative pain in the first 24 hours. Chest drains were removed on postoperative day 3, and the patient was discharged on postoperative day 4.
After 5 years, late postoperative outcomes were extremely favorable clinically, radiologically, and cosmetically speaking.
Conclusion: The thoracoscopic approach to the management of pulmonary hydatid cysts is feasible. It completely changed the postoperative evolution of thoracotomy, which causes pain and parietal sequelae in children.
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
1184 views
88 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
761 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.
Laparoscopic management of a pediatric bronchogenic cyst in a 6-year-old boy
We report the case of a 6-year-old boy who presented with an infectious bronchopulmonary episode during which a plain anterior chest X-ray was performed. The X-ray showed an opacity at the right apex. A thoracic CT-scan allowed to demonstrate the presence of a right superior and posterior mediastinal cystic structure, which could be either a non-communicating cystic duplication of the esophagus, or a bronchogenic cyst.
The 3D CT-scan image modeling analysis allowed the surgeon to become familiar with a benign superior mediastinal cystic tumor including its surrounding anatomical structures. The tumor was immediately found above the arch of the azygos vein laterally to the superior vena cava and to the right phrenic nerve, and anteriorly to the right vagus nerve.
The resection was performed thoracoscopically, without any difficulty after a small opening of the mediastinal pleura in order to provide direct access to the paramedian cyst.
Pathological findings demonstrated the presence of a bronchogenic cyst without any communication with the airway tree or the esophagus. Postoperative outcomes were uneventful and the patient was rapidly discharged from hospital.
F Becmeur, C Boff
Surgical intervention
3 years ago
837 views
43 likes
0 comments
04:49
Laparoscopic management of a pediatric bronchogenic cyst in a 6-year-old boy
We report the case of a 6-year-old boy who presented with an infectious bronchopulmonary episode during which a plain anterior chest X-ray was performed. The X-ray showed an opacity at the right apex. A thoracic CT-scan allowed to demonstrate the presence of a right superior and posterior mediastinal cystic structure, which could be either a non-communicating cystic duplication of the esophagus, or a bronchogenic cyst.
The 3D CT-scan image modeling analysis allowed the surgeon to become familiar with a benign superior mediastinal cystic tumor including its surrounding anatomical structures. The tumor was immediately found above the arch of the azygos vein laterally to the superior vena cava and to the right phrenic nerve, and anteriorly to the right vagus nerve.
The resection was performed thoracoscopically, without any difficulty after a small opening of the mediastinal pleura in order to provide direct access to the paramedian cyst.
Pathological findings demonstrated the presence of a bronchogenic cyst without any communication with the airway tree or the esophagus. Postoperative outcomes were uneventful and the patient was rapidly discharged from hospital.
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
852 views
41 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
3 years ago
1185 views
41 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
3 years ago
442 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
3 years ago
1054 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.
Hybrid lung malformation with intralobar pulmonary sequestration and congenital cystic adenomatoid malformation (CCAM): thoracoscopic left lower lobectomy (LLL)
This is the case of an infant presenting with a hybrid left lower lung malformation with intralobar pulmonary sequestration and congenital cystic adenomatoid malformation (CCAM).
The systemic arterial vascularization of the sequestration originated from the thoracic aorta. The infant was 8 months old when the thoracoscopic procedure was performed. Prenatal diagnosis helped to identify the uncomplicated lung malformation. A CT-scan was performed when the patient was 6 months old before surgery was scheduled. The surgical intervention, a left lower lobectomy, was immediately preceded by a bronchial endoscopy in order to control the anatomy, the good health of the airway tree, and to place a blocker in the left main bronchus. The first operative step consisted in a ligation-division of the systemic artery as close to the diaphragm as possible. The second operative step consisted in a conventional left lower lobectomy with primary treatment of pulmonary arteries, veins, and bronchi.
F Becmeur, A Schneider, I Lacreuse
Surgical intervention
4 years ago
1274 views
55 likes
0 comments
06:25
Hybrid lung malformation with intralobar pulmonary sequestration and congenital cystic adenomatoid malformation (CCAM): thoracoscopic left lower lobectomy (LLL)
This is the case of an infant presenting with a hybrid left lower lung malformation with intralobar pulmonary sequestration and congenital cystic adenomatoid malformation (CCAM).
The systemic arterial vascularization of the sequestration originated from the thoracic aorta. The infant was 8 months old when the thoracoscopic procedure was performed. Prenatal diagnosis helped to identify the uncomplicated lung malformation. A CT-scan was performed when the patient was 6 months old before surgery was scheduled. The surgical intervention, a left lower lobectomy, was immediately preceded by a bronchial endoscopy in order to control the anatomy, the good health of the airway tree, and to place a blocker in the left main bronchus. The first operative step consisted in a ligation-division of the systemic artery as close to the diaphragm as possible. The second operative step consisted in a conventional left lower lobectomy with primary treatment of pulmonary arteries, veins, and bronchi.
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
981 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
984 views
13 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.
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
1008 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
1137 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.
Complex left upper lobectomy with lymphadenectomy by robotic assisted thoracoscopy (CPRL-3) for cT2N2 non-small-cell lung carcinoma (NSCLC)
This video demonstrates a left upper lobectomy for the management of a proximal cT2N2M0 lung tumor. It is usually considered a contraindication of minimally invasive surgery. Our aim is to show the feasibility and the safety of the procedure. Robotic surgery will allow for more minimally invasive indications.
The tumor lies proximally to the left trunk of the pulmonary artery which could be a contraindication to a minimally invasive surgery. A CT-scan combined with a 3D reconstruction helps to rule out the existence of pulmonary artery invasion. Hilar adenopathies as well as adenopathies of the aortopulmonary window present a hypermetabolism on PET-scan. No neoadjuvant chemotherapy is performed since a R0 surgery is potentially feasible immediately and can be associated with a full lymphadenectomy.
This video presents our technique of robotically assisted left upper lobectomy combined with a lymph node dissection. We have attempted to standardize our lung resection technique using 6 areas of dissection to gain in efficacy and save time. The first operative step is to free the triangular ligament and to sample potential lymph nodes (station No. 9). A hilar lymphadenectomy (lymph node station No. 10) is then performed using a posterior approach first followed by a subcarinal approach (lymph node #7, by skeletonizing the pulmonary artery and the left main bronchus. The third step of the procedure is to dissect the fissure to skeletonize the pulmonary artery and its lingular branches as well as branches of the posterior fissure, dissection of lymph node stations No. 11 is performed simultaneously. The elements of the hilum are then approached using an anterior approach. The superior pulmonary vein is dissected. The roof of the hilum is then freed. The left upper bronchus is divided last. Dissection of lymph node station No. 5 completes the procedure with preservation of the left recurrent nerve
Abbreviation:
CPRL-3: complete portal robotic lobectomy using 3 arms
J Cahais, JM Baste, C Peillon
Surgical intervention
4 years ago
764 views
18 likes
0 comments
11:07
Complex left upper lobectomy with lymphadenectomy by robotic assisted thoracoscopy (CPRL-3) for cT2N2 non-small-cell lung carcinoma (NSCLC)
This video demonstrates a left upper lobectomy for the management of a proximal cT2N2M0 lung tumor. It is usually considered a contraindication of minimally invasive surgery. Our aim is to show the feasibility and the safety of the procedure. Robotic surgery will allow for more minimally invasive indications.
The tumor lies proximally to the left trunk of the pulmonary artery which could be a contraindication to a minimally invasive surgery. A CT-scan combined with a 3D reconstruction helps to rule out the existence of pulmonary artery invasion. Hilar adenopathies as well as adenopathies of the aortopulmonary window present a hypermetabolism on PET-scan. No neoadjuvant chemotherapy is performed since a R0 surgery is potentially feasible immediately and can be associated with a full lymphadenectomy.
This video presents our technique of robotically assisted left upper lobectomy combined with a lymph node dissection. We have attempted to standardize our lung resection technique using 6 areas of dissection to gain in efficacy and save time. The first operative step is to free the triangular ligament and to sample potential lymph nodes (station No. 9). A hilar lymphadenectomy (lymph node station No. 10) is then performed using a posterior approach first followed by a subcarinal approach (lymph node #7, by skeletonizing the pulmonary artery and the left main bronchus. The third step of the procedure is to dissect the fissure to skeletonize the pulmonary artery and its lingular branches as well as branches of the posterior fissure, dissection of lymph node stations No. 11 is performed simultaneously. The elements of the hilum are then approached using an anterior approach. The superior pulmonary vein is dissected. The roof of the hilum is then freed. The left upper bronchus is divided last. Dissection of lymph node station No. 5 completes the procedure with preservation of the left recurrent nerve
Abbreviation:
CPRL-3: complete portal robotic lobectomy using 3 arms
Video-assisted thoracoscopic (VATS) lobectomy: left lower lobe
Standard treatment of early-stage non-small cell lung cancer (NSCLC) 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 the following:
- 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 performed with lower morbidity and an equivalent or better oncologic outcome to traditional open surgery. We present a VATS lobectomy for a carcinoid tumor of the left lower lobe in a 42-year-old patient. The video lays emphasis on the steps of lobe resection; mediastinal lymph node dissection was performed but is not shown.
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens for their continued support.
G Rakovich
Surgical intervention
4 years ago
850 views
85 likes
0 comments
08:05
Video-assisted thoracoscopic (VATS) lobectomy: left lower lobe
Standard treatment of early-stage non-small cell lung cancer (NSCLC) 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 the following:
- 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 performed with lower morbidity and an equivalent or better oncologic outcome to traditional open surgery. We present a VATS lobectomy for a carcinoid tumor of the left lower lobe in a 42-year-old patient. The video lays emphasis on the steps of lobe resection; mediastinal lymph node dissection was performed but is not shown.
Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens for their continued support.
Video-assisted thoracoscopic surgery (VATS): Right middle lobectomy and complete mediastinal lymphadenectomy
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is actually preferred over a thoracotomy in experienced centers.
Potential advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital length of stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 63-year-old woman with clinical cT2 cN0 lung adenocarcinoma of the middle lobe. The patient underwent right middle lobectomy with complete mediastinal lymph node dissection using an anterior three-port thoracoscopic approach.
M Gonzalez, T Krueger, JY Perentes
Surgical intervention
4 years ago
1762 views
41 likes
0 comments
10:42
Video-assisted thoracoscopic surgery (VATS): Right middle lobectomy and complete mediastinal lymphadenectomy
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is actually preferred over a thoracotomy in experienced centers.
Potential advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital length of stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 63-year-old woman with clinical cT2 cN0 lung adenocarcinoma of the middle lobe. The patient underwent right middle lobectomy with complete mediastinal lymph node dissection using an anterior three-port thoracoscopic approach.
Thoracoscopic middle lobectomy with sleeve resection for bulky carcinoid tumor
We report the case of a 35-year-old female patient presenting with hemoptysis from a bulky carcinoid tumor of the middle lobe protruding in the truncus intermedius.
A middle lobectomy with sleeve resection was performed, using a full thoracoscopic approach, i.e. without utility incision. Resection margins were free. The final pathologic examination confirmed a typical pT1bN0carcinoid tumor.
The patient was discharged on postoperative day 4, after an uneventful postoperative course.
The main steps of the procedure are described. The slightly hemorrhagic atmosphere of the operation is due to vascular compression from the tumor.
D Gossot, M Grigoroiu, E Brian
Surgical intervention
5 years ago
824 views
13 likes
0 comments
09:22
Thoracoscopic middle lobectomy with sleeve resection for bulky carcinoid tumor
We report the case of a 35-year-old female patient presenting with hemoptysis from a bulky carcinoid tumor of the middle lobe protruding in the truncus intermedius.
A middle lobectomy with sleeve resection was performed, using a full thoracoscopic approach, i.e. without utility incision. Resection margins were free. The final pathologic examination confirmed a typical pT1bN0carcinoid tumor.
The patient was discharged on postoperative day 4, after an uneventful postoperative course.
The main steps of the procedure are described. The slightly hemorrhagic atmosphere of the operation is due to vascular compression from the tumor.
Video-assisted thoracoscopic (VATS) lobectomy: middle 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 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 (Although we favor a fully thoracoscopic technique for all our cases, some centers may use a 4 to 5cm “working incision” near the axilla);
- 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 middle lobe in a 67-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 and Suzanne Desbiens RN for their unfaltering dedication and continued support.
DD Masckauchan, G Rakovich
Surgical intervention
5 years ago
472 views
42 likes
0 comments
08:49
Video-assisted thoracoscopic (VATS) lobectomy: middle 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 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 (Although we favor a fully thoracoscopic technique for all our cases, some centers may use a 4 to 5cm “working incision” near the axilla);
- 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 middle lobe in a 67-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 and Suzanne Desbiens RN for their unfaltering dedication and continued support.