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Thoracoscopic management of empyema
From the mid-1990s, thoracoscopic treatment of empyemas has gained a wide acceptance. Potential advantages of video-assisted thoracoscopic surgery (VATS) include improved visualization, less surgical trauma and improved quality of life. VATS was initially used in early stage empyema to debride purulent collections and resect fibrin septae that failed to resolve with antibiotics and chest tube drainage (with or without fibrinolytic therapy).
The goals of the thoracoscopic treatment of empyema are as follows: 1) the debridement of purulent collections and fibrin, 2) the evacuation of necrotic material, 3) the breakdown of loculations, 4) to obtain adequate lung re-expansion, and 5) optimal chest tube placement for drainage.
Several reports have demonstrated that VATS debridement is a valid treatment option for stage II empyema, which allows an appropriate control of infection and a complete restoration of pulmonary function in early stage empyemas. Formal exclusion criteria for a primary VATS approach are suspicion of lung abscess, bronchopleural fistula, tumor at initial work-up or the need of muscle flaps with or without thoracoplasty. Presumed stage III empyema with pleural thickening and signs of restriction on CT-scan no longer are formal contraindications, but the conversion rate to decortications via thoracotomy is higher.
M Gonzalez, JY Perentes, T Krueger
Surgical intervention
5 years ago
3163 views
105 likes
0 comments
07:09
Thoracoscopic management of empyema
From the mid-1990s, thoracoscopic treatment of empyemas has gained a wide acceptance. Potential advantages of video-assisted thoracoscopic surgery (VATS) include improved visualization, less surgical trauma and improved quality of life. VATS was initially used in early stage empyema to debride purulent collections and resect fibrin septae that failed to resolve with antibiotics and chest tube drainage (with or without fibrinolytic therapy).
The goals of the thoracoscopic treatment of empyema are as follows: 1) the debridement of purulent collections and fibrin, 2) the evacuation of necrotic material, 3) the breakdown of loculations, 4) to obtain adequate lung re-expansion, and 5) optimal chest tube placement for drainage.
Several reports have demonstrated that VATS debridement is a valid treatment option for stage II empyema, which allows an appropriate control of infection and a complete restoration of pulmonary function in early stage empyemas. Formal exclusion criteria for a primary VATS approach are suspicion of lung abscess, bronchopleural fistula, tumor at initial work-up or the need of muscle flaps with or without thoracoplasty. Presumed stage III empyema with pleural thickening and signs of restriction on CT-scan no longer are formal contraindications, but the conversion rate to decortications via thoracotomy is higher.
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
1264 views
18 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.
Video-assisted thoracic surgery (VATS): middle lower bilobectomy with lymph nodes dissection for carcinoid tumor
Objective
Carcinoid tumors represent less than 5% of the bronchopulmonary cancers [1], but often concern young people. A lung-sparing anatomical resection is often preferred if possible [2]. However, an uneasy intrabronchial localization mandates a major resection such as bilobectomy and/or sometimes pneumonectomy for complete resection as it is the aim of carcinoid tumor treatment. This can be achieved using a minimally invasive approach [3, 4].
Case presentation
This is the case of a 34-year-old woman suffering from recurrent right pneumopathy, without any other medical history. A mass in the middle lobe bronchus with partial obstruction of the intermedius bronchus was found on CT-scan. Bronchoscopy found the extension of a strawberry-like tumor until segment 6 bronchus. Histopathology confirmed the presence of a carcinoid tumor. A radical excision with middle lower bilobectomy by VATS was decided upon rather than middle lobe sleeve lobectomy in order to ensure complete resection.
Results
There was no postoperative complication and the patient was discharged on postoperative day 5. The operative specimen contained the tumor. Vascular and bronchial resections were free. Histopathology confirmed a typical pT1N0 carcinoid tumor.
Conclusion
Complete middle lower bilobectomy can be performed using a VATS approach. This therapeutic option seems worthwhile in young people because of low postoperative morbidity and fast recovery for active people.

Bibliographic references
1. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119:1647-51.
2. Schrevens L, Vansteenkiste J, Deneffe G, De Leyn P, Verbeken E, Vandenberghe T, Demedts M. Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience. Lung Cancer 2004;43:39-45.
3. Hansen HJ, Petersen RH, Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Lung Cancer 2011;71,25(4):1263-9.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothoracic Surg 2003;23:397-402.
JM Baste, P Rinieri, A Sebestyen
Surgical intervention
5 years ago
1266 views
20 likes
0 comments
07:26
Video-assisted thoracic surgery (VATS): middle lower bilobectomy with lymph nodes dissection for carcinoid tumor
Objective
Carcinoid tumors represent less than 5% of the bronchopulmonary cancers [1], but often concern young people. A lung-sparing anatomical resection is often preferred if possible [2]. However, an uneasy intrabronchial localization mandates a major resection such as bilobectomy and/or sometimes pneumonectomy for complete resection as it is the aim of carcinoid tumor treatment. This can be achieved using a minimally invasive approach [3, 4].
Case presentation
This is the case of a 34-year-old woman suffering from recurrent right pneumopathy, without any other medical history. A mass in the middle lobe bronchus with partial obstruction of the intermedius bronchus was found on CT-scan. Bronchoscopy found the extension of a strawberry-like tumor until segment 6 bronchus. Histopathology confirmed the presence of a carcinoid tumor. A radical excision with middle lower bilobectomy by VATS was decided upon rather than middle lobe sleeve lobectomy in order to ensure complete resection.
Results
There was no postoperative complication and the patient was discharged on postoperative day 5. The operative specimen contained the tumor. Vascular and bronchial resections were free. Histopathology confirmed a typical pT1N0 carcinoid tumor.
Conclusion
Complete middle lower bilobectomy can be performed using a VATS approach. This therapeutic option seems worthwhile in young people because of low postoperative morbidity and fast recovery for active people.

Bibliographic references
1. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119:1647-51.
2. Schrevens L, Vansteenkiste J, Deneffe G, De Leyn P, Verbeken E, Vandenberghe T, Demedts M. Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience. Lung Cancer 2004;43:39-45.
3. Hansen HJ, Petersen RH, Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Lung Cancer 2011;71,25(4):1263-9.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothoracic Surg 2003;23:397-402.
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
1123 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.
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
3806 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.
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
1897 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.
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
7 years ago
3428 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.
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
644 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
769 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
958 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.
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
3141 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
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
2276 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
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
1852 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
1568 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
548 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
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
845 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.
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
S Perretta, B Dallemagne, J Marescaux
Surgical intervention
6 years ago
3418 views
36 likes
0 comments
09:11
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
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
1632 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.