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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
982 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.
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.