Эндоскопическая техника резекции эндобронхиальной обтурирующей злокачественной опухоли

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.

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.

A 62-year-old man had an asymptomatic middle mediastinal tumor with a 4.5cm diameter, opposite to the superior vena cava and the azygos vein in the Barety’s space, which was discovered on thoracic CT-scan performed during an urothelial tumor follow-up.
Past history includes an urothelial carcinoma grade I treated with transurethral cystectomy, an ischemic cardiopathy with a single medical treatment, a prostate hypertrophy, and a sigmoid diverticulosis.
After a multidisciplinary review of the case, a mediastinoscopy was performed. It demonstrated the presence of a thymoma.
The patient was well informed of the operative risks and of the possibility of conversion, but thanks to our experience and national recommendations, we were able to perform a radical robotic assisted thymectomy.
The operation took during 3 hours with less than 100cc of bleeding.
The postoperative course was uneventful and the patient was discharged on postoperative day 3.
Histopathological analysis showed a type AB thymoma according to the OMS 2015 classification. The staging was IIb according to Masaoka. No adjuvant radiotherapy was indicated.

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.

The idea of this lecture originated from the fact that there is very little teaching material which described bronchoscopy as practiced by the thoracic surgeon. Chest physicians (pulmonologists) perform flexible bronchoscopy on a sedated patient, and they get up-side-down views to that obtained by the surgeons. Bronchoscopy at our department is performed under general anaesthesia, usually in the anaesthetic room just before the operation. We introduce a rigid bronchoscope first, and then a flexible fibre optic 5mm bronchoscope through the rigid scope into the trachea. This arrangement enables precise diagnosis due to excellent vision, with the ability to transform the procedure into a therapeutic session, for example, to take large biopsies, and decide to laser a lesion or to put in a central airway stent. Controlled breathing makes it safer to control significant bleeding during the procedure, and it is understandable that chest physicians shy away from biopsying carcinoid tumours.
The video is divided into 6 chapters. Chapter one deals with the identification of the bronchopulmonary segments and a bit of history about the two systems of nomenclature. It describes in a simplified way the effects of the heart growing in the left chest and the results of fusion, rotation and delayed branching of bronchi. Chapter 2 deals with normal bronchoscopy and anatomy of trachea, main bronchi, and segmental bronchi. Chapter 3 deals with abnormalities of the upper airways and trachea. Chapter 4 deals with abnormalities of the right bronchial tree, and chapter 5 deals with abnormalities of the left bronchial tree. The emphasis is on surgical pathology, assessment of airway for resection and decision-making. The viewer is encouraged to take the test on chapter 6 to bolster his/her knowledge of the anatomy of the airways.

1. Objectives:
a. To identify the bronchopulmonary segments in a logical and easy way to recall.
b. To understand the embryological changes resulting from heart growing into left chest.
c. To state what the operator should look for, what is normal and what is abnormal.
d. To help decision-making at operation and in the perioperative period.

2. For whom is this video made:
a. Consultants and trainees in the specialty of cardiothoracic surgery, including paediatric thoracic surgeons.
b. Thoracic and general anaesthetists who are involved with single lung ventilation.
c. Chest physicians who perform bronchoscopy, to understand views and capabilities of flexible over rigid bronchoscopy, and to have a gist of what goes on the mind of a thoracic surgeon when performing bronchoscopy.
d. Intensivists who might perform bronchoscopy via an endotracheal tube for a ventilated patient in the intensive care unit (ICU).
e. Medical students interested in the detailed anatomy of the central airways.

3. What this video is not intended to do:
a. This is not a compendium of abnormalities and pathologies revealed by bronchoscopy.