Video-atlas of thoracoscopic formal lung resections emulating traditional open techniques
Masters of Cardiothoracic Surgery

Video-atlas of thoracoscopic formal lung resections emulating traditional open techniques

Todd L. Demmy

Department of Thoracic Surgery Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA

Corresponding to:
Todd L. Demmy, MD, Chair. Department of Thoracic Surgery, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
Tel: (716) 845-5873; Fax: (716) 845-7692. E-mail: todd.demmy@roswellpark.org.

Editor’s Key Points

  1. VATS lobectomy can be safely performed using the same patient positioning and sequence of steps as for open thoracotomy
  2. Choose endoscopic instruments that you are familiar and comfortable with
  3. Adequate retraction and maximum exposure can be obtained by interchanging the placement of the thoracoscope and other instruments between the 2 ports and the additional access incision
--K.D.

Submitted Mar 10, 2012. Accepted for publication Apr 17, 2012.
DOI: 10.3978/j.issn.2225-319X.2012.04.06

Video 1. Video-atlas of thoracoscopic lobectomy - Left upper lobectomy
Video 2. Video-atlas of thoracoscopic lobectomy - Complex left lower lobectomy
Video 3. Video-atlas of thoracoscopic lobectomy - Right upper lobectomy
Video 4. Video-atlas of thoracoscopic lobectomy - Right middle lobectomy
Video 5. Video-atlas of thoracoscopic lobectomy - Right lower lobectomy

Thoracoscopic lobectomy began 20 years ago as a natural extension from performing less complex VATS operations. During this evolution, the traditional open lobectomy steps have been modified in some centers to accommodate the limitations in available technology, most notably resulting from the constraints in exposure, vantage point, and retraction. As an example, one such modification is to divide the interlobar fissure rather than the bronchus last.

These modified techniques are quite powerful but require training to become accustomed to the different views of the hilar structures. These variations in the standard thoracotomy approach often reflect individual practices and don’t always build on aggregated surgeons’ experiences, and also may be difficult to use when faced with complex and aberrant anatomy.

Given the rising popularity of less invasive surgery, technology has been developed to emulate or even surpass the exposure and retraction options used in traditional open techniques. Specifically, high-definition thoracoscopic cameras with deflectable optics provide excellent exposures. Angled, low profile (5 mm shaft) retractors and other instruments can be used simultaneously through single small incisions to set up the traction and counter-traction forces that uniformly enable safe dissection techniques.

This set of videos demonstrates methods that viewers can use to translate their open operative experiences to a successful minimally invasive practice. Even if the viewer has adopted a different preferred approach, many of the demonstrated techniques (like opening incomplete fissures) will come in handy in the presence of bulky tumors or aberrant vascular anatomy.

Table 1 lists the videos and some of the specific maneuvers of interest. The appendix provides a timed narrative to help locate specific points in the procedure. The viewer is encouraged to view all the videos as some basic elements are emphasized in only 1-2 of the compilations. Furthermore, it may be useful to view some portions of the videos repetitively concentrating first on the live action and then later on the side bar animation. The animation provides important information on which ports are used for the camera vantage point and or tool manipulations. Since the tools are constrained by the ports, full lung mobilization (by dividing adhesions) is essential to move anatomic structures into the proper orientation for viewing and dissection. Retraction techniques (that are often not visible in the video frame) are the hardest elements to teach and the movies attempt to emphasize these using the sidebar animations.

  Table 1 Highlighted maneuvers in each thorascopic lobectomy demonstrated in the video clips
Video   Highlighted Maneuvers
  Left Upper Lobe (Video 1) • Methods for deep nodule wedge
• Division of superior vein and anterior artery
• Optimal retractor usage for vascular exposure
• Division of the anterior and posterior major interlobar fissure
• Division of lingula and remaining artery branches
• Division of the bronchus last
  Complex Left Lower Lobe (Video 2) • Control of vascular adhesions and diffuse oozing
• Opening the fissure to safely divide continuation artery without sacrificing distal origin of lingular artery
• Dissection of central tumor from esophagus.
• Opening of pericardium to divide inferior vein
• Division of bronchus last
  Right Upper Lobe (Video 3) • Division of the upper lobe portion of the superior vein and truncal artery
• Division of the minor fissure
• Division of the posterior major interlobar fissure
• Exposure of the continuation pulmonary artery to safely divide the ascending posterior artery
• Division of the bronchus last
  Right Middle Lobe (Video 4) • Division of the vein then bronchus to expose the middle lobe arteries
• Division of the fissure last
  Right Lower Lobe (Video 5) • Division of the anterior and posterior major interlobar fissure
• Division of the pulmonary artery and vein with optimal stapler angles
• Low profile diaphragm retraction to optimize exposure of the inferior pulmonary ligament
• Division of the bronchus last

Acknowledgements

This video atlas project was funded by a research grant from Covidien. I gratefully thank the Roswell Creative Services Staff, in particular Rolando Rosado and Ben Richey for their tireless efforts in the project.

Disclosures: The author declares no conflict of interest.


  Appendix 1 Narration of operative steps presented in the video clips
  Time Stamp   Left Upper Lobectomy Narration (Video 1)
  00 min 19 sec   This overhead view shows the initial port planning for thoracoscopic left upper lobectomy including the flexible camera port
  00 min 27 sec   A needle defines the optimal position in line with the fissure but as anterior as possible
  00 min 43 sec   Now the same finder needle finds the optimal wide anterior interspace that is useful for dissecting the critical structures of the superior hilum
  00 min 54 sec   Here a 4 cm incision has been made and you can see how the two low profile retractors provide the necessary traction and counter traction enabling the passage of a 5 mm dissection tool to divide adhesions
  01 min 09 sec   It is important to mobilize adhesions and now you can see the spiculated undiagnosed mass in the left upper lobe
  01 min 19 sec   For tumor margins that are only palpable, marking with ink provides visual cues for deep wedge resections
  01 min 24 sec   Also deep wedge resections are facilitated by lung compression clamps as demonstrated here
  01 min 39 sec   An extra thick stapler load device divides this bulky tissue with less risk of bleeding or lung fracture
  02 min 04 sec   Additional compressions are shown here and then the stapler is brought in and applied rapidly after removing the lung compression to allow passage of the stapler without injury by the anvil
  02 min 19 sec   Another advantage of this wedge resection is that there is less tissue remaining to manipulate during the later lobectomy dissection
  02 min 27 sec   As the tissue thins a standard stapler load is used
  02 min 36 sec   Now the specimen is placed into an extraction sac and pulled out through the anterior access port
  02 min 43 sec   While waiting for the pathologic diagnosis it is useful to perform intercostal nerve block at this point or even earlier for its preemptive effect
  03 min 04 sec   Now viewing toward the working port one retractor depresses the diaphragm while a cautery instrument placed in the same port divides the inferior pulmonary ligament to give mobility to the lung for later re-expansion
  03 min 25 sec   Viewing from the medial working port provides better exposure of the anterior and superior hilum
  03 min 32 sec   Again you can appreciate this enhanced view
  03 min 39 sec   Multiple retractors are placed through the former camera port to provide optimal retraction and counter-traction and to tense the pleura to make it easier to divide
  03 min 51 sec   Generally one retractor is placed on the anterior upper lobe and another near the apex to provide this excellent exposure
  04 min 04 sec   The superior vein with its lingular branch is demonstrated nicely here
  04 min 28 sec   The retractors are manipulated to improve exposure and even a portion of the inferior vein can be visualized
  04 min 37 sec   By using a blunt curved clamp it is possible to create a tunnel posterior to the superior vein
  04 min 45 sec   It is safer to dissect closer to the heart where the vein anatomy is more predictable with fewer branch vessels
  04 min 58 sec   For both right and left sided lobectomies it is useful to perform some posterior dissection early as it tends to improve mobility of the hilum
  05 min 09 sec   Here retractors through the access and working ports and the Ligasure™ from the working port open the posterior pleura to expose the ongoing pulmonary artery nicely
  05 min 26 sec   Now with the diagnosis confirmed, a lobectomy is indicated
  05 min 30 sec   A retractor swap is made so that the lung is grasped through the access incision and the curved tip stapler is passed through the former camera port while viewing through the working port to divide the upper lobe vein
  06 min 03 sec   Now the retraction is moved back to the inferior port
  06 min 33 sec   Blunt dissection now exposes the anterior segmental artery as well as to clean some of the posterior pleura not divided from the posterior view
  06 min 50 sec   Here the third retractor safely grasps the distal cut portion of the superior vein to provide additional upward exposure to improve the view of the segmental artery
  07 min 10 sec   A blunt tip clamp surrounds this vessel and another retraction swap is made
  07 min 26 sec   A stapler is again passed through the former camera port to divide the segmental branch
  07 min 53 sec   One can see the bronchus inferior to it
  07 min 59 sec   Now it is useful to divide the rest of the arterial branches and this can be done by using a traditional camera vantage point by providing traction and counter-traction and rotation of the fissure to yield optimal visualization
  08 min 11 sec   Here are the two working port instruments to provide this traction and counter-traction and optimize the visualization of this incomplete fissure
  08 min 28 sec   As this is done one can use a third dissection tool via this anterior working port
  08 min 45 sec   Now the arterial anatomy becomes clearer
  08 min 57 sec   These small fibers can be thinned out by using a small clamp or, in this case, blunt dissection exposes the vessel nicely
  09 min 09 sec   Now with retractors applied posteriorly to pull the lung medially the blunt tip clamp exits the space created by the earlier posterior dissection
  09 min 20 sec   This tunnel is maintained with a silicone loop
  09 min 26 sec   By retracting this loop through the access incision and replacing the stapler through the working port the posterior fissure is divided
  09 min 35 sec   Alternatively a stapler with a catheter leader connected can pass through this tunnel as well
  09 min 43 sec   The long incomplete anterior fissure is easy to divide and greatly improves the lung mobility and hilar exposure
  09 min 56 sec   Access incision retraction and a retractor from the working port beside the stapler make it easier to take multiple safe divisions of that fissure and the artery visible and protected
  10 min 18 sec   As this is done, it is easy to move the lung and hilum more efficiently
  10 min 26 sec   Completing this anterior fissure will be demonstrated momentarily
  10 min 35 sec   With one retractor on each lobe providing opposing retracting forces the residual tissue covering the bronchus is exposed
  10 min 54 sec   Now by pulling the lung anteriorly the basilar artery branch to the lower lobe and the lingular branches to the upper lobe are being exposed
  11 min 32 sec   Now a catheter leader can be placed between these 5 mm retractors and brought out through the access incision
  11 min 54 sec   This leader catheter’s flange will be sufficient to grasp the tip of a standard round tip stapler
  12 min 02 sec   However cutting it and applying it to the curved tip stapler allows it to pass through the tunnel with less resistance
  12 min 13 sec   This is also useful when the flange is one the wrong end of the passage plane
  12 min 24 sec   Here you can see completion of the remaining anterior fissure, which allows excellent exposure of the artery for further maneuvers
  12 min 34 sec   Note how important the lower lobe retractor is to put the artery into perfect orientation for dissection
  12 min 49 sec   Now a large right angle clamp is passed about the bronchus to completely create the space behind and the three lingular branches
  13 min 03 sec   A retraction swap is again performed
  13 min 15 sec   One inferior retractor remains to provide exposure while the curved tip stapler slides through the newly created tunnel
  13 min 43 sec   There remains one additional posterior arterial branch
  13 min 54 sec   Using the same lung retraction method as before pulling inferiorly on the lower lobe and cephalad on the upper lobe through the access incision the stapler passes through the anterior working port to divide this remaining branch
  14 min 16 sec   Excessive upper lobe retraction can create an injury to these small vessels
  14 min 26 sec   The branch is being inspected for hematoma or any other sign of injury
  14 min 40 sec   A Diamond Flex Retractor can pull tissue up and away to allow cleaning of the bronchus
  14 min 49 sec   And then through the same port the thick load stapler is passed to divide the bronchus
  15 min 08 sec   The bronchus continuation to the lower lobe is clearly visible
  15 min 16 sec   A test inflation is demonstrated here insures that the bronchus to the lower lobe is has not been impinged
  15 min 21 sec   Alternatively one can view through a pediatric bronchoscope while doing this maneuver
  15 min 28 sec   Using cooperating instruments the specimen is placed into the extraction sac
  15 min 38 sec   Then to avoid rib injury it is useful to create a lead point through the sac and provide some additional force bluntly from inside to coax the specimen through the 4 cm access incision
  16 min 05 sec   Cooperating instruments and low profile lymph node graspers as shown here dissect the lymph node packet for the AP window region as well as the lymph nodes in the level 10 L and level 8 positions
  16 min 21 sec   Fibrin glue can be applied to any area of concern for later bleeding
  16 min 32 sec   Viewing from the anterior working port it is useful to position the chest tube through the former camera port
  16 min 42 sec   Viewing the stump under water while 20 cm of pressure is applied to the airway and then pulling back insures pneumostasis and reinflation of the remaining lung
  Appendix 2
  Time stamp   Complex left lower lobectomy narration (Video 2)
  00 min 13 sec   Here you can see the working port incision
  00 min 18 sec   The left lower lobe is severely adherent to the posterior chest wall with signs of pleural fluid and active inflammation
  00 min 32 sec   The Ligasure™ is used to separate the adhesions between the left lower lobe and diaphragm as well as the posterior chest wall
  00 min 42 sec   Generally areas of movement such as the diaphragm and aorta have less adherent planes to dissect the overlying tissues away
  00 min 52 sec   Close to the chronic inflammation you can see the oozing from all of these surfaces that will be controlled later by energy devices
  01 min 00 sec   Here the plane between the aorta and the lower lobe is being created bluntly
  01 min 10 sec   The Aquamantys™ bipolar tissue linking device is delivered through the access incision and does a nice job controlling the diffuse oozing typically for these cases
  01 min 28 sec   It is evident that the inflammation extends into the inferior pulmonary ligament
  01 min 34 sec   Both the Ligasure™ and the retractor are placed through the working port
  01 min 39 sec   One tool depresses the diaphragm and the other tool divides the inferior pulmonary ligament extending up to the thickened pleura adjoining the aorta
  01 min 47 sec   This area is also inflamed and hemostatic agents can be placed to promote clotting
  01 min 56 sec   Attention is given to interlobar fissure for dissection to continue without wasting time
  02 min 03 sec   Here a Heart-port™ grasper is used to tent the pleura while standard cautery opens the inflamed tissues to expose the pulmonary artery
  02 min 19 sec   Better views of the pulmonary artery result from completely opening fissures
  02 min 25 sec   Here the landing zone is created with a peanut dissector at the junction of the interlobar fissure and the medial hilum
  02 min 38 sec   The pulmonary artery is shown there and a straight blunt clamp tunnels beneath the fissure posteriorly to terminate in the landing zone
  02 min 56 sec   This allows passage of loop to help hold open the tract and then a curved tip stapler hugs the back of this dissection pathway to complete the anterior portion of the interlobar fissure
  03 min 10 sec   Notice how two retractors both from the anterior working port provide traction and counter traction
  03 min 16 sec   Once done it is now useful to complete the posterior fissure
  03 min 31 sec   Again looking posteriorly between the aorta and the hilum the exit zone is identified and cleaned bluntly
  03 min 41 sec   Then by using a slightly curved blunt clamp through the access incision and gently spreading in the direction of the landing zone it is possible to open the posterior fissure to expose the arterial anatomy safely
  04 min 13 sec   Although not always necessary, loops such as this help to define the tunnel, particularly when using a standard round tip stapler
  04 min 31 sec   Two retractors from the anterior working ports provide traction and counter traction and a peanut blunt tip retractor further defines the arterial anatomy
  04 min 51 sec   A blunt instrument gently separates it away from lymphatic tissue
  04 min 56 sec   A surgical stapler or a 5 mm energy sealing device can then be passed between the two retractor instruments through the same anterior working hole
  05 min 04 sec   Here you can see the curved tip stapler device dividing the remaining posterior fissure to expose the superior segmental artery
  05 min 13 sec   Notice that this artery arises from the continuation pulmonary artery proximal to the lingular artery
  05 min 20 sec   Again using the same maneuver, it is divided with a curved tip stapler to preserve the continuation pulmonary artery down to the origin of the lingular artery
  05 min 43 sec   The base of the artery branches are then dissected bluntly from the surrounding inflamed tissue
  05 min 54 sec   Here a large right angled clamp is shown in accelerated speed demonstrating how multiple small spreads with no more force than the weight of the instrument will help it open that tunnel beneath the vessel
  06 min 08 sec   Then using the supplied silicone extension of the curved tip stapler, the anvil is guided through safely to allow division of this artery, while preserving flow to the lingular segment
  06 min 38 sec   A curved tip extension does not require removal before firing the stapler
  06 min 49 sec   Pulsatile flow into the lingular artery is verified after the oblique firing of this vascular stapler
  06 min 56 sec   Now the lung is transferred to a ring retractor passed through the access incision to allow separation of the inflamed thickened tissues
  07 min 10 sec   If there is any question of aberrant venous drainage, vascular staplers can be used to divide these tissues
  07 min 19 sec   This central lower lobe tumor was adherent to the esophagus
  07 min 24 sec   You can see muscle fibers being thinned out and dissected off of the tumor
  07 min 43 sec   This is a useful Diamond Flex retractor initially developed for laparoscopic liver retraction
  07 min 49 sec   Even larger specimens like this can be controlled with a single instrument provided the dissection has been performed to the point that the diamond flex retractor can be passed around the hilum
  08 min 02 sec   This 5 mm retractor also allows other instruments such as the stapler to pass beside it
  08 min 08 sec   Here you can see the bulky tumor anatomy and its adherence to the esophagus and pericardium that keeps the inferior pulmonary vein within it from being divided at this point
  08 min 21 sec   Lymph nodes, such as the level 8 station are shown
  08 min 27 sec   To open the pericardium, it is grasped at an area where the heart can be seen moving beneath it. Here you can see pericardial fluid egressing and with an endoscopic scissors passed through the access incision further opening into the pericardium is created to allow safe visualization of the inferior pulmonary vein
  08 min 56 sec   In this case it would have been very difficult to divide this vascular structure without entering the pericardium
  09 min 09 sec   Further dissection of the pericardium off of the vein circumferentially is performed
  09 min 14 sec   Here a large right angle clamp can be passed safely around the pulmonary vein and its insertion into the left atrium
  09 min 36 sec   This right angle clamp can deliver a catheter to help guide the curved tip stapler through a tight passage such as demonstrated here
  09 min 47 sec   One advantage of the curved tip anvil extension is that it no longer requires using the whole open flange of such a leader catheter
  10 min 04 sec   The tubing can simply be cut, in this case it is 14 French red rubber tubing
  10 min 11 sec   The catheter can be stretched onto the tip, just like the leader that comes with this product except it has the advantage of being much longer
  10 min 42 sec   Since this stapler is going across thicker atrial tissue, notice that we are using the longer length purple load tri-staple cartridge
  11 min 02 sec   In this view you can see the tumor and its effect on tissues immediately above the stapler
  11 min 22 sec   Now the remaining pericardium and inflamed tissues around the bronchus are divided with an energy device
  11 min 30 sec   The surgeon can help feel for the bronchus within this structure using the suction catheter
  11 min 34 sec   Here you can see a lymph node grasper removing an 11 L lymph node. Additional lymphatics are divided with the Ligasure™ as the main-stem bronchus is being dissected
  11 min 58 sec   The same Diamond Flex retractor provides downward force to lengthen the bronchus so that a black tri-staple load cartridge can be positioned and closed
  12 min 12 sec   Green or black load staplers are useful for thick tissue like the bronchus
  12 min 20 sec   Here the Diamond Flex retractor remains in and provides a convenient way to provide base stabilization of the triangular opening into the extraction sac
  12 min 30 sec   Large specimens such as this are manipulated into the extraction sac using cooperating instruments one through the access incision and one sharing the anterior working port
  12 min 45 sec   The site of the tumor is inspected and here you can see the application of fibrin glue sealant to the area of previous oozing and placement of a chest tube
  Appendix 3
  Time stamp   Right Upper Lobectomy Narration (Video 3)
  00 min 10 sec   This view shows the thoracoscopic appearance of the right upper and middle lobe
  00 min 24 sec   Adhesions are divided using the Ligasuretm
  00 min 35 sec   A right angle clamp dissects the posterior pleura posterior to the right upper lobe bronchus
  00 min 41 sec   Multiple graspers through a single port provide traction and counter traction for optimal viewing
  00 min 51 sec   Now attention is giving to the interlobar fissure which is nearly complete in this patient except for the posterior fissure
  01 min 00 sec   A thoracoscopic DeBakey forceps is used to lift the pleura and incise it
  01 min 07 sec   Later this will be useful to complete division of the minor fissure
  01 min 24 sec   This view shows the phrenic nerve and the superior hilum but by viewing from the anterior port there is a much better view of the middle lobe and upper hilum
  01 min 36 sec   The middle lobe and upper lobe branch of the superior pulmonary vein is shown in this view
  01 min 43 sec   With two retractors holding the lung in optimal orientation a large blunt clamp separates the vein to the upper lobe
  02 min 04 sec   To aid passage of the stapler, an elastic retractor is placed as an optional step
  02 min 10 sec   An important aspect of this technique is swapping retraction from the inferior port to the access incision to allow passage of the stapler
  02 min 20 sec   The inferior port retraction is switched to the access incision to hold the upper lobe and the vein in the proper orientation
  02 min 34 sec   The stapler coming from the inferior port is passed around the vein branch to the upper lobe
  02 min 41 sec   Notice how the stapler has to be articulated and then rotated to allow the anvil to follow the correct course around the vein
  02 min 51 sec   This orientation allows entry behind the vein and now rotation of the stapler allows the anvil to pop out behind and divide the vein
  03 min 00 sec   This gains exposure for the continuation pulmonary artery and the apical trunk artery
  03 min 18 sec   Still viewing from the anterior port, the pleura and the lymph node packet from the superior truncal artery are dissected
  03 min 29 sec   Once the artery is properly dissected the same exchange of instruments is performed with graspers switching from below to the access incision
  03 min 38 sec   Full articulation almost always provides an excellent angle for passing the stapler using the rotational move to allow the anvil to hug the back of the vessel
  03 min 55 sec   The minor fissure is partially divided with a stapler from outside in
  03 min 59 sec   Applying the stapler at the level of the chest wall adds to safety
  04 min 08 sec   Now you can see a blunt clamp dissecting just lateral to the continuation pulmonary artery
  04 min 22 sec   A large blunt right angle clamp manipulated through the access incision traverses all the way through to exit within the fissure where the pleura was dissected earlier
  04 min 40 sec   To facilitate passage of the stapler and completion of the minor fissure a red rubber catheter can hold open the track
  04 min 56 sec   The catheter tip needs to be sutured to another red rubber catheter which will then act as a leader for the stapler anvil
  05 min 12 sec   Once partially through as a leader the anvil is delivered by pushing tissue over top of the red rubber
  05 min 21 sec   To ease passage of subsequent reloads for long incomplete fissures the leader can remain attached provided the stapler is not fired all the way to the tip
  05 min 46 sec   In this case firing the stapler was aborted to further investigate the pulmonary vein drainage that appeared aberrant in this view
  05 min 52 sec   By opening the posterior fissure the venous drainage to the upper lobe can be selectively dissected thereby exposing the ascending posterior pulmonary artery branch
  06 min 19 sec   This is dissected with a large blunt clamp through the access incision while providing both traction and counter traction through the single anterior working port
  06 min 53 sec   The stapler through the access incision is well aligned to divide structures that lie within the incomplete fissure using a 2.5 mm load
  07 min 02 sec   Once the venous anatomy has been confirmed, it is then possible to repeat the earlier steps to complete the minor fissure
  07 min 20 sec   Here the Snowden-Pencer Diamond Flex loop retractor is used to snare the upper lobe to define the remaining bronchus
  07 min 30 sec   The Ligasure™ is used to clean the remaining tissue
  07 min 39 sec   And then through the same port that the retractor holds the lobe, it is possible to pass a 4.8 mm green load stapler to complete the division of the upper lobe bronchus
  07 min 53 sec   After division of the bronchus the upper lobe is removed using a specimen extraction sac as seen on the other videos
  Appendix 4
  Time stamp   Right Upper Lobectomy Narration (Video 4)
  00 min 12 sec   The working port is created anteriorly in line with the interlobar fissure
  00 min 18 sec   Then using a 4 cm access incision similar to that used for upper lobectomies a third interspace opening is created
  00 min 29 sec   Here two retractors show manipulation of the upper and middle lobe
  00 min 36 sec   This is viewed better by inserting retractors in the former camera port to show the tumor in the right middle lobe as indicated here
  00 min 46 sec   These two retractors hold both the upper and middle lobe to put the superior vein on stretch so that the pleura can be resected bluntly off of it
  00 min 55 sec   Here you can see two branch veins to the middle lobe coming into view during the dissection
  01 min 09 sec   After creating a passage behind these two branch veins it is then necessary to pass the stapler from the former camera port to which the retractors are currently residing
  01 min 19 sec   This requires transferring the retraction to a clamp through the access incision
  01 min 31 sec   Then the curved tip vascular stapler hooks behind both of these veins to allow the easier passage of the stapler anvil through the tunnel
  02 min 03 sec   With retractors back through the former camera incision the upper lobe is stretched to put tension on the middle lobe bronchus shown here to facilitate peanut sponge dissection
  02 min 19 sec   Cautery is used to complete part of the interlobar fissure by incising the pleura
  02 min 27 sec   Here a ring clamp extracts the lymph node next to the bronchus to improve the exposure
  02 min 38 sec   As in this case, removing lymphatic tissues frequently improves visualization
  02 min 56 sec   Now with a clear view of the bronchus a large blunt clamp can be placed safely around it
  03 min 05 sec   Depending on the anatomy any of the working incisions can be used to pass the stapler
  03 min 09 sec   In this case, the access incision had adequate angle to divide the bronchus
  03 min 27 sec   This now improves exposure of the remaining vasculature the two branches of the middle lobe artery
  03 min 33 sec   Some of the incomplete fissure is divided to ease passage of the stapler
  03 min 40 sec   Again the retraction swap is being performed and you can see that the tunnel behind these branch arteries is somewhat long and serpentine
  03 min 54 sec   A leader is useful to help guide the stapler through this passage
  03 min 59 sec   Alternatively each branch could be divided individually
  04 min 09 sec   The silicone leader is incorporated into the tip of the stapler thus being able to guide the stapler anvil without needing to dilate the tunnel excessively
  04 min 39 sec   Putting the tissue on proper stretch allows passage of the stapler easily and then this enables division of the two branch pulmonary arteries
  05 min 00 sec   While it would be possible to divide the minor fissure through this view, one can get a better view of the anatomy back through the original camera port
  05 min 13 sec   Here one can see the interlobar boundary - the lobe is now positioned to facilitate dividing the fissure
  05 min 22 sec   Because this tumor extends toward the upper lobe additional lung can be taken in continuity with the middle lobe to provide a better margin
  05 min 32 sec   The stapler is passed through the anterior working port
  05 min 44 sec   The lobe is viewed from this position then flipped over and viewed again from underneath being careful to keep the residual bronchus above the stapler
  05 min 57 sec   Then an additional stapler fire completes the dissection
  06 min 04 sec   As usual a specimen extraction sac is inserted and then the specimen is placed into it and removed through the access incision
  06 min 13 sec   An intercostal nerve block is performed for most of the interspaces
  06 min 20 sec   The right paratracheal space is inspected and dissected for the lymph nodes as well as the subcarinal space as shown
  06 min 28 sec   Finally while viewing through the anterior working port the chest tube is inserted
  06 min 32 sec   Under water it is possible to pass the scope to view the bronchial stump while ventilating with 20 cm of water pressure
  Appendix 5
  Time stamp   Right Upper Lobectomy Narration (Video 5)
  00 min 10 sec   This view shows the entry into the right chest exposing upper, middle, and lower lobes
  00 min 16 sec   The working port should be as medial as possible and optimally in-line with the major fissure
  00 min 21 sec   A 4 cm access incision is made over the continuation pulmonary artery because this is the area of most delicate dissection
  00 min 31 sec   Now with two retractors through the anterior working port and instruments passed through the access incision, the pleura over the interlobar artery is opened
  00 min 46 sec   This shows the anterior surface of the pulmonary artery
  00 min 50 sec   To enable the posterior pleural dissection, the grasper pulls the superior segment of the lower lobe and posterior segment of the right upper lobe towards the sternum
  00 min 58 sec   This makes it easy to open the posterior pleura starting at the right upper lobe bronchus and continuing inferiorly
  01 min 05 sec   This also makes it easier to divide the posterior fissure later
  01 min 21 sec   Once the pulmonary artery has been identified, it is then safe to bluntly dissect immediately posterior to it aiming toward the interlobar fissure termination that was just explored from the posterior view
  01 min 47 sec   With the lung being pulled anteromedially the blunt clamp exits in the correct spot inferior to the right upper lobe bronchus
  01 min 52 sec   This allows passage of a vessel loop to hold open the tract
  02 min 04 sec   With the stapler introduced in the anterior working port and instruments passed through the access incision to retract the lung it is possible to pass the anvil of the stapler through this tunnel
  02 min 32 sec   With the posterior fissure divided, it is then possible to explore this area by further retracting the lower lobe inferiorly, a blunt clamp is introduced into the access incision to create a posterior plane to the continuation pulmonary artery
  02 min 55 sec   The basal segment artery branch is seen beside the bronchus
  02 min 58 sec   A curved Harkin clamp is used to complete the posterior dissection
  03 min 18 sec   The cautery is passed through the access incision to divide tissue behind the artery and then a loop provides additional exposure so that the stapler can be passed behind it safely
  03 min 38 sec   The stapler is articulated inferiorly after passage through the anterior working port
  03 min 48 sec   Rotation guides the stapler anvil behind the artery
  03 min 56 sec   The loop is removed and the stapler is closed
  04 min 08 sec   A small amount of additional fissure posteriorly is divided with the stapler as well
  04 min 24 sec   This leaves only the bronchus and the inferior pulmonary vein
  04 min 28 sec   To expose the inferior pulmonary vein the lower lobe is passed with retractors from the anterior working port to a ring clamp that is passed through the access incision
  04 min 39 sec   Then the anterior working port retractor depresses the diaphragm to give good exposure to the inferior pulmonary ligament
  04 min 46 sec   Through the same port that the retractor is passed a long spatula tip cautery divides the inferior ligament
  04 min 53 sec   Additional posterior pleural attachments are mobilized between the bronchus intermedius and the vein
  05 min 01 sec   Then a large right angle clamp is passed through the access incision and two retractors through the anterior working port provide optimal exposure
  05 min 35 sec   The lung retraction is passed to the instrument through the access incision so that the stapler can be brought in through the anterior working port angulated downward and rotated behind the posterior vessel
  05 min 57 sec   Then the stapler is articulated so it can be pushed toward the left atrium
  06 min 12 sec   Although the same retraction can be done with two instruments through the anterior working port, a single loop retractor for large lobes or large tumors is useful to provide exposure to clean the remaining tissue on the bronchus
  06 min 35 sec   Here you can see that the bronchus to the middle lobe branches somewhat distally and therefore it is important to perform enough distal airway dissection so that the middle lobe bronchus is not impinged
  06 min 56 sec   Now the stapler is passed through the same port through which the loop retractor currently retracts the lung and it is closed temporarily to test inflate the middle lobe
  07 min 16 sec   Next the same loop retractor provides basal stabilization of the bag that was introduced into the access incision
  07 min 23 sec   Then using cooperating instruments, one through the same port that the loop retractor resides and an angled instrument through the access incision the specimen is advanced into the sac
  07 min 36 sec   This view shows the importance of selecting a lead point through the access incision so that the remainder of lobe can follow
  07 min 44 sec   Gentle pushing from inside also is useful
  07 min 56 sec   With the lobe removed, it is easy to dissect off the nodes in the level 8 position as well as continue this superiorly to remove nodes in the subcarinal space
  08 min 04 sec   This is done using a ring clamp through the access incision
  08 min 16 sec   An intercostal nerve block can be performed at any time during the case using a long needle
  08 min 24 sec   Then the chest is filled with water and the camera port is used to place a chest tube
  08 min 36 sec   While viewing through the anterior working port under water it is possible to inspect the bronchus with 20 cm of water pressure
  08 min 43 sec   While withdrawing the camera lung inflation is confirmed
Cite this article as: Demmy TL. Video-atlas of thoracoscopic formal lung resections emulating traditional open techniques. Ann Cardiothorac Surg 2012;1(1):88-99. DOI: 10.3978/j.issn.2225-319X.2012.04.06

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