LLL for metastatic Osteosacoma

This video demonstrates a thoracoscopic lobectomy in a young woman for metastatic osteosarcoma. The patient was a 20-year-old who had previously been treated for osteosarcoma in the limb with a limb preservation. She had been disease-free for 4 years when she developed shortness of breath and eventually hemoptysis. CT scan showed a large mass in her left lower lobe. This shows the room set up for the surgery. And 3 ports were used for the procedure initially 35 millimeter ports, with 1 port being increased to a 12 for the stapler. The 5 millimeter Trinity was the main instrument used for the entire procedure. Here you can see, looking into the major fissure, which is relatively complete. However, there is still lung tissue overlying the pulmonary artery. The 5 millimeter cool seal with its fine dissecting tips and dual action. And dual action jaws allows for excellent dissection around these delicate structures. Here you can see the jaws dissecting over the pulmonary artery, which is just below the surface of the lung. By gently dissecting. Just above the artery and creating a space along the incomplete fissure, the sealer can then be used to grasp the tissue, seal, and divide safely without injury to the remaining upper lobe or to the underlying pulmonary vessel. This movement is repeated until the pulmonary artery is completely exposed. The surgeon's left hand is retracting the lung. Downward, thereby gaining better exposure of the major fissure. Again, because of the. Fine dissecting tips of the cool seal and the dual action movement, the surgeon is basically able to operate with one hand while retracting with his other hand. Now that the fissure is basically complete, the tips of the cool seal are used to dissect out the pulmonary artery to the lower lobe. In smaller patients, we will often take this vessel at the segmental level, using the cool seal to seal the vessel and safely divide it. However, in a larger patient, it is often more efficient to find the pulmonary artery to the lower lobe as it crosses through the fissure as we're seeing here. This allows us to get the main trunk above the. Bifurcation to the apical and basal segments. And we can use a vascular stapler to safely take the vessel at this point, saving. A fair amount of time and then they need to dissect into the lung to find the segmental vessels. The surgeon dissects behind the pulmonary artery, feeling the bronchus behind it to allow for safe dissection in this plane. Again, the jaws of the cool seal allow this to be done very safely. With an adequate space created behind the pulmonary artery, the endoGIA vascular stapler can now be inserted. And the Pulmonary artery to the lower lobe divided. Below this, we see the bronchus to the lower lobe. In many cases, we will take this structure next as it presents itself before taking the inferior pulmonary vein. However, in this case, because of the large tumor and the large amount of inflammation in this area, dissection of the bronchus is difficult, and we did not want to injure the vein in dissecting this out. We therefore approached. The inferior pulmonary ligament, which you see here. You can see the tumor just above the jaws of the trinity, and as we take down the inferior pulmonary ligament, we're very careful to dissect, uh, just on the ligament and away from the tumor. The section is carried superiorly until we identify the inferior pulmonary vein. This is hidden in this very thickened tissue and. Great care was taken not to inadvertently injure the vein. Again, the fine tips of the Trinity allow us to do this without hazard or difficulty. Now we can use the tips of the trinity to dissect out the trunk of the inferior pulmonary vein, which is coming into view here. Again, the tissues around it are quite thickened, but we can develop a plane at the superior aspect of the inferior pulmonary vein and also at the inferior aspect which we've now dissected out. Here you can see the trunk dissected out by the Trinity. And now with an adequate space created we are able to insert another load of the vascular stapler and divide the vein without difficulty. This is done a good 1 centimeter away from the pericardium to allow for safe division. Now all that's left is the bronchus to the lower lobe, which is well exposed here now that the vein is divided. We now use a tissue load of the endoscopic stapler to take this structure. With this completed. The lobe is completely free and is now placed in an endoscopic bag and brought out through a wide lower trochar site. The entire procedure was done in 90 minutes through 25 and 112 millimeter trochar. The patient recovered well and was discharged on the second postoperative day. The use of the 5 millimeter Trinity sealer dissector greatly enabled this case and allowed it to be done safely and efficiently.