Thoracoscopic Right Upper Lobectomy in a 3-Month-Old with Incomplete Fissures

This video demonstrates a thoracoscopic right upper lobectomy in a 3 month old with a type 2 CPAP with significantly incomplete fissures. Here you see the room set up. The patient is in a left lateral decubitus position, and the surgeon and the assistant are standing at the patient's front. Monitors are placed posteriorly for the best view. The trochar position is used to maximize dissection from the anterior chest wall. Here you can see the trochars in place. The scope is placed in approximately the 5th intercostal space just posterior to the mid-axillary line. The right and left operating ports are placed above and below this in the anterior axillary line. Initially, a 4 millimeter trocar is used for the scope, and 23 millimeter ports are used for the right and left hand operating port. The 3 millimeter vessel sealer is used as the primary mode of dissection for the entire procedure. Here you can see the right hand operating port going in in approximately the 3rd intercostal space up in the axilla. You can see the hyperinflated, all right. Apical segment of the lower lobe. The section is started at the top where the pulmonary artery transverses below the upper lobe and branches go into the upper lobe. This helps to devascularize the upper lobe and decrease. Congestion within the lobe during the rest of the deception. The pleura overlying branches to the anterior. Through the apical segment. Are individually isolated, sealed proximally and distally with at least. 3 to 4 millimeters between the seals and then divided. This technique provides the safest way to approach the pulmonary vasculature. And making two separate seals and then dividing between them. One can be sure that the vessel is adequately sealed before it retracts and bleeding occurs, which could lead to the need to convert to open. You can see the vessel being. Serially divided, ensuring that it is adequately sealed. The other branches of the artery are now better visualized. Again, the subsegmental branches are taken individually. Sealed approximately. And then just going. And divided between them. This technique Allows for an extremely safe deception. And prevents uncontrolled bleeding. Posterior segmental artery branch can now be visualized. If inadequate length of the vessel. I cannot be obtained. But in order to get adequate vascular control, then one should dissect down into the lung. Creating length by divide by dissecting into the quankum. The vessel sealer will take vessels up to 5 millimeters in diameter. Most of these vessels at the subsegmental level in this size child are 2 to 3 millimeters in diameter. This is a relatively fast and efficient way to take the pulmonary vasculature. While ensuring adequate vascular control throughout the procedure. As opposed to the lower lobe where the main trunk can easily be identified as it courses through the fissure. It's often necessary to take the upper lobe vessels at the subsegmental level to ensure there is no injury to vessels transversing. Behind the upper lobe and going to the middle and lower lobe. With the main primary branches of the artery sealed and divided, the bronchus. To the upper lobe becomes. Visible. You can see behind the ceiling. Right main stem bronchus, which will then later divide into the. Upper, middle, and lower lobe. Bronchi. This will become important for. Changing the bronchus later on in the dissection. Now, with the arterial branches taken. The minor fissure is evaluated. Here you can see that the major fissure is complete anteriorly, but the minor fissure is almost non-existent. There is a small cleft posteriorly where the minor fissure adjoins the major fissure. One can see the hyperinflated. Apical and posterior segments of the upper lobe. Secondary to the CPAP. There is a slight cleft at the most anterior portion of the minor fissure, and this is now being sealed and divided. The sealer is an excellent way to go across Long Priama in the area of the fishery when it is incomplete. fissure can be developed in a layer by layer process, sealing and then dividing in the middle of the seal as one works across the fissure. However, because this fissure is so incomplete, further devascularization will be done to try and better delineate this. With the lung retracted superiorly, you're exposing the superior pulmonary vein. Because of the hyperinflated lung, it is difficult to visualize, and so a few moments will be taken to try and compress the upper lobe using the energy device. This works extremely well with large cysts, but even works when the cysts are much smaller. Now the pulmonary vein to the upper lobe can be visualized, and it is sealed and divided in the same fashion. Care must be taken here, however, to ensure that there is no injury to the vein to the middle lobe. Surgeon should. Reorient as often as possible. To have a clear understanding. Of the plane between the upper and middle lobes as he continues to take the pulmonary vasculature. These branches are clearly going to the hyperinflated upper lobe. Approximate seal here did not appear complete and therefore it is being resealed. Again. The area between the two seals is slowly divided to ensure that there's no bleeding and the seals are complete. This process is continued until all subsegmental branches of the vein to the upper lobe are sealed and divided. This point. It appears that all the branches of the pulmonary vein to the upper lobe. Are now taken. However, one residual branch is now seen as the lung is retracted. Upwards exposing it. The last vein to the upper lobe. The vein to the middle of can be. Seen intact and just to the left of this, it is not dissected out. There is usually a clear delineation between the middle lobe vein and the upper lobe veins. But extreme care must be taken to preserve the middle lobe. With the vein to the upper lobe completely divided, it helps differentiate between the upper and middle lobe. Fairly good guess can be made where the fisher. Yes. By using the Ischemic upper lobe. As well as the posterior congenital cleft, which was earlier seen. The sealer is then used to create the fissure. Again, going through the lung in a layer by layer. Fashion. This is very similar to finger fracturing of the liver during a. Segmente Again. Sealer is used to compress the lung. Where it is believed the fissure exists. And then One parenchyma is divided in the center of the seal. Occasionally. A lot of char can build up on the sealer during this type of deception, so it is important to have the scrub tech. Uh, clean the jaws of the instrument when it is removed on a regular basis. You can see that there is minimal bleeding because of the devascularization of the upper lobe. And because the fissure is a relatively avascular plant. We can now see where the anterior portion of the fissure is lining up with the previously seen posterior. Congenital crop Again reorientation showing where the two. Aspects of the mind of Fisher. Begin to come together. And the septum between the anteriorly created fissure and the posterior cleft is now sealed and then divided. This method is not only. Very hemostatic. There is also no. Air leak or significant air leak, uh, postoperatively when using this method. By lifting the lung anteriorly, we can see the last bit of renchyma between the. Middle. And the upper lobe anterior. By taking this, we will get better exposure of the bronchus to the upper lobe. In cases of a complete fissure, this portion of the dissection is much quicker. Rather than taking 10 to 15 minutes requires only a few minutes to. There is usually a branch of the artery coming back up. From the pulmonary artery to the anterior segmental branch. Anterior segmental segment. And that should be sealed and divided as well. And the lung parenchyma overlying the bronchus. In the last arterial branch. I sucked out. And see it. Moves that branch of the artery. Now with that portion of the the section complete. We're near the Harlem. Of the upper lobe. Then flip back anteriorly. And superiorly to re-expose the bronchus which was previously seen. Where you can clearly see the bronchus. And this can now be safely dissected out. In general, we get the upper lobe bronchus past the point of bifurcation. Taking the. Apical and posterior segmental bronchus. Separately from the anterior segmental problem. The lower or left hand port, which is in the larger inner space, is then changed to a 5 millimeter port. And the 5 millimeter endoscopic stapler is inserted. Second application. Is used. To divide the. Segmental bronchus at this level. This done. Tension is then turned back into the dog. Minor Fisher Some residual rink and the Fisher had sealed and divided. And the last segmental bronchus is now dissected out. Staper can also be used to complete the incomplete. Major Fisher Posteriorly. Some residual tissue is then. Provided with a second application of this statement. The upper lobe is now disconnected. From the rest of the lung. Lower 5 millimeter port is then removed. And you can see the. More posterior scope port. And the 5 millimeter port in the anterior exit line is slightly increased in size. To allow for a. Tonsil clamp to be inserted. The lung is removed piecemeal through the incision site. Here you see the hylum of the upper lobe after the specimen is removed. This operation took 1 hour and 35 minutes.