Thoracic Surgery Atlas

[Fortun Bawa]

Thisbook represents the definitive robotic thoracic surgery atlas, containing didactic material necessary to facilitate effective practice in thoracic surgery and to provide learning tools in these methods both to practicing surgeons and to those in training. It defines the complete operative pathway for each procedure for surgeons who wish to be a complete robotic cardiothoracic surgeon and includes hints and procedural pitfalls derived from the experiences of chapter contributors.

The Atlas of Robotic Thoracic Surgery is illustrated with high quality illustrations and color photographs from surgical operations and contains expert analysis from leading surgeons who provide the key visual features of their chosen topics. Anesthetic and cardiopulmonary support preparation for each operation are included and selected references are provided to emphasize evidence-based outcomes.This book has been designed to augment Atlas of Robotic Cardiac Surgery edited by Ranny Chitwood, both being developed from these same concepts of simplicity and practical instruction. It will therefore be an important resource for all involved in thoracic robotic surgery or interested in learning more about the techniques involved.

Provides new information on ERAS protocol summaries for perioperative care, consensus guidelines for essential steps in minimally invasive lung resection, new surgical approaches to mediastinal abnormalities, increased focus on VATS and robotic operations including uniportal surgery, new methods of treating thoracic outlet syndrome, new approaches to managing malignant ventricular arrhythmias through sympathectomy, more advanced techniques for pleurectomy for mesothelioma, and descriptions of a variety of newer muscle flaps for reconstruction.

An eBook version is included with purchase. The eBook allows you to access all of the text, figures, and references, with the ability to search, customize your content, make notes and highlights, and have content read aloud.

* Elsevier is a leading publisher of health science books and journals, helping to advance medicine by delivering superior education, reference information and decision support tools to doctors, nurses, health practitioners and students. With titles available across a variety of media, we are able to supply the information you need in the most convenient format.

Thoracoscopic lobectomy or segmentectomy via the posterior approach is a safe, reliable and reproducible technique. It was first developed by Mr. William Walker from Edinburgh in 1992. The main advantages of the posterior approach include: (I) easy access to posterior hilum and segmental bronchi; (II) safe dissection, as the tips of the instruments are coming towards the operating surgeon; and (III) complete ipsilateral lymph node clearance.

Video-assisted thoracoscopic surgery (VATS) is a well-established technique for major pulmonary resections (1). Since the first procedure was performed more than 20 years ago, the operative approach and instrumentation have matured. In 2007, CALGB 39802 trial established the most authoritative and accepted definition of the VATS lobectomy technique, i.e., 4-8 cm access incision, totally endoscopic approach, without rib spreading and individual anatomical dissection and division of pulmonary vein, artery and bronchus (2). Compared to open surgery, the minimally invasive approach has a number of benefits especially in the immediate post-operative period (3). A recent meta-analysis of propensity score matched patients demonstrated significantly lower incidences of overall complications, prolonged air leak, pneumonia, atrial arrhythmias and renal failure, as well as shorter hospitalization compared to open thoracotomy (4). This study further consolidated the benefits of VATS and offered the highest clinical evidence on this topic.

The posterior approach was first developed by Mr. William Walker from Edinburgh in April 1992. In contrast to the anterior approach, the main differences in techniques of the posterior approach include: (I) the surgeons stand posterior to the patient; (II) the utility incision is made at the 6th or 7th intercostal space anterior to latissimus dorsi muscle, instead of the 4th intercostal space; (III) the camera port is made through the auscultatory triangle, instead of lower anterior incision; and (IV) the order of dissection is from posterior to anterior, by opening up the fissure first to identify and isolate pulmonary arterial branches. The main advantages of the posterior approach include: (I) easy access to posterior hilum; (II) lymph nodes are clearly visualized; and (III) tips of the instruments are coming towards the camera, which allows safer dissection. The fact that the posterior hilum can be clearly seen greatly facilitates dissection of the segmental bronchial branches and pulmonary arteries. Hence, the posterior approach offers great advantages for VATS segmentectomy.

I have adopted VATS resection as the preferred surgical strategy of choice for all cases of peripheral lung carcinoma of 7 cm or less in diameter and for suitable benign disease. Lobectomy and anatomic segmentectomy are standard procedures. It is possible to utilize VATS techniques in patients with more advanced disease such as moderate chest wall or pericardial involvement and, rarely, for pneumonectomy in patients with low bulk hilar involvement. However, with the trend towards lung conservation strategies, we now reserve pneumonectomy for individuals in whom bronchovascular reconstruction is not feasible.

Baseline pulmonary function is assessed by using a combination of spirometry and CO transfer factors. Additionally, selected patients undergo exercise testing. Cardiological assessment is carried out as relevant to the individual patient. Echocardiography assessment of pulmonary (PA) pressure is undertaken in patients at risk of pulmonary hypertension (PAP >45 mmHg). Few patients are declined surgery on the basis of poor pulmonary function data (e.g., both FEV1 and FVC

I prefer a zero degree 5 mm high definition STORZ video thoracoscope, as it provides a single axis view allowing easy correction of orientation. A combination of endoscopic and standard open surgical instruments is used. Lung retraction and manipulation are performed using ring-type sponge-holding forceps. Long artery dissection forceps (30 cm) with or without mounted pledgets are employed for blunt dissection, which are particularly useful for exposing the PA at the base of the oblique fissure, cleaning structures and clearing node groups. A range of curved forceps and an endodissector are used gently as probes to create a passage between the lung parenchyma and major hilar structures. A right-angled dissector or long curved artery forceps is used to dissect out and pass slings around pulmonary arteries and veins. Endoscopic clips are used to ligate small vessels whilst large vessels and lung parenchyma are divided using endoscopic stapling devices to ensure haemostasis and aerostasis. Both endoscopic shears and specific VATS Metzenbaum type scissors to be helpful. The latter have the advantage of curved blade ends, which reduce the risk of vascular injury.

Three access ports are used and port position is standard irrespective of the lobe or segment to be removed (Figure 2). A 3-4 cm utility port site incision is made in the sixth or seventh intercostal space (whichever is the wider). The camera is temporarily introduced through this port to facilitate safe creation of a 0.5 cm incision posteriorly in the auscultatory triangle at the point nearest to the upper end of the oblique fissure. The anterior hilum dissection is not essential for the posterior approach. However, for completeness of this article, it is important to understand the segmental anatomy of the pulmonary veins viewed from the anterior hilum. The pulmonary veins are the most anterior structures in the hilum (Figure 3). Their tributaries are also anterior to the segmental arteries and bronchi. The interlobar vein often traverses between the upper and lower lobes in the oblique and then the upper and middle lobes in the horizontal fissure before joining the superior pulmonary vein in the hilum. In majority of cases, the middle lobe vein drains into the right superior pulmonary vein.

A port is inserted to accommodate the camera, which is positioned in the auscultatory triagle for the remainder of the procedure. A further 1 cm port is created in the mid-axillary line level with the upper third of the anterior utility port. The anterior and posterior ports lie at opposite ends of the oblique fissure. A video-imaged thoracoscopic assessment is performed to confirm the location of the lesion, establish resectability and exclude unanticipated disease findings that might preclude resection. If the lesion is small or cannot be palpated easily, sound knowledge of segmental anatomy is crucial for determining the location of the lesion within the segment(s) of the respective lobe.

The first step is to identify the PA within the central section of the oblique fissure. In some patients the PA is immediately visible, but in the majority of cases, the PA is revealed by separating the overlying pleura using blunt dissection with mounted pledgets. If the fissure does not open easily or is fused, an alternative approach utilizing a fissure-last dissection should be considered. Once the PA has been identified, the sheath of the artery is grasped with a fine vascular clamp or long artery forceps and an endoscopic dissector is used to enter the sheath defining the anterior and posterior margins of the artery. The apical lower branch of the PA is often exposed during this dissection (Figure 4).

Having divided the posterior fissure, the posterior ascending segmental branch of the PA is often evident, and should be divided at this stage if appropriate. It is frequently small enough to clip. The upper lobe bronchus is then identified and dissected out. It is common to find a substantial bronchial artery running alongside the bronchus, which should be ligated with clips and divided. Note that clips are only used on the proximal end and the distal end is not clipped since clips in this position may interfere with subsequent stapling of the bronchus. The upper lobe is then retracted inferiorly and blunt dissection with mounted pledgets is used to free the cranial border of the upper lobe bronchus and define the apico-anterior trunk. The azygos vein is often closely related to the bronchus and can be pushed away using a gentle sweeping motion. Long artery forceps are passed around the upper lobe bronchus close to its origin in the plane between the bronchus and the associated node packet (Figure 7). It should be appreciated that the apico-anterior trunk lies immediately anterior to the bronchus, but sometimes separated by station 11 right upper lobe lymph nodes. The bronchus is transected at this level using an endoscopic linear stapling device. It is not necessary to inflate the lung to test that the correct bronchus is being divided, as the vision is invariably excellent via the posterior approach and the re-inflated lung may subsequently obscure the view for remainder of the resection.

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