Raffaele J. Marchigiani, M.D., presents a surgical case of a 30 year-old female, who needed a lower lobectomy to remove a relatively large carcinoid tumor.
My name is race market Johnny. I'm a thoracic surgeon. It's entirely hospital. I worked for some terror surgery specialist. Today will be reviewing a case of a 30 year old female with a relatively large left lower lobe. Carcinoid will be going through the case the lower lumpectomy and the details around that case. So here we are in the O. R. Patient is positioned right side down, left chest up in the air. We're looking at where to place a camera port. And here we are putting the camera in the chest. We're observing, looking around. Making sure we don't find anything suspicious in this situation. Everything looks satisfactory. Were able to identify the anatomy the lesion. We then mapped out our additional ports. There's one port anti really which we're currently placing. We use a needle to find the inner space. Using the camera to identify where we want to be anatomically. Once that anti reports place we work on placing a poster report from my assistant to help with retraction. We use basically the same technique using a needle to find the inter space you want to be at Based on anatomy. Now we're placing the posterior report. We specifically use these wound retractors. They help protect the skin and the muscle from additional trauma during the case. Also help maintain some ease of insertion in and out of the chest and pleural space. So here we are rolling it down. Um And now you see us with instruments within the chest cavity where taking a look around moving things around. Making sure there's no surprises. Before we start the actual dissection in the surgery. So again, this is going back to its place in the ports. You can see the Kateri being used to go through the muscle in the pleura and the lung is below. As you can see that. And here we are placing our Kateri again, making sure we have human stasis. And this is that wound retractor we're referring to again, just helps protect the muscle, the skin. And this is again the poster report doing the same idea with just a smaller incision. This is just for retraction and assistance. The front port is not. So these are some adhesions formed by the tumor tumors on the right side. It's hard to see right now, but those adhesions are connecting the upper lobe and the lower lobe together. And that's just from the reaction of the cancer on the right side there you can see kind of that bulbous area that's the tumor within the right lower lobe. Right along that fisher. That fisher is that little canyon in the middle separating the upper lobe from the lower lobe. I'm grasping the upper lobe and pulling it towards the top towards the head and the lower lobes are attracted by my assistant. And here we are dissecting that fisher trying to identify the main structures of the lower lobe. This is some additional anterior fisher we call it. We're doing additional dissection here to open it up below here will begin to find our pulmonary artery which is the blood supply to the lower lobe. This is one of our staples we use. This is going to transact that lung tissue in between the upper and the lower lobe. Although there's very minimal lung tissue there, it still requires to be transacted with a stapler to make sure we do not have any bleeding or any air leaking after surgery. So we do use staples from majority of our operation. As you can see, we're still separating the upper and lower lobes. Were using retraction. With those council balls are basically little sponges. That vessel is called the pulmonary artery. It supplies all the blood to the lower lobe to become oxygenated. Here we are transect in it and again that tumor is being pushed down towards the feet and the upper lobes being pulled up towards the head to separate the two. And as you can see it stapled and cut. And now here we are taking up the lower lobe so the lower lobe is being retracted upwards. And this is at the very bottom of the chest. On the bottom of the screen is the heart. On the right of the screen is the diaphragm. And we were taking up that ligament and now you see us dissecting out the pulmonary vein which was found within that ligament. So again the lower lobe is still being tented upwards. The upper lobe is all the way down to the left of the screen. As we take the additional ligament. You can see the vein coming into view. We're dissecting. Now post eerily the aorta is along the right side of the screen, the hearts along the left side of the screen and the spine is right behind the aorta. We're dissecting up between the lung and the aorta. Now this is that vein we've been dissecting out here, we are trying to get behind it. This allows us to facilitate stapling it. Once we get around it, once we can get around the vein, this is what takes the oxygenated blood from the lung back to the heart. So here we are behind the vein we're now going to place a stapler and the staple will then staple it and then obviously transect it to allow us to facilitate further dissection. Now the stapler when it's done cutting you'll see that we have completed that dissection. Now the next steps of the procedure here as we manipulate the lung is to finish off some of that posterior ligament that we did not finish, there is also likely a small superior vein that we had to take in addition to that beige color vein. So once that's completed we now turn our attention to the fisher. Once again now we're dissecting right along the bronchus. The broncos is what's taking the air into the lower lobe we have to isolate the lower lobe bronchus from the upper lobe bronchus and here we are getting behind it. You can see the transected pulmonary artery towards behind my suction when I put it in. And we're trying to dissect that bronchus away from the pulmonary artery to isolated and then transect it. So here we are doing some more dissection. Ultimately we do finally get around the bronchus and isolated from the remaining distal or posterior fisher. And then we transect the broncos using another staple or a little bit of a thicker stapler. And now eventually we were able to complete that fisher as well as the bronchus. And what's left is a little bit of the separation between the upper lobe and the lower lobe. And what we do is we take the last little bit and use the stapler and transected to completely separate the lower lobe from the upper lobe and now that is a completed left lower lobe ectomy we then put it in a bag to protect again the skin even though we have a wind protector. We use a bag as additional protection. It's removed from the pleural space with the bag and here we are in the back table we're taking a look at the specimen, making sure our margins will clean although we do check them microscopically before we close we're dissecting additional lymph nodes away from the heil. Um You can see my assistant helping me by holding the lung or lobe and then we mark our stitch or we mark the bronchus with the stitch in order for have pathology check our margins. Make sure there's no residual cancer where we stapled from the upper lobe. Here we are just finishing up that back table preparation for pathology. Now we're back in the chest, we're doing our nodal dissection as part of every cancer operation. We do take lymph nodes taken from different stations within the chest. This is one of the ones located in fairly called Level eight and Level nine. We do irrigate make sure we have good homeostasis before closing. We tend to use sterile water gives us a better visualization. Um and technically we like to do that as it causes what we say a popped Asus of any additional cancer cells that could have been spilled, although unlikely in the case of a lumpectomy. The powder we use is for him a stasis as well and then it's irrigated out once again before closing. These are the nerve blocks we perform from the inside and that is the intercostal bundle you're seeing there that blue stripe. We inject the nerves to help with pain control and finally get him a stasis along the chest wall before closing
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