I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 4 · 1:02
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 4 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 4 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 4 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
▶Ep 4 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 4 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 4 · 10:41
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 4 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 4 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 4 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 4 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 4 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 4 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 4 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 4 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 4 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 4 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 4 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 4 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 4 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 4 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 4 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 4 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 4 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 4 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 4 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 4 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 4 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 4 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 4 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 4 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 4 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 4 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 4 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 4 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 4 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 4 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 4 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 4 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 4 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 4 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 4 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 4 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 4 · 23:06
quoteThe hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
▶Ep 4 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 4 · 23:06
quoteThe hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
▶Ep 4 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
▶Ep 4 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012
▶Ep 7 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 7 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 7 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 7 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 7 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
▶Ep 7 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 8 · 5:43
epidemiological6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear↗
▶Ep 8 · 6:11
epidemiologicalFetal intervention for lung lesions is extremely rare; CHOP performs open fetal surgery less than once every couple of years↗
▶Ep 8 · 7:54
clinicalCyst volume ratio (CVR) greater than 2 has an extremely bad prognosis for fetal lung lesions↗
▶Ep 8 · 9:09
clinicalHybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology↗
▶Ep 8 · 9:48
clinicalIntralobar sequestration shares a common pleura with the lobe, usually the lower lobe↗
▶Ep 8 · 9:52
clinicalExtralobar sequestration has its own pleural lining and is 90% separate from the lobe↗
▶Ep 8 · 10:02
clinicalSequestrations are defined by having a systemic artery coming directly off the aorta↗
▶Ep 8 · 10:14
clinicalSystemic vessels to sequestrations can come off the abdominal aorta and pass through the diaphragm↗
▶Ep 8 · 10:40
clinicalCPAM type 3 lesions are more solid and have the worst prognosis↗
▶Ep 8 · 10:57
quoteI consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about.↗
▶Ep 8 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 8 · 14:50
clinicalChest X-ray alone is not adequate to ensure there is no residual lung lesion after prenatal diagnosis↗
▶Ep 8 · 15:47
epidemiological20-40% of untreated congenital lung lesions will develop significant infection at some point↗
▶Ep 8 · 15:55
quoteI think that, you know, especially with thoracoscopic techniques, the morbidity of, of removing these lesions so that the family and the child never have to worry about it ever again is, is relatively small↗
▶Ep 8 · 16:58
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series↗
▶Ep 8 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 8 · 18:04
opinionOperating by 3 months of age avoids pneumonia or severe respiratory infection before surgery↗
▶Ep 8 · 18:20
opinionSurgery is technically easier in younger infants because vessels are smaller and anatomy is fresh↗
▶Ep 8 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection↗
▶Ep 8 · 18:46
clinicalEven asymptomatic patients often have enlarged lymph nodes and inflammation in fissures by one year of age↗
▶Ep 8 · 19:32
clinicalHospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg↗
▶Ep 8 · 19:46
clinicalBy one month post-op, chest X-ray shows no evidence of prior surgery due to compensatory lung growth↗
▶Ep 8 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours↗
▶Ep 8 · 21:13
quotethe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room↗
▶Ep 8 · 23:38
clinicalMost asymptomatic infants will tolerate single lung ventilation without problem↗
▶Ep 8 · 26:02
clinicalBabies initially desaturate after lung collapse but saturations improve once they stop shunting blood to the collapsed lung↗
▶Ep 8 · 27:41
clinicalEnd-tidal CO2 in the mid-40s during thoracoscopy does not cause significant acidosis or deleterious effects↗
▶Ep 8 · 30:02
opinionStanding at the patient's front provides more room from the chest wall to the hilum than standing at the back↗
▶Ep 8 · 30:39
opinionThe camera port should be anterior to the tip of the scapula in the mid-axillary line to allow working from front to back↗
▶Ep 8 · 33:01
opinionA 4mm scope provides a more wide-angle view comparable to a 5mm scope compared to a 3mm scope↗
▶Ep 8 · 33:22
opinionShort scopes (20cm) allow the surgeon to get close to the patient without the assistant getting in the way↗
▶Ep 8 · 35:01
clinical3mm vessel sealing devices can seal vessels up to 5mm in diameter↗
▶Ep 8 · 35:15
opinionMaking two separate seals 4-5mm apart on vessels and cutting between them maximizes safety↗
▶Ep 8 · 35:52
quotevascular control in these cases is everything. You really want to maximize the downside.↗
▶Ep 8 · 36:11
opinionCutting partway through a sealed vessel until seeing the lumen allows detection of bleeding while maintaining control↗
▶Ep 8 · 36:36
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 8 · 36:50
opinionClips on vessels can be knocked off and are less reliable than vessel sealing↗
▶Ep 8 · 37:44
opinionUsing energy devices that seal and cut simultaneously is a mistake that sets up the surgeon for trouble↗
▶Ep 8 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble↗
▶Ep 8 · 38:30
opinionEvery sealing device can fail at some point, so techniques should allow for recovery↗
▶Ep 8 · 42:01
opinionThe inferior pulmonary ligament should be taken down first to check energy source function and identify systemic vessels↗
▶Ep 8 · 42:24
clinicalSystemic vessels to sequestrations can be missed on CT scan and should be actively looked for during surgery↗
▶Ep 8 · 43:13
opinionIncomplete fissures can be completed by working through tissue layer by layer, similar to finger fracturing in liver surgery↗
▶Ep 8 · 45:20
clinicalThe bronchus sits directly underneath the pulmonary artery and can be felt to aid dissection↗
▶Ep 8 · 48:31
clinicalThe pulmonary vein is directly behind the bronchus in the same plane as the fissure dissection↗
▶Ep 8 · 49:11
clinicalA 5mm stapler is inadequate for bronchus or vessels in children over 10 kg↗
▶Ep 8 · 50:33
quoteyou cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 8 · 50:33
clinicalThe pulmonary vein trunk must never be taken near the pericardium because retraction into the pericardium after device failure causes fatal hemorrhage↗
▶Ep 8 · 51:10
clinicalMiddle lobe vessels come off just above the right lower lobe pulmonary artery and can be damaged if dissection migrates too cephalad↗
▶Ep 8 · 57:38
opinionLarge cysts should be decompressed with the sealing device at the beginning of the procedure to improve visualization and lung manipulation↗
▶Ep 8 · 58:40
clinicalSystemic vessels to sequestrations can number up to 6 and range from small to 15mm in diameter↗
▶Ep 8 · 59:55
clinicalUsing both sealing technology and clips on the same vessel risks delayed bleeding as the vessel changes nature and clips lose secure footing↗
▶Ep 8 · 1:00:26
quoteeither use clips or use vessel sealing, but don't use both on the same vessel.↗
▶Ep 8 · 1:00:43
clinicalSystemic vessels to sequestrations have higher pressure from the aorta compared to low-pressure pulmonary vessels↗
▶Ep 8 · 1:01:07
clinicalExtralobar sequestrations become infected and can cause problems even if malignant potential is uncertain↗
▶Ep 8 · 1:01:23
opinionEmbolization of sequestrations requires general anesthesia and significant arterial intervention with no advantage over thoracoscopic resection↗
▶Ep 8 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity↗
▶Ep 8 · 1:01:35
clinicalExtralobar sequestration resection does not require a chest tube and patients go home the next day↗
▶Ep 8 · 1:03:48
opinionSegmentectomy is feasible when disease is confined to the superior segment of lower lobe or lingula with favorable anatomy↗
▶Ep 8 · 1:05:33
clinicalAverage length of stay for lobectomy in patients coming in the morning is about 2.5 days↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 23 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 23 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 23 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 23 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 23 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 23 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 23 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 23 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 23 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 23 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 23 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 23 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 23 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 23 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 23 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 23 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 23 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 23 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 23 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 23 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 23 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 23 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 23 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 23 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 23 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 23 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 23 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 23 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 23 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 23 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 23 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 23 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 23 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 23 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 23 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 23 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 23 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 23 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 23 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 23 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 23 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 23 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 23 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 23 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 23 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 23 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 23 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 23 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 23 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 23 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 23 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 23 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 23 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 23 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 23 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 23 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 23 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 23 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 23 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 23 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 23 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 23 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 23 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 23 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 23 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 23 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 23 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 23 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 23 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 23 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 23 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 23 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 23 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 23 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 23 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 23 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 23 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 23 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 23 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 23 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 23 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 23 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 23 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 23 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 23 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 23 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 23 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 23 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 23 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 23 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 23 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 23 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 23 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 23 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 23 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 23 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 23 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 23 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 23 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 23 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 23 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 23 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 23 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 23 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 23 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 23 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 23 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 23 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 23 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 23 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 23 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 23 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 23 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 23 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 23 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 23 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 23 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 23 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 23 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 23 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 23 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 23 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 23 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 23 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 23 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 23 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 23 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 23 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 23 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 23 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 23 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 23 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 23 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 23 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 23 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 23 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 23 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 23 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 23 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 23 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 23 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 23 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 23 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 23 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 23 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 23 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 23 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 23 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 23 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 23 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 23 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 23 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 23 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 23 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 23 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 23 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 23 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 23 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 23 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 23 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 23 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 23 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 23 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 23 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 23 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 23 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 23 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 23 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 23 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 23 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 23 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 23 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 23 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 23 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 23 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 23 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 23 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 23 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 23 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
▶Ep 23 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 25 · 36:37
clinicalSingle-lung ventilation is preferable for thoracoscopic lobectomy, achieved by main stem intubation of contralateral bronchus↗
▶Ep 25 · 38:55
clinicalFor thoracoscopic lobectomy, scope port should be anterior to scapula tip in mid-axillary line over major fissure to allow front-to-back working approach↗
▶Ep 25 · 43:06
quoteVascular control in these cases is everything.↗
▶Ep 25 · 43:09
clinicalVascular control technique involves making two seals on vessel with space between, then cutting partway to visualize lumen before complete division↗
▶Ep 25 · 48:53
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 25 · 48:53
clinicalCritical safety point: do not take pulmonary vein trunk near pericardium; if device fails, vessel will retract into pericardium causing fatal hemorrhage↗
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 3 · 1:02
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 3 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 3 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 3 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
▶Ep 3 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 3 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 3 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 3 · 10:41
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 3 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 3 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 3 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 3 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 3 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 3 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 3 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 3 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 3 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 3 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 3 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 3 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 3 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 3 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 3 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 3 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 3 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 3 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 3 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 3 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 3 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 3 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 3 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 3 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 3 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 3 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 3 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 3 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 3 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 3 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 3 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 3 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 3 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 3 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 3 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 3 · 23:06
quoteThe hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
▶Ep 3 · 23:06
quoteThe hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
▶Ep 3 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 3 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
▶Ep 3 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012
▶Ep 6 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 6 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 6 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 6 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 6 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
▶Ep 6 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 7 · 5:43
epidemiological6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear↗
▶Ep 7 · 6:11
epidemiologicalFetal intervention for lung lesions is extremely rare; CHOP performs open fetal surgery less than once every couple of years↗
▶Ep 7 · 7:54
clinicalCyst volume ratio (CVR) greater than 2 has an extremely bad prognosis for fetal lung lesions↗
▶Ep 7 · 9:09
clinicalHybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology↗
▶Ep 7 · 9:48
clinicalIntralobar sequestration shares a common pleura with the lobe, usually the lower lobe↗
▶Ep 7 · 9:52
clinicalExtralobar sequestration has its own pleural lining and is 90% separate from the lobe↗
▶Ep 7 · 10:02
clinicalSequestrations are defined by having a systemic artery coming directly off the aorta↗
▶Ep 7 · 10:14
clinicalSystemic vessels to sequestrations can come off the abdominal aorta and pass through the diaphragm↗
▶Ep 7 · 10:40
clinicalCPAM type 3 lesions are more solid and have the worst prognosis↗
▶Ep 7 · 10:57
quoteI consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about.↗
▶Ep 7 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 7 · 14:50
clinicalChest X-ray alone is not adequate to ensure there is no residual lung lesion after prenatal diagnosis↗
▶Ep 7 · 15:47
epidemiological20-40% of untreated congenital lung lesions will develop significant infection at some point↗
▶Ep 7 · 15:55
quoteI think that, you know, especially with thoracoscopic techniques, the morbidity of, of removing these lesions so that the family and the child never have to worry about it ever again is, is relatively small↗
▶Ep 7 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 7 · 16:58
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series↗
▶Ep 7 · 18:04
opinionOperating by 3 months of age avoids pneumonia or severe respiratory infection before surgery↗
▶Ep 7 · 18:20
opinionSurgery is technically easier in younger infants because vessels are smaller and anatomy is fresh↗
▶Ep 7 · 18:46
clinicalEven asymptomatic patients often have enlarged lymph nodes and inflammation in fissures by one year of age↗
▶Ep 7 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection↗
▶Ep 7 · 19:32
clinicalHospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg↗
▶Ep 7 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours↗
▶Ep 7 · 19:46
clinicalBy one month post-op, chest X-ray shows no evidence of prior surgery due to compensatory lung growth↗
▶Ep 7 · 21:13
quotethe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room↗
▶Ep 7 · 23:38
clinicalMost asymptomatic infants will tolerate single lung ventilation without problem↗
▶Ep 7 · 26:02
clinicalBabies initially desaturate after lung collapse but saturations improve once they stop shunting blood to the collapsed lung↗
▶Ep 7 · 27:41
clinicalEnd-tidal CO2 in the mid-40s during thoracoscopy does not cause significant acidosis or deleterious effects↗
▶Ep 7 · 30:02
opinionStanding at the patient's front provides more room from the chest wall to the hilum than standing at the back↗
▶Ep 7 · 30:39
opinionThe camera port should be anterior to the tip of the scapula in the mid-axillary line to allow working from front to back↗
▶Ep 7 · 33:01
opinionA 4mm scope provides a more wide-angle view comparable to a 5mm scope compared to a 3mm scope↗
▶Ep 7 · 33:22
opinionShort scopes (20cm) allow the surgeon to get close to the patient without the assistant getting in the way↗
▶Ep 7 · 35:01
clinical3mm vessel sealing devices can seal vessels up to 5mm in diameter↗
▶Ep 7 · 35:15
opinionMaking two separate seals 4-5mm apart on vessels and cutting between them maximizes safety↗
▶Ep 7 · 35:52
quotevascular control in these cases is everything. You really want to maximize the downside.↗
▶Ep 7 · 36:11
opinionCutting partway through a sealed vessel until seeing the lumen allows detection of bleeding while maintaining control↗
▶Ep 7 · 36:36
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 7 · 36:50
opinionClips on vessels can be knocked off and are less reliable than vessel sealing↗
▶Ep 7 · 37:44
opinionUsing energy devices that seal and cut simultaneously is a mistake that sets up the surgeon for trouble↗
▶Ep 7 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble↗
▶Ep 7 · 38:30
opinionEvery sealing device can fail at some point, so techniques should allow for recovery↗
▶Ep 7 · 42:01
opinionThe inferior pulmonary ligament should be taken down first to check energy source function and identify systemic vessels↗
▶Ep 7 · 42:24
clinicalSystemic vessels to sequestrations can be missed on CT scan and should be actively looked for during surgery↗
▶Ep 7 · 43:13
opinionIncomplete fissures can be completed by working through tissue layer by layer, similar to finger fracturing in liver surgery↗
▶Ep 7 · 45:20
clinicalThe bronchus sits directly underneath the pulmonary artery and can be felt to aid dissection↗
▶Ep 7 · 48:31
clinicalThe pulmonary vein is directly behind the bronchus in the same plane as the fissure dissection↗
▶Ep 7 · 49:11
clinicalA 5mm stapler is inadequate for bronchus or vessels in children over 10 kg↗
▶Ep 7 · 50:33
clinicalThe pulmonary vein trunk must never be taken near the pericardium because retraction into the pericardium after device failure causes fatal hemorrhage↗
▶Ep 7 · 50:33
quoteyou cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 7 · 51:10
clinicalMiddle lobe vessels come off just above the right lower lobe pulmonary artery and can be damaged if dissection migrates too cephalad↗
▶Ep 7 · 57:38
opinionLarge cysts should be decompressed with the sealing device at the beginning of the procedure to improve visualization and lung manipulation↗
▶Ep 7 · 58:40
clinicalSystemic vessels to sequestrations can number up to 6 and range from small to 15mm in diameter↗
▶Ep 7 · 59:55
clinicalUsing both sealing technology and clips on the same vessel risks delayed bleeding as the vessel changes nature and clips lose secure footing↗
▶Ep 7 · 1:00:26
quoteeither use clips or use vessel sealing, but don't use both on the same vessel.↗
▶Ep 7 · 1:00:43
clinicalSystemic vessels to sequestrations have higher pressure from the aorta compared to low-pressure pulmonary vessels↗
▶Ep 7 · 1:01:07
clinicalExtralobar sequestrations become infected and can cause problems even if malignant potential is uncertain↗
▶Ep 7 · 1:01:23
opinionEmbolization of sequestrations requires general anesthesia and significant arterial intervention with no advantage over thoracoscopic resection↗
▶Ep 7 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity↗
▶Ep 7 · 1:01:35
clinicalExtralobar sequestration resection does not require a chest tube and patients go home the next day↗
▶Ep 7 · 1:03:48
opinionSegmentectomy is feasible when disease is confined to the superior segment of lower lobe or lingula with favorable anatomy↗
▶Ep 7 · 1:05:33
clinicalAverage length of stay for lobectomy in patients coming in the morning is about 2.5 days↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 17 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 17 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 17 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 17 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 17 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 17 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 17 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 17 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 17 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 17 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 17 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 17 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 17 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 17 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 17 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 17 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 17 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 17 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 17 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 17 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 17 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 17 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 17 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 17 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 17 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 17 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 17 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 17 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 17 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 17 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 17 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 17 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 17 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 17 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 17 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 17 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 17 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 17 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 17 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 17 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 17 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 17 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 17 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 17 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 17 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 17 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 17 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 17 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 17 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 17 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 17 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 17 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 17 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 17 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 17 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 17 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 17 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 17 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 17 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 17 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 17 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 17 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 17 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 17 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 17 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 17 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 17 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 17 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 17 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 17 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 17 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 17 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 17 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 17 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 17 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 17 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 17 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 17 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 17 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 17 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 17 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 17 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 17 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 17 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 17 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 17 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 17 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 17 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 17 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 17 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 18 · 36:37
clinicalSingle-lung ventilation is preferable for thoracoscopic lobectomy, achieved by main stem intubation of contralateral bronchus↗
▶Ep 18 · 38:55
clinicalFor thoracoscopic lobectomy, scope port should be anterior to scapula tip in mid-axillary line over major fissure to allow front-to-back working approach↗
▶Ep 18 · 43:06
quoteVascular control in these cases is everything.↗
▶Ep 18 · 43:09
clinicalVascular control technique involves making two seals on vessel with space between, then cutting partway to visualize lumen before complete division↗
▶Ep 18 · 48:53
clinicalCritical safety point: do not take pulmonary vein trunk near pericardium; if device fails, vessel will retract into pericardium causing fatal hemorrhage↗
▶Ep 18 · 48:53
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 14 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 14 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 14 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 14 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 14 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 14 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 14 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 14 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 14 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 14 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 14 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 14 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 14 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 14 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 14 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 14 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 14 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 14 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 14 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 14 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 14 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 14 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 14 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 14 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 14 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 14 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 14 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 14 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 14 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 14 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 14 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 14 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 14 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 14 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 14 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 14 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 14 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 14 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 14 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 14 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 14 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 14 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 14 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 14 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 14 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 14 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 14 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 14 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 14 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 14 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 14 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 14 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 14 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 14 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 14 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 14 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 14 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 14 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 14 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 14 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 14 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 14 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 14 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 14 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 14 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 14 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 14 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 14 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 14 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 14 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 14 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 14 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 14 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 14 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 14 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 14 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 14 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 14 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 14 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 14 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 14 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 14 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 14 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 14 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 14 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 14 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 14 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 14 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 14 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 17 · 36:37
clinicalSingle-lung ventilation is preferable for thoracoscopic lobectomy, achieved by main stem intubation of contralateral bronchus↗
▶Ep 17 · 38:55
clinicalFor thoracoscopic lobectomy, scope port should be anterior to scapula tip in mid-axillary line over major fissure to allow front-to-back working approach↗
▶Ep 17 · 43:06
quoteVascular control in these cases is everything.↗
▶Ep 17 · 43:09
clinicalVascular control technique involves making two seals on vessel with space between, then cutting partway to visualize lumen before complete division↗
▶Ep 17 · 48:53
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 17 · 48:53
clinicalCritical safety point: do not take pulmonary vein trunk near pericardium; if device fails, vessel will retract into pericardium causing fatal hemorrhage↗
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 2 · 7:29
opinionThe argument that you needed to put your hand in to feel all the granules means you automatically should do a bilateral thoracotomy because this is a systemic disease, not a unilateral disease↗
▶Ep 2 · 7:29
clinicalSurvival didn't change when you had only 3 to 4 nodules on the side↗
▶Ep 2 · 7:29
quoteI'm very happy to see these, these studies have finally come out because we actually did report it on our data almost 20 years ago, but survival didn't change when you had only 3 to 4 nodules on the side↗
▶Ep 2 · 7:52
clinicalWe can only see 1 or 2 millimeter nodules now even with the best CTs, and you still miss some↗
▶Ep 2 · 8:02
quoteThere's no question that tumor clearing is, is improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel.↗
▶Ep 2 · 8:02
clinicalThere's no question that tumor clearing improves survival↗
▶Ep 2 · 8:05
clinicalThere are ones that you can feel and not see, and there are ones that you can't feel↗
▶Ep 2 · 8:12
opinionIf there's only 3 to 4 nodules on the side and they're applicable to thoracoscopy, that's how we go just to reduce the morbidity↗
quoteI was a cryo skeptic. But we, and I'd planned to go out and see Sean do some, and then COVID came↗
▶Ep 23 · 32:40
quotewe now do the New York time crossword while we do the cryotherapy. So that's one suggestion to help↗
▶Ep 23 · 33:05
quoteI will tell you that it took me about four cases to realize because most of our patients went home on day two or three, but it's not just when they go home. It's how they feel when they go home and the cryo, it's been unbelievable↗
▶Ep 23 · 33:40
clinicalPatients at two weeks post-cryoanalgesia do not notice chest wall numbness as a significant issue↗
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 26 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 26 · 6:59
opinionBar flippage is completely a surgical technique issue↗
▶Ep 26 · 8:19
clinicalSternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses to allow less tissue damage↗
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 18 · 7:29
quoteI'm very happy to see these, these studies have finally come out because we actually did report it on our data almost 20 years ago, but survival didn't change when you had only 3 to 4 nodules on the side↗
▶Ep 18 · 7:29
clinicalSurvival didn't change when you had only 3 to 4 nodules on the side↗
▶Ep 18 · 7:29
opinionThe argument that you needed to put your hand in to feel all the granules means you automatically should do a bilateral thoracotomy because this is a systemic disease, not a unilateral disease↗
▶Ep 18 · 7:52
clinicalWe can only see 1 or 2 millimeter nodules now even with the best CTs, and you still miss some↗
▶Ep 18 · 8:02
clinicalThere's no question that tumor clearing improves survival↗
▶Ep 18 · 8:02
quoteThere's no question that tumor clearing is, is improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel.↗
▶Ep 18 · 8:05
clinicalThere are ones that you can feel and not see, and there are ones that you can't feel↗
▶Ep 18 · 8:12
opinionIf there's only 3 to 4 nodules on the side and they're applicable to thoracoscopy, that's how we go just to reduce the morbidity↗
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 2 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 2 · 6:59
opinionBar flippage is completely a surgical technique issue↗
▶Ep 2 · 8:19
clinicalSternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses to allow less tissue damage↗
epidemiological6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear↗
▶Ep 21 · 6:11
epidemiologicalFetal intervention for lung lesions is extremely rare; CHOP performs open fetal surgery less than once every couple of years↗
▶Ep 21 · 7:54
clinicalCyst volume ratio (CVR) greater than 2 has an extremely bad prognosis for fetal lung lesions↗
▶Ep 21 · 9:09
clinicalHybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology↗
▶Ep 21 · 9:48
clinicalIntralobar sequestration shares a common pleura with the lobe, usually the lower lobe↗
▶Ep 21 · 9:52
clinicalExtralobar sequestration has its own pleural lining and is 90% separate from the lobe↗
▶Ep 21 · 10:02
clinicalSequestrations are defined by having a systemic artery coming directly off the aorta↗
▶Ep 21 · 10:14
clinicalSystemic vessels to sequestrations can come off the abdominal aorta and pass through the diaphragm↗
▶Ep 21 · 10:40
clinicalCPAM type 3 lesions are more solid and have the worst prognosis↗
▶Ep 21 · 10:57
quoteI consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about.↗
▶Ep 21 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 21 · 14:50
clinicalChest X-ray alone is not adequate to ensure there is no residual lung lesion after prenatal diagnosis↗
▶Ep 21 · 15:47
epidemiological20-40% of untreated congenital lung lesions will develop significant infection at some point↗
▶Ep 21 · 15:55
quoteI think that, you know, especially with thoracoscopic techniques, the morbidity of, of removing these lesions so that the family and the child never have to worry about it ever again is, is relatively small↗
▶Ep 21 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 21 · 16:58
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series↗
▶Ep 21 · 18:04
opinionOperating by 3 months of age avoids pneumonia or severe respiratory infection before surgery↗
▶Ep 21 · 18:20
opinionSurgery is technically easier in younger infants because vessels are smaller and anatomy is fresh↗
▶Ep 21 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection↗
▶Ep 21 · 18:46
clinicalEven asymptomatic patients often have enlarged lymph nodes and inflammation in fissures by one year of age↗
▶Ep 21 · 19:32
clinicalHospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg↗
▶Ep 21 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours↗
▶Ep 21 · 19:46
clinicalBy one month post-op, chest X-ray shows no evidence of prior surgery due to compensatory lung growth↗
▶Ep 21 · 21:13
quotethe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room↗
▶Ep 21 · 23:38
clinicalMost asymptomatic infants will tolerate single lung ventilation without problem↗
▶Ep 21 · 26:02
clinicalBabies initially desaturate after lung collapse but saturations improve once they stop shunting blood to the collapsed lung↗
▶Ep 21 · 27:41
clinicalEnd-tidal CO2 in the mid-40s during thoracoscopy does not cause significant acidosis or deleterious effects↗
▶Ep 21 · 30:02
opinionStanding at the patient's front provides more room from the chest wall to the hilum than standing at the back↗
▶Ep 21 · 30:39
opinionThe camera port should be anterior to the tip of the scapula in the mid-axillary line to allow working from front to back↗
▶Ep 21 · 33:01
opinionA 4mm scope provides a more wide-angle view comparable to a 5mm scope compared to a 3mm scope↗
▶Ep 21 · 33:22
opinionShort scopes (20cm) allow the surgeon to get close to the patient without the assistant getting in the way↗
▶Ep 21 · 35:01
clinical3mm vessel sealing devices can seal vessels up to 5mm in diameter↗
▶Ep 21 · 35:15
opinionMaking two separate seals 4-5mm apart on vessels and cutting between them maximizes safety↗
▶Ep 21 · 35:52
quotevascular control in these cases is everything. You really want to maximize the downside.↗
▶Ep 21 · 36:11
opinionCutting partway through a sealed vessel until seeing the lumen allows detection of bleeding while maintaining control↗
▶Ep 21 · 36:36
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 21 · 36:50
opinionClips on vessels can be knocked off and are less reliable than vessel sealing↗
▶Ep 21 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble↗
▶Ep 21 · 37:44
opinionUsing energy devices that seal and cut simultaneously is a mistake that sets up the surgeon for trouble↗
▶Ep 21 · 38:30
opinionEvery sealing device can fail at some point, so techniques should allow for recovery↗
▶Ep 21 · 42:01
opinionThe inferior pulmonary ligament should be taken down first to check energy source function and identify systemic vessels↗
▶Ep 21 · 42:24
clinicalSystemic vessels to sequestrations can be missed on CT scan and should be actively looked for during surgery↗
▶Ep 21 · 43:13
opinionIncomplete fissures can be completed by working through tissue layer by layer, similar to finger fracturing in liver surgery↗
▶Ep 21 · 45:20
clinicalThe bronchus sits directly underneath the pulmonary artery and can be felt to aid dissection↗
▶Ep 21 · 48:31
clinicalThe pulmonary vein is directly behind the bronchus in the same plane as the fissure dissection↗
▶Ep 21 · 49:11
clinicalA 5mm stapler is inadequate for bronchus or vessels in children over 10 kg↗
▶Ep 21 · 50:33
clinicalThe pulmonary vein trunk must never be taken near the pericardium because retraction into the pericardium after device failure causes fatal hemorrhage↗
▶Ep 21 · 50:33
quoteyou cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 21 · 51:10
clinicalMiddle lobe vessels come off just above the right lower lobe pulmonary artery and can be damaged if dissection migrates too cephalad↗
▶Ep 21 · 57:38
opinionLarge cysts should be decompressed with the sealing device at the beginning of the procedure to improve visualization and lung manipulation↗
▶Ep 21 · 58:40
clinicalSystemic vessels to sequestrations can number up to 6 and range from small to 15mm in diameter↗
▶Ep 21 · 59:55
clinicalUsing both sealing technology and clips on the same vessel risks delayed bleeding as the vessel changes nature and clips lose secure footing↗
▶Ep 21 · 1:00:26
quoteeither use clips or use vessel sealing, but don't use both on the same vessel.↗
▶Ep 21 · 1:00:43
clinicalSystemic vessels to sequestrations have higher pressure from the aorta compared to low-pressure pulmonary vessels↗
▶Ep 21 · 1:01:07
clinicalExtralobar sequestrations become infected and can cause problems even if malignant potential is uncertain↗
▶Ep 21 · 1:01:23
opinionEmbolization of sequestrations requires general anesthesia and significant arterial intervention with no advantage over thoracoscopic resection↗
▶Ep 21 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity↗
▶Ep 21 · 1:01:35
clinicalExtralobar sequestration resection does not require a chest tube and patients go home the next day↗
▶Ep 21 · 1:03:48
opinionSegmentectomy is feasible when disease is confined to the superior segment of lower lobe or lingula with favorable anatomy↗
▶Ep 21 · 1:05:33
clinicalAverage length of stay for lobectomy in patients coming in the morning is about 2.5 days↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 29 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 29 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 29 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 29 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 29 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 29 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 29 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 29 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 29 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 29 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 29 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 29 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 29 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 29 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 29 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 29 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 29 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 29 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 29 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 29 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 29 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 29 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 29 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 29 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 29 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 29 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 29 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 29 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 29 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 29 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 29 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 29 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 29 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 29 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 29 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 29 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 29 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 29 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 29 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 29 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 29 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 29 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 29 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 29 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 29 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 29 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 29 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 29 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 29 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 29 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 29 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 29 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 29 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 29 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 29 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 29 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 29 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 29 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 29 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 29 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 29 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 29 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 29 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 29 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 29 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 29 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 29 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 29 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 29 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 29 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 29 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 29 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 29 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 29 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 29 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 29 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 29 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 29 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 29 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 29 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 29 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 29 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 29 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 29 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 29 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 29 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 29 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 29 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 29 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 29 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 29 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 29 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 29 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 29 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 29 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 29 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 29 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 29 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 29 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 29 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 29 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 29 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 29 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 29 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 29 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 29 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 29 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 29 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 29 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 29 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 29 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 29 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 29 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 29 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 29 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 29 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 29 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 29 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 29 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 29 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 29 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 29 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 29 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 29 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 29 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 29 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 29 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 29 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 29 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 29 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 29 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 29 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 29 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 29 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 29 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 29 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 29 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 29 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 29 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 29 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 29 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 29 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 29 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 29 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 29 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 29 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 29 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 29 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 29 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 29 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 29 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 29 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 29 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 29 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 29 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 29 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 29 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 29 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 29 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 29 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 29 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 29 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 29 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 29 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 29 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 29 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 29 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 29 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 29 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 29 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 29 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 29 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 29 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 29 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 29 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 29 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 29 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 29 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 29 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
▶Ep 29 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
