Neonatal Lung Lesions with Dr. Steven Rothenberg

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Nicholas Bruns, and Ian Glenn in partnership with Globalcast MD and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to Stay Current in Pediatric Surgery. This is Ian Glenn, co-editor of Stay Current. I would like to encourage you to download our app for your mobile device from the Google Play or Apple iTunes Store. Unique to this episode, you can watch Doctor Rothenberg perform lobectomies on each of the lung lobes. Thank you and enjoy the show. Today, we're going to be talking about lung lesions and with us, we have Doctor Steven Rothenberg. Doctor Rothenberg is chief of pediatric surgery at Rocky Mountain Hospital for Children in Denver, Colorado. He's also the clinical professor of surgery at Columbia University College of Physicians and Surgeons and operates pretty frequently at the Morgan Stanley Children's Hospital. Steve, thanks for joining us. Oh, it's a pleasure, Todd. Thanks for having me on. Well, Steve, I know that, um, you've not only been a leader in our field in, in minimally invasive surgery, but specifically thoracic surgery. Um, And I know you've had some actual additional training in thoracic surgery. What, when did you do that and what exactly did you do? Um, so I, I did a year of general thoracic in England, and I did it. I had a gap year between when I finished my general surgery, uh, chief year and when, um, I got into, um, my pediatric surgery fellowship. Actually, I was applying to fellowships and, and I didn't know I was applying a year late, so I was going to have a year free, and I wanted to do something that if I got into pediatric surgery I thought would help me and if I didn't get into pediatric surgery would help me do general surgery and I had a big interest in thoracic surgery and this job just sort of presented itself. I got very lucky. Well, it certainly set off a lot of the elements of your career you Described the minimally invasive approach for tracheoesophageal fistula repair and are clearly one of the leaders, if not the leader in Lobectomy, and lung surgery and probably have the largest series that I know of. And so you certainly qualify as our key opinion leader today to talk about these lung lesions. So thanks again for joining us. Uh, Steve, we'll dig right in. Specifically today we're going to talk about congenital lung lesions and let me start off with a prenatal question for you. So. What is the usual, uh, when, when you have a patient that comes to you for a prenatal evaluation, um, what is the usual workup that's done prenatally to evaluate these lung lesions? So we see probably the vast majority of our patients, we get a chance to see the families prenatally. We have an extensive perinatal network that that is doing screenings and any of the children that are in the region usually get referred into their group for follow-up screens. And then once the perinatologist identifies what they consider to be a cystic lung lesion in the chest. They'll refer the patients, the families in death to talk with them prenatally, so we get an opportunity to counsel the families prior to the baby being delivered. Our routine method of following these is basically serial prenatal ultrasounds. This, I think, is the best way to watch the development of these cystic lung lesions. It's noninvasive. It can be done quickly. And our perinatologists probably do the scans every couple of weeks depending on how the child's doing. Some people like to get fetal MRIs, but really I have found this to be of little benefit with these, these particular lesions. It doesn't really change your plan. It doesn't give you that much more definition. And so we are not routinely routinely doing those for fetal lung lesions. What kind of things are they looking at on the ultrasound? So two things mainly. One is that, you know, you always worry about if the cysts become large, and you can get cases where you get very large cysts, and that can cause compression of normal lung as well as mediastinal shift, and in the worst cases, you can get um fetal eye drops, and those are really the extreme cases. More often we're just kind of watching to see how big the cysts get, whether we think it's going to be of consequence, you know, when the baby's born. Is this a lesion that we feel like the baby might have some respiratory distress when they're born, and so we want them to deliver at our institution and we have a high risk maternal service attached to our children's hospital so the moms can deliver right here. In some cases, the lesions, you know, don't seem to be causing any mass effect. Uh, and they're not too big, we'll often let the moms deliver at their home hospital with their home OB, um, counseling that, you know, if there's a problem, we might need to transfer emergently, but otherwise, they're often more comfortable with that. The other thing we look for is regression, and anywhere from 6 to 40% of these lesions that are seen will regress with time, and in some cases appear to completely disappear. And so. Um, we follow that along as well. So have you ever had a case or heard of a case where they've had fetal intervention and, and if so, when, when would that happen? So, you know, it's extremely rare. I think, you know, Chop, who probably has the biggest series in the in the world of that, does, uh, you know, one open fetal surgery for this less than every couple of years. It's extremely rare. Occasionally we'll get a Um, a case with a, you know, with an extremely large cyst or a couple of large cysts, and we have done fetal thoracentesis to decompress these, um, or in some cases, um, a thoraco amniotic shunt can be placed. But again, this is by far the vast minority of cases, and usually it's only done if the fetus is starting to show significant distress and show evidence of high drops, so that the mortality rate goes up significantly. So when would we give steroids? So we, you know, if we see patients with um. Uh, larger cysts and some degree of, uh, we're worried about some degree of of mediastinal shift, then we'll often our perinatologists will give steroids at that point. Um, also, if we're trying to mature the lung a bit, um, if we think we might need to do an early delivery, almost all these babies we allow just to have a spontaneous vaginal delivery. It's, it's, I can't even remember the last time we might have done a. A C-section for one of these, but it, we also sometimes use it to for lung maturation. Steve, what exactly is CVR, the cyst volume ratio. Yeah, so that's something that that is measured in some centers, and the concern is if the cyst volume to head ratio is greater than 2, that has an extremely bad prognosis. It's sort of like when we measure for diaphragmatic hernias, um, but that's a kind of a magic number, and I think it was. I don't remember if it was UCSF or CHOP that came up with that, those dimensions, but those are the cases where they're more prone to need fetal intervention. You know, now I know that terminology has changed somewhat where we now call it a CPAM, uh, and it's a congenital pulmonary adenomatoid malformation, and I think that sort of incorporates. Sequestration and CAMs, but can you talk to us about the spectrum of lesions that you can see? Well, yeah, I, I, I think that's the key. It really is a spectrum. I suspect that, you know, during our lifetimes, the nomenclature will change again. You know, people used to very clearly talk about, um, uh, CAMs or CAMs, cystic congenital adenomatoid malformations. Now it's CAMs, and separately sequestrations, and it's not uncommon that when we remove one of these lesions, we often see a hybrid lesion on the pathology. So you know, the basically the most simple lesions that we see are bronchogenic cysts, and those are cysts that can arise off the trachea or the bronchus, um, usually have a common wall. Sometimes we'll see them kind of seeming to be in the parenchyma of the lung. Then there are sequestrations and there are intralobar and extra lobar sequestrations, and intralobar sequestration is within involved within the parenchyma of the lung. And shares a common pleural with that lobe, usually the lower lobe. An extra lobar sequestration generally has its own pleural lining and it and is either completely separate or 90% separate from the lobe. Uh, the reason we classify things as a sequestration is because they have a systemic artery, uh, coming into them generally right off the aorta. Um, it can come either directly off the thoracic aorta, or there is a number of cases where it'll actually come off the abdominal aorta and come up through the diaphragm, and that's just an important distinction, especially for the resections. And then we have the CAMs or the cystic lung lesions, and there's types 1 to 41 or 0 to 4, depending on which nomenclature you look at, and that basically just talks about. The different type of cysts, so type 1 or macro cysts, type 2 or medium cyst, um, type 3 or more solid and have the worst, uh, prognosis, uh, and then type 4 tiny cysts, and, and again, that tends to vary some. But I 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. The only real thing that we sort of stick with is that if it, if it's got a systemic. A vessel coming in, we still tend to classify it as a sequestration. Let's say, Steve, so you get called the baby that you have been following prenatally has been doing well and has not required any fetal intervention, no steroids. The the ratio has been low. So the baby's born and they call you to the NICU and uh the baby's actually doing quite well on room air, looks good. What do you do for that child? So, um, if the baby's has basically no respiratory distress or no issues, um, we get a chest X-ray, um, just to make sure that there's not some large cystic component that would have us concerned about treating the baby in a more delayed fashion. And assuming that the chest X-ray either shows some mild cystic changes with no significant mediastinal shift or doesn't show anything, then. We let the moms and babies go home. Um, I think that it's rare for them to, when the chest X-ray is relatively normal or it doesn't show anything really significant, it's rare for the babies to run into problems, and we like to let mom go home with the baby and have some time to bond and grow a bit. And then we bring them back, uh, usually 4 to 6 weeks, um, and get a CT scan to fully evaluate the lesion. Um, I 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. Some 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. So I'm sorry, the timing of your CT, you wait till at what point? Usually 4 to 6 weeks, and primarily that's so that sometimes the babies need to be intubated for the CT scan. And if we wait that period of time, I think we get less adalectasis during the study, so you get less confusing findings on the scan. We can do them as outpatients so that the kids don't need to stay in overnight. Occasionally we can do them without um a general anesthetic just with sedation. Um, and I think they're a little bit easier to read when the kids are a little bit bigger. And in general, we don't intervene in an asymptomatic kid before 4 to 6 weeks of age. And do you ever get MRI? Um, we don't. I think that for planning surgery, that, um, CT scan, um, is a much better, uh, modality. It gives us a far better resolution in the lung. The MRI is a bit more difficult to read in the lung, and, uh, with the high resolution CT scans, the amount of radiation that the babies are exposed to is really, um, minimal. So, for this particular lesion, I don't, I don't like MRI. So just I want to make sure I understand correctly, if the baby is born, doing well, and the X-ray is normal, doesn't show anything, you still get a CAT scan at about a month of age. Yes, I, 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. So I don't think a plain chest X-ray or an ultrasound are adequate to ensure that there is absolutely no lesion there. Yeah, we practiced the same thing. But I'm wondering, Steve, I know you have some Canadian colleagues that may not follow exactly the same protocol. What exactly do people like Jack Langer or Jean-Martin LaBerge, what would they say about their management? Well, I think, I think some people are more comfortable that these lesions completely go away, and some people say, well, even if they don't, the likelihood that the child will have a problem later is, is significantly small. I'm, you know, I 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. And so, um, I prefer to be um aggressive in treating these, um, as opposed to just watching them. Um, and I 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, right. And I think the argument that they would make is that the that not everyone has such a low morbidity and that we don't really know the true incidence of the cancer or the infection and so it may be OK to just wait. Is that pretty much what they say? I think so. I mean, I think, you know, again, I think some, some people feel these lesions just are inconsequential and that you don't need to treat them. I've seen enough. The 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. So and certainly the infection rate is well documented in other series if they're not treated, so. Um, I, I, one case of cancer would be too many, and, and, you know, 10 out of 100 severe infections, or 10 or 20, I think is way too high as well, OK. All right, Steve, so you've made the decision. You get the CAT scan. You do see a lesion on the CAT scan, and we can go through the different lobes later, but you see, uh, let's say a left lower lobe lesion. When do you decide to operate? And I know when you answer this, tell me what you do, but I know that not everyone necessarily agrees with your timing, right? So, you know, I think most people, I, I, I think I tend to operate earlier. I think there are other people like um Alan Flake at CHOP who also tends to operate earlier. I 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. It takes, um, I think with the equipment we have available today and the instrumentation and all the other accessories that we have to do these, um, that it's with the vessels smaller. That it's quite, quite, well, it's, it's not simple, but it's easier surgery and the anatomy is fresh. I 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 and so I think they get kind of low grade infections or inflammation in these areas because of these lesions, and the longer you wait, the more difficult it can be. And lastly, in our own series and looking at this and looking at kids, we did, um, you know, initially we looked at all the kids we did versus those that were under 10 kg, so that would be about, you know, a year of age or less. And then we looked at a subset of kids that were less than 5 kg. The, the hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients. And so, um, and by getting that lung out early, most of the kids we do are discharged within 48 hours, and they have, uh, you know, by a month post-op on a chest X-ray, you can't even tell they had anything done. The lung. The rest of the lung gets to undergo compensatory growth, and I think that just benefits them. You know, Steve, I, I want to touch on this a little bit more. Um, I, uh, I am a believer in the early operation, but I will tell you that probably what I felt, which is probably the same of what most people feel, is that the space is just too small, that it's a little scary to be doing this operation thoracoscopically for a lot of people, and to do it in such a small child is even more concerning and that the thought is, well, let me let them get bigger. I'll have more space. It'll be easier and safer. And I agree with you, uh, having followed your lead that I don't find that the space is too small. That's never really been an issue that I felt. There are other issues that we'll talk about, but the size or the space did not ever seem, and in fact it did seem easier because the vessels were smaller. Um, and so I think that that's an important point to make, when I think a lot of people that I talked to do like to wait. Um And the and the only thing I would add to that is the 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, and I think that's where people struggle and have difficulties, and, and it's a hard thing to learn, especially because the majority of us don't get a lot of thoracic experience, and so we're not as comfortable with the anatomy, but I really think the setup has everything to do with the success in the smaller patients. And, and we're going to dig deeper into that in a little bit when you sort of take us through the technical perils of doing this operation, but before we get into the actual chest, let's get, uh, let's get some pre-op preparation. What do you do? You've made the decision. You're going to operate on the patient at about 3 months of age or 2 months of age. What do you do to prepare the patient for surgery? So, you know, again, in most of these kids, we don't have to do anything. Obviously if the kid's having respiratory issues, then we move up our time scale and we will approach, um, it's rare, but we'll approach a neonate, um, you know, in the first few days of life, we'll still do it thoracoscopically because again I think we have the techniques and the instrumentation to do that now. Um, but assuming that the patient's gone home and they're coming in for the surgery, um, we do always type in cross blood for the surgery. Um, it's probably the only case I do that for. Um, uh, I guess PDA ligations would be the other one, but I do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available. Um, but that's pretty much it. The, the, the patients show up the morning of surgery. Um, we do routine pre-op. Um, you know, the only labs we get are a CBC. Uh, we have a, the pre, um, preoperative CT scan, and we get blood available. OK, so you're now you're in the room and talk to me about anesthetic considerations and specifically uh if you could get into how do you isolate the lung. So I think that, you know, it's important to have an anesthesiologist who's comfortable doing this with you. What we've learned over the years is that most kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem. I think if you can get single lung ventilation for these cases, it's preferable. You can do these cases quite well if you just insufflate CO2 and collapse the lung by creating a mild tension pneumothorax, but I think for most people they're probably a little more comfortable if they can get single lung ventilation. And the way we obtain that is by doing a main stem innovation of the contralateral bronchus. So if we're doing a right lower lobe, we'll do a left main stem intubation. And that just prevents the lung getting, um, you know, overinflated and kind of popping up in your face during the case when you're maybe dissecting out a. A key vessel or structure um and so we'll usually try to do that. In general, I don't like using bronchial blockers and things like that. I find that they're difficult to place. It adds a lot of extra time to the procedure. Um, often we can do the main stem intubation uh just blindly by, um, you know, either a right main stem. Uh, usually, it will, that will happen automatically if you, if you put the endotracheal tube in a bit further, but by placing the child in like a right lateral decubitus position and and bending the tube a little bit and turning the head, you can usually get it to go down the left side. But we like to keep it relatively simple, avoid blockers, bronchial blockers, and other maneuvers like that, and just do a main stem intubation. If you can't do it, or the child doesn't tolerate it, then, you know, I would just pull the endotracheal tube back into the trachea and use CO2 insufflation to help collapse the lobe. And if the anesthesiologist is aware and doesn't overventilate, um, usually that gives you enough collapse to work. So you talked about overventilation. What other anesthetic considerations are there for this operation, because I know that this is one of the things that can make this operation not work so well if you're not having a good coordination, right? So the first thing is, is that if you do get your single lung ventilation and or you insufflate with CO2, and I use CO2 in addition to the main stem intubation. All these babies initially are going to desaturate. So, once 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. So one thing is that the anesthesiologist needs to be a bit patient and allow the baby to come back on their own. The second thing is, is that you don't want them using high peak ventilatory pressures because they'll overcome your. Um, insufflation or your main stem intubation because there's always a little bit of overflow ventilation, so it's important that they use lower pressures and if they need to increase their ventilation to try and improve saturations, they just increase the rate but not the pressure and the temptation for them is to start bagging harder, so you kind of have to work with them on that. Those are really the two main issues. Um, the other thing is it just depends on their comfort level. When we do these cases, we basically do it with one. Uh, you know, depending on the size of the child, but, um, you know, 122 gauge IV in an infant or, um, and, and that's it, um, we don't, we don't, we use, uh, pulse oximetry, but and entitled CO2s, but we don't, we don't use art lines and things like that because we find it just adds time to the prep of the case and really isn't necessary, but I think. That you kind of have to work out with your anesthesiologist, and if you're not doing as much, they may not be comfortable with that. The other thing is the entitle CO2s will tend to go up a little bit, but, you know, an entitle CO2 in the mid-40s is really not a problem and doesn't cause any deleterious effects. The kids don't get significantly acidotic or anything from that, and so I think they just need to be willing to tolerate that for the duration of the procedure. And actually I find that sometimes it sort of equilibrates out as you touched on earlier. I think if you just wait a few minutes in any thoracic operation, um, some of that equilibrates out after about 10 minutes or so. All right, so now you've got your single lung ventilation through a main stem intubation. Talk to me about how you position the patient and how you set up the room and port placement, and then let's talk about what kind of equipment you use. So let's first start with patient positioning. So, you know, if we're doing a lobectomy, if, if I, if I have an extra lobar sequestration, um, then I'll, I'll tune the patient maybe a bit more prone, but basically for all lobectomies we keep the patient in a pure lateral decubitus position. Um, I tend to move them, these tend to be small children, so I tend to move them. Uh, to the, to the edge of the table, so with their front. So I, the surgeon and the assistant stand at the front of the child. So we're towards the nipple is pointing towards us, the back is away from us, and we move the child towards the edge of the table, primarily because we're using 3 millimeter instruments. And if you have the child in the center of the table, sometimes the handle of the instruments and smaller children can get, can get caught on the. On the table, um, or if you use a beanbag, can get caught on the beanbag. You don't have the range of motion you need, so I like to have them near the edge of the table. People don't like doing that sometimes because they think, well, if I need to convert, I need to have a surgeon on both sides. But the truth is, if you need to move the child to the middle of the table, you can do that quite easily even while they're sterile. So I prefer to maximize things for the thoracoscopic approach. Um, we generally, you know, in the, in, in infants we'll just use rolls, but if the kids are a bit older, we have a small bean bag and that, um, we use that to support them and get them in the position we want, and I find that can be quite helpful. Um, in terms of port placement, it depends a little bit on the lobe, but it's, it's relatively consistent, and I think that, again, the surgeon and the assistant are standing at the child's front, and I do that because I feel there's more room from the front of the chest towards the hilum of the lung than there is if you're standing at the patient's back. Now when I do open thoracotomies, which I don't do anymore, but when I used to do them, I always stood at the patient's back. Um, and that's where I would stand as the surgeon. The assistant would be across from me, but thoracoscopically, I think there's a better orientation and there's more room to work if you're standing at the patient's front. The scope port, um, it's always a guess initially, but, but I try to put the scope port over the major fissure, um, and so if we're doing a lower lobe, um, that means it's going to be in the 5th or 6th inner space, uh, and then that port is anterior to the tip of the scapula, not posterior. And the reason for that, that, that scope port really is more in the mid-axillary line, and the reason for that is that I like to work from front to back, um, and so we'll start basically in the front of the fissure and work towards the back. If you put the scope posteriorly or behind the tip of the scapula, then you end up having to look back at your instruments. And you're working in a paradox, and so I would rather have my scope where it's sort of as if my eyes were looking down on my instruments as if there was no chest wall there or I could see right through it and so I want that scope more anteriorly, and then my working ports end up being more in the anterior axillary line, um, and my left hand port is usually, um, just about under the camera port so again in the, in the 5th or 6th. Inner space and and then um the uh right hand port if if you're in the left chest ends up being in the 8th or 9th inner space just above the diaphragm and I look um from inside to where the diaphragm is to position that port. If we're going in the, in the right chest, everything's flipped, but it's still, you know, the, the right hand just under the scope port and the left hand down close to the diaphragm. So you mentioned um the three ports, the camera and the left and the right, do you ever use 1/4 instrument? Almost never. Um, I, I, you know, I think if you need to do it to get retraction, I think it's fine, but by using, um, by using, you know, gravity and, and collapse of the lung to basically keep those structures out of your way, especially in the chest of a smaller child, it, it almost just more gets in the way. Um, but if you need it. You can absolutely put in a 4th port, so. Regarding the ports, I'm assuming that you use mostly 3 millimeter instruments. Yeah, we use, so we use for these cases I use um a 4 millimeter 30 degree scope um that's short, that's about 20 centimeters for the lens, and the reason I use a 4 as opposed to a 3 is you just get a more wide angle view, so it's very comparable to the view you get with a 5 a 5 millimeter scope. Um, I like the short scope because if you have a long scope, then it gets, you can't get close to the patient and your assistant gets in your way. And then for most of these cases use 3 millimeter instruments um which um obviously go through 3 millimeter ports and are also 18 to 20 centimeters in length, um, the, the, um, and I use low profile reusable ports so these ports as opposed to most of the trocars that are available to us that are reusable have very small heads and so in the small space of an infant. Uh, they don't, they don't bang against each other. Um, occasionally I, I, I go other places in the world and, and operate and invariably I end up with much larger, uh, either disposable or reusable 5 millimeter ports where the heads are quite large and it's difficult to get everything in that smaller space. So having low profile, uh, valve ports really helps. Um, we now, you know, and then usually we'll end up putting in a 5 millimeter port. Um, and I tend to put it in the, the lower port side, um, now, um, and that's for use of depending on what equipment you have, you know, whether it's a, a 5 millimeter clips or 5 millimeter stapler, or if you don't have a 3 millimeter vessel sealer, a 5 millimeter, um, vessel sealing device, um, so if you, if you have to use a larger instrument, that's where I try to put it in. So you mentioned 3 versus 5 sealers. So you, for your vessel sealing, you're using a 3 millimeter device now? Yeah, we now have available a 3 millimeter vessel sealing device. It's a variation on bipolar technology, but it'll seal vessels at least up to 5 millimeters in. Uh, diameter, um, and the technique that I've sort of developed over the years for taking vessels when we're doing lobectomies is to make two separate seals, um, on the vessel, um, as far apart as I can, but you at least 4 to 5 millimeters apart and then to cut between the two seals. Um, and, and I think the 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. You really want to maximize the downside. And so. Um, the 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. If you get into the lumen and you start to see some bleeding, you have the ability to compensate and recover. You can get control of the vessel. You can, you know, seal it again with vessel sealing. You can put a clip on it. You can put a tie on it, but you have control. You only lose control once you've completely divided the vessel. And so this technique has worked very well for me, and it's much quicker than trying to tie up all these vessels separately. I don't really like using clips on vessels because routinely because the clips can come off and can be knocked off and so I have found this to be the safest way to approach this. So Steve, myself and most of the people I know have switched to this the 3 millimeter just right surgical sealer, and I know that you like this because it just seals and then you can cut separately. But if someone doesn't have the just right 3 millimeter sealer, I know some people talk about using sort of energy devices that that seal and cut at the same time. I know you have strong feelings about this, and I want you to tell us your thoughts on which device to use. Yeah, I 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, and I know people have done it, and they've I hate to say I've gotten away with it, but you know, gotten away with it. So I don't, you know, if you don't have the 3 millimeter vessel sealer, then I would, you know, and you have to use a 5 millimeter again, I would use something like the, the ligature, uh, which is, um, you know, that you can seal without cutting. I 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. And so I, my, 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. And so I think especially in these cases where you're, you know, you're operating on large vessels coming directly out of the heart. And if you get into significant bleeding, you're probably not going to be able to recover and in fact you could have a disastrous outcome even if you get in there quick, that you're much better off doing something that that seals separately and making a partial cut. So I, I would never use a device that that seals and cuts at the same time. And in 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, so I'm very hesitant to use that. I want to just clarify one thing. So for years, Covidian made a 5 millimeter, the LS 1000 that you like to use that seals but doesn't have any cutting in it, and then you would take it out and put a scissors in to cut. Now that that's not there, I just want to point out that even though if they don't have the just right 3 millimeter sealer, they can still use the Covidian ligature but not use the cutting function so that you would use it, you would seal, don't use the cutting function, take it out and use a scissor so that you can make just a little nick in what you sealed to make sure that it's sealed, or, or as you say, the space between. the two seals that you made, you make a little nick to make sure, and if you just use the ligature as it's designed, it'll cut through the whole thing and you won't have that safety opportunity. Is that, is that a good summary there? OK, yeah, no, that's exactly correct. And the other thing, that thing I liked about the LS 1000 is that it actually had a very fine tip and you could dissect with it. Now that that's no longer available, you know, the 3 millimeter sealer has the same fine tip. It looks like a Maryland. The other devices that are 5 millimeter really don't have it. So if you're using those, and I do, and I don't have the 3 millimeter sealer or in much larger patients, you often have to do the dissection with a Maryland, a standard 5 millimeter Maryland, and then once you have the vessel dissected out, you can put in the ligature and and use that to make seals, but I definitely would make two separate seals and not. Cut unless you're really on a small segmental vessel where you, you could easily grab the vessel proximately and get control if you need to. Yeah, that's that's a good point. I think that's the highest level of anxiety of this operation, so I'm glad we spent time on it is the ceiling of the vessels. How do we manage the different lobes and what sort of technical pearls can you give us regarding how to take these lobes? I know we talked about vessel management. Let's start with um. Oh, a left lower lobe. OK, so I mean, briefly, left lower lobe, so we have a right main stem intubation. The, the camera port again is going to probably be in about the 6th inner space in the, in the, um, mid axillary line, and then my left hand's gonna be either in that inner space in the anterior axirior line or maybe one above, and my right hand's gonna be in the 8th or 9th inner space just above the diaphragm, initially a 3 millimeter instrument, then later changed to a 5. The first thing I always do is I take down the inferior pulmonary ligament because I want One, I want to make sure my energy source is using whatever I'm using and I'm comfortable with it, and that's a relatively avascular plane. And the other thing is to check for that systemic vessel to even, you know, so if you saw it on CT scan, great, you know to go look for it and get it, and the first thing you want to do is get control of that vessel and then, and then divide it. If you didn't see it, that doesn't necessarily mean it's not there. Occasionally it's missed, and so this way you go look for it. And you take down the inferior pulmonary ligament up to the inferior pulmonary vein, and I expose the vein so that if I do have a problem at any point, I'll already have exposure there, so I can take it. And then we turn into the, the major fissure, um, and, you know, the ease of the operation really depends on how complete the fissure is. If the fissure is very complete, complete, and you're just looking at the pulmonary artery as it traverses through the fissure to the lower lobe, that's great. Um, life is very easy, but I think the one thing, even for surgeons who are comfortable with, um, you know, thoracoscopic techniques is when there's an incomplete fissure, they're not quite sure how to proceed. And so this is, this is really the key, and so I like using the same vessel sealing technology to complete the fissure, and basically what you do is you kind of go through it a layer at a time. It's almost like finger fracturing. Um, during a liver lobectomy, but you start at the front and you start to work into the fissure in the plane that you believe it's going, and you just go in and you, you kind of dissect in a little bit, and then you grab the tissue and you seal, and you cut in the middle of the seal, or you can make two seals and cut between them, and you gradually work your way um posteriorly and down the fissure until you expose the pulmonary artery. And then once you find a branch of the pulmonary artery, you know that everything that is anterior to that, so coming up towards the chest wall, is going to be safe. And then you can be a little bit more aggressive in completing the fissure, but you're basically unroofing the pulmonary artery, and you're going to find in a lower lobe, you're going to find usually a main trunk that then bifurcates into four branches. Um, to the basal segments, and then there's going to be a branch that comes off a little bit higher and a little more posterior, and that's gonna be the superior segmental branch, um, and usually in these cases what I'll do is once I've exposed the artery, um, I'll complete the fissure and so again once you've found the trunk, you can be a little bit more aggressive in completing the fissure and if. If you've got a lot of lung tissue posteriorly, but you've exposed the artery, you can even use the 5 millimeter stapler to compete the fissure posteriorly if you don't want to use the sealer. And then I will dissect out that superior segmental branch, um, and seal it, you know, make two seals on it and divide it, and that just gives me more access to the, to the, um, main trunk to the basal segments. Mhm. And then, um, and then once we have that, I'll dissect, I'll get underneath the, the trunk to the basal segments, and, and the advantage you have here is that the bronchus sits right underneath the artery. It's always there. And so you can actually feel the bronchus and use that to help you dissect behind the artery. Um, and get control of that. And then, then you have a decision to make. If you have a good length of, of the main trunk and you feel like you've got good control and depending on the size of the vessel, and you can take it at that main trunk, or if you want to be more conservative, you can dissect out into the segmental basal branches and identify each basal segment branch separately. And seal and divide those so that you're dealing with smaller vessels. When I've gotten that basal segment and I have a nice trunk and I feel like I have good length, even if that vessel's a bit big for the vessel sealer, I've started to use the 5 millimeter stapler on that because it just quickens the operation as opposed to isolating four different vessels. I can now take the main trunk. Um, but if you're going to do that, I always make sure that I have enough of the vessel proximately that I can have a clamp on it in case there's a problem with the stapler, so that once you fire the stapler, if there's any bleeding at all or anything from the, the staple line, you've got proximal control. But if you're not comfortable with that, or if you don't feel like you have enough length, then the key is just to dissect down into the lung, use the, the sealer to just dissect out. The basal segment branches and individually isolate them and then make your two seals and divide them and that's probably the safest thing in terms of vascular control. This is great going step by step because this is like, I think, as I said before, this is what is giving people the most anxiety. I know. If people are listening to this on the Stay Current app, if you click the video button or the watch button, you'll be able to watch Steve's videos that I'm hoping he'll be able to lend to us for this so that you can see exactly how to do each lobe. The next step in the left lower lobe is now we've divided the artery, and it used to be that then I would go take the vein because that's what we did open. But in fact, when 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. And because it's, it's hard because it's hard to flip the lung back and forth and get different exposures, I now basically go from front to back, straight through the fissure. And so the next thing I do is the bronchus is sitting right there, and I treat the bronchus very much the same way as I did. Um, the artery, depending on the size of the child, so, um, the first thing I'll probably do is. Isolate that segmental bronchus, superior segmental bronchus, um, and either, um, use clips or or a 5 millimeter stapler on it and divide that. And then that gives me good access to the main trunk of the bronchus to the lower lobe of the basal segments, and I'll isolate that. And the 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. But once you get through that, you can then, again, um, use a stapler or clips, in most cases, and again, especially if the child's smaller, um, you can then divide the bronchus at that, at that main trunk, um, and completely open that up. Um, if you're in a kid that's probably over 10 kg, um, the 5 millimeter stapler is not going to be big enough and clips aren't going to be big enough, and you're probably going to have to use a 12 millimeter stapler, but once you start getting up to 10 or 15 kg, you've got enough space in the chest to put in the larger staplers. And then once you've divided the bronchus, you're looking at the inferior pulmonary vein, um, and you can usually what I'll do is I'll dissect up into the lung enough to the first bifurcation. Um, I'll take the smaller branch, which is usually inferior. I'll usually do that with vessel sealing um to get a little more length on that trunk, and then when I'm sure that I've got enough length on that trunk that I can put the stapler across the trunk. And I have, and I can get my, my left hand with an atraumatic grasper on the, on the base of the trunk. I'll just take the pulmonary vein at that level. And again, if I have any problems, I've got vascular control because I've got a clamp on it proximally and it gives me a chance to recover. If you don't have the 5 millimeter stapler, then I would just dissect up into the lung to where you get to small enough branches that you can do two seals and divide between them. But the 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. So you need to make sure that you've got enough length away from the pericardium that you can get proximal control if whatever device you're using fails. So that's the left lower lobe. The right lower lobe is the exact opposite. You just switch hands and flip sides, but it's almost the exact same thing. The only thing you have to be careful of is that as you take, as you isolate the pulmonary artery to the lower lobe, the branches to the middle lobe are going to be coming off just above that. And so again, depending on how complete the fissure is, you can get fooled a little bit. And if you migrate north towards the head, you could potentially damage those branches that come off. So you just need to make sure that you're getting the trunk. Um, below the level of the middle lobe vessels, but otherwise it's almost exactly the same thing. What about the left upper lobe or the right upper lobe? So left upper lobe, um, what I like to do now, I've changed my technique and it goes for basically the, the same for the right upper lobe is we'll, I'll put my camera port, so instead of the 6th inner space I'll probably be in the 5th. I might move my left hand, both my hand, my right and left hand ports up in inner space because I'm working, you're doing a lot of your work in the fissure, but you're also doing. Um, up around the apex of the lung, and so what I'll do is we'll collapse the lung and then I'll retract the lung down. I'll use my left hand, grab the apex of the lung, and retract it inferiorly to expose the pulmonary artery as it comes into the upper lobe near the apex of the chest, and, and you can, and you just angle your scope enough so your cameraman. The, the, the orientation of the scope is up towards the apex and then they should use the angle of the scope a little bit to give you a good view of that artery as it comes off the main pulmonary artery and so you can find the um the main trunk right there that's going to the um. The apical segment and the um uh anterior segment, and you can isolate it. Excuse me. Um, and I dissect that trunk out there, and then again, I'll go, dissect out to where it bifurcates and seal those vessels and divide them. So that gets the main flow to the upper portion of the upper lobe, um, so that apical segment and then, uh, the, uh, the superior segment and also the posterior segment. And then I'll retract the lung posteriorly, exposing the superior pulmonary vein as it comes into the lung. And I'll go ahead and I'll take the branches of the vein as it, as it goes into the upper lobe, and it's the same technique. You'll see the main trunk coming off, um, and I will, um, take wait dissect up high enough so that I get to a place where the vessel's a bit smaller and we're away from the pericardium, um, and then take, um, it either at the first bifurcation or dissect up a little bit further if I, if I need to get length. And then I keep working inferiorly and you'll find the pulmonary vein to the lingula. Um, and it's the same thing on the, on the right side. This is really the pulmonary vein that goes to the middle lobe. So where we almost always take the lingula with an upper lobectomy on the left, in the, in the right, we're usually trying to preserve the middle lobe, but in this case we just isolate the vein and take it, um, same technique, and then we start working in the fissure, and if it's complete, great. If it's not, we complete it in the same way, that kind of piecemeal fashion. And the first thing you'll come to is the lingular artery. And so we isolate that again proximal and distal seals and divide it and then as you work posteriorly, there's always one large branch um coming back up to the posterior segment of the of the upper lobe um and that's usually the last artery you have to take. And then you'll have the upper lobe bronchus coming off, um, and depending on the size of the child, you can take it at the main trunk where it comes off, or you can dissect a little bit up into the lung and get it at its first bifurcation. Um, so we sort of work from top, then down around the front, and then up through the fissure. The other way of doing it is to just work from the fissure. If you can't get good lung collapse or you're having difficulty visualizing, it's to start in the fissure and this basically strip the upper lobe off all of the structures. Um, I just like getting that large branch of the pulmonary artery first that's coming in at the superior aspect of the upper lobe. Um, just because I think it diminishes blood flow and makes it a little bit easier. What about in the middle lobe, the right middle lobe, the middle lobe is, you know, on the right side, obviously. So the first thing I do is complete the minor fissure and work back, you know, that the pulmonary artery is going to come in at the posterior aspect of that middle lobe. It's going to bifurcate um. Into an, uh, upper and lower branch. And so you want to try, so you complete the minor fissure and, and as you're kind of holding the lung up with your left hand, um, to expose it, you know, if the fissure is complete, great. If it's not. You can there's usually some sort of cleft anteriorly that gives you a hint where it is, and then you can aim back towards the major fissure. The other thing you can do is you can see where the the superior pulmonary vein comes in anteriorly, and you'll see the branch going to the upper lobe, and then you'll see the branch going to the middle lobe, and that also can help you identify where that plane will be. And then you just kind of finger fracture through it again using the sealing device until you expose the pulmonary artery, and then once you've done that, you can take the branches and the bronchus will be right underneath it and then you can also, you know, prior to that you complete the major fissure if you need to if it's not complete. Are there any other technical pearls before we move on to sequestration? I just wanted to ask you briefly about sequestration. Any other technical pearls for lobectomy? No, I think, I think that's it. Again, I think it's just be methodical, have a good picture in your mind of the anatomy so that you're comfortable. You know, working in one plane, I think, I think it's just if you start trying to flip the lung back and forth and going around, and sometimes you can't help but do that, but if you, if you can avoid doing that, it really helps you, and so you just have to have a comfort level of where that artery's going to be in the fissure so that you trust yourself to work in that plane. The other thing I didn't mention that is if 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, and if I, if I go in the chest and we can post these videos for those listening. But if I go into the chest where I've got these large cysts and you really have no room to see because the lung won't collapse, so I take the sealing device and grab the cysts and apply energy and gradually basically do kind of a lung reduction thing where I'm compressing the lung till it gets small enough that I feel like I'm able to manipulate it without problem and that I can see much better, and that's a key part. You should do that right at the beginning of the procedure. If you have large cysts, it's a great tip, and I've tried that based on your recommendation. It works well, Steve. So real quickly, how do you take the vessel for extra lobar sequestration? So I think you know it depends. So the first thing is there can be more than one vessel. The most I've ever seen have been 6 vessels. The vessels can be smaller, they can be quite large. We did a case last year where the vessel was almost 15 millimeters in diameter. So you know, the easiest thing to do, and what we used to do is you'd expose the vessel and then apply a number of clips to it. Um, you can certainly, you know, suture, tie it off, but I, I would do something more than just that. You can, you can use the endoscopic clips, and in most cases that's, um, they're large enough to get across the vessel. But again, I would do it in such a fashion if you're using clips that you have. Um, you know, you have enough length on the vessels so that you can apply clips proximately. You can apply clips distally, and you can cut partway between them because again everything fails. And so if you do that, if you use the same technique as we do with the sealer, then if for some reason it doesn't work, you can do something else. You can get another clip on. The 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 and I believe that's because as the vessel, the nature of the vessel changes, that the clip no longer has secure footing, that the the vessel sort of necrosis a bit and the clip falls off, and you can get late bleeding. So either use clips or use vessel sealing, but don't use both on the same vessel. And you can also use vessel sealing on these vessels if they're, you know. Depending on the size of the vessel, but you want to make sure again that you've got a good length of the vessel exposed and that you cut partway. Just remember the pressure head is coming off the aorta as opposed to the pulmonary vessels where the pressure head is very small. Um, and then the case I mentioned with the 15 millimeter vessel coming off, we just used the 5 millimeter stapler on that, and that worked quite well. Yeah, I was going to ask you if a stapler would work. Is it ever reasonable to just leave these alone or even embolize them? I 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. Uh, it's very popular in some places in the world to go in and embolize these, but if you're going to embolize them, that kid needs a general anesthetic and needs a fairly significant intervention um through their arteries. I 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. Um, and we've had no significant complications from doing this. So, um, we don't ever, we don't ever do that. We remove them all and basically because of the concern of infection, uh, later on. There are some people who are comfortable watching them. Um, you know, I guess you can have that discussion, but again, I worry about what might happen later on, and I 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. I agree. Steve, do you, um, ever going back to the lobectomy, consider doing not a complete lobectomy and doing just a segmental resection? You know, I, I used to say no, I always did a lobectomy. I have changed some. Some of that came out of me. The first case I ever did it in was a kid who I thought I was going to do a lower lobectomy for a CPAP that I thought was primarily in the You know, in the superior segment of the left lower lobe, and I got in there and in fact there was cystic disease probably in the superior segment of the lower lobe and the posterior segment of the upper lobe, but there was absolutely no fissure. There was no major fissure, and so my only option would have been to do a total pneumonectomy, and I wasn't willing to do that. There were some congenital cliffs, and I ended up doing sort of a segmental resection of those two segments and following that kid. Since then, we've had probably about 20 cases where on the, the preoperative CT scan, um, and then correlating with findings at the time of surgery, that there's really Um, the disease appears to be, um, confined to just a segment. Um, and the easiest ones to, to deal with in those cases are the, the superior segment of the lower lobes or the lingula. Um, and if that's the case, and on the scans, it looks like there's really no disease in the basal segments, and the anatomy is favorable, we have done segmentectomies in those cases. We're following those kids. Um, my hope is that with, you know, further improvements of, uh, CT resolution and reconstruction, that we'll be able to be more confident that the rest of the lung is normal. Um, but right now we've been preserving lung, you know, lung segments in those few cases. The kids seem to do quite well, and we haven't seen any recurrent disease on follow-up, but it's not something that I can widely recommend because I'm, I'm just not sure yet, but we're, we're evaluating it. OK, so what is your general postoperative course for your lobectomies? Do they, how long do they usually stay in the hospital? So when we do a lobe, um, and it's the one case I do leave a chest tube in, um, like I said, you know, extra, extra lobar sequestrations we don't, but if we do a formal lobectomy, even if the fissure's complete, even if I'm convinced there's no air leak or anything, we always leave a chest tube in overnight just to make sure in case there's some bleeding or an air leak that pops up. If in the morning there's no air leak and there's no significant drainage, then we pull the chest tube. That morning we check a chest X-ray in 2 hours and we discharge the child that that afternoon if the family lives in town. If there's an air leak or there's some fluid, then we'll leave the chest tube in longer. Our average length of stay for a lobectomy of those patients who come in the morning. It is about 2.5 days. So it's, it's pretty quick and that and it's even a little bit shorter than the kids who are under who are under 5 kg. I think they do incredibly well. Well, um, Steve, this was very good. I know that, um, like I said, this is one of those things that, um, everyone feels probably a little uncomfortable with, uh, because it's it's high stakes here and, um, I know that you frequently will fly out to places or have people bring their cases to you. um I know that uh that's a big help since these are never emergent cases um it's always good to have someone. In the room who's done this quite a bit, so I appreciate your expertise in taking time out of your day to record this with us and uh uh we would love to have uh the associated videos so that people can watch those as well um so again thank you very much Steve for doing this. Todd, it was a pleasure. I appreciate the opportunity. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current in Surgery app. Please send questions or comments to us attacurrent podcast@gmail.com. We'll see you next time.