Technique: Blinded Left Upper Lobectomy

A 4 month old, 5 kg infant with a prenatally diagnosed CAm was brought to the OR for thoracoscopic left upper lobectomy. An anterior approach, as shown here was used using 3 ports, a 4 millimeter in the. Posterior axillary line for the telescope, 23 millimeter ports placed in the anterior axillary line, the lower port later being changed to a 5 for axis of the endoscopic clippopod. A new 3 millimeter sealer dissector was used for the case. Here you see the sealer being used to compress cysts in the left upper lobe to compress the specimen and allow for easier access to the pulmonary vessels. Once the cysts had been decompressed. The upper lobe is retracted inferiorly exposing the superior branches of the pulmonary artery as it goes to the apical posterior and anterior branches. Here the main trunk of the artery to the upper lobe is dissected out and sealed proximally and distally. And then divided between the seals. This technique allows for a safe. And effective and reproducible method for sealing pulmonary vessels. Without risk of bleeding. With the main branches of the pulmonary artery to the apical posterior segment and anterior segment dissected out, attention is then turned to the superior pulmonary vein. The vein is dissected out in the same manner. Each of the main branches of the superior pulmonary vein are individually isolated, dissected out, and then sealed proximally and distally with division of the vessel between the seals. With the main branches of the pulmonary vein to the upper lobe sealed, attention is turned to the major fissure. The major fissure is incomplete anteriorly, and the sealer is again used to help define this plane. The lung between the upper and lower lobes is sealed and then divided. As the section continues posteriorly towards the main pulmonary arteries, it courses through the major fissure, and almost finger fracture technique is used to divide the lung parenchyma and expose the artery. Here you see a small posterior branch of the artery going to the upper lobe. With this finished, the main branches of the pulmonary artery going to the lingula can be identified. The superior and inferior branches are individually isolated, sealed, and divided again using the 3 millimeter sealer. Once the artery to the lingula has been sealed and divided. The bronchus to the lingula is then exposed. This is sealed with a 5 millimeter clip applier, both proximally and distally, and divided between these. 5 millimeter clips have proven to be an effective way to seal. The bronchus in infants under 10 kg. With this done, the main bronchus. To the remainder of the upper lobe is visualized. Here it's seen it's bifurcation between the apical posterior and anterior branches. Each branch is individually sealed with a 5 millimeter clip. And then divided proximal to this. With this done, the upper lobe is completely free and is then brought out through the lower trochar side in a piecemeal fashion. This child had a chest tube in for 24 hours and was discharged on the 2nd postoperative day. Here you see the incisions at one month postoperatively.