Steven Rothenberg
Anatomic Dissection Avoid Mass ligatures Respect the other Bronchi For Sequestration: Identify systemic vessel first Understand anatomic relationships Complete Lobectomy (Maybe Not!)
Single lung Ventilation: Mainstem intubation, Double lumen tube, Bronchial blocker, Tracheal Intubation Lateral Decubitus Position CO2 Insufflation (4mm Hg, 1L/min) Valved Trocars 3 to 4 Ports
Suture Ligation Endo-GIA Endo-clips Tissue Sealing devices: Ultrasonic shears, Ligasure, JRS Bronchus: Suture, 5mm clip, 5 mm stapler
Meticulous Dissection and Hemostasis Create space Work anterior to posterior Understand spatial relationships of Pulmonary anatomy
Lat Decub Head Monitor MonitorSurgeonAssist Nurse
Scope port over the major fissure: mid- axillary line (4th or 5th interspace) Working ports more anterior/ inferior: 4th to 8th interspace
¨ January 2001- November 2015¨Prenatally diagnosed lung cystic lung disease as well as acquired disease¨396 patients¨Weight: 2.8-78 Kg¨Age: 1 day – 18 years
¨CPAM & BPS – 346¨Bronchiectasis– 31¨CLE – 15¨Malignancy- 4
¨393/396 procedures completed thoracoscopically¨87 upper/ 28 middle/ 281 lower lobectomies¨Operative time: 35 min – 240 min (mean 115)¨Average time for trainee : 160 min¨Intra-op complication rate: 1.1%¨Chest tube duration: 1.2 days¨Hospital Days: 1-5(mean 2.6 days)
¨Four conversion to open: Bleeding in 3, compromised bronchus in 1, malignancy 1¨No post-operative bleeding or BPF¨4 re-operation for air leak
¨96 pts with no significant respiratory distress operated on electively¨Average operative time 90 minutes¨Average length of stay post-op 1-16 days (mean 3.2)
¨3 unsuspected malignancies¨2 pulmonary blastomas¨1 adenocarcinoma. ¨K-ras mutations, either c35G>T (G12V) or c35G>A (G12D
Thoracoscopic lobectomy in infants and children is a safe and effective procedure. New energy sources have eliminated the need for staples, clips, and ligatures in the majority of cases. Current instrumentation allows the surgeon to limit his largest trocar to 5mm and intervene in infants as small as 2.5kg. The long term benefits include not only improved cosmetics, but also the lack of shoulder girdle weakness and chest wall deformity.