Left Lower Lobectomy for Sequestration: Pediatric Thoracic Surgery Part...

Yes, they've got that image live. I'm hearing something. OK. You guys still there? We, we are back. We're watching the case. We're trying to see if we can hear Dr. Rothenberg and Dr. McCollum. OK, do you want me to, I'm gonna put it on speaker. Yeah, can we hear them? Can you guys hear us? Uh, sort of. I can sort of hear. That wireless to get or not. So anyway, um, I'm just a 2 month old. This is, can you hear me? Yeah, perfectly. Uh, can the audience, hold on, can the audience, uh, hear you? Uh, Stefan, can the audience hear them? Yes, it's Jean Martin says he can hear. Perfect. OK, great. Go ahead, uh, Steve or Mark, whoever that was. All right, well it's Steve. So this is a, this is a patient of Mark's. This is a 6 month old with a prenatal diagnosis of a, uh, thought to be a cystic lung lesion had a CT scan, um, at, uh, back in, in January. Uh, 2 weeks alive and, uh, showed what appeared they thought at that time was, uh, uh, a, a solid cystic, uh, uh, lower lobe lesion. Um, kid's been asymptomatic, um, has not had a repeat study, and I, you can't see the CT scan, but it looks quite solid and dense on the CT and we just put the scope in and it's actually, um, an, a, uh, extra lobar sequestration. OK. Uh, so it's not gonna be a lobectomy, but we can go over some of the points about it, um, as we show you. Um, but can you see, are you seeing the, are you, what view are you guys looking at? We're seeing the thoracoscopic view. We're looking at the sequestration. It's a huge, I mean, that's as big a sequestration as I've ever seen. I'm a little worried to look at it. So we, um, now you're looking, you're seeing the upper and lower lobe. We're still getting some ventilation. So we have a single 5 millimeter port in right now and we're insufflating at a pressure of 8. Um, with a 2 L flow and I, and we, so I don't think we really have lung isolation in this case, but it, it won't be a big deal, um, and I'll go ahead and show you, but the port placement, um, can we can. you No. Um, if you can see, are you looking? Yeah, but you're very quiet now. Can you hear me now? Yes, OK, so the port placement, here's, here's her nipple. OK. OK. Here's the tip of her scapula. OK. All right, and so we're about. 64, about 2/3, uh, um, between the tip of her scapula and the nipple, and we're right in about the fifth intercostal space and that ends up being right over the fissure. OK, OK, so now we're gonna go ahead, we're gonna put in, uh, our other ports. OK, so go ahead and look and look down here if you can. So now, especially because we're doing a, a, uh. An extra lowbar sequestration but so you can see there we're. I'm injecting the skin. I'm going to look for my needle, and there you can see it. So I want, I wanna be. As low an inner space as I can, and bigger inner space just so I have uh room to go and it's in the anterior axillary line. OK, and we're still looking at the external view. Yeah, we'll show you the inside ones, but that's what I was looking at in the inside was where the needle came out. So this will be a 5. Because this is where we're gonna put the ligature. And then we'll put it, Mark came back, we're gonna put in a 3 millimeter port and I'm gonna put this basically right underneath. Right pretty much underneath where um. See, I think you're gonna bump ports cuz that uh head of that port is so big. Yeah. So that again that's the advantage of having low profile ports, by the way, we have those in the OR there. The anchor ports are in the OR if you want to use it, OK. Um, we can show it. So here's a 3 millimeter port. This is a kind of, but this is really long. Why would you put a port in there? It's a, you said 3 millimeter. Why, why not just. Put the instruments in without a port. Why? What? Why use a port there? Because I'm, I'm using CO2. Yeah, no, you have the CO2 through the 5. Why do you need a 3 millimeter port? You'll leak around if you do enough manipulation, why not just make a stab wound? Yeah, because eventually you'll leak around it. Ports are cleaner. OK, that, that's, and I need a stitch to put, you have like a 30 silk or something. Would you consider just using two ports, Steve? It's a big lesion, but it'll have a narrow pedicle. You can see it's edematous. So 2 ports, a scope, and then just 1 other instrument. Uh, I guess. I don't know that I, I don't know that I would. I'm just throwing it out there. I've, I've done smaller BPSs with just two ports. Yeah Maryland. I guess you could try, you know, I, I honestly, I, um, yeah, it's not a big deal. Inter incision stroke our incision is pretty benign. What I actually I'm like. So we're just talking about so we're coming in and. Alright, let's go to the endoscopic. Yeah, let's switch to the inside view. Is, uh, Jean Martin, are you on the phone? No, I think unfortunately one of the problems that we are because of the size of these ports is there's a little bit of dueling. Give me the Maryland huh give me the, not the Maryland, I'm sorry, the leg. Back up. This is a really pretty good sized mask, so we're gonna try and record this. So So if we were doing a lobectomy, uh, there's the inferior pulmonary ligament, and I would just come in and take that down. The other thing, let's show you as long as we're in here, we'll go look in the picture. Is anyone else on the phone? So here's the fissure. Uh, that's what I think we should do a lobectomy anyway. You know, I just for Jack. We are I we. Just so you guys know, you don't have single lung ventilation, not even close. As a matter of fact, if you, I would not be surprised if you were preferentially ventilating this low. There you can see the major, so there's the fissure. So of course, because we're not doing one, there is, uh, you can see the pulmonary artery right here. So look down a little bit. That's a beautiful fissure. Yeah, look at this it would be beautiful. So here's the, the anterior basal segment come in here you can even see the uh the superior segment coming off right there. Yeah it would uh. It would be amazing. OK, so we'll come, we'll go do what we came to do. But you can see that we're where the where the scope is set up, we're right perfectly placed for it. So unfortunately we're, we're, we're a week and half. You're having a hard time getting the lung down, huh? Yeah, they're, yeah, we're. That person 00 no, that was my assistant who closed the port. No, we're better now. We've got. Sorry, Steve, do you want me to send in a different assistant? OK, look up. So let's go and see if we can find the where we're dealing with. So you kind of need it. So a lot of times, so your cameraman, it really has to work sometimes to get the view and to stay out of your way. The one thing we can do here is we use the angle of the scope. And have him come in kind of like this so he's out of my way. I quite get it, um, can you. Like that, that's how I want it, yep, yeah, like I, everybody likes the orientation a little bit differently. So It's uh. So there's uh, there's, we're looking underneath now if you can put that in the center. I mean uh. You can see how narrow that pedicle is. All these edematous ones have that very. A small tight pedicle. Is that because you think outflow obstructed? Yeah, well, I think it, you know, it's so edematous because the pedicle is small, and I'm not sure the lymphatics develop normally through that. So here we're just trying to open it up and you could use a hook or whatever you want in here. I mean you're on a very narrow pedal. Why do you need to dive into the face of it all because I wanna know what's there. The question Mark just asked me, why do I need to dissect through it? Why not just do a mass ligature? It's because I like, I wanna know what a mass. Can you lower the table some more, sorry. Yeah, I agree. I mean, I probably could get away with it. And the, the other thing is, even in this, this child's a little bit bigger, but you'd have to see outside with my, you know, it's kind of awkward because I've got one very short instrument in and one very long instrument. So we'll just kind of tease away the pleura. Trying to get to where we want to be. And um we may use clips on this if we have clips. Just a regular 5 millimeter lip. It's got a little more body to it. Steve, tell us what, uh, what energy device you're using there. So this is the ligature. This is that Maryland detector. Is this the LS1000 LS 1000? And you know, it's interesting, Steve, um, who was it that said it, uh, I think Liam, uh, that COVIDian's really not trying hard to or they're, they're not very interested in people using this. It's really only. Because pediatric surgeons. Right. Well, you know, most people don't like it because it doesn't come. Um, but again, I think you know for the the the number of and you're really talking minutes in a case. Um, the safety factor. I think it's significant. That will help. The picture in picture. Greatly. So we're gonna just because uh this is really interesting, this is a big heavy lesion. What's the roe on. What's going on? You need me to come down there and help you lift it, Steve. I may need a 5 just because I'm going to have an air leak. You said you have an air leak. Well, because I'm using this 5 millimeter port. And I'm using a 3 millimeter instrument. Oh, that port doesn't have a reducer. We have in that room that you're in, we have a 5 millimeter steptro car with a reducer on it. Oh, I thought. No, we do. I use them on every case. So they are in room 9 or 10. So what I'm just trying to do is dissect out the pedicle. What's really going on here. It's worth getting that instrument if you're, I mean that trocar, I think we have it, it'd be great. Yeah, they're in the cabinet in the room in 9 or 10. That's what I, that's what I showed in the videos. That's what. Like me to open it. And uh if they're opening it, Steve, make sure they know to get the varus needle with it. Yeah, I don't need that so much because I already have a hole. Yeah, but it's not um it's gonna be hard to get it in, but I'll show you. Steve, my job here is to give you guidance. Thank you, I appreciate that. You're welcome. You can see the pleural effusion associated with this sequestration too. It's just from, you know, because of the leakage from the capsule. Or do you think, and this could have also partly related to the fact that there was decreased venous return, do you think? Yes, it was, it's either lymphatic or venous. I think it's mostly lymphatic. You can see a The the dilated channels on the surface. But it just weeps fluid. If anyone wants to call in, Stefan, can we put the call-in number back up again? Uh, if anyone has a question they wanna ask Doctor Rothenberg, uh, feel free to call in and ask your questions. So if you already have a hole, you don't need the various needles. You just put the sheets in and then you put the choker. OK, that's true. And the only other thing, do you have a, if, if you can, do you have any mineral oil or just at least, yeah, um, so when you use this reducer you wanna show. Let's do an external shot and show that because I think that's really important, especially for the TEFs as well. Yeah, so this is a, you can see here the step and you see this little orange cap. Wait, hold on, we don't have an external view yet, Steve. We're still looking thoracoscopically, you know, when you've got the outside view. Oh, you have, you don't have a 3 millimeter. There you go. We can see it now, Steve. Um, yeah, 3 would be better. So when you this little orange cap, it's a little toilet seat comes on and off. So that's a 5, and then that makes it a 3 reducer, and it's, um, the only thing to recall about this is that, um, when you, the instruments tend to stick and so you need to lube the outside with preferentially a little mineral oil or just some fluid, you get any fluid at all. Bye. So a little mineral oil just makes it slide easier. I, and we're, we're, uh, you just put it over the shaft of the instrument. We're broadcasting live I converted comments. All right, so. And the other thing is we could we might secure this port in. So you know we're just a little, a little because this is so big because we don't have much lung collapse it's uh. We go, Jeremy, uh, if Jeremy's there, could he bring us back thoracoscopically? Oh yeah, sorry, can't go back there we go. I wanna thank uh Stryker for providing this, uh, this, this broadcast to us by making this uh. Taking the room and making it broad broadcast out. All right, so what are we looking at here, Steve? That's the. OK, and the, so that's the only thing that's attaching this lesion. To the uh the 3 millimeter. The only thing that's attaching the lesion and so the assumption is is that there's a vessel in there somewhere. It's a 3 millimeter hook. I. And the the um the CT scan, they thought they saw saw a large feeding vessel as well. So For dramatic sake we'll go ahead and. We'll, we'll milk this out. You were impatient, you could just put a clip on it at this point, probably. But again, sort of the principle of just getting. Getting some length There you can start to see the vessel. Yeah. Bye. All right. With me. Again, I'm retracting with my left hand and operating with my right. Your left hand is in the 3 millimeter port. Your camera's in that 5, and your other hand is in the other 3 millimeter port. Can you retract with your right and operate with your left? Only if I'm chewing gum. That Bye. This thing really wants to twist. Yeah. We don't have So again, you know, if I had known that this is what we're dealing with, I would have put my camera in a different. You would have put it lower, yes, because we're, we're fighting to stay under the lung, you know, when to just dissect out a vessel, it's fine, but when you're, you know, trying to do the whole operation, it can be. A little out of focus. I don't know if you there we go. that looks out of focus to me. Is that are we just Gonna try and get you a little better picture here. We were um About So again, well, you know, really at any point you could. Take this vessel. Yeah, I would take it. You've done enough. You want me to take it with a ligature or a clip? Well, I would use the wet clip here. I would use the wet clip on this one. I would use the ligature. I know you would. You love that. It's not a very big vessel. You can take a boat. No, you would use the end seal. If I had it. All right, let's, what do you think? I mean, I guess let's uh. Take it with the ligature. Do you have the LS 1000? It's only about a 2 millimeter artery, right? It's pretty small. I think there's 2 vessels there actually. That's what I was trying to show you. Is there a little vein? I think there's 2. That's interesting. Sean McLean, you know, Steve, stop me if I'm talking when you wanna say something, but, uh, Uh, I'm just getting bored here watching you dissect out this vessel, so I got to think of something else to say. Yeah, there you go. Uh, he says that he uses the, you know, that, have you seen that Geiger immobilizer, the pyloric thing? So I love that. I use that for pylorics, but Sean says he uses it, uh, to retract the lung because it's, it's, it's like a, it's got such a long jaw. Yeah. You normally don't need to retract the lung. Usually you can do it with gravity and, and ventilation. And Sean, do you use it? Do you grab the lung or do you just push it aside? Or you can, we can try and detect number they were getting with. And the hardest part of this case will be pulling that edematous sequestration out of the chest. You're right, I'm I'm leaving after this. So is that a little sticky? Not really. Not really. Too much edema. So yeah you see we have two separate seals. But a little bit lower. Bye You have a 3 millimeter. So I, I still think we ought to take out the lower lobe. I think you should. You know, the shame is, what are we doing 3 tomorrow? Yes. So again, so we look at it there's a seal there there's a seal up there. So we'll just start to cut slowly. They're my the steel that's coming out. We're kind of trying to catch it anyway. Remind me to send you some sharp scissors. No we're OK. So I want you to see, you'll see a loom in here pretty soon. But this is not the wrong way to do it, you know, this is the way you want to do it. You want to be sure. I know. To bring you instructor. You can see the two separate vessels that I was talking about? Yeah, yeah, yeah. Always again because they were so small we and you guys were getting patient we just took it in one. Oh my God, All right. Chip shot. So now what? Now do a thoracotomy and take it out. Yeah, exactly. So this. This will be uh. So, and that, so what's the other point is once I've seen a seal like that, I've never had a seal break open. I know Alan did once, but I think, you know, if you see that you can be pretty comfortable that you're OK. Yeah, Um, so now we got this thing. Uh, so now what we do, Ellen, you think you could get that through a 5 millimeter truck car without making it any bigger? Absolutely. All right. All right, so give me a, uh, you missed that, not in one piece though. So I, alright, so I've taken the bottom tro car out. This is just a hemostat. So the thing you don't want to do here is you don't wanna grab normal lung and bring normal lung out of the trochar site. Yeah. Bad idea. All right, so we're gonna bring this up. Other hemostat. So I don't know, can we get a picture in a picture or? This is going to be the hardest part of the procedure. Can we get an external view of the, or can you just go to external? The internal view is going to be boring. You might as well go external internal external. So then this is we call this clinic. I always stop the recording at this point. Yeah, that's what I was gonna say. I think it's, uh, I think we get it. You don't need to, that's, uh, well, Steve, while you're, uh, slugging away at this, there was a question from, was it Liam or Yama. Who wanted to know about what you found when you, it was Liam, I think when you go back in on your yama ass on your on your segmentectomy, you went back in for a recurrence. He wanted to know how bad was it adherent when you went in. It wasn't bad at all, which is what Alan said in his one case as well, so it's interesting. Remarkably clean. And then, uh, Giovanna had a question about, do you, when you do a, if there's really no, uh, fissure and you create a fissure, uh, with the ligature, do you seal it with fiber and glue? Um, the parenchyma. If there's no fissure, you're not talking about a segment if you complete a fissure, if you complete a fissure, no, I don't routinely. What about a segment? No, only if I think if I'm not anatomic. I checked for an air leak though, so I, if I um see a significant air leak. Then I will. Oh, so you, what do you, uh, do you put saline in the chest? It's the wrong thing to do. Right, right, I know there's not much downside, although Alan's point, which is a really good one, is that the fiber and glue clogs up the, the chest tube, yeah, um. Uh, do you check for an air leak, Steve, with saline? Have a um OK. Lesion is So that. OK. Hey, um, hey, Stefan, are you there? Can you pull up my slide presentation? I wanna show Alan my case and see what he would do. I know what he's gonna say, but I. No, no, my case, it's just like 44 X-rays. No, no, keep the, oh, keep the hour, just minimize it. I mean, just make it split screen. That. There you go. Yeah I get the fun of doing a little bit. Oh, OK. Marco, you wrote up, you up stretching. I don't know what you're saying, it's stretching. I don't know what you meant by that. I Oh. Oh, it was, um. Would not be. Not, not now, right? Um, Uh, we'll just get out of there. I Yeah, I'm going mile away. I. So is there anybody who would have left this lesion alone and watched it? Is that a comedic question or are you serious? Everybody's saying, well, what if it's. I leave them. Uh, Jack, are you there? Let's see. It had a baby in it. Yeah. Yeah. I can have that beer now. Yeah, you can. You probably could have had it before the case. I could have. cases in Colorado. Are you here? Yeah, I know. Uh, there we go. Alan and I drank them all already. All right, that's why, that's why I'm so quiet over here. Yeah, good job. That's all it is. That's all it is. Look at the size of it compare the kids' chest. They squeezed all the edema out of it, yeah. Very nice. Very nice. Steve. What do you do with the, uh, uh, what's your, for the 3 millimeter things, do you just glue them shut? Yeah, I, oh, you know, basically either in laparoscopy or thoracoscopy if I can see, if I can see fascia, I close it, and you can do that sometimes through the 3, the 3 millimeter ports I put just a monochrome in the skin, very monochrome. What about, um, do you put, are you gonna put a chest tube in him? Yeah, OK. We'll just evacuate his chest through the trocar and then have them pull it or or you, you know, but we, I would not leave a chest tube in this kid you can evacuate it at the end however you want, but. All right, well, that's pretty much it. All right, very nice job. Thank you. Yeah, I don't think I wanna mess with that. Thank you very much. Uh, it was a great broadcast and a great case. Thank you both. Um, so it looks like we're gonna draw to a close. I, I, uh, Alan, thank you very much, uh, for joining us. Um, I know it was painful to have to watch Steve at the end, but I appreciate you staying with us. Uh, Steve, thank you very much, Mark, thank you. Um, I wanna thank all of our visiting faculty and everyone who stayed up all throughout the night to watch this. We will have the archive up in about 6 weeks, and you'll be able to watch it at that point. Uh, thank you again. Uh, I hope you enjoyed the show and, uh, don't forget, uh, you'll get your email for the CME credits soon, but also, uh, don't forget to join us. You can sign up now for the oncology show, uh, next month, and then the, uh, Alan's gonna come back here for the fetal show in November and then the trauma show in, uh, in February. So, uh, thank you all very much and, uh, we'll, we'll talk to you soon. Good night from Akron.