EmilyC
Networker
This surgeon titled his surgery as a trisegmentectomy, but it was performed on the left, and I'm struggling to see how this is more than a left lobectomy with lymph node dissection. I would appreciate any input.
Procedure:
Patient was taken to the operating room and placed in the supine position. General anesthesia was induced using a left-sided double-lumen endotracheal tube placed under direct bronchoscopic guidance. An arterial catheter and urinary catheter were placed for monitoring. She was then positioned in the right lateral decubitus (left side up) position on bolsters with all pressure points padded. The left chest was prepped and draped in usual sterile fashion. A 1 cm incision was made in the eighth intercostal space mid axillary line through which the 8 mm robotic port was placed. After confirming intrapleural entry we began CO2 insufflation. Intercostal nerve blocks were performed using 0.5% Marcaine with epinephrine from interspaces 3-11. A 12 mm robotic port was placed in the eighth intercostal space 1 hands with posterior to the initial port. An 8 mm robotic port was placed posteriorly in the eighth intercostal space. A 12 mm robotic port was placed anteriorly in the eighth intercostal space where the chest wall meets the diaphragm. An assistant port was placed down by the diaphragm. The robot was docked in standard fashion and all instruments were advanced under vision.
We began with a pleural exploration which demonstrated no evidence of pleural metastases. The left upper lobe tumor was identified and noted to be adherent to the pericardial fat. There were adhesions from the apex of the left upper lung to the apex of the chest cavity which were divided. We then excised the pericardial fat to free the lung and tumor from the mediastinum. Next we divided the inferior pulmonary ligament up to the level of the inferior pulmonary vein. Level 9 lymph nodes were sent for pathology. The lung was then retracted anteriorly and we open the posterior mediastinal pleural reflection. Level 10 and 11 lymph nodes were dissected off the posterior hilum and sent for pathology. The subcarinal space was opened and the level 7 lymph nodes completely removed and sent for pathology. We dissected the posterior aspect of the fissure. Similarly we dissected the pulmonary artery branches towards the posterior apex. The lung was then returned to its anatomic position and we identified the pulmonary artery in the fissure. The fissure was completely opened using serial firings of the robotic blue load stapler. We then divided a posterior pulmonary artery branch with the robotic stapler. This PA branch was bleeding slightly through the staple line and therefore we reinforced this with a clip. Next we circumferentially dissected the lingular artery branch and this was divided with a vascular load stapler. 2 additional apical posterior pulmonary artery branches were then divided similarly with the robotic stapler separately. Next we retracted the lung posteriorly and open the anterior mediastinal pleural reflection and identified the superior pulmonary vein. The superior pulmonary vein was completely encircled and divided with the robotic vascular load stapler. Level 5 and level 6 lymph nodes were then dissected out and sent for pathology. The anterior apical pulmonary artery branch was then dissected and divided with a robotic vascular load stapler which completed the vascular divisions. Peribronchial lymph nodes along the left upper lobe bronchus were removed and sent for pathology. A green load stapler was then placed across the takeoff of the left upper lobe bronchus and this was divided completing the left upper lobectomy. The left upper lobe of the lung was then placed in a specimen retrieval bag and removed from the chest and sent for permanent pathology.
We ensured hemostasis in the surgical field. A 24 French Blake drain was placed through the prior camera port and secured. All instruments and ports were then removed under direct thoracoscopic vision. The camera was then removed and all incisions closed in layers.
Procedure:
Patient was taken to the operating room and placed in the supine position. General anesthesia was induced using a left-sided double-lumen endotracheal tube placed under direct bronchoscopic guidance. An arterial catheter and urinary catheter were placed for monitoring. She was then positioned in the right lateral decubitus (left side up) position on bolsters with all pressure points padded. The left chest was prepped and draped in usual sterile fashion. A 1 cm incision was made in the eighth intercostal space mid axillary line through which the 8 mm robotic port was placed. After confirming intrapleural entry we began CO2 insufflation. Intercostal nerve blocks were performed using 0.5% Marcaine with epinephrine from interspaces 3-11. A 12 mm robotic port was placed in the eighth intercostal space 1 hands with posterior to the initial port. An 8 mm robotic port was placed posteriorly in the eighth intercostal space. A 12 mm robotic port was placed anteriorly in the eighth intercostal space where the chest wall meets the diaphragm. An assistant port was placed down by the diaphragm. The robot was docked in standard fashion and all instruments were advanced under vision.
We began with a pleural exploration which demonstrated no evidence of pleural metastases. The left upper lobe tumor was identified and noted to be adherent to the pericardial fat. There were adhesions from the apex of the left upper lung to the apex of the chest cavity which were divided. We then excised the pericardial fat to free the lung and tumor from the mediastinum. Next we divided the inferior pulmonary ligament up to the level of the inferior pulmonary vein. Level 9 lymph nodes were sent for pathology. The lung was then retracted anteriorly and we open the posterior mediastinal pleural reflection. Level 10 and 11 lymph nodes were dissected off the posterior hilum and sent for pathology. The subcarinal space was opened and the level 7 lymph nodes completely removed and sent for pathology. We dissected the posterior aspect of the fissure. Similarly we dissected the pulmonary artery branches towards the posterior apex. The lung was then returned to its anatomic position and we identified the pulmonary artery in the fissure. The fissure was completely opened using serial firings of the robotic blue load stapler. We then divided a posterior pulmonary artery branch with the robotic stapler. This PA branch was bleeding slightly through the staple line and therefore we reinforced this with a clip. Next we circumferentially dissected the lingular artery branch and this was divided with a vascular load stapler. 2 additional apical posterior pulmonary artery branches were then divided similarly with the robotic stapler separately. Next we retracted the lung posteriorly and open the anterior mediastinal pleural reflection and identified the superior pulmonary vein. The superior pulmonary vein was completely encircled and divided with the robotic vascular load stapler. Level 5 and level 6 lymph nodes were then dissected out and sent for pathology. The anterior apical pulmonary artery branch was then dissected and divided with a robotic vascular load stapler which completed the vascular divisions. Peribronchial lymph nodes along the left upper lobe bronchus were removed and sent for pathology. A green load stapler was then placed across the takeoff of the left upper lobe bronchus and this was divided completing the left upper lobectomy. The left upper lobe of the lung was then placed in a specimen retrieval bag and removed from the chest and sent for permanent pathology.
We ensured hemostasis in the surgical field. A 24 French Blake drain was placed through the prior camera port and secured. All instruments and ports were then removed under direct thoracoscopic vision. The camera was then removed and all incisions closed in layers.
