The Easy Way to do a VATS Lobectomyaz9194.vo.msecnd.net/pdfs/120401/16.04.pdf2012/04/28 · Robert...

The Easy Way to do a

VATS Lobectomy

The Easy Way to do a

VATS Lobectomy

Robert J McKenna Jr. MD

Head, Thoracic Surgery

Cedars Sinai Medical Center

Robert J McKenna Jr. MD

Head, Thoracic Surgery

Cedars Sinai Medical Center

AATS Saturday 4/28/2012

VATS Lobectomy

Current Status in US

VATS Lobectomy


•STS database: 40%

•Throughout US: 15%

•STS database: 40%

•Throughout US: 15%

VATS Lobectomy


VATS Lobectomy


If you want to lose lung cancer If you want to lose lung cancer If you want to lose lung cancer surgery to RFA and SBRT, continue to not do VATS

Lobectomy

If you want to lose lung cancer surgery to RFA and SBRT, continue to not do VATS

Lobectomy

VATS Lobectomy

(N=2804)

VATS Lobectomy

(N=2804)

•1992-2012

•Women (54.1%)

•1992-2012

•Women (54.1%) •Women (54.1%)

•Men (45.9%)

•mean age = 71.2 years (range 16-95)

•Women (54.1%)

•Men (45.9%)

•mean age = 71.2 years (range 16-95)

VATS Lobectomy

should be:

• Same Operation Performed as

an Open Procedure

• Same Operation Performed as

an Open Procedurean Open Procedure

•Anatomic Dissection

•Node Dissection or Sampling

an Open Procedure

•Anatomic Dissection

•Node Dissection or Sampling

Operative approach:

the start

Operative approach:

the start

• Switch from postero-lateral

thoracotomy to muscle sparing

• Switch from postero-lateral

thoracotomy to muscle sparingthoracotomy to muscle sparing

• Get used to working from

anteriorly

•Make a larger utility incision

thoracotomy to muscle sparing

• Get used to working from

anteriorly

•Make a larger utility incision

Operative approach:

next step

Operative approach:

next step

•Make the muscle sparing

incision smaller and dissect with

•Make the muscle sparing

incision smaller and dissect with incision smaller and dissect with

VATS

• Set a time limit

• Get used to the VATS incisions

and angles

incision smaller and dissect with

VATS

• Set a time limit

• Get used to the VATS incisions

and angles

VATS

LOBECTOMY

VATS

LOBECTOMY

TECHNIQUETECHNIQUE

VATS LOBECTOMY:

INCISIONS• #1: 5mm for trocar, 8th Intercostal

space for 300 lens

• #2: 2cm, 6th Intercostal space, mid-

• #1: 5mm for trocar, 8th Intercostal

space for 300 lens

• #2: 2cm, 6th Intercostal space, mid-• #2: 2cm, 6th Intercostal space, mid-

clavicular line

• #3: 4-6cm, 4th Intercostal space, mid-

ax line (Utility Incision)

• #4: 1cm, in auscultatory triangle

• #2: 2cm, 6th Intercostal space, mid-

clavicular line

• #3: 4-6cm, 4th Intercostal space, mid-

ax line (Utility Incision)

• #4: 1cm, in auscultatory triangle

AnteriorAnterior

axillaaxilla Costal Margin

PosteriorPosterior

Scapula

VATS LOBECTOMY:

INCISIONS

• 2, 3, or 4 incisions for a VATS

lobectomy are OK

• 2, 3, or 4 incisions for a VATS

lobectomy are OKlobectomy are OK

•Make enough incisions to get

good exposure and good angles

for instruments

•No rib spreading

lobectomy are OK

•Make enough incisions to get

good exposure and good angles

for instruments

•No rib spreading

Operative approachOperative approach

• Patient in lateral decubitus

position

• Patient in lateral decubitus

positionposition

• Surgeon stands anterior to the

patient

•Dissection starts in the hilum

of the lung

position

• Surgeon stands anterior to the

patient

•Dissection starts in the hilum

of the lung

Utility Incision

• For upper and middle

lobectomy: at level of superior

pulmonary veinpulmonary vein

• For lower lobectomy: 1

intercostal space lower

• From edge of latissimus muscle

anteriorly

InstrumentsInstruments

• 5 mm 300 thoracoscope

• Standard instruments (not endoscopic instruments)

• 5 mm 300 thoracoscope

• Standard instruments (not endoscopic instruments)endoscopic instruments)

• Metzenbaum scissors

• DeBakey pickups

• Curved Ring Forceps

• Endoscopic stapler

endoscopic instruments)

• Metzenbaum scissors

• DeBakey pickups

• Curved Ring Forceps

• Endoscopic stapler

VL: TechniqueVL: Technique

•Dissect anteriorly to

posteriorly

•Dissect anteriorly to

posteriorly

•Do not move lung back and

forth

•Completeness of fissure is

NOT an issue

•Do not move lung back and

forth

•Completeness of fissure is

NOT an issue


• Start with removing lymph

nodes to define the anatomy

• Start with removing lymph

nodes to define the anatomy

•Dissect on named structures•Dissect on named structures

Phrenic Nerve

PA

Upper Division V.

Remove level 5 and 6 nodes

Phrenic Nerve

Lingular V.


•Create tunnels to transect

vessels and fissures

•Create tunnels to transect

vessels and fissures

Mobilize Superior Pulmonary Vein

SPV

IPV

Staple Superior Pulmonary Vein

SPV


•Completeness of fissure has

nothing to do with VL

•Completeness of fissure has

nothing to do with VL

Dissect PA to create a tunnel

LLL Bronchus PA

Place Anvil of stapler on PA

PA

Staples through utility incision

for which structures

•Minor Fissure

•RUL Bronchus

•Minor Fissure

•RUL Bronchus•RUL Bronchus

• Inferior Pulm. Vein

•RML vein, artery,

bronchus

•RUL Bronchus

• Inferior Pulm. Vein

•RML vein, artery,

bronchus

Staples through anterior

incision for which structures

•Major Fissure

•Minor Fissure

•Major Fissure

•Minor Fissure•Minor Fissure

• Lower Lobe Artery

• IPV

• Lower Lobe Bronchus

•Minor Fissure

• Lower Lobe Artery

• IPV

• Lower Lobe Bronchus

Staples through auscultatory

incision for which structures

• Superior Pulm. Vein• Superior Pulm. Vein• Superior Pulm. Vein

• Anterior Trunk Artery

• RML Artery

• RML Vein

• LUL Bronchus

• Superior Pulm. Vein

• Anterior Trunk Artery

• RML Artery

• RML Vein

• LUL Bronchus

Right Upper LobectomyRight Upper Lobectomy

•Retract lung posteriorly

• Identify the minor fissure to


• Identify the minor fissure to

identify upper lobe vein

•Right angle clamp around the

upper lobe vein

• Staple the vein

identify upper lobe vein

•Right angle clamp around the

upper lobe vein

• Staple the vein


• Complete most of the minor

fissure with EZ 45, green stapler

• Preserve middle lobe vein

• Complete most of the minor

fissure with EZ 45, green stapler

• Preserve middle lobe vein• Preserve middle lobe vein

• Retract lung posteriorly and

inferiorly

• Remove hilar lymphatics

• Preserve middle lobe vein

• Retract lung posteriorly and

inferiorly

• Remove hilar lymphatics


• Right angle clamp around the

anterior trunk of the artery

• Staple the artery with endo 35

• Right angle clamp around the

anterior trunk of the artery

• Staple the artery with endo 35 • Staple the artery with endo 35

vascular stapler

• Clip or tie additional artery

• Complete more of the minor fissure

• Staple the artery with endo 35

vascular stapler

• Clip or tie additional artery

• Complete more of the minor fissure


• Right angle clamp around the posterior

ascending artery

• Tie the artery

• Right angle clamp around the posterior

ascending artery

• Tie the artery• Tie the artery

• Spread scissors between posterior

ascending artery and the upper lobe

bronchus

• Remove lymph node between upper

lobe and intermediate bronchi

• Tie the artery

• Spread scissors between posterior

ascending artery and the upper lobe

bronchus

• Remove lymph node between upper

lobe and intermediate bronchi


• Staple upper lobe bronchus with EZ 45

green stapler

• Complete fissure between posterior

• Staple upper lobe bronchus with EZ 45

green stapler

• Complete fissure between posterior • Complete fissure between posterior

segment of upper lobe and the superior

segment of lower lobe with EZ 45 green

stapler

• Place lobe in lapsac bag for removal

• Complete fissure between posterior

segment of upper lobe and the superior

segment of lower lobe with EZ 45 green

stapler

• Place lobe in lapsac bag for removal

Right Lower LobectomyRight Lower Lobectomy

• Electrocautery on inferior pulmonary

ligament

• Remove level 8 and 9 lymph nodes

• Electrocautery on inferior pulmonary

ligament

• Remove level 8 and 9 lymph nodes• Remove level 8 and 9 lymph nodes

• Retract lung anteriorly

• Remove subcarinal lymph nodes

• Retract lung posteriorly

• Right angle clamp around IP Vein

• Remove level 8 and 9 lymph nodes

• Retract lung anteriorly

• Remove subcarinal lymph nodes

• Retract lung posteriorly

• Right angle clamp around IP Vein


• Staple IP Vein with endo 35 vascular

stapler

• Retract lung anteriorly and posteriorly

• Staple IP Vein with endo 35 vascular

stapler

• Retract lung anteriorly and posteriorly• Retract lung anteriorly and posteriorly

• Complete fissure between the middle

lobe and the lower lobe with EZ 45

green stapler

• Dissect bronchus and artery

• Retract lung anteriorly and posteriorly

• Complete fissure between the middle

lobe and the lower lobe with EZ 45

green stapler

• Dissect bronchus and artery


• Dissect along the surface of lower lobe

artery

• Complete the fissure over the artery

• Dissect along the surface of lower lobe

artery

• Complete the fissure over the artery • Complete the fissure over the artery

with EZ 45 stapler

• Right angle clamp around the artery

• Staple the artery with endo 35 vascular

stapler

• Dissect posterior edge of bronchus

• Complete the fissure over the artery

with EZ 45 stapler

• Right angle clamp around the artery

• Staple the artery with endo 35 vascular

stapler

• Dissect posterior edge of bronchus


• Staple the remaining fissure between

the lower lobe and the posterior

segment of the upper lobe with EZ 45

• Staple the remaining fissure between

the lower lobe and the posterior

segment of the upper lobe with EZ 45 segment of the upper lobe with EZ 45

stapler

• Remove lobar lymph nodes

• Identify middle lobe bronchus

• Staple the lower lobe bronchus

segment of the upper lobe with EZ 45

stapler

• Remove lobar lymph nodes

• Identify middle lobe bronchus

• Staple the lower lobe bronchus


•Completeness of the

fissure is not important

•Completeness of the

fissure is not importantfissure is not importantfissure is not important

Left Upper LobectomyLeft Upper Lobectomy


• Identify the minor fissure to • Identify the minor fissure to identify upper lobe vein

•Right angle clamp around the upper lobe vein

• Staple the vein


• Retract lung posteriorly and inferiorly

• Remove hilar lymphatics • Remove hilar lymphatics

• Right angle clamp around the anterior trunk of the artery

• Staple the artery with endo 35 vascular stapler


• Complete fissure between lingula and

lower lobe with EZ 45 green

• Identify artery in the fissure and dissect • Identify artery in the fissure and dissect

on the surface of the artery

• Remove lymph nodes on artery and by

the bronchus

• Complete fissure with EZ 45 green


• Right angle clamp around the lingular artery

• Tie or staple the artery• Tie or staple the artery

• Remove lymph nodes around the bronchus

• Right angle clamp around bronchus


• Staple lobar bronchus with EZ 45

green

• Tie or staple additional arteries• Tie or staple additional arteries

• Complete the remaining fissure

with EZ 45 green stapler

• Place lobe in bag

VATS Lobectomy:Conclusions

•Reasonable treatment for lung cancer•Reasonable treatment for lung cancerfor lung cancer

•Complete nodal dissection is possible

for lung cancer

•Complete nodal dissection is possible

VATS Lobectomy:Conclusions

•Not for all lung cancers•Not for all lung cancerscancers

•Not for all thoracic surgeons

cancers

•Not for all thoracic surgeons

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