Prevention and Management of Intraoperative Complications. Todd L. Demmy

Transcription

1 Prevention and Management of Intraoperative Complications Todd L. Demmy

2 Disclosures/ Questions

3 Catastrophic Complications Age, Sex Lobe Complication Outcome 72, F LUL Transection of entire left PV trunk Primary anastomosis 54, M RLL Bleeding PV retracting into pericardium Primary repair 80, F RUL Bleeding PA Pneumonectomy stage 50, F LUL Bleeding PA Pneumonectomy (delayed) 72, M RUL Transection of PA distal to truncus Primary anastomosis 46, F RUL (RML) Transection of main PA Primary anastomosis 61, M LUL Transection main bronchus and main PA Pneumonectomy 60, F RLL Transection of RML bronchus Bilobectomy 58, M RUL Membranous injury Primary repair 57, M LUL wedge Splenic bleeding Splenectomy 73, F RUL Bleeding azygos/svc Primary repair Flores, J Thorac Cardiovasc Surg 2011;142:1412-7

4 Objectives Preparation/Organization Exposure/Retraction Oozing control Major Bleeding Prevention/Control Other Major Injuries

5 CT Angio Planning (1) 95.2% (139 of 146) of PA branches precisely identified. Fukuhara, 2008, Eur J Cardiothorac Surg 34(4):

6 CT Angio Planning

7 Pick a Preferred... Roswell

8 Choose your Best Approach: Posterior vs. anterior Bronchus vs. Fissures last Vein vs. Artery first Emulate open vs. different order But know the others!

9 General Troubleshooting Approaches for Preferred System Access incision optimal for tedious dissection? Document system for primary maneuvers Visualization (change least) Retraction/tissue control Dissection/division Multiple uses same port?

10 Posterior Camera Views P B1-3 BI

11 Objectives Preparation/Organization Exposure/Retraction Oozing control Major Bleeding prevention/control Other Major Injuries

12 Basic Moves Access View Kamiyoshihara, 2011, Interact Cardiovasc Thorac Surg 12(4):

13 Visualization Tools 5 mm Optimal For Sharing ports

14 VATS WEDGE Bronchoplasty Kamiyoshihara, 2010, Interact Cardiovasc Thorac Surg 11(5):

15 Visualization Tools High Definition Optimal Endocameleon

16 Retraction Tools

17 Importance of Low Profile and Angles

18 Importance of Low Profile and Angles

19 Diamond-Flex Retractor Cardinal Health

20 Realize Goldfinger Ethicon Gastric Band Dissector

21 Making Space - Surgeon CO2 Vent Bullae Retraction/Pack/Restraint Release diaphragm Hand-Assist

22 Getting Diaphragm Out of Way Suture and bring out of camera port 5 mm retractor with or without holder 00:12

23

24 Follow the Fs when you are stuck- 1 Free All Adhesions, All Lobes Find Somewhere else to work Pleurae and lymphatic tissue Divide more distally Fissure Division (also opens camera angles) Partially (outside in) Completely (blunt clamp technique)

25 Fissure Division Videos section/videos/2013_video-atlasthorascopic-lobectomy.html

26 Follow the Fs when you are stuck - 2 Flip order of anatomical divisions (eg. Change to Fissure Last Technique) Fill the port/access incisions ( fers ) Traction Countertraction to define anatomy (eg. Two-fer and vessel loops) Fresh planes (eg. Open pericardium)

27 Objectives Preparation/Organization Exposure/Retraction Oozing control Major Bleeding prevention/control Other Major Injuries

28 Topical Oozing Control 00:19

29 Methods-Tissuelink

30 Cold Cautery - Aquamantys

31 JK - Index Case 9/ yo female yt2n0 RLL Squamous Cell Induction chemo VATS resect Dec 2008 R hilar recurrence 4/2009 rx by concurrent chemo/rt

32 Oozing Lung Make Space Cold Cautery View inferiorly Depress diaphragm Mass suture lung 2:28

33 Objectives Preparation/Organization Exposure/Retraction Oozing control Major Bleeding prevention/control Other Major Injuries

34 Curve Tip Innovation Mayfield Demmy Demmy

35 Median (s) Curved Tip Cartridge for Thoracic Surgery Stapler Passage Times Complex Cases Straight Curved 0 PA Branch Vein Demmy&Mayfield,Ann Thorac Surg 2012;93:

36 Low Profile TA Stapler & 5mm Vessel Sealing Technology

37 Low Profile Stapler

38 Low Profile TA Stapler - Resealing 00:28

39 Use of Leaders CHEST 1999; 116:450S 454S

40 Bleeding Control Algorithm Yamashita, Ann Thorac Surg 2013;95:

41 VATS PA Operations Ref N Deaths Complications EBL (ml) Time Hosp Stay Watanabe, 2007?????? MAIN PA Nakanishi, ? Nakanishi, ? * Kamiyoshihara, Kamiyoshihara, /56 176/200 5 / 10 * Mei, * Zhang, *

42 Experimental PA Occlusion 30 Swine Custom Swan-Ganz pulmonary artery catheters 19mm, 2.5-3cm length balloon optical fiber 5 displacements Conlan, 1998, Ann Thorac Surg 65(2):

43 Importance of Low Profile and Angles D Amico DeBakey Chitwood Knot Pusher

44 PA control RU & RML Sleeve Chitwood Knot Pusher

45 Methods-Bleeding Control PA control Suffusion Experience N = 11 off-label

46 Methods-Bleeding Control PA control M. Kamiyoshihara et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010)

47 Methods-Bleeding Control PA control M. Kamiyoshihara et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010)

48 Methods-Bleeding Control PA control M. Kamiyoshihara et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010)

49 Methods-Bleeding Control PA control Mei, Surg Endosc (2013) 27:

50 Methods-Bleeding Control PA control Mei, Surg Endosc (2013) 27:

51 Methods-Bleeding Control PA control Nakanishi, 2008, Interact Cardiovasc Thorac Surg 7(6):

52 Methods-Bleeding Control PA control Nakanishi, 2008, Interact Cardiovasc Thorac Surg 7(6):

53 Methods-Bleeding Control PA control Xu, J Biomed Res, 2013, 27(4):

54 Methods-Bleeding Control PA control #1 Silk A. Watanabe et al. / European Journal of Cardio-thoracic Surgery 31 (2007)

55 Methods-Bleeding Control NK-Stapler (Endopath ETS45- Flex No Knife NAW; Johnson & Johnson, Cincinnati, OH,USA) PA control Yoshida, 2007, Gen Thorac Cardiovasc Surg 55(2):

56 Methods-Bleeding Control PA control Zhang, 2012, J Thorac Cardiovasc Surg 144(2):

57 Locking Clips Teleflex medical Conmed Reflex

58 Thermal Sealing Technology N=211 Lobes/Segments J Thorac Cardiovasc Surg 2010;140:

59 Thermal Sealing Technology Burst experiments from fresh lung cancer lobectomy specimens 13 arteries < 5mm 12 arteries > 5 mm Clinical series 84 lobectomy or segmentectomies 203 pulmonary arteries divided. Tsunezuka, 2010, Interact Cardiovasc Thorac Surg 11(3):

60 Thermal Sealing Technology Open Experiment Ligasure vs Suture 15 large and 15 small Equal controls Lesser T, J Thorac Cardiovasc Surg 2013;145:1525-8

61 Thermal Sealing Technology No bleeding but... Open Experiment Lesser T, J Thorac Cardiovasc Surg 2013;145:1525-8

62 RS - Index Case 6/ yo male Left lung occlusion Palliative XRT Induction Chemo

63 RS - Index Case 6/ yo male Left lung occlusion Palliative XRT Induction Chemo

64 PA Control Attempt at LUL Sleeve Open Pericardium Third retractor PA control -proximal Small anvil stapler/ligasure Divide more distal Failed Ligasure Repair PA PA control -Distal 05:29

65 Azygous Vein Injury Sponge stick control Stapler control proximal Suture control distal 1:53

66 Sequestration Liu, J Thorac Cardiovasc Surg 2013;-:1-5)

67 LIMA Dissection

68 LIMA Dissection Funaki, Interactive CardioVascular and Thoracic Surgery 15 (2012)

69 MB - Index Case 7/ yo male 7 stents, LIMA LAD DLCO 75% FEV-1 127% LUL Squam

70 MB - Index Case 7/ yo male 7 stents, LIMA LAD DLCO 75% FEV-1 127% LUL Squam

71 MB - Index Case 7/ yo male 7 stents, LIMA LAD DLCO 75% FEV-1 127% RML Adeno VATS resection 6/2013

72 MB - Index Case 7/ yo male 7 stents, LIMA LAD DLCO 75% FEV-1 127% Progression of LUL lesion

73 MB - Index Case 7/ yo male 7 stents, LIMA LAD DLCO 75% FEV-1 127% Progression of LUL lesion

74 Anchor Tissue Pouch Acute Innovations Biobridge

75 Lung Stuck to Median Sternotomy Adhesions Oozing LIMA Dissection Dissect IMA Tunnel for Stapler Free Lung from Sternum Debride devitalized lung Divide Vein/Fissures/PA branch/bronchus Main PA control/remaining branches/bag 8:43

76 Objectives Preparation/Organization Exposure/Retraction Oozing control Major Bleeding prevention/control Other Major Injuries

77 Risk for Narrowing BI B1-3 1:27 BI

78

79 Visualization Tools Keeping Lens Clean Internal fluid jet Gauze wick in port Gas Jet on oversheath