Session II: Thoracoscopic Rsxns: Advancing the Envelope

Session II: Thoracoscopic Rsxns: Advancing the Envelope Prevention & Management of Intra-op Events Shanda H. Blackmon, M.D., M.P.H., FACS Duke Masters of Minimally Invasive Surgery Meeting 2014 2014 MFMER slide-1

Disclosure I have no Disclosures 2014 MFMER slide-2

Objectives: Identify helpful maneuvers in VATS upper lobectomy Review potentially dangerous situations and how to manage them Review several sample cases of VATS upper lobectomy events 2014 MFMER slide-3

The best way to avoid an unexpected event in surgery is to prevent it 2014 MFMER slide-4

Know your instruments TA stapler Ethicon & Covidien have different firing mechanisms: 2014 MFMER slide-5

Technical Considerations Endoscopic Stapling Prevent complications by releasing tension on the vessel when stapling Encircle the main PA whenever you are concerned about an arterial dissection Beware of LN erosion into vessels Do not continue to dissect when there is bleeding and you cannot see- apply coagulant or pressure and go somewhere else 2014 MFMER slide-6

Technical Considerations Camera Make sure you can see the vessel at all times 30 camera is key Back up the camera when there is bleeding to gain perspective Must positively identify structures prior to dissection and division Keep camera oriented as if open view Experienced camera driver helps Develop a language that allows rapid communication, especially in an emergency Identify other surrounding structures to be sure they will be uninjured (i.e. upper vein when dividing lower vein ) 2014 MFMER slide-7

Technical Considerations Staplers Port placement is important Camera port must be posterior enough so stapler lines up with the hilum Access incision overlying major fissure Optimize stapler angles Both incisions, roticulation 2014 MFMER slide-8

General Principles Never force an instrument or stapler Unlike open surgery; where with a hand present a little bit of twisting is helpful Resistance means important tissue in the way Visual cues substitute for tactile cues Look for stretch of vascular structures Direction of travel of vessels is informative 2014 MFMER slide-9

General Principles Watch for progress and time of operation If a step is taking inordinately long, a problem exists Tendency is to try to go faster but if the step in question is difficult this will lead to problems, for example dissecting the first branch of the left PA in an upper lobectomy If you are not satisfied, then open Never compromise the operation! 2014 MFMER slide-10

Intraoperative Events Lung deflation Airway separation Cannot locate lesion Airway stenosis Cannot see target Space Bleeding from PA Leak Bleeding from PV Other Bleeding from lung parenchyma 2014 MFMER slide-11

While collapsing the lung Exposure is key in VATS surgery Lung must be out of your way Be sure ETT in correct position, cuff adequately inflated and diaphragm is paralyzed May need a bit of CO2 insufflation Change/add port placement 2014 MFMER slide-12

What if you cannot find the lesion? May lead to removal of the wrong part of lung Know the anatomy on the CT scan Learn how to triangulate the lesion using CT scan landmarks that translate into structures that can be identified at surgery Azygous vein Inferior pulmonary vein Fissures Divide chest into thirds anterior,middle and posterior in an AP dimension Using such triangulation, one can do a blind wedge or perhaps segmental resection to make diagnosis 2014 MFMER slide-13

What if you cannot see the anatomy? Cannot see well during surgery even if lung is deflated This can lead to injury to vascular structures Generally this is due to poor port placement Camera too anterior and heart is in the way Camera too inferior and diaphragm is in the way Ports not centered well in the interspace leading to inability to move instruments in all directions 2014 MFMER slide-14

LUL Utility Port 4cm Directly above LSPV for LUL Staples: fissure Camera Port Posterior axillary line 8 th ICS 5mm 30 degree scope (this one is more posterior for L>R to aviod the pericardial fat pad) Thanks to Dr. McKenna 2014 MFMER slide-15

Hazards: PA Branch Tear Release retraction of the lobe when stapling Apply gentle pressure Silence the room Sponge on back table at all times (here, we just used the ring clamp to collapse the lung onto the vessel) Do not be afraid to convert to open Take several deep breaths Do NOT just open- you may find the bleeding stops enough to finish w VATS 2014 MFMER slide-16

What about PA bleeding? Biggest fear in VATS surgery Generally not a problem Stay calm Reaction to the injury can cause more of a problem than injury itself Compress the area with a pledget or kitner Put surgical cellulose between injury and compression 2014 MFMER slide-17

What about PA bleeding? Wait several minutes during which time the problem is reviewed with your team and appropriate measures are readied Blood in room Thoracotomy kit ready to go Plan A, B and C developed Do not put clamp on injury in a pool of blood 2014 MFMER slide-18

What are your options at this point? Wait and see if the bleeding stops Consider VATS Repair: Knot pusher needle driver Avoid clamping the vessel Conversion to open Extend utility incision Traditional postero-lateral approach 2014 MFMER slide-19

If VATS Repair is not possible, Conversion Options: Postero-lateral Thoracotomy Anterior Thoracotomy 2014 MFMER slide-20

RUL: my first VATS lobe Auscultory Incision (optional) beneath scapula Staples: SPV Anter Trunk Artery Camera Port Posterior axillary line 8 th ICS 5mm 30 degree scope Angle superiorly Utility Port 4cm Directly above RSPV (#2) Staples: Minor fissure RUL bronchus Anterior Port 2cm (as far anterior as possible) MCL anterior 6 th ICS Incise angle towards hilum (below infra-mammary fold) Staples: Maj/min fissure Thanks to Dr. McKenna 2014 MFMER slide-21

Bronchial Stapler Misfire 2014 MFMER slide-22

How to avoid PA bleeding from the start Check pre-op for pulmonary HTN Enlarged PA s R heart cath if not sure Echo if not sure 2014 MFMER slide-23

What about pulmonary vein bleeding? Low pressure system Will stop with compression and time Unusual situations whereby this is a problem Other tissue caught in stapler such as pericardium or fibrotic node Do not appreciate a vein branch is not controlled in your dissection of lobar vein, i.e. superior segmental vein during lower lobe vein resection 2014 MFMER slide-24

What about bleeding from the lung parenchyma? Avoid trying to place large sponges through a small hole Generally seen in re-do cases where adhesions are significant Bovie on very high setting and arc d on to tissue will help if bleeding is from a raw surface If pulmonary hypertension, then re-inflating lung will help Occasionally re approximating visceral pleura over the raw area will help 2014 MFMER slide-25

What about leakage from the bronchus? This is a rare problem where the staple line dehisces or is inadequate Easy to suture but be sure the mechanism for the problem is understood If tension is the reason this must be relieved, may require a sleeve resection If staple line is too oblique and not at a right angle then again a sleeve may be needed Always test suture line 2014 MFMER slide-26

What about narrowing the bronchus? Rare Right lower lobectomy where the middle lobe is pinched by bronchial staple line Always see the middle lobe takeoff and course prior to dividing the lower lobe Bronchoscopy at time may help Sleeve resection and reimplantation of middle lobe 2014 MFMER slide-27

What about space problems and air leak? Leak without a space is usually not an issue Be sure the lung fills space at conclusion of operation If not, then perform typical maneuvers to help this - ligament takedown, pleural tent, nerve injection, omentum or muscle flap If leak is from a deep injury may require sutures If significant leak present then be sure to use 2 chest tubes with one between lung and access incision to prevent subcutaneous emphysema 2014 MFMER slide-28

Other Complications: Esophageal injury Thoracic duct injury Other vascular injury subclavian vessels SVC Heart Diaphragm injury 2014 MFMER slide-29

LLL What to do when the PA turns black Utility Port 4cm Directly above LSPV for LUL Staples: fissure Anterior Port 2cm MCL anterior Incise angle towards hilum (below infra-mammary fold) Camera Port Posterior axillary line 8 th ICS 5mm 30 degree scope (this one is more posterior for L>R to aviod the pericardial fat pad) Thanks to Dr. McKenna 2014 MFMER slide-30

PA Dissection 2014 MFMER slide-31

PA Dissection 2014 MFMER slide-32

Getting around difficult angles or navigating around the bronchus.. 2014 MFMER slide-33

One hour 2014 MFMER slide-35

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Be aware of Anatomy Common vein is possible- i.d. upper and lower 2014 MFMER slide-37

Things to watch for: Common pulmonary vein & RML vein Small RUL PA PA Additional L posterior LUL PA branches Passing behind the bronchus for LUL Adherent LN Tension on the lung during stapling 2014 MFMER slide-38

Most Dangerous Weapons: Stapler w errant clip Sucker tip w clip Forcing a sponge on a ring clamp through a small opening Pushing clamps into the chest Staple (10mm) in the jaws of a stapler 2014 MFMER slide-39

Pearls Place another trocar if angle is not good Don t be afraid to open Use leads to navigate Pressure controls 90% of bleeding 2014 MFMER slide-40

Pearls If you are having difficulty and feel you may be close to pulmonary artery bleeding in a morbidly obese patient, convert early These patients cannot have an efficient thoracotomy performed with ease.. Positioning obese patients is critical for having adequate angles 2014 MFMER slide-41

Beware of anatomic variations Variations may exist: Don t be afraid to change the order of dividing vessles & bronchus If the posterior branch of the LUL artery is proximal enough, taking it next will make the bronchus easier Sometimes it s too far behind the bronchus to be taken first, therefore, typically, the next step is to take the bronchus next 2014 MFMER slide-42

Summary VATS is beneficial to patients Intra-operative complications are rare Knowledge of anatomy is essential in avoidance of problems Visual cues are key If there is any concern, the surgeon should convert to open 2014 MFMER slide-43

Questions What is the best way to control PA bleeding during a VATS lobectomy? A) clamp B) release pressure from retraction C) sponge stick D) endo-loop E) B and C 2014 MFMER slide-44

Questions What is the best way to control PA bleeding during a VATS lobectomy? A) clamp B) release pressure from retraction C) sponge stick D) endo-loop E) B and C 2014 MFMER slide-45

Questions What is the first thing you do before dividing the pulmonary vein? A) inflate the lungs B) bronchoscopy C) look for the other lobar vein D) divide the artery 2014 MFMER slide-46

Questions What is the first thing you do before dividing the pulmonary vein? A) inflate the lungs B) bronchoscopy C) look for the other lobar vein D) divide the artery 2014 MFMER slide-47

Questions If you have accidentally divided only half of the bronchus with a stapler (leaving the membraneous part still attached), what do you do? A) inflate the lungs B) bronchoscopy C) Divide the rest & repair it with 4-0 vicryl or pds D) Cut the other half off and close 2014 MFMER slide-48

Questions & Discussion 2014 MFMER slide-50

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Questions? 2014 MFMER slide-53