Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана

2. Preoperative bronchoscopy for secretion clearance and visualization of anatomy

7. Division of inferior pulmonary ligament (for mobilization in upper lobe segmentectomy, exposure of the vein in lower

9. Correct identification of vascular and bronchial anatomy

Potential Complications and Pitfalls

2. Identification and separation of the intersegmental plane is performed by differential inflation after occluding the

3. The identification and division of correct segmental vein is essential.

4. Meticulous dissection and careful handling of the tissues are essential, especially in patients with pre-existing

emphysema, to avoid significant air leak which can complicate the post-operative course. Traditional dissection of

the intersegmetal plane using scissors or cautery increases the risk of postoperative airleak and bleeding. Surgical

staplers, while less prone to these complications, are limited by the thickness of the lung parenchyma, and thus

vulnerable to staple line disruption. This risk can be reduced by careful reinforcement of the staple line with

interrupted, vertical mattress sutures.

Thoracotomy

benign etiology, particularly if diagnostic uncertainty is present]

Postoperative Diagnosis: specific diagnosis (i.e. cancer histology, if not known preoperatively and if frozen section

2. Segmentectomy (specify segment removed)

3. Mediastinal lymph node dissection (if done for malignancy)

Attending Surgeon: [BLANK]

Assistant Surgeon: [BLANK]

Assistants: [BLANK]

Indication(s) for Procedure: This is a [AGE] year-old [ G E N D ER ] who presented with history of

the [SIDE, LO BE, AND SEGMENT]. A CT-guided biopsy was performed, which was noted to be suspicious for [TISSUE

mediastinal lymph node involvement. Based upon the patient’s presentation and preoperative workup, it was determined that

including death. All questions were answered to the satisfaction of the patient and family, including all alternatives to

Description of procedure: The patient was taken to the operating room and placed supine on the operating table. Following

induction of general anesthesia and intubation with a single-lumen endotracheal tube, a “time out” was performed, verifying

correct patient, correct procedure, and correct site. Antibiotics were then given to ensure delivery within one hour of

incision. Bronchoscopy was then performed; all segments were identified bilaterally, and all visible secretions were cleared.

[FINDINGS]. The single-lumen endotracheal tube was then exchanged for a double-lumen tube with bronchoscopic guidance

to ensure total lung isolation.

The patient was then placed in the [S IDE] lateral decubitus position. All vulnerable pressure points were appropriately

padded, the bed flexed to extend the intercostal spaces, the up arm was extended cephalad to expose the axilla and secured into

place, and the patient secured to the operating table using a belt and cloth tape. After positioning was completed, correct

The patient was then prepped and draped in the usual sterile fashion. A standard, posterolateral thoracotomy skin incision was

made overlying the fifth intercostal space, just inferior to the tip of the scapula. Using electrocautery, subcutaneous flaps were

created superiorly and inferiorly, and the dissection was carried down to the level of the latissimus dorsi, which was then

divided in hemostatic fashion. The serratus anterior muscle was encountered and mobilized from the chest wall by incising its

nodes removed after ligation of the lymphatic pedicle. We then turned our attention to dissection of the mediastinal lymph node

basins. Using [ALLISON RETRACTORS/SPO NGE STICKS/DUVAL GRASPERS/RING FORCEPS], the lung was

retracted inferiorly, exposing the superior mediastinal structures.

For Right Lung Segmentectomies

The pleura immediately cephalad to the azygous vein was sharply incised, the level III and IVR lymph nodes were bluntly

microscopic analysis.

For Right Upper Lobe Segmentectomies

segmental branch of the superior pulmonary vein was then ligated and divided in a similar fashion. The lung was then

then isolated and divided using an endoscopic stapler.

could be identified and isolated using a blunt clamp. The dissection was then continued over the main pulmonary artery

distally, exposing its segmental branches. The posterior segmental branch was identified, circumferentially dissected, and

identification of the upper lobe bronchus. Dissection was then carried distally along the bronchus until the bifurcation of the

For Right Lower Lobe Segmentectomies

Superior Segment: The oblique fissure was bluntly opened, exposing the interlobar pulmonary artery. Dissection was

carried out distally along the Plane of Leriche, and the overlying lung parenchymal divided with an endoscopic stapler using

bronchus was then identified and divided using an endoscopic stapler.

through the thoracotomy incision, the surgical margin marked with a sterile marker, and the specimen sent to pathology for

identification and margin analysis.

sutures in a figure-of-eight fashion. The serratus muscle was reattached to the chest wall using a single, 0-vicryl running

For All Left Lung Segmentectomies

were sent to pathology for identification and microscopic analysis.

For Left Upper Lobe Segmentectomies

Lingula: The oblique fissure was bluntly opened and the interlobar pulmonary artery identified. The lingular branch(es) were

of the superior pulmonary vein from a medial approach. Dissection was continued along the vein until the lingular branch

could be identified, at which point it was bluntly skeletonized and ligated using an endoscopic stapler.

For Left Lower Lobe Segmentectomies

Preoperative Diagnosis: [INDICATION for operation; typically neoplasm, but may be done for lesions with infectious or

benign etiology, particularly if diagnostic uncertainty is present]

2. Segmentectomy (specify segment removed)

3. Mediastinal lymph node dissection (if done for malignancy)

Attending Surgeon: [BLANK]

Assistant Surgeon: [BLANK]

Assistants: [BLANK]

Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]

[COMPLAINT/DURATION]. The patient was noted on diagnostic [CHEST RADIOGRAPHY] to have a [SIZE] nodule in

mediastinal lymph node involvement. Based upon the patient’s presentation and preoperative workup, it was determined that

performed for malignancy). The patient was informed of the risks and benefits of proceeding, including, but not limited to:

operation for repair, infection, either at the incision sites or elsewhere, persistent air leak from the lung or bronchus,

operation, as well as those risks associated with the induction of general anesthesia, up to and including death. All questions

were answered to the satisfaction of the patient and family, including all alternatives to operative intervention. The patient

Description of procedure: The patient was taken to the operating room and placed supine on the operating table. Following

incision. Bronchoscopy was then performed; all segments were identified bilaterally, and all visible secretions were cleared.

The single-lumen endotracheal tube was then exchanged for a double-lumen tube with bronchoscopic guidance to ensure total

lung isolation. The patient was then placed in the [SIDE] lateral decubitus position. All vulnerable pressure points were

operative lung excluded. The patient was then prepped and draped in the usual sterile fashion. A 1-centimeter incision was

then advanced through an endoport inserted into the intercostal space, and the thoracic cavity was assessed visually. Under

direct visualization, the utility port (4 cm in length) is created in anterior axillary line at the level of hilum (usually 4

th

axillary line about one hand breath away from the camera port.

1. Supine positioning

2. Lines and monitoring

3. General endotracheal anesthesia (can use double lumen tube or single lumen tube advanced into the left main stem

bronchus prior to accessing the pleural cavity)

6. Right posterolateral thoracotomy (left thoracotomy if left pneumonectomy)

10. Left: Mobilize and retract aortic arch laterally and cephalad (division of ligamentum arteriosum)

11. Lymphadenectomy and mobilization of the airway

13. Right: If SVC has been invaded by tumor, then heparinize, clamp the vessel proximally and distally, excise the

16. Incise left main bronchus (frozen section for tumor-free margins; right main bronchus if left pneumonectomy)

17. Remove right lung and carina (or appropriate lobes; left lung if left pneumonectomy)

21. Running sutures to parachute trachea and bronchus

through membranous trachea)

23. Terminate cross-field ventilation and re-advance endotracheal tube

24. Test anastomosis for air leaks (ventilate up to 40cm of pressure)

25. If desired, reinforce with pedicled flap

27. Chest tube placement

28. Assess hemostasis

29. Thoracotomy closure

30. A guardian or “Grillo” stitch can be placed between chin and sternum (decreases airway tension)

3. Injury to the left recurrent laryngeal nerve during dissection

4. Injury to the thoracic duct during aortic mobilization

5. Improper deairing if SVC is resected and grafted

6. Excessive lateral dissection along the airway resulting in inadequate blood supply to the anastomosis

7. No attempt should be made to crimp or wedge the edges of the anastomosis to correct the size discrepancy between

progressively with each suture

9. Tension on the airways leading to failure of the anastomosis

Preoperative Diagnosis: [INDICATION – e.g. Centrally located right middle lobe nonsquamous-cell lung cancer, NSCLC

Procedure(s) Performed:

1. Cervical mediastinoscopy

2. Right/Left posterolateral thoracotomy with right/left-sided carinal pneumonectomy

Secondary Surgeon: [BLANK]

Indication(s) for Procedure: The patient is a [AGE] [GENDER], who presented to us in the clinic with a concerning lesion

Preoperative assessment of the mediastinum including [TESTS/SCANS ORDERED] [FINDINGS]. Pre-operative PFTS

was placed behind the shoulders and the neck was maximally extended. The neck and anterior chest were prepped and draped

below the level of the xiphoid process to achieve a sterile field that would allow a sternotomy if necessary. The procedure

was commenced with a 2-cm incision in a horizontal fashion one fingerbreadth cranial to the suprasternal notch. The platysma

The mediastinoscope was advanced into the pretracheal plane to the level of the carina. The proximal right and left main

bronchi were bluntly dissected. The azygos vein was identified cranial to the right main bronchus and the right pulmonary

artery was visualized crossing over the right bronchus. Lymph node biopsies were taken from the subcarinal region and were

bronchus and were sent for analysis labeled as level 4R lymph nodes. Hemostasis was achieved in both the level 4R and 7

regions using electrocautery. Additional lymph nodes were taken just above the left main bronchus and these were sent labeled

as level 4L lymph nodes. The use of electrocautery was minimized while sampling the level 4L lymph nodes in order to avoid

injury to the recurrent laryngeal nerve. Frozen section analysis of the resected lymph nodes did not show any evidence of

metastatic disease. [FINDINGS].

The mediastinoscope was withdrawn after hemostasis was achieved and Surgicel was placed. The incision was closed in

endotracheal tube into the left bronchus using a bronchoscope for guidance. A Finochietto retractor was used to spread the ribs

and a Tuffier retractor was positioned at a right angle to the Finochietto to retract the soft tissues. The chest was visually and

divided as well. The lung was then retracted posteriorly while the pleura overlying the anterior aspect of the hilum was

division with the endo-GIA stapler using a second vascular load. The proximal right main pulmonary artery was then carefully

At this point a sterile ventilation circuit was passed off the field and prepared for the use of cross-field ventilation. After

possible, but also free of gross tumor involvement. The transected bronchial lumen was then visually inspected to ensure that

confirm meticulous hemostasis.

After confirming negative bronchial margins, the airway anastomosis was undertaken. The entire anastomosis was completed

bronchus. Each of these sutures were pre-placed and tied with the knots inside the lumen after they all were placed. Each of the

sutures approximating the membranous portion of airway was placed. While these sutures were placed the endotracheal tube

was intermittently removed from bronchus to facilitate better visualization. After each of the sutures was placed the bronchial

endotracheal tube was removed and the trans-oral endotracheal tube was advanced by the anesthesiologist across the

anastomosis into the left bronchus. This was manually directed from the surgical field. The sutures on the membranous airway

were then tied with knots on the outside of the lumen. Finally, sutures were placed to re-approximate the remaining

these sutures was placed, they were tied with the knots on the outside of the lumen.

was again thoroughly inspected to assure complete hemostasis. A single 28 French chest tube was placed into the chest cavity

and it was secured at the skin with a 0-silk suture.

muscle belly with #0 Vicryl and the latissimus dorsi fascia was closed with a running #0 Vicryl. The deep dermal and

3. Double-lumen endotracheal tube (left-sided for right pneumonectomy and right-sided if possible for left

7. Begin extrapleural dissection around the circumference of the incision, separating the tumor from the endothoracic

9. On the left, careful sharp dissection lateral and anterior to the descending thoracic aorta performed up to about the

14. Intrapericardial division of the pulmonary veins

15. Division of the pulmonary artery (intrapericardially on the right and extrapericardially on the left)

19. Hemostasis is assured.

20. Ipsilateral divided bronchial stump is tested to rule out air leaks by submerging beneath saline and having anesthesia

insufflate the ipsilateral side to 40 mm Hg.

21. Thoracic lymphadenectomy or lymph node sampling: stations 2R, 4R, 7, 8, 9, 10R for right sided tumors and stations

4L, 5, 6, 7, 8, 9, and 10L for left sided tumors.

duct injury.

23. There often isn’t local tissue to routinely cover the bronchus. Consider bringing up an omental pedicle through the

diaphragmatic opening.

is reimplanted into the chest wall anteriorly, laterally, and posteriorly with individually placed #1 nonabsorbable

suture. Medially the patch is secured to the crura and remaining pericardium with 0 nonabsorbable suture. A