VIDEO ASSISTED THORACIC SURGERY: LOBECTOMY AND LYMPHADENECTOMY FOR LUNG CANCER MT. SINAI MEDICAL CENTER NEW YORK, NY May 22, :00:10 ANNOUNCER:

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1 VIDEO ASSISTED THORACIC SURGERY: LOBECTOMY AND LYMPHADENECTOMY FOR LUNG CANCER MT. SINAI MEDICAL CENTER NEW YORK, NY May 22, :00:10 ANNOUNCER: This program is sponsored by Ethicon Endo-Surgery, Inc. Welcome to this ORLive webcast presentation from the Mt. Sinai Medical Center in New York, New York. During the program, it's easy to request more information. Just click on the button on your webcast screen and open the door to informed medical care. ORLive, the vision of improving health. 00:00:44 SCOTT J. SWANSON, MD, FACS: Hello and welcome. We are coming from you live in Mr. Sinai Medical Center in New York, New York. I'm Dr. Scott Swanson, your host for the program. I'm the chief of thoracic surgery here at Mt. Sinai Medical Center. And joining me to my left is Dr. Daniel Miller, who's the chief of general thoracic surgery at Emory University in Atlanta and a Mansour professor of thoracic surgery. Today's program is on surgical techniques used in video-assisted lobectomy and lymphadenectomy for lung cancer. During the program, we will be showing video segments of a left upper and a right lower lobectomy. But before we get started, I just have a few housekeeping items. First, we will be answering questions from the audience. To send us your question now, just click the MDirectAccess button on your webcast screen. We welcome all of your questions and will answer as many of them as we can. Second, an archive of this program will be posted shortly after this webcast and can be accessed through this web site. We'll begin by showing some slides for the background of this technique and then show the two lobectomies as we mentioned earlier. This slide is our disclaimer. And in this first slide, we'd like to document the benefits of a VATS lobectomy for early stage lung cancer. The most important tenets are listed here on the slide. It must be the same operation as an open lobectomy. It does provide excellent visibility and is oncologically sound. It has -- it provides an excellent capability for node dissection and there's very good data, and I'm sure all of you are experienced, which is just there's less trauma and also less immune suppression and postoperative pain. We also see less arrhythmias and less problems with prolonged air leak. There's an increased ability to deliver adjuvant therapy, and I think that will be one of the benefits that we'll really focus on going forward. And if need be, it's easy to convert. Dr. Miller, do you have anything else to add to those points? 00:02:38 DANIEL L. MILLER, MD, FACS: I think, Scott, all these are an excellent outline of the benefits of VATS lobectomies, but I think the most important here, as we only get to operate on 25% of our patients with lung cancer, that the oncologic principles must be preserved. 00:02:52 SCOTT J. SWANSON, MD, FACS: That's a good point. I think we like to think of that throughout all our concepts regarding this operation, and hopefully we'll point that out

2 repeatedly. The oncologic results are equal or perhaps there may be some benefit, although this is controversial. But certainly in major series from California, from Scotland, and from Italy, you can see the five-year survivals listed here on this slide, and they're excellent, all in the sort of 75-80% range. And problems with port-site recurrence are nonexistent, as we've shown with our series. And I know, Dr. Miller, you've found the same thing. 00:03:27 DANIEL L. MILLER, MD, FACS: That is correct. It's not really a factor in the VATS procedure. 00:03:32 SCOTT J. SWANSON, MD, FACS: In terms of other outcome issues, I think that the pain issues are hard to measure, but certainly all the single series have shown a good benefit. Here at Mt. Sinai, we've kept track of what kind of medication people are using and have found that at two weeks after surgery, when we see them back in the office, about half the patients are taking no medication, and only about 10% are taking codeine. And that, for us, is much different than with a thoracotomy. 00:04:00 DANIEL L. MILLER, MD, FACS: I think that's very important, because a lot of these patients are in the elderly population. And especially has greatly reduced the pulmonary complications such as pneumonia, requirement from bronchoscopy, and it's been a major benefit in these marginal patients. 00:04:15 SCOTT J. SWANSON, MD, FACS: That's right. We can provide this, perhaps, to more patients than we could've through a thoracotomy. In terms of issues around nodal dissection, that has been something that people think is controversial, but I think as you see what we show you today and as you gain experience -- and those who have experience know -- it's very easy to do. You can take out as many nodes as you wish, and certainly some Japanese studies have carefully documented that what we remove thoracoscopically is similar to what we remove open. 00:04:48 DANIEL L. MILLER, MD, FACS: And this is one of the most important techniques with a VATS lobectomy is the lymph node dissection, not only from a staging standpoint where a number of patients will get adjuvant therapy, but also, too, it may be a survival advantage that we'll find out in the next two or three years with the Z30 trial. 00:05:05 SCOTT J. SWANSON, MD, FACS: That's right. And this -- this is from that Japanese study I mentioned. Watanabe's group carefully looked at each of the lymph node stations, sampled both in an open and a closed technique, and I don't expect you to memorize this slide, but it certainly is a carefully done study that shows no difference in the nodes taken from each of those stations, whether it's open or closed. 00:05:26 DANIEL L. MILLER, MD, FACS: That's correct. 00:05:29 SCOTT J. SWANSON, MD, FACS: In terms of other issues -- traumatic issues, immune suppression issues, pain issues -- there's no question that VATS seems to have a benefit. This is one slide from a paper from Walker's group that showed neutrophil function is better preserved after VATS versus open and would be, perhaps, a biologic indicator of why we might see better immune function after a VATS procedure.

3 00:05:51 DANIEL L. MILLER, MD, FACS: And this -- we won't know this for some time, but this may be one of the biggest potential improvement on survival is in regards to the less immune suppression. 00:06:03 SCOTT J. SWANSON, MD, FACS: In terms of pain, the randomized studies are few, but there was one from Scotland and one from Paris that showed less pain medication use and a lower pain scale in those patients receiving a VATS approach rather than either muscle-sparing or regular thoracotomy. There -- there's a CALGB that we published last fall in a phase-two study done at six centers, and the arrhythmia rate was only 5% and prolonged air leak was 1%. And those seem to be favorable compared to open series. 00:06:38 DANIEL L. MILLER, MD, FACS: I think, too, with this one, the most important complication which is reduced is the incidence of air leaks. And because a majority of these cases are done fissureless surgery, so you don't have as much dissection within the hilum. And too, because the majority of these patients that you don't have as much of a complication with a thoracotomy, and it will be better for them long-term. 00:07:02 SCOTT J. SWANSON, MD, FACS: That's right. And that's an excellent point, Dan. We do seem to handle the lung a little more carefully and we don't get into the fissure and certainly the upper lobes. And we use stapling techniques that may be much less traumatic to the lung and therefore less air leak. In terms of another point that's come out more recently, first from the Duke group by Tommy D'Amico, and we've seen it as well in a paper we published recently, and I know you've seen it as well in Atlanta, that we are able to better deliver adjuvant chemotherapy, which is being done in various settings now. We can get the doses in more completely and we can get it done on time, which may have benefit for the patient. 00:07:44 DANIEL L. MILLER, MD, FACS: Well, this will be very important. As you know, that even though we have an early-stage cancer, they will develop a recurrence, and that can be anywhere from 20-30%. So if they can complete their adjuvant treatment, it would be a major benefit for them to hopefully beat their cancer. 00:08:00 SCOTT J. SWANSON, MD, FACS: That's right. And we notice what the Duke group noticed, that about 73% of the time we can get it in on time and full course, which compares with about 50 or 55% in the Canadian and CALGB studies. Looking at adjuvant therapy, this isn't randomized, this is retrospective, but certainly is provocative. And I think we're all suspecting that we will be able to better deliver his therapy. In summary, in terms of instrumentation, we try to use mostly standard instruments, although the thoracoscope, we do like the 30-degree. I've not used the 45-degree, so I don't have experience with it, but the 30-degree is very beneficial. We use staplers -- Endo staplers such as the Echelon product, which is a very robust stapler. And we use endoscopic kitners as well as the Harmonic shears and various retrieval bags. 00:08:54 DANIEL L. MILLER, MD, FACS: I think the most important thing in regards to instrumentation is that the majority of these instruments are the same ones you use for an open technique, and so you're very comfortable with that when you make the transition from an open to a VATS technique. Also, too, with the staplers, it's what you become comfortable with. And a lot of

4 times, we will use these on the open technique as we're making that transition and learning that learning curve between open and VATS, so it's been very, very beneficial. 00:09:23 SCOTT J. SWANSON, MD, FACS: In terms of other technical issues, a double-lumen tube is certainly a benefit and perhaps superior to the bronchial blocker in terms of avoiding the fissures. That's an important point and may lead to some of the reduced trauma and postoperative problems that are seen with a VATS technique. And make sure you protect the specimen in an impermeable bag. 00:09:47 DANIEL L. MILLER, MD, FACS: Well, and that's going back to your transition. If when you're doing an open technique you're going to start doing the dissection medially, working on the vein first or artery. And to do that in a time-wise fashion is very important for your learning curve and also, too, from the learning curve of the O.R. It's very important to have a time limit so you're not in there for four to five hours and you're in two hours for patient safety and also, too, to make sure you're progressing in the operation. Also, too, we comment about the double-lumen endotrachial tube, which is very important in these patients. We prefer not to use a bronchial blocker, because you have a problem with deflating the lung. So it's very important that you take control of that with your anesthesiologist to make sure it's in a good position. 00:10:30 SCOTT J. SWANSON, MD, FACS: Those are great points, Dan, and I agree with the concept of time, because that helps keep everybody paying attention, and when you're doing something new, sometimes you lose track of how long you're doing it, so watching the clock can be very helpful for the patient and for the O.R. team, as you said. In summary then, I think we've shown you some data that a VATS lobectomy may be a good approach for early-stage lung cancer and you need to all learn and be comfortable with that. We've shown that morbidity and survival data compares favorably with an open technique. Length of stay, other complications that we mentioned, are better, and we think that in the era of multi-modality therapy that a VATS approach may allow a better delivery of that other therapy. What we'd like to do next is begin to show the various techniques. We're going to show a right lower lobectomy first in a patient who has a fairly well-developed fissure, and then we'll finish with a left upper lobectomy where we spare the lingula and show some of the techniques around that operation as well. Here we see the camera going in to the seventh interspace in the posterior axillary line in preparation for a right lower lobectomy. With the camera in place, you can identify where you want to put your other ports, although generally they're in a very standard place. This posterior port in our hands, we put it just either at the tip of the scapula or just behind it and come down on top of the rib to avoid trauma to the nerve or neurovascular bundle. We then turn anteriorly and define the access port, which for a lower lobectomy, as you'll see, comes right over the fissure between the middle and lower lobe and at the level of the vein, the lower vein. 00:12:27 DANIEL L. MILLER, MD, FACS: As shown in that first picture, we only use a port in the access incision where the camera is. We usually don't put them in the upper ones because you can use multiple instruments. And also, too, posteriorly, you can have a lot of increased pain from torquing that, and because you don't use CO2, it's very nice that you don't have to use those ports. 00:12:45

5 SCOTT J. SWANSON, MD, FACS: That's right. That's exactly right. We don't use CO2, so you don't have to have a sealed port. Here we're looking at the middle lobe being retracted gently medially and the lower lobe's off to the left of the screen, which you can see here. And we see that the fissure is coming into view off into the distance. But first what we'll do is lift up the lung generally for a lower lobectomy and bring down the inferior pulmonary ligament generally with a cautery device or a Harmonic instrument and then open up the parietal plura, mediastinal pleura posteriorly over the posterior hilum to both define the vein posteriorly but also to access the subparietal nodes. 00:13:29 DANIEL L. MILLER, MD, FACS: And I think that's a very good point, because the number one thing, you've got to do your metastatic survey when you start the case, just like when you do an open case, make sure there's no pleural implants, pericardial pleural fusion, which you did there, which is very, very important. 00:13:44 SCOTT J. SWANSON, MD, FACS: So one of the questions that comes up now is how do we use lymph-node staging or sampling, and that's a broad question, but I think specifically to what we're doing here is -- and this is a point that is done differently at different places -- we will access level seven in the subcarinal space and the paratracheal level-nine nodes, particularly if we haven't done a mediastinoscopy even in CT and PET-negative patients to be sure we're not missing that 5 or 10% of patients that might be Stage 3A, in which case we would typically elect to stop with just the VATS incisions and give adjuvant chemotherapy. The patients generally don't have to stay overnight and they can get right on with their neoadjuvant therapy. 00:14:31 DANIEL L. MILLER, MD, FACS: And I think that would be -- your preference of lymph-node dissection will be how you learned the technique. At our institution, we usually do the lymphadenectomy last, the N2 nodes. For the hilar nodes, we do those at the time that we isolate the vessels, and -- but if we do have a questionable node that is larger than one centimeter and is PET neg and we're very concerned about that and you can't reach that from mediastinoscopy, we would biopsy that at the time. And you're correct, if it is positive, we would prefer to go ahead with neoadjuvant treatment. 00:15:02 SCOTT J. SWANSON, MD, FACS: So we've then at the beginning of this operation here taken out -- sampled level seven and now we're going to sample the paratrachial nodes. And in general, as I mentioned and as Dr. Miller mentioned, it's a rare instance when you find them positive, so unless you see something concerning, you can -- as you've sent the lymph nodes off, at least the way we do it, we'll go ahead and start to mobilize the vessels in preparation for the lobectomy. And only rarely will we end up having to stop, and that saves a little bit of time. We like to use our Harmonic instrumentation, Harmonic technology, to divide the nodes, because it seems to be a little quicker and a little less bloody. Is that something, Dan, that you like, or what's your preference? 00:15:49 DANIEL L. MILLER, MD, FACS: That's correct, and I think the number-one thing is you try to remove the complete node. As you know, with these anthracotic nodes, they can be a little friable and break apart. And using the Harmonic works out very well to make more of a bloodless field. Also, too, in regards to the camera, a lot of times we will keep it mainly just in the chest tube site, the lower inferior access incision, and use a 30-degree or even a 45-degree on the left. And

6 the most important thing is that you can move the camera around to any access incision, which really helps you with the lymph node dissection but also it can help you when you're getting around the hilar vessels. 00:16:27 SCOTT J. SWANSON, MD, FACS: So here we're completing our sampling at the beginning of the operation, and as Dan mentioned, we'll do a full dissection at the conclusion of the lobectomy. And I think having the lobe out of the way often opens up space and makes it a little easier to get a full dissection. So that's one of the reasons we do it at that time. Here we're looking at the inferior pulmonary vein and where it comes in posteriorly. The esophagus was running at the back from the top to the bottom, and I think we spotted a lymph node under the parietal pleura behind the esophagus, so we go ahead and actually removed that level-eight node. It's not something we typically go after, but we do notice it, so you'll see in a minute that we removed that. But right there we're getting the vein prepared from the back, and then we'll move around to the front in a few minutes. And as I said, we'll take this node out. We tend to use a lot of Endo kitners because it's an easy instrument to use and it's readily available, but other people use standard kitners or sharp dissection. I don't know how you like to open the pleura and dissect structures. 00:17:39 DANIEL L. MILLER, MD, FACS: Well, I do a lot of blunt dissection also, and that's what we used to in the open technique. And the kitner works out very well, that sucker technique works out well. I use a gold tip Yankauer. It's whatever you're comfortable with from an open technique. And as you know, the majority of these -- of surgeons who are going to be doing a VATS lobectomy now has a tremendous amount of open experience. They know the anatomy, they know what they're comfortable with, they're just looking at it from a different angle. So that's why using the same instruments really takes a lot of that comfort and allows you to have more comfort with that technique. 00:18:14 SCOTT J. SWANSON, MD, FACS: That's right. And I would agree. Do what you're comfortable with, use instruments that are familiar. There aren't too many specific instruments that are needed. I think a sucker of some variety that doesn't suck the lung up to any great extent. Or if you use a regular Yankauer, then one thing you can do is just use a Weitlaner retractor in your access incision to push the soft tissue out of the way to essentially create a blow hole, and that helps prevent the lung from being expanded. Here we're identifying the pulmonary artery just under the surface of the pleura in one spot, and this is the technique I like to use in getting the artery out, which is to identify where it is, get down on that nice shiny white plane and then lift everything up anteriorly and superficially to create what I call -- like, it looks like a tunnel, so we kind of call it the tunnel on the artery. And then you can either use your Harmonic scalpel or you can use an Endo stapler to complete the fissure, and I think we tend to staple more than scalpel just because we're a little bit concerned about any postoperative air leak, so that seems to be a nice way to avoid that. 00:19:22 DANIEL L. MILLER, MD, FACS: And this is of that true fissural dissection you do during open. You have the subvascular tunnel that you're doing to fire your staples, which is a very good technique. A lot of times surgeons will divide the fissure at the end. I think, too, for the right lower lobe, this may be more of an advantage to do it this way, because what you're concerned about is is getting that right middle lobe bronchus when you get across the fissure and

7 converting the patient from a single lobectomy to a bi-lobectomy, which is -- if someone has marginal lung function, you've done them a major disservice. 00:19:55 SCOTT J. SWANSON, MD, FACS: That's an excellent point. And here where we're creating the anterior fissure with a stapler between the middle and lower lobe, we're being careful about that middle-lobe bronchus. Here we're completing the fissure posteriorly with the Endo 45 Echelon gold, which is a nice robust stapler, and particularly if you have thick parenchyma, but certainly other loads are equally -- equally good. You can see the whole lower-lobe pulmonary artery heading down to the left of the screen. And that's just mainly to point out there that you want to try to keep that stapler fairly stable. Any traction you apply at the handle end can be transmitted to the artery or whatever structure, so we always like to let the residents know to keep very steady. 00:20:43 DANIEL L. MILLER, MD, FACS: Also, here, too, once you've opened up the fissure, you can dissect on those sump nodes, or number 11 nodes, which will complete your hilar dissection. And, too, just from knowing your anatomy, now that you've opened up the fissure, you know there's only bronchus behind you, that you can be more aggressive in getting around the vessel. And here, too, you're using a curved clamp, you can use a Harken or you can use a renal pedicle, which is a very familiar instrument. 00:21:09 SCOTT J. SWANSON, MD, FACS: That's right. And I think you could see that we were able to get around that fairly readily. Now we're passing the flatter end of the stapler behind the artery and careful not to provide too much traction to that artery. We try to pass it in and then gently push the stapler down towards the main PA so we're not lifting up and causing any sort of subadventitial dissection. We wait a couple of seconds to make sure there's good compression and then we actually fire that stapler. This is a 35 white load, which tends to be our standard for vessels. 00:21:44 DANIEL L. MILLER, MD, FACS: That's the same that we use. I like the very small anvil size, which is very safe getting around the vessel. It's been a very nice technique. You can also use a complacent 0 silk around the vessel or even a red rubber catheter that's secured to the anvil. As you can see, once you get 20, 30, 50 of these under your belt, usually you don't need to use any other assist device to get around the vessel. 00:22:09 SCOTT J. SWANSON, MD, FACS: That's right. And it's nice to have some tricks in the bag, so it's good to point those out, Dan. And here we're finishing off the arterial transection with a 35 load to the basilar trunk. And at this point we'll go ahead and take the vein. We tend to do the artery first just to prevent congestion, although it's probably not critical, and we're bringing the stapler in from the access incision in all of these cases towards the back, lifting the lung up with a ring forcer from the back, and using the camera down in its camera port. But as you point out, and that's a good tip, is if you don't like the angle of the view, you can move your camera around. 00:22:49 DANIEL L. MILLER, MD, FACS: And also, too, I think it's very important before you take any of the veins is to make sure there's not a common trunk. That's very, very uncommon on the right side, but on the left, that can be in an incidence of anywhere from 7-9%, so you don't want to

8 convert somebody from a lobectomy to a pneumonectomy. So you've got to make sure that everything is setting up correctly for you. 00:23:07 SCOTT J. SWANSON, MD, FACS: That's a good point, too. I think that underscores the idea of just being sure about your anatomy. One of the things I found when I began doing this is that you can sometimes be closer in on structures or farther away, and it can make you unsure about what you're actually looking at, so always take time before stapling something to be sure you've got the right structure in mind. Here we're about to divide the lower-lobe bronchus, which is being retracted towards the anterior chest wall, and you can see the middle-lobe bronchus down to the right over in this area, and you want to be real careful that you don't kink that long narrow middle-lobe bronchus. If there's any issue, you should inflate the middle lobe beforehand. We tend to do it early, and we don't as much anymore because we are comfortable, but you should always check that. 00:23:57 DANIEL L. MILLER, MD, FACS: That's a very good point, because when you have your assistant tracking up on the lobe, you can tent the mucosa up and narrow that. So if there's any question at all, I would recommend a ventilation test. 00:24:08 SCOTT J. SWANSON, MD, FACS: So we've divided all the fissures, as you saw earlier. We divided the artery, two branches, and the vein, and now the bronchus. So the lobe is finished. We'll put it in a large lap sac and then bring it out through our access incision, which we generally will enlarge to about four or five centimeters to get that lobe out of the chest. And an impermeable bag is important. Which bag you use is whatever you think is best. 00:24:33 DANIEL L. MILLER, MD, FACS: I think, too, sometimes you can have a very big lobe that has emphysema, and especially if you don't know the underlying pathology, doing a wedge excision first to remove that, which is obviously needed, it really decreases the volume of your lobe and really helps you to keep that access incision to that four to five centimeter size. 00:24:51 SCOTT J. SWANSON, MD, FACS: That's a good point as well. And here we're completing the lymphadenectomy. That's the subcarinal space looking from below. This is the paratracheal space also looking from below. And that 30-degree ability of the camera allows you to look around corners to some extent and see spaces that would be difficult with a 0-degree scope. We like to open the plura up widely so we can see that vena cava and that trachea and that azygos vein and clear all the tissue out in between. 00:25:18 DANIEL L. MILLER, MD, FACS: I think, too, the graphics are just incredible with the cameras that we use, and so the magnification is two and a half to three times. You can really see very well to cut down on the complications of vagal injuries, thoracic duct, and so forth. The Harmonic shears have been very nice to minimize the bleeding and also using your suction and using a grasper to bring the nodes up is an excellent technique. 00:25:42 SCOTT J. SWANSON, MD, FACS: So I think as Dan points out, and I would whole-heartedly agree, one of the things to take away from this is just to see how well you can see. You know, the magnification and the clarity is different than 10 years ago or 15 years ago, and there's nothing you can't see or get to. It's really a matter of angles and views, and as you get more experience,

9 you get comfortable with how to get the best views, moving the camera, changing the angle on the arm, retracting along a different way. 00:26:13 DANIEL L. MILLER, MD, FACS: Especially, too, when you're dissecting the chest, and because we are seeing more and more patients who are nonsmokers and they have a very small chest cavity, so you really want to have that contralateral lung on a very low tidal volume, you know, anywhere from 250 to 300 cc's just allow you to have that access and have that room until the lung becomes completely atelectatic. So it's very important as you communicate with your anesthesiologist that they really help you out, because you know, they're changing every 15 minutes, getting in a coffee break, so you've got to really keep communicating with that person who's in there, because that will really make your job a lot easier, having a very large chest cavity to work in. 00:26:54 SCOTT J. SWANSON, MD, FACS: That's a good tip about the contralateral ventilation. I think can get you out of some trouble. Here we're completing the hilar node dissection. And we'll check for hemostasis. We'll place this -- we use a 24 French chest tube that we place posteriorly up to the apex, mostly for fluid. If we're concerned about air leak, which is pretty unusual, but if we are, we'll add an anterior tube to be just below the access incision to prevent air from tracking out and creating subcutaneous emphysema. 00:27:21 DANIEL L. MILLER, MD, FACS: Do you use any sealants at all? 000:27:23 SCOTT J. SWANSON, MD, FACS: I have not. We haven't. I mean, we're looking for the perfect sealant. When you find it, let us know. 00:27:28 DANIEL L. MILLER, MD, FACS: Okay. 00:27:29 SCOTT J. SWANSON, MD, FACS: We're interested. And we do test the stump. We bring the lung up using a dental pledge to hold the lung down but test the actual bronchial stump by putting it under -- underwater. We usually come up around 30 of pressure and make sure there's no worry about air leak. 00:27:45 DANIEL L. MILLER, MD, FACS: If there is a leak, you know, at the bronchus stump, usually from a calcified cartilaginous ring, it's very easy just to put a single stitch in there thorascopically, but it occurs about 1 or 2% of the time, but it's very easily handled thorascopically. 00:27:58 SCOTT J. SWANSON, MD, FACS: And I think that's another good point. Most -- most issues can be dealt with. The main thing is don't panic. Don't let your fellow panic, don't let your anesthesiologist panic, and don't panic. Just get a sponge on whatever it is, think for a minute, and most things are easily solvable. 00:28:16 DANIEL L. MILLER, MD, FACS: Because most of the time, you do an open technique, it's for oncologic purposes, not from a complication. 00:28:21

10 SCOTT J. SWANSON, MD, FACS: That's right. So that completes the right lower lobectomy, which is a fairly straightforward lobe and probably one of the better lobes to begin with. We're next going to show a left upper lobectomy, which I think is probably one of the harder lobes. And before we do that, we'd like to take a couple questions. And we appreciate you letting us know what your questions are. One of the first questions was: what are the best cases to start out with a VATS procedure, and I think I mentioned one of them. I don't know what your thoughts are about that, Dan. 00:28:57 DANIEL L. MILLER, MD, FACS: Well, starting out with these procedures, I think you want to pick a lobe that's easiest to do, either the right lower lobe or the left upper lobe -- I mean, left lower lobe. And when -- during the learning process, you do it in a step-wise fashion. If you're doing the open technique -- I mean, if you're doing the VATS technique, do the veins first, then open up and do the open technique and just do a step-wise fashion into that. Also, too, it's very important when you're looking for these VATS lobectomy patients, you should also look at their hilar lymph nodes. Being in the South, we have a lot of granulomatous disease, sarcoidosis, which can have a lot of calcification, benign lymph node adenopathy. And so that can be very difficult. So it's very important as you're planning a procedure to spend a lot of time looking at the CT scan in regards to that. 00:29:42 SCOTT J. SWANSON, MD, FACS: That's -- those are good tips, and that goes to another question from one of our viewers that said a relative had a right lower lobectomy where two tumors were seen, one of which was wrapping around a major blood vessel, making it not operable; how can we determine if these tumors are operable ahead of time? And I think, as Dr. Miller points out, a careful analysis of the CT generally will tell us, particularly if there's contrast used, where the issues are going to be. And you pretty well sure what you need to deal with, but with that said, a few percent of the time, you're surprised. But with the VATS approach, it's nice because you can see what's going on before you've committed to a thoracotomy when you might need induction therapy or it might be inoperable for metastatic reasons and you've only done a few incisions to figure that out. 00:30:28 DANIEL L. MILLER, MD, FACS: And, too, even in the preoperative analysis, if you do have hilar disease, now with EBUS, you can biopsy those lymph nodes, and that's an excellent technique to determine if you need to give pretreatment and to determine the resectability. 00:30:43 SCOTT J. SWANSON, MD, FACS: That's exactly right, and a couple other questions before we go to the next lobectomy. We're asked what is the percentage of conversion to open thoracotomy? And I would say don't worry about it. Whatever it is, it is. If it's 80%, that's fine. Convert as much as you need to, because if you didn't convert, they would've got a thoracotomy anyway. I think as you get more comfortable, it probably drops into single digits, but don't look at it as some kind of failure. 00:31:13 DANIEL L. MILLER, MD, FACS: That's right. The most important thing is do the correct procedure. And you know, your first 50 cases, you might open up 10-15%. The next 100, you might open only one time. So don't worry about that. Number one is have a low threshold to open if there is an issue. 00:31:29

11 SCOTT J. SWANSON, MD, FACS: And that's right. In Atlanta, they don't often open, so you know, that's good. And we don't either here, but you know, you'll all get to that level just by taking your time. What are your landmarks or structures that we should pay attention to during this procedure? And I think you'll see, we'll point those out going forward, but in terms of making the ports, you tend to use the axillary line, the anterior superior iliac spine, the tip of the scapula, are fairly routine landmarks, and you can count on those. I don't know if there are other things you like to use. 00:32:06 DANIEL L. MILLER, MD, FACS: What I do when I inject the skin with Marcaine, I will use a very long needle to go into the chest to see my location of where the vein, the fissure is going to be, and that really helps out, so -- because if you're in a different interspace, you might be torquing more on that. And also on those upper access incisions, you can be straight down into the intercostal space. You don't want to be over one because you'll have problems with the instruments. 00:32:30 SCOTT J. SWANSON, MD, FACS: That's right. And that's a good point. I think you want to be directly in so you have the most degrees of freedom for whatever instrument. If you're angled up or down, it kind of limits your ability to do that. The other question, we'll take one more before we go to the next lobectomy, asks about the flexible thoracoscope versus the rigid thoracoscope. I personally have only used the flexible on a number of occasions. I think it's useful but I would say it increases the degree of difficulty for your assistant and I'm not sure it's needed. So sometimes perhaps around the GE junction in esophageal procedures, it might be more helpful, but for this, I haven't found it needed. I don't know what you think. 00:33:11 DANIEL L. MILLER, MD, FACS: Yeah, it adds another element you don't need to worry about. If you're looking to turn 90 degrees and you're not on the same pace or keeping it straight, I'll use a zero scope a lot, but also the 30's very advantageous for the lymph nodes or even the 45 in the left coronal. I know there are some new scopes that are coming out that one scope will be able to go from zero to 45, so those are exciting things so you don't have to keep bringing the scope in and out. 00:33:34 SCOTT J. SWANSON, MD, FACS: And I think that does point out that the technology is really what's allowed us to do these procedures, and it keeps evolving over time. So I think whatever we're doing now will get only easier as time goes on. I think if you learn with the technology we have now, it'll just be that much easier when the technology improves. I think probably at this point we should move on to the next lobectomy, which as I mentioned, is the left upper lobectomy and is, in my opinion, one of the harder lobes to do. And we'll show a technique where we spare the lingula just to add a little bit of the discussion around how you do that. Do you -- are there -- what's your most difficult lobe would you say, Dan? 00:34:17 DANIEL L. MILLER, MD, FACS: I think it's the left upper lobe. We just did one on Tuesday that had seven separate branches of the pulmonary artery that we had to take care of and it was -- once we got into the correct plane that you were talking about, the subadventitial plane, it opens up for you, and it's just taking your time. And also, too, on the left side, make sure you don't have the common vein, which is very, very important. 00:34:39

12 SCOTT J. SWANSON, MD, FACS: That's a very good point. DANIEL L. MILLER, MD, FACS: And, too, because you've got the heart there. If the patient has any hypertension, you can have an enlarged hart, and so all those come into play. But I think the left upper lobe gives you the most challenge. 00:34:49 SCOTT J. SWANSON, MD, FACS: That's right. And here we're beginning on a left upper lobe by dissecting the AP window nodes. Not only does it give us more information about any nodal spread or lack thereof, it does open up the space around the artery and vein. The camera's coming in through a seventh or sixth interspace in the anterior axillary line, and the posterior port where those two Endo kitners are coming through are just behind the tip of the scapula. Again, we see the artery right in the fissure. It's a nice, easy fissure, and therefore we're dissecting on it in one spot. We're removing a node to create a little space and then again get in that sort of vascular tunnel that allows us to staple the fissure and avoid any problems with it in terms of air leak. And to make that simpler, we'll retract the lung posteriorly. As you see here, we have a Ring forcep through that fourth interspace to access the incision anteriorly, and we're bringing the lung anteriorly and using the two Endo kitners through the posterior port to dissect the lymph nodes that are sitting on the pulmonary artery as it traverses into the fissure. And this allows us to open that space up so that the fissure will -- when we create the fissure from the other side, we have a spot where the staple will come through and it's not going to hit the aorta or any other structures. 00:36:11 DANIEL L. MILLER, MD, FACS: Also, too, you can -- which is a very nice technique that you're showing here -- you can use a Harmonic shears. You can even just use a standard pair of Metzenbaum scissors to divide the lymph nodes, get into that nice plane, and really to lift that off, it really works out well. Because you're doing more of an advanced technique here of a lingula-sparing segmentectomy, in this you would get into the fissure. A lot of times, you just stay medially, but this is an excellent technique to identify the structures you're going after. 00:36:42 SCOTT J. SWANSON, MD, FACS: So there we're seeing the posterior segmental artery where the tip of that suction irrigator is. There's a node just to the right of that. And we're kind of looking up proximally on the artery and staying on that plane just to lift up the -- that areolar tissue that sits on the artery there. And at this point, we've identified no sign of metastatic disease that would make us concerned. I didn't show the CT scan, but it was a small lesion that was perfectly centered up in the upper division that made us think it would be helpful to do it this way. We palpated the lung to make sure we were happy with what those margins would be doing this technique, and we were comfortable. But always at the end we'll check and we can convert to a full lobectomy if we're not happy. Here we're passing the stapler through that tunnel to create the fissure between the posterior segment of the left upper lobe and the superior segment of the left lower lobe. We're using, I believe, a 60 gold load there that is a nice stapler for this part of the operation. And this just splays open the fissure. And again, you can do it without doing this, but I think as Dr. Miller points out, if you're going to do a segmental resection, it's nice to see those structures individually as you go. 00:37:54 DANIEL L. MILLER, MD, FACS: I think, too, is it's also a very good technique. You're bringing the stapler through the anterior access incisions. We also will bring a lot of times through the che-- the lower inferior incision and even have it next to the scope sometimes. So that's one thing in doing VATS procedure, a lot of times you'll have multiple instruments through

13 one incision. That's why it's nice to have a little bit larger incision, not have a port. And it really becomes very comfortable. 00:38:17 SCOTT J. SWANSON, MD, FACS: That's right. And so at this point, we'll retract the lung back posteriorly with, again, a Ring forceps is what we like to use. You can use a DuVal or whatever you like to use on the lung, and we'll start to look at the vein. The lingular vein is generally one or two branches, similar to the middle lobe vein on the other side, and there can be intersegmental veins, unlike the artery or the bronchi, and you just have to take your time. So here you'll see we spend a few seconds on this tape showing you that we're trying to sort out where those veins go. There's clearly one or two that go down to the lingular portion and there's one that goes up and there's kind of this straggler in the middle, and one thing you can do is take what you're sure is an upper division or whatever segment you're working on structure and leave the other one till you've defined things a little better to see if you need to take it. 00:39:13 DANIEL L. MILLER, MD, FACS: I think you did an excellent technique earlier by removing the AP window node. That really allowed you to open up that plane. And like you said, you do the safest maneuver first. If you're concerned that this one middle vessel is with the lingula, you would just take the apical interior segment. As you see, he's using the renal pedicle here. You do have the pulmonary artery behind you, so you've got to be very careful there. And as you're doing that, you're pulling medially toward the patient to not injure the pulmonary artery posteriorly. 00:39:43 SCOTT J. SWANSON, MD, FACS: That's right. And I think that Dr. Miller brings up a good point, which is we essentially think of the pulmonary artery as the key structure, so when we're dealing with a vein, we're lifting away from the PA bronchus, we're lifting away from the PA, and that leads to less problems. But you can see, we're using pretty standard technology instruments -- just a right-angle or the renal clamp that Dan was mentioning. And that's coming down through the access port with the lung retracted straight up, and you can see the suction irrigator in the right of the picture, which is there to suck any smoke or anything that might fog your camera. That can be a little bit of a nuisance, and I don't know that anyone's solved that one yet, but I think irrigating a little bit sometimes helps. 00:40:32 DANIEL L. MILLER, MD, FACS: That would be -- you would win a Nobel Prize for that invention, that's for sure. 00:40:36 SCOTT J. SWANSON, MD, FACS: Here we're passing a zero silk around the lingular vein, and again, it just ensures that you've got enough room, but you don't often have to use it anymore once you get comfortable, but feel free. There's a red rubber technique that Dan alluded to where you can tie one end to a red rubber catheter and it will help guide the stapler if you're not sure how to push it. We're passing the 35-millimeter stapler, white load, around that lingular vein, that top vein. And as you see, we're sparing that middle one to make sure we actually are going to need to take it, and you'll see that later on. We divide that and that immediately shows us the underlying first two branches of the artery. 00:41:20 DANIEL L. MILLER, MD, FACS: I think it's also very important as you're applying the stapler, you allow it to compress the tissue for a little bit, but also, too, the most important thing is when

14 you release that stapler, you control that, because you don't want to bruise the pulmonary artery behind it and just take it very controlled. Also here as Dr. Swanson took that AP window node earlier to get this truncus branch, this is probably one of the most critical areas. We can get into bleeding difficulties, and he's done an excellent job of dissecting that of dissecting that free to cut down that risk. 00:41:48 SCOTT J. SWANSON, MD, FACS: We're not showing that video tip today. But we moved the camera up to the access incision and having a direct shot at those first branches. That's the vein in the foreground. And we passed the 35 stapler up from the camera port, and that's for us a nice angle for that approach. We're looking at the lingular branch of the artery here and the posterior segmental artery there. And we're passing the stapler from the posterior port up to the apical anterior aspect of the chest. We've passed a kitner around to make sure, because you're not seeing the tip. But we've made sure it passes easily. And we didn't put it on this, but you flip the lung around and be happy that it's going into a space you're comfortable with. 00:42:30 DANIEL L. MILLER, MD, FACS: What stapler do you usually use on the bronchus? 00:42:34 SCOTT J. SWANSON, MD, FACS: Well, that's a good question. As we're getting ready to do the bronchus, you can see that upper division bronchus to the right of those Endo kitners there in the breeze, and the lingular bronchus is here. For segmental bronchi, at 35 blue or 45 blue works. For most low-bar bronchi, I like a green in a 45 or 60 length. But I think, you know, for a segmental, it really depends on the size of the segment. This is a relatively small one, so I think we end up using a blue load. Is that similar to -- 00:43:05 DANIEL L. MILLER, MD, FACS: I agree. The majority of the time for almost all lobes we'll use the green. And when I do a segment -- most commonly, that's a speared segment lingulectomy, we'll use the blue. 00:43:16 SCOTT J. SWANSON, MD, FACS: So once we defied this structure, then -- and again, you could if you're not sure, make sure you ventilate the lung at any point when you're coming around an airway structure. You can have the anesthesiologist puff the lung a little. But be careful. It takes a little longer to deflate. But anybody who's beginning ought to do a lot of ventilating, both themself and the patient. 00:43:37 DANIEL L. MILLER, MD, FACS: And also, too, before you divide anything, just like this, getting ready to divide this segment with the fissure, just kind of take the lobe down, reposition the normal anatomy, because a lot of times you'll take more than you want to, especially when you're doing a segment-sparing procedure. 00:43:55 SCOTT J. SWANSON, MD, FACS: So that's a good point, and here we spent a little time making sure we're happy with the orientation. This is the first fissure I usually create for the lingular-sparing procedure, which is anteriorly between the upper division anteriorly and the lingula. And I tend to use the vein as a guideline. I try to obviously spare the lingular vein and then orient it in the direction of the lingular vein, and that is generally -- you can see the vein down at the base here, and we're going to be careful to make sure we're coming down and sparing that vein. And once you've divided that, that sort of sets your anterior landmark, and then

15 we'll go ahead and start the posterior segment, and that's angled towards the angle that the front fissure's heading but beginning posteriorly and using the artery as your guideline, leaving the lingular artery behind, obviously, and going just inferior to where the posterior segmental artery was divided. And we are, as Dan pointed out aptly, a little foreshadow there, that you reorient the lung carefully so you make sure you know what you're actually doing and not confused. 00:45:07 DANIEL L. MILLER, MD, FACS: Yes, because you get into the surgical momentum and you're moving along pretty well and you can make a fatal flaw -- not a fatal flaw, but a flaw in committing more of the lobectomy than you wanted to do. 00:45:19 SCOTT J. SWANSON, MD, FACS: That's excellent. And so always take your time when you're dividing anything with the stapler. Make sure you're happy. Pull the camera back, get oriented, make sure you're not too close or too far from some structure that you're concerned about. So here we divide that posterior fissure, and now it's pretty obvious where you're heading, because you've created sort of your orientation. And the key part now is to complete it, and we usually do it from the anterior aspect because it's a nice angle from that anterior access incision, but we make sure, as you can see here, the upper division bronchus, which we divided, is by that kitner. We want to obviously leave that with the specimen and angle our stapler so it's parallel with the lingular bronchus, which is coming out at us. And if you've got any concern about that, just have your anesthesiologist give a couple puffs and make sure that lingula comes up. Now, it can sometimes be hard to interpret, because you're pulling up on it and things are twisted, there's a little bit of blood, but it's good to be sure you see some air get in there and you're happy. 00:46:23 DANIEL L. MILLER, MD, FACS: And, too, I think it's very important that -- you showed with this case that you can put that stapler through in the access incision. A lot of times you use the posterior more than the anterior. And also, too, when you're doing the dissection, you're doing this all by observing the monitor. You're not looking down through the small incision, the access incision. If you do that, it's going to throw off your depth perception, but you're going back to that eye/hand coordination by using the monitor. 00:46:46 SCOTT J. SWANSON, MD, FACS: That's right, Dan. That's an excellent tip. And here we put it in the bag and bring it out, and then we're going to show you some of the -- some of the lymph node dissection aspects of this operation once we have the lobe out of the way. We're just -- it's a time to mention that you should be careful and look at your specimen, make sure you're happy with your margin, that it's what you want. If it's not, you can do more. And that's a twocentimeter range lesion, which is a good lesion, I think, size for a segmental resection, assuming it's centered in the proper place. 00:47:19 DANIEL L. MILLER, MD, FACS: I think, too, when you do a lobectomy, you send it down to the pathologist, they've got a staple line on the bronchus, which they're not used to, because we always ask for a bronchus margin. And so you've had to kind of teach them a little bit more to pull it out and get a nice cut on that. 00:47:33 SCOTT J. SWANSON, MD, FACS: That's right. And here now we're going to show you a little bit about some nodes, and we'll show that a little more as well, but we're using just a simple cautery device to take down the ligament, which allows you to get easily up to the subcarinal