| 00 min 13 sec |
Here you can see the working port incision |
| 00 min 18 sec |
The left lower lobe is severely adherent to the posterior chest wall with signs of pleural fluid and active inflammation |
| 00 min 32 sec |
The Ligasure™ is used to separate the adhesions between the left lower lobe and diaphragm as well as the posterior chest wall |
| 00 min 42 sec |
Generally areas of movement such as the diaphragm and aorta have less adherent planes to dissect the overlying tissues away |
| 00 min 52 sec |
Close to the chronic inflammation you can see the oozing from all of these surfaces that will be controlled later by energy devices |
| 01 min 00 sec |
Here the plane between the aorta and the lower lobe is being created bluntly |
| 01 min 10 sec |
The Aquamantys™ bipolar tissue linking device is delivered through the access incision and does a nice job controlling the diffuse oozing typically for these cases |
| 01 min 28 sec |
It is evident that the inflammation extends into the inferior pulmonary ligament |
| 01 min 34 sec |
Both the Ligasure™ and the retractor are placed through the working port |
| 01 min 39 sec |
One tool depresses the diaphragm and the other tool divides the inferior pulmonary ligament extending up to the thickened pleura adjoining the aorta |
| 01 min 47 sec |
This area is also inflamed and hemostatic agents can be placed to promote clotting |
| 01 min 56 sec |
Attention is given to interlobar fissure for dissection to continue without wasting time |
| 02 min 03 sec |
Here a Heart-port™ grasper is used to tent the pleura while standard cautery opens the inflamed tissues to expose the pulmonary artery |
| 02 min 19 sec |
Better views of the pulmonary artery result from completely opening fissures |
| 02 min 25 sec |
Here the landing zone is created with a peanut dissector at the junction of the interlobar fissure and the medial hilum |
| 02 min 38 sec |
The pulmonary artery is shown there and a straight blunt clamp tunnels beneath the fissure posteriorly to terminate in the landing zone |
| 02 min 56 sec |
This allows passage of loop to help hold open the tract and then a curved tip stapler hugs the back of this dissection pathway to complete the anterior portion of the interlobar fissure |
| 03 min 10 sec |
Notice how two retractors both from the anterior working port provide traction and counter traction |
| 03 min 16 sec |
Once done it is now useful to complete the posterior fissure |
| 03 min 31 sec |
Again looking posteriorly between the aorta and the hilum the exit zone is identified and cleaned bluntly |
| 03 min 41 sec |
Then by using a slightly curved blunt clamp through the access incision and gently spreading in the direction of the landing zone it is possible to open the posterior fissure to expose the arterial anatomy safely |
| 04 min 13 sec |
Although not always necessary, loops such as this help to define the tunnel, particularly when using a standard round tip stapler |
| 04 min 31 sec |
Two retractors from the anterior working ports provide traction and counter traction and a peanut blunt tip retractor further defines the arterial anatomy |
| 04 min 51 sec |
A blunt instrument gently separates it away from lymphatic tissue |
| 04 min 56 sec |
A surgical stapler or a 5 mm energy sealing device can then be passed between the two retractor instruments through the same anterior working hole |
| 05 min 04 sec |
Here you can see the curved tip stapler device dividing the remaining posterior fissure to expose the superior segmental artery |
| 05 min 13 sec |
Notice that this artery arises from the continuation pulmonary artery proximal to the lingular artery |
| 05 min 20 sec |
Again using the same maneuver, it is divided with a curved tip stapler to preserve the continuation pulmonary artery down to the origin of the lingular artery |
| 05 min 43 sec |
The base of the artery branches are then dissected bluntly from the surrounding inflamed tissue |
| 05 min 54 sec |
Here a large right angled clamp is shown in accelerated speed demonstrating how multiple small spreads with no more force than the weight of the instrument will help it open that tunnel beneath the vessel |
| 06 min 08 sec |
Then using the supplied silicone extension of the curved tip stapler, the anvil is guided through safely to allow division of this artery, while preserving flow to the lingular segment |
| 06 min 38 sec |
A curved tip extension does not require removal before firing the stapler |
| 06 min 49 sec |
Pulsatile flow into the lingular artery is verified after the oblique firing of this vascular stapler |
| 06 min 56 sec |
Now the lung is transferred to a ring retractor passed through the access incision to allow separation of the inflamed thickened tissues |
| 07 min 10 sec |
If there is any question of aberrant venous drainage, vascular staplers can be used to divide these tissues |
| 07 min 19 sec |
This central lower lobe tumor was adherent to the esophagus |
| 07 min 24 sec |
You can see muscle fibers being thinned out and dissected off of the tumor |
| 07 min 43 sec |
This is a useful Diamond Flex retractor initially developed for laparoscopic liver retraction |
| 07 min 49 sec |
Even larger specimens like this can be controlled with a single instrument provided the dissection has been performed to the point that the diamond flex retractor can be passed around the hilum |
| 08 min 02 sec |
This 5 mm retractor also allows other instruments such as the stapler to pass beside it |
| 08 min 08 sec |
Here you can see the bulky tumor anatomy and its adherence to the esophagus and pericardium that keeps the inferior pulmonary vein within it from being divided at this point |
| 08 min 21 sec |
Lymph nodes, such as the level 8 station are shown |
| 08 min 27 sec |
To open the pericardium, it is grasped at an area where the heart can be seen moving beneath it. Here you can see pericardial fluid egressing and with an endoscopic scissors passed through the access incision further opening into the pericardium is created to allow safe visualization of the inferior pulmonary vein |
| 08 min 56 sec |
In this case it would have been very difficult to divide this vascular structure without entering the pericardium |
| 09 min 09 sec |
Further dissection of the pericardium off of the vein circumferentially is performed |
| 09 min 14 sec |
Here a large right angle clamp can be passed safely around the pulmonary vein and its insertion into the left atrium |
| 09 min 36 sec |
This right angle clamp can deliver a catheter to help guide the curved tip stapler through a tight passage such as demonstrated here |
| 09 min 47 sec |
One advantage of the curved tip anvil extension is that it no longer requires using the whole open flange of such a leader catheter |
| 10 min 04 sec |
The tubing can simply be cut, in this case it is 14 French red rubber tubing |
| 10 min 11 sec |
The catheter can be stretched onto the tip, just like the leader that comes with this product except it has the advantage of being much longer |
| 10 min 42 sec |
Since this stapler is going across thicker atrial tissue, notice that we are using the longer length purple load tri-staple cartridge |
| 11 min 02 sec |
In this view you can see the tumor and its effect on tissues immediately above the stapler |
| 11 min 22 sec |
Now the remaining pericardium and inflamed tissues around the bronchus are divided with an energy device |
| 11 min 30 sec |
The surgeon can help feel for the bronchus within this structure using the suction catheter |
| 11 min 34 sec |
Here you can see a lymph node grasper removing an 11 L lymph node. Additional lymphatics are divided with the Ligasure™ as the main-stem bronchus is being dissected |
| 11 min 58 sec |
The same Diamond Flex retractor provides downward force to lengthen the bronchus so that a black tri-staple load cartridge can be positioned and closed |
| 12 min 12 sec |
Green or black load staplers are useful for thick tissue like the bronchus |
| 12 min 20 sec |
Here the Diamond Flex retractor remains in and provides a convenient way to provide base stabilization of the triangular opening into the extraction sac |
| 12 min 30 sec |
Large specimens such as this are manipulated into the extraction sac using cooperating instruments one through the access incision and one sharing the anterior working port |
| 12 min 45 sec |
The site of the tumor is inspected and here you can see the application of fibrin glue sealant to the area of previous oozing and placement of a chest tube |
