| 00 min 10 sec |
This view shows the thoracoscopic appearance of the right upper and middle lobe |
| 00 min 24 sec |
Adhesions are divided using the Ligasuretm |
| 00 min 35 sec |
A right angle clamp dissects the posterior pleura posterior to the right upper lobe bronchus |
| 00 min 41 sec |
Multiple graspers through a single port provide traction and counter traction for optimal viewing |
| 00 min 51 sec |
Now attention is giving to the interlobar fissure which is nearly complete in this patient except for the posterior fissure |
| 01 min 00 sec |
A thoracoscopic DeBakey forceps is used to lift the pleura and incise it |
| 01 min 07 sec |
Later this will be useful to complete division of the minor fissure |
| 01 min 24 sec |
This view shows the phrenic nerve and the superior hilum but by viewing from the anterior port there is a much better view of the middle lobe and upper hilum |
| 01 min 36 sec |
The middle lobe and upper lobe branch of the superior pulmonary vein is shown in this view |
| 01 min 43 sec |
With two retractors holding the lung in optimal orientation a large blunt clamp separates the vein to the upper lobe |
| 02 min 04 sec |
To aid passage of the stapler, an elastic retractor is placed as an optional step |
| 02 min 10 sec |
An important aspect of this technique is swapping retraction from the inferior port to the access incision to allow passage of the stapler |
| 02 min 20 sec |
The inferior port retraction is switched to the access incision to hold the upper lobe and the vein in the proper orientation |
| 02 min 34 sec |
The stapler coming from the inferior port is passed around the vein branch to the upper lobe |
| 02 min 41 sec |
Notice how the stapler has to be articulated and then rotated to allow the anvil to follow the correct course around the vein |
| 02 min 51 sec |
This orientation allows entry behind the vein and now rotation of the stapler allows the anvil to pop out behind and divide the vein |
| 03 min 00 sec |
This gains exposure for the continuation pulmonary artery and the apical trunk artery |
| 03 min 18 sec |
Still viewing from the anterior port, the pleura and the lymph node packet from the superior truncal artery are dissected |
| 03 min 29 sec |
Once the artery is properly dissected the same exchange of instruments is performed with graspers switching from below to the access incision |
| 03 min 38 sec |
Full articulation almost always provides an excellent angle for passing the stapler using the rotational move to allow the anvil to hug the back of the vessel |
| 03 min 55 sec |
The minor fissure is partially divided with a stapler from outside in |
| 03 min 59 sec |
Applying the stapler at the level of the chest wall adds to safety |
| 04 min 08 sec |
Now you can see a blunt clamp dissecting just lateral to the continuation pulmonary artery |
| 04 min 22 sec |
A large blunt right angle clamp manipulated through the access incision traverses all the way through to exit within the fissure where the pleura was dissected earlier |
| 04 min 40 sec |
To facilitate passage of the stapler and completion of the minor fissure a red rubber catheter can hold open the track |
| 04 min 56 sec |
The catheter tip needs to be sutured to another red rubber catheter which will then act as a leader for the stapler anvil |
| 05 min 12 sec |
Once partially through as a leader the anvil is delivered by pushing tissue over top of the red rubber |
| 05 min 21 sec |
To ease passage of subsequent reloads for long incomplete fissures the leader can remain attached provided the stapler is not fired all the way to the tip |
| 05 min 46 sec |
In this case firing the stapler was aborted to further investigate the pulmonary vein drainage that appeared aberrant in this view |
| 05 min 52 sec |
By opening the posterior fissure the venous drainage to the upper lobe can be selectively dissected thereby exposing the ascending posterior pulmonary artery branch |
| 06 min 19 sec |
This is dissected with a large blunt clamp through the access incision while providing both traction and counter traction through the single anterior working port |
| 06 min 53 sec |
The stapler through the access incision is well aligned to divide structures that lie within the incomplete fissure using a 2.5 mm load |
| 07 min 02 sec |
Once the venous anatomy has been confirmed, it is then possible to repeat the earlier steps to complete the minor fissure |
| 07 min 20 sec |
Here the Snowden-Pencer Diamond Flex loop retractor is used to snare the upper lobe to define the remaining bronchus |
| 07 min 30 sec |
The Ligasure™ is used to clean the remaining tissue |
| 07 min 39 sec |
And then through the same port that the retractor holds the lobe, it is possible to pass a 4.8 mm green load stapler to complete the division of the upper lobe bronchus |
| 07 min 53 sec |
After division of the bronchus the upper lobe is removed using a specimen extraction sac as seen on the other videos |
