| 00 min 10 sec |
This view shows the entry into the right chest exposing upper, middle, and lower lobes |
| 00 min 16 sec |
The working port should be as medial as possible and optimally in-line with the major fissure |
| 00 min 21 sec |
A 4 cm access incision is made over the continuation pulmonary artery because this is the area of most delicate dissection |
| 00 min 31 sec |
Now with two retractors through the anterior working port and instruments passed through the access incision, the pleura over the interlobar artery is opened |
| 00 min 46 sec |
This shows the anterior surface of the pulmonary artery |
| 00 min 50 sec |
To enable the posterior pleural dissection, the grasper pulls the superior segment of the lower lobe and posterior segment of the right upper lobe towards the sternum |
| 00 min 58 sec |
This makes it easy to open the posterior pleura starting at the right upper lobe bronchus and continuing inferiorly |
| 01 min 05 sec |
This also makes it easier to divide the posterior fissure later |
| 01 min 21 sec |
Once the pulmonary artery has been identified, it is then safe to bluntly dissect immediately posterior to it aiming toward the interlobar fissure termination that was just explored from the posterior view |
| 01 min 47 sec |
With the lung being pulled anteromedially the blunt clamp exits in the correct spot inferior to the right upper lobe bronchus |
| 01 min 52 sec |
This allows passage of a vessel loop to hold open the tract |
| 02 min 04 sec |
With the stapler introduced in the anterior working port and instruments passed through the access incision to retract the lung it is possible to pass the anvil of the stapler through this tunnel |
| 02 min 32 sec |
With the posterior fissure divided, it is then possible to explore this area by further retracting the lower lobe inferiorly, a blunt clamp is introduced into the access incision to create a posterior plane to the continuation pulmonary artery |
| 02 min 55 sec |
The basal segment artery branch is seen beside the bronchus |
| 02 min 58 sec |
A curved Harkin clamp is used to complete the posterior dissection |
| 03 min 18 sec |
The cautery is passed through the access incision to divide tissue behind the artery and then a loop provides additional exposure so that the stapler can be passed behind it safely |
| 03 min 38 sec |
The stapler is articulated inferiorly after passage through the anterior working port |
| 03 min 48 sec |
Rotation guides the stapler anvil behind the artery |
| 03 min 56 sec |
The loop is removed and the stapler is closed |
| 04 min 08 sec |
A small amount of additional fissure posteriorly is divided with the stapler as well |
| 04 min 24 sec |
This leaves only the bronchus and the inferior pulmonary vein |
| 04 min 28 sec |
To expose the inferior pulmonary vein the lower lobe is passed with retractors from the anterior working port to a ring clamp that is passed through the access incision |
| 04 min 39 sec |
Then the anterior working port retractor depresses the diaphragm to give good exposure to the inferior pulmonary ligament |
| 04 min 46 sec |
Through the same port that the retractor is passed a long spatula tip cautery divides the inferior ligament |
| 04 min 53 sec |
Additional posterior pleural attachments are mobilized between the bronchus intermedius and the vein |
| 05 min 01 sec |
Then a large right angle clamp is passed through the access incision and two retractors through the anterior working port provide optimal exposure |
| 05 min 35 sec |
The lung retraction is passed to the instrument through the access incision so that the stapler can be brought in through the anterior working port angulated downward and rotated behind the posterior vessel |
| 05 min 57 sec |
Then the stapler is articulated so it can be pushed toward the left atrium |
| 06 min 12 sec |
Although the same retraction can be done with two instruments through the anterior working port, a single loop retractor for large lobes or large tumors is useful to provide exposure to clean the remaining tissue on the bronchus |
| 06 min 35 sec |
Here you can see that the bronchus to the middle lobe branches somewhat distally and therefore it is important to perform enough distal airway dissection so that the middle lobe bronchus is not impinged |
| 06 min 56 sec |
Now the stapler is passed through the same port through which the loop retractor currently retracts the lung and it is closed temporarily to test inflate the middle lobe |
| 07 min 16 sec |
Next the same loop retractor provides basal stabilization of the bag that was introduced into the access incision |
| 07 min 23 sec |
Then using cooperating instruments, one through the same port that the loop retractor resides and an angled instrument through the access incision the specimen is advanced into the sac |
| 07 min 36 sec |
This view shows the importance of selecting a lead point through the access incision so that the remainder of lobe can follow |
| 07 min 44 sec |
Gentle pushing from inside also is useful |
| 07 min 56 sec |
With the lobe removed, it is easy to dissect off the nodes in the level 8 position as well as continue this superiorly to remove nodes in the subcarinal space |
| 08 min 04 sec |
This is done using a ring clamp through the access incision |
| 08 min 16 sec |
An intercostal nerve block can be performed at any time during the case using a long needle |
| 08 min 24 sec |
Then the chest is filled with water and the camera port is used to place a chest tube |
| 08 min 36 sec |
While viewing through the anterior working port under water it is possible to inspect the bronchus with 20 cm of water pressure |
| 08 min 43 sec |
While withdrawing the camera lung inflation is confirmed |
