lung surgery technique  

exposure of the hilum

exposure of the hilum

- exposure of the hilum ทำอย่างไร

** เปิด medistinal pleura

** ระวัง vagal nerve

- lung cancer อยู่ที่ hilum ให้ทำอย่างไร

pneumonectomy

- dissection of the pulmonary ligament

- subcarinal lymph node dissection

- divisoin of the inferior pulmonary vein

- division of the superior pulmonary vein

- division of the right pulmonary artery

- dissection of the upper mediastinum

- division of the right main bronchus

 

dissection of the pulmonary ligament

- หลังเปิด pleura ให้แบ่ง fatty tissue จาก esophagus และ vagus nerve จนเห็น lower border of inferior pulmonary vein

 

division of the inferior pulmonary vein

- ให้ทำ inferior mediastinal + subcarinal lymph node dissection ก่อน

- เปิด adventitia of inferior pulmonary vein

- ตัด inferior pulmonary vein

 

division of the superior pulmonary vein

- ถ้า tumor invade or located in the hilum ให้ทำอย่างไร

 

division of the right pulmonary artery

- ให้แบ่ง membrane ที่คลุม superior pulmonary vein, right pulmonary artery เพื่อให้เห็น right pulmonary artery

- apply vascular clamp ที่ right pulmonary artery

- dissect central stump ที่ตัดแล้วไม่ให้ stump ไปบาดเจ็บต่อรอบข้าง

 

dissection of the upper mediastinum

- เปิด mediastinal pleura จากไหนถึงไหน

- ถ้า upper mediastinal lymph node บวม ให้แบ่ง azygos vein

- indication covering stump

- indication omentoplexy

 

division of the right main bronchus

- ถ้า right main bronchus ยาวให้ทำ sweet technique

- ถ้า right main bronchus สั้นให้ทำ overholt method

upper lobe lobectomy

- division of the superior pulmonary vein

- division of the superior pulmonary artery

- dissection of the upper mediastinum

- division of the interlobar space

- dissection of the interlobar lymph nodes

- division of the upper lobe bronchus

division of the superior pulmonary vein

- เปิด pleura ดู hilum

- superior pulmonary vein ligation

- ligate branches of superior pulmonary vein

 

division of the superior pulmonary artery

- large hilar or intrapulmonary node ให้ทำอย่างไร

 

dissection of the upper mediastinum

- ligate upper + intermediate bronchus

- ligate bronchial artery

 

division of the interlobar space

- ให้ตัดแบ่ง major fissure จะเห็น intermediate pulmonary arteyry or lymph node attaching to the artery

 

dissection of the interlobar lymph nodes

 

division of the upper lobe bronchus

- sweet procedure vs overholt procedure ต่างกันอย่างไร

rigth upper lobe lobectomy

- right upper lobe lobectomy มีเทคนิคการทำอย่างไร

right upper lobe lobectomy มีเทคนิคการทำอย่างไร

- anterior aspect of the right hilum. Division of the apical segmental vein facilitates dissection of the superior trunk of the pulmonary artery

- the superior arterial trunk before ligation. The anterior as well as the apical segmental vein has been divided to demonstrate the interlobar trunk of the pulmonary artery

- posterior aspect of the right-upper-lobe hilum after division of the mediastinal pleura. vagal branches posterior to the bronchus are not yet divided.

- The right -upper-lobe bronchus is dissected.

- finger dissection separates the bronchus from the interlobar pulmonary artery

- the bronchus has been stapled and divided. Medial traction on the specimen facilitates dissection of the posterior ascending artery

- the oblique fissure is completed by a sharp and blunt dissection and stapled where required.

- retracting the lobe medially and stapling the minor fissure exposes the middle trunk of the superior pulmonary vein. Note teh relationiship of this trunk to the underlying interlobar pulmonary artery. The middle lobe vein has been identified and preserved.

- Edges of the middle and lower lobes are approximated with silk ties to prevent middle lobe torsion.

left upper lobectomy

- left upper lobectomy มีเทคนิคการผ่าตัดอย่างไร

left upper lobe lobectomy มีเทคนิคการผ่าตัดอย่างไร

- the mediastinal pleura is incised and the pulmonary artery is dissected in the subadventitial plane.

- the interval between the pulmonary artery and the superior pulmonary vein is defined.

- dissection of the posterior aspect of the left-upper-lobe hilum medial to the vagas nerve

- the left pulmonary artery is dissected from the left main branches and encircled with a silastic loop

- the posterior portion of the fissure is completed by stapling, and the segmental arteries are demonstrated

- after division of the lingual and posterior segmental arteries, rotation of the lobe aids dissection of the apical and anterior segmental arteries

- the pulmonary artery is rolled away from the left upper bronchus. The site of bronchial transection is indicated.

- the left-upper-lobe bronchus is stapled and divided. The superior pulmonary vein is stapled and occluded distally by a Sarot clamp.

right lower lobe lobectomy (RLL lobectomy)

- right lower lobe lobectomy มีขั้นตอนการผ่าตัดอย่างไร

right lower lobe lobectomy มีขั้นตอนการผ่าตัดอย่างไร (RLL lobectomy)

- ลง incision pleura อย่างไร

** interlobar pulmonary artery อยู่หลังต่อ oblique fissure

++ dissection of the oblique fissure at its junction with the horizontal fissure demonstrates the interlobar pulmonary artery and its branches

++ dissection of the oblique fissure at its junction with the horizontal fissure demonstrates the interlobar pulmonary artery and its branches with one middle lobe artery is divided.

- ligate pulmonary artery branch

++ stapling the posterior portion of the oblique fissure facilitates the dissection of the superior segmental artery.

- the lung is retracted anteriorly.

- the inferior pulmonary ligament is divided.

- การแบ่ง inferior pulmonary vein

++ the inferior pulmonary vein is then dissected, stapled, and divided.

- ตัด lower lobe bronchus

lower lobectomy

- division of the interlobar space

- division of the pulmonary artery

- dissection of the interlobar lymph nodes

- division of the lower bronchus

- covering with pericardial fat pad

division of the interlobar space

- ในกรณีที่ incomplete separation ให้ทำอย่างไร

 

division of the pulmonary artery

 

dissection of the interlobar lymph nodes

- ควรเลาะ upper mediastinal lymph node

 

division of the lower bronchus

 

covering with pericardial fat pad

- indication cover with peritoneal fat pad

- ทำไมต้อง cover

right lower lobe lobectomy (RLL lobectomy)

- right lower lobe lobectomy มีขั้นตอนการผ่าตัดอย่างไร

right lower lobe lobectomy มีขั้นตอนการผ่าตัดอย่างไร (RLL lobectomy)

- ลง incision pleura อย่างไร

** interlobar pulmonary artery อยู่หลังต่อ oblique fissure

++ dissection of the oblique fissure at its junction with the horizontal fissure demonstrates the interlobar pulmonary artery and its branches

++ dissection of the oblique fissure at its junction with the horizontal fissure demonstrates the interlobar pulmonary artery and its branches with one middle lobe artery is divided.

- ligate pulmonary artery branch

++ stapling the posterior portion of the oblique fissure facilitates the dissection of the superior segmental artery.

- the lung is retracted anteriorly.

- the inferior pulmonary ligament is divided.

- การแบ่ง inferior pulmonary vein

++ the inferior pulmonary vein is then dissected, stapled, and divided.

- ตัด lower lobe bronchus

left lower lobe lobectomy

- left lower lobe lobectomy มีขั้นตอนการผ่าตัดอย่างไร

left lower lobe lobectomy มีขั้นตอนการผ่าตัดอย่างไร

- ลง incision pleura

- หา pulmonary artery

++ oblique fissure is completed and pulmonary artery branches are demonstrated

++ the superior segmental artery is ligated. Basal arteries are ligated and divided after teh lingual arterial branches are demonstrated.

- การ ligate pulmonary artery

- การ ligate inferior pulmonary vein

++ the interval between the pulmonary vein and the lower lobe bronchus is defined.

++ the inferior pulmonary vein has benn stapled. A Sarot clamp is applied to the speciment side before transection.

- การตัด lower bronchus

++ oblique transection of the bronchus prevents formation of a cul de sac

++ view of the hilum after left lower lobectomy

middle lobectomy

middle lobectomy

- middle lobe bronchus will be cut

lymph node dissection

- lymph node station location

- subcarinal lymph node dissection

lymph node station location

- station 2: located between the cephalad border of the innominate vein and the cephalad border of the aortic arch

- station 3 anterior node : found anterior and medial to the superior vena cava at the insertion of the azygos vein

- station 4 : lying between the cephalad border of the aortic arch and the cephalad border of the zygos vein

- station 4R : located between the cephalad borders of teh azygos vein and the origin of the right upper lobe bronchus

- station 5 : lymph node founded posteriorly to the ligamentum arteriosum

- station 6 : lymph node located in the fat pad anterior to the ligamentum arteriosum

- station 7 : retracting the lung anteriorly and incising the pleura. The pleural edge overlying the esophagus is placed on traction and the esophagus is retracted posteriorly

 

- station 9 ; lymph nodes are found in the inferior pulmonary ligament and are readily resected using clips or cautery.

- station 10 : node along the anterior border of the bronchus intermedius, distal to the pleural reflection, and are exposed by retracting the lung posteriorly and the pulmonary artery anteriorly

- station 11 : lymph node found in the sump of Borrie between the lobar bronchi

- station 12 : lymph node situated at the distal aspect of the lobar bronchi and are resected with the specimen

 

subcarinal lymph node dissection

cervical mediastinoscopy

- cervical mediastinoscopy มีเทคนิคการทำอย่างไร

cervical mediastinoscopy

 

general technique of left-sided pulmonary resection

- การจัดท่า

- การลง incision

- การแหวกลงไปผ่านกล้ามเนื้อจนถึง rib

- หากไม่มี LN โต ก็ biopsy LN at left-sided lung อย่างไร

- ไม่ควรทำ pulmonary vein ligation เนื่องจากอะไร

- ถ้าเป็น case ที่ยากอาจทำ ligation and division of the vascular pedicle

- moblization of main pulmonary artery

- ในกรณีที่ disseciton ยากหรือทำ pneumonectomy จะมีเทคนิคการทำอย่างไร