Open Left Upper Lobectomy in an Adult Cystic Fibrosis Patient

CHAPTER 1

Hi, I’m Chris Morse. I’m a thoracic surgeon at the Massachusetts General Hospital, and today we're going to do a left upper lobectomy for an adult patient with cystic fibrosis. He has a chronically infected and damaged left upper lobe likely from the cystic fibrosis, and this is in turn leaving him with recurrent and chronic pulmonary infections beyond even what we would see with cystic fibrosis. He’s a little bit of an unusual case only because he's reached 50 to 55 years of age with the diagnosis of cystic fibrosis and has moderately preserved pulmonary function although he does the - the usual issues that go along with CF including recurrent pulmonary infections. This will be a rather difficult operation I suspect because of his recurrent infections in the chest as I think his lung will likely be stuck to the chest wall to will require significant amount of work to achieve hemostasis, and we'll do something that is somewhat unusual for a routine lobectomy in that we will use some muscle from his chest wall to reinforce or buttress the bronchial closure because of his underlying pulmonary issues.

CHAPTER 2

That's good - rotate towards me - Kelly clamp, please. Kelly - that's good - Kelly. So we’re going to make a posterolateral thoracotomy in this patient, and the standard posterolateral thoracotomy starts halfway between the back of the scapula and the spinal processes - yeah, please - and then sort of one fingerbreadth off the tip of the scapula. As I mentioned before we started in this case, we're going to harvest muscle on the way in to help buttress- knife please - to help buttress the closure because of the infectious issues in his chest, and so we'll do that as we get going. Great, thank you. Knife. Pick up. Forceps. And blue towel, please. We're going to come through the latissimus muscle first. And this is the latissimus being divided here. And so this is the latissimus muscle almost completely divided. So we spare the serratus muscle, and we come down the inferior border of the serratus muscle and onto the chest and we're going to mobilize along the inferior border of the serratus muscle to not have to divide it. And we’re going to come into the chest over the fifth interspace so we have to cut some ribs to do that.

CHAPTER 3

Harvest the muscle here, so score this and this. And as we talked about before starting the case, because of the infectious issues in his chest, we were planning to harvest a piece of muscle to help reinforce the closure of the airway - pick up please, got it - and that's what we're going to do now. So we're now we're scoring the center of each rib, which will allow us to harvest the periosteum off the rib. So now we're just peeling the periosteum off the rib. Do the bottom. So we just peeled it off the 6th rib, and now we're going to take out the 5th. We need to get into the plane and you keep it perpendicular when you carry it - perpendicular to the rib. As best you can, you got to stay perpendicular. Then you gotta make it feel right. Nope, not right. Alright, hold the retractor for a second. Sometimes it can be a little sticky as we do this. Buzzer. Extended tip, please. Pick up. Hold that there, just like that. Forceps, please. Suction to another hand, please. So the reason this is a little trickier is again because his pleura, the lining of the inside of the chest, is not totally normal again from a lot of repeat infection and…

CHAPTER 4

So we’ve got part of the muscle harvested here, we're going to get a little more of this. I think we're going to shingle the rib first. You can go up - up and down - paraspinus along the bottom. Madison? We shingle the rib so that we can allow it - the chest to open without hopefully fracturing the ribs, and this is sort of a controlled break of the ribs. We’ll actually take a little piece of the rib out as we do this. Pick-ups. This will be 6th rib for permanent pathology. Kocher. Bovie. Two blue towels, please. Can we get a 30-30 on the cautery, please? Forceps. So this is the harvested intercostal muscle flap. It's the muscle that lies between the ribs. This is what we're going to use ultimately, hopefully to help reinforce the closure of the airway. We’ll probably need to lengthen that a little bit more, but it's a start.

CHAPTER 5

Can I have a Balfour retractor please? So we got to take down a couple of adhesions - one right at the apex of the chest here, which you probably can't see as of yet. It's okay, can I have a Duval, please. Small. We’ll take the bend-to-beam - yep, top one - but don't - actually, sit tight for a second - it’s not as terribly stuck as I thought it might be - so have it - have it right there but don't open it yet. So, we need to - now we need to sort of carefully start taking down some of the adhesions in the chest, which are not nearly as bad as we thought they might be. One thing when we're working at least in the - in the anterior aspect of the chest, or the anterior aspect of the hi - of the hilum - of the center of the lung - is something called the phrenic nerve, which innervates the diaphragm. It’s a very important nerve in terms of respiration. Stop. Make sure you see it, so I can talk about it. And especially in a guy who's got some - stay up on the lung - some intrinsic pulmonary disease, something we do not want to - stay up on the lung - something we don't want to injure, and does not appear that we did. It’s sort of right there, you can sort of see with the end of my suction. This is the phrenic nerve. It does get drawn slightly up into the center of the hilum there probably from the inflammatory changes at the hilum. And looking at the chest, in the left chest, posteriorly to the hilum, to the center of the lung, this is the aorta, going down to provide blood to the distal part of the body. And we're going to start sort of a dissection around the hilum to free it up - free up all the pleura, and expose some of the structures we need to identify and divide to get this specimen out. So we'll start by working posteriorly here. I'm retracting the lung towards me in - he was going to start to open up some of this pleura off the lung. The plane here that we like to achieve is staying right on the lung and releasing the pleura. Natalie, is the Bovie on 30-30? Can you get him longer pickups, please? I would expect he'll have some enlarged lymph nodes in this area, which will make this rather difficult. Point it out. Right below where we are right now is the pulmonary artery, so... And now, as we work posterior and superior, now we’re going to go anteriorly. Anteriorly, we have the - hold this up - superior pulmonary vein. So we try to open the pleura anteriorly to find that. We’re just continuing to work the pleura circumferentially around this area. The top of the hilum is the pulmonary artery, which we’ll try to avoid. Please have a 4-0 Prolene on an SH and a 4-0 on a BB, and a sponge stick loaded at all times. And doing a lobectomy, we’ll often take down the inferior pulmonary ligament. When we're doing a cancer operation, we look for lymph nodes in this area. In this operation, we’re taking ligament down to allow the lower lobe to expand to help fill the rest of the chest after we remove the upper lobe, and the plan here is to stay right between the lung in the ligament. At the top of the inferior pulmonary ligament is the inferior pulmonary veins - a millimeter towards the vein - I mean towards the ligament. And it’s always nice to confirm that you have both an inferior and superior vein before you start to divide things - stay out of the lung. You can see how that allows the lung to come up. And as we get to the top, I’ll be looking for the vein - top of the ligament. We've reached the - after taking down the ligament, we’ve reached the inferior pulmonary vein on this side. I'm going to check our hemostasis here. And with that done, we’ll go back to work on our superior pulmonary vein now. I'll take a big Duvall now, please. Forceps, please. I’d say these tissue planes are a little more stuck than they usually are - again, from chronic infections. 4-0 Prolene on a BB, backhand. Looks like a bronchial... Maybe. I’m sure - sure - sure it is, I don’t really know. Okay so we’re going to work at this top of the hilum for a while now. Pick - pick - please tent it up. No, I’d…pick it up at the bottom first. We’ll continue to mobilize this pleura - thickened pleura - off the artery here. And it continues to be a very delicate dissection because of the all the inflammation that is present here. Again, very inflamed. So a pickups and a Bovie - or pickups in one hand a Bovie - why don't you- sorry… There might be just a tiny bit more traction so we can see. I’ll take a Bovie, please. The - I think you need to open a little bit of that up, so we can see - towards me. So in attempting to get around the vein, we made a small rent or hole in the vein, and that’s what we just... Finished placing a couple stitches in to try and control while we do the rest of this operation - hopefully. Hold this up, please. So now we will continue to work around the vein, which has proven to be somewhat difficult today. Now we're just trying to work behind the vein to find the inferior aspect of it. Another Duvall, please. Right above me - stay close to me. My clamp back - take suction. So that was a rather difficult approach around the superior pulmonary vein, and we're going to show it to you in just a second. The reason it was difficult was 1) we made a hole in it, and 2) there's a significant amount of inflammation - significant amount of inflammation around the vein itself.

CHAPTER 6

The tissue planes are not normal - again that's from chronic infection in his chest. Lying right behind the superior pulmonary vein in the chest is the bronchus, so we knew we had some space there that we can move inferior towards the center of the lung safely, but up near the top of the - of the hilum, or the center of a lung, is the pulmonary artery, which we had to try to avoid. I think in taking this vein at some point, we will significantly free up the hilum so that we’ll have better visibility of other structures, which hopefully we’ll see in just a moment. So we’re going to staple the - don't close it yet - we’re going to staple the pulmonary vein - superior pulmonary vein now closed. Like that - take it. A vascular staple load. Great. Scissors. So that’s going to give us much better exposure to the hilum now. So now we’re going to do some very difficult work as we expected around the pulmonary artery, which we knew was going to be very difficult from the imaging beforehand because the inflammation extended down right to the origin of some of the pulmonary artery. We’ll adjust to go to the top now. Yep, I got it. Tent it out - use your pickups. Lift up on the vein gently. The vein needs to come off the bronchus slightly here. So we've got that partially dissected out, going forward. Now we’re going to come to the back of the hilum, or the posterior hilum, and we're going to work on the artery back here. That white structure that you can see is the pulmonary artery that we're working on. You need to be all the way out there. And then come back this way. Find a branch. Unlike some operations where we have the option of getting into the - into the fissure or the center of the lung between the upper and the lower lobe, we do not have that option here - again because of the inflammation. So we have to do this all from the - from the top, from the back, in the front, from the side. That’s what we’re working on. Can I have the Metz, please? Gotta tent the tissue - it won’t spread. Peanut please. Hold that, Nick, please. 30-curved tip tan, so this is an apical branch of the pulmonary artery that we're trying to get. I’ll take a peanut first, please. Peanut, please. Peanut. This is a apical branch of the pulmonary artery that we’re trying to get around here. Can we have a loop? Towards the feet side. I can’t see. And again, we're going to take this with a vascular staple load. Close. So we continue to work circumferentially around the center of the hilum. Forceps, lower. And we have one large apical branch - slightly tricky to control. Okay so this is a big, very proximal apical branch. This is quite - do we have a leak somewhere? Kelly, does he have a leak somewhere? Am I hearing his airway? Maybe not. I thought I heard a leak. Oh yea, it’s coming out of the… Can we have a Forceps? Hold this, gently. Take the vessel loop out. Hold your breathing now, please. So this is the largest, most proximal apical branch of the pulmonary artery, which is now divided, and it puts us in a significantly better situation now to finish this operation. Pull up - forceps. Breathe now. So we’ve taken the superior pulmonary vein. We’ve taken some branches of the pulmonary artery. No, not here. Now, we’re going to find a lingular branch of the pulmonary artery, and we'll just- right now, we're working on dividing this airway off of the pulmonary artery. And we’re just sort of taking tissue off of the airway. So we’re worked a little in posterior. Now we’re going to go to anterior hilum to work on the airway a little bit here. Hold that up. Yeah, I’ll take it - thanks. Forceps. So we're trying to define the - the airway. I'm going to follow this, so take this tissue right here. Take this issue down right here. This is just soft tissue, inflammatory tissue, nodal tissue, that’s around the airway. And this tissue here. Get this tissue out, there’s going to be a lingular pulmonary artery branch in there somewhere. Up here, right there. So make sure you can see everything you Bovie through, please. So we’re just sort of again feeling all this inflammatory tissue around the center of the lung - take that down towards the airway there, just up here. Push up a little bit. So again, an incredibly difficult dissection around the left upper lobe airway as a result of his chronic pulmonary infections. A lot of what we deal with here is not only just infectious tissues, but nodal tissue that's enlarged as well, and so we’re... One of the easiest ways to figure out where normal structures are is to remove the nodes - the - especially when they are enlarged - both in this, infectious situations or in cancer situations. Or maybe that's not just a lobe. Cauterize my pickups. Lift up with this end, towards you. Good, stop. Divide the tissue. 3-0 silk tie on a passer, please. Sometimes when you have again a big infectious - situation in the chest, the arteries along the airways, the bronchial arteries, can be massively enlarged and inflamed. Lift up towards you and I’ll retract in a second, here. I think that’s a little bit what we're dealing with right here. So we’re going to control that with a tie. Last thing you want to do is - we'll sort out some bleeding later - bleeding cause of this situation - there we go. Gentle - Jesus. Okay. Pickups. So we’re going to continue to work around this airway, sweeping some of this nodal stuff up this thing difficult - peanut, please - difficult to somewhat sort out. Okay, coming back towards - Duvall - coming back towards the center of the lung, we’ll look for this airway and dissect - dissect it out again on this side. It’s a terrific view of it. Release that node - bring it up here more. Don’t pull in, try to go up. Good. Let's take a feel. So we’re going to take a feel of it, and see if we can feel for airway there. Oh, I don’t know. Pull that tissue out. So now we’re on the - the I believe is the left upper bronchus, and we’ll confirm that in a couple different ways. And so what we’ll do next is dissect this out a little more thoroughly now that we think we're around it. Now lift the other side. So flipping the lung back to expose the anterior aspect of the hilum. Hold this tissue down. Hold that tissue down there. With some of these nodes are nodes we’re seeing from the other side. And as we discussed, it's sometimes in a difficult dissection, it’s easy to - easier - to take some of the nodes out to help define the anatomy. So again, we’re just trying to clean up the bronchus so that we can transect it. Forceps. Looks good. Maybe that’s the left upper lobe bronchus. Stapler. So now we’re going to divide the airway. We’ll use a thicker stapler than we had in the past. Just going to inspect this from a couple different angles - hold this here. Take it out. Hold that there - pull this guy out. So, Taylor, we’re going to give her breath to this side in a moment. The left side - we’ll tell you when. Close. So part of our way of confirming that we're in the proper spot is to - is to clamp the bronchus that we're going to divide and then ventilate this side to prove that the rest of the lung comes up - that we have just the left upper lobe bronchus. Can you give us a breath to the left side to 15? Yep. Or 20. Good, so you can see that lower lobe start to expand. Okay, you can let it down. You happy with that? You can let it down and isolate it again. So now we feel comfortable that we've got just the left upper lobe bronchus done, and with that, we will divide this - nice and slow. Great. So with that complete, we’ve done all - almost all the major structures of the - of the left upper lobe. We’ve done the bronchus, we’ve done the artery, we’ve done the vein. And so now we just need to figure out how to get the rest of the specimen out. You stick the lingular artery with the Fischer? I don’t know if I see the artery, As you just pointed out, we need to find one more branch of the pulmonary artery, which we’re going to do right now. So again we're going to just make sure we have all the vessels divided that we want. Forceps. The tissue is off - I’d pick that up towards me. Ring clamp for a second, please. Ring clamp. Connor. We’re going to divide on the stapler. Stapler. 45-black. Take this first bite here. So we’re going to start dividing the fissure, which I think is a little bit of an unusual step only in the sense that it will help expose a little more stuff in this very thickened area of the lung. So this is the fissure, the delineation between the left upper and lower lobe bronchus. I'll take a 60. Good close. Let me just see something here. Close. Close? Close. It’s closed. Take it. Alright. And we’ll take one more 60, please. Close. Take it. 45 black - actually 60 black. So, it’s a very damaged left upper lobe and see that it's kind of beaten up now, but it's definitely smaller, more consolidated and certainly a result of his chronic pulmonary infections. As we talked about, we took the superior pulmonary vein. We took several individual apical branches of the pulmonary artery. Then we worked hard to get around the left upper lobe bronchus and divided that all with staplers, different varying degrees of height - thinner for the vascular staple loads and thicker for the bronchus. This is the bronchial staple line right here, right in front of my grasper - this white structure here. These are some lymph nodes that are adjacent to it. This is a vein cuff it looks like here. I can't really see the bronchial artery. Staple. Staples in here right now - maybe one right there. Anyways, so left upper lobe for permanent pathology. Warm irrigation, please. So we irrigate out the chest. Where are you now? This is irrigation now. I don't think so. Sponge though. Forceps. Retract that. So next we're going to, with the specimen out, and this not being a cancer operation, so we're not going to do a comprehensive lymph node harvest, we’re going to work on reinforcing that staple line. After we make sure - coagulate me. Good work. So we're going to now secure that muscle flap over the top of the airway. Long 4-0 silk, please. So we’ll do this in four points around the airway. One of the top, one at the bottom. We’ll do the heel first. May be too - come up towards me. More length on the - flap? You don’t have enough flap. No, pull it through. I don't like it. Come back towards you now. Lift that up. I'm going to go across the back of it, so stop. We're going to go this way. Peanut. So you - it's going to lay this way, so you need to go this - under - you pick this direction right because you're going to come out on this side. Yeah. Pickups to me, please. Got to go back towards the PA? I think that’s some... Cut and a snap, please. Stitch. And now we do one on either side of the airway. Forceps. So this is the side towards me. Here you go. Can I have a snap? Stitch?

CHAPTER 7

Okay. Okay. So, we’re going to put a couple chest tubes in now. Knife. Knife. Schnidt. Tunnel one posterior, tunnel one anterior, forehand. Small square hole, please. Bring the lung up, please. Can you bring the lung up, please? Can you bring the lung up? Can we bring the lung up? Can you inflate the lung, please? Forceps. The lung is reinflating now - the left lower lobe. If you can ventilate both sides now, that’d be great. And ultimately this will expand I think to fill the chest. Another breath and hold, just to get some atelectasis out. Can you give us another breath and hold, please? Can we have another breath and hold to like 20? That’s good, great. Thanks. And silks. And so with the chest tubes in place, we’ll close the chest in sort of the opposite way we came into it, by closing the ribs. I put stitches around the ribs to pull them together. Travel. We’re only putting two in. Cut. Another stitch. You take some of the flex out of the bed for us, please? That’s good, thank you. Zero, please. So now we're going to close the serratus layer that we had opened additionally. We’ll try to put a number of layers in so it's watertight and airtight - back to the corner. So again, just closing the serratus, closing latissimus which we’ll close in two layers, and tie these two layers to themselves. Can you roll the table away from me, please? And bring it down a little bit.

CHAPTER 8

So that was a left upper lobectomy as we talked about for a rather difficult situation. Guy who has CF, but as an adult, with fairly preserved pulmonary function, but had a very damaged left upper lobe from recurrent pulmonary infections. And this damaged lobe was never going to heal despite antibiotic therapy, and I think it contributed even further pulmonary issues than his baseline CF does. So because of that, we chose to proceed with a left upper lobectomy given his pulmonary function was adequate to remove it. The things that made this operation more difficult than a typical lobectomy, for a lung cancer for example, were just the dense inflammatory changes at the hilum, which is not unexpected given his - his CF diagnosis and his recurrent infections.