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Atlas of Major Thoracoscopic Pediatric Lung Resection For Congenital Pulmonary Airway Malformation Full Book Download

The document is an atlas detailing thoracoscopic pediatric lung resections for congenital pulmonary airway malformations, authored by Arnaud Bonnard. It provides a comprehensive guide for pediatric surgeons, including techniques, anatomical considerations, and postoperative care, aimed at improving surgical outcomes and minimizing complications. The atlas is supported by illustrations and videos to enhance understanding and reproducibility of the procedures described.
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100% found this document useful (13 votes)
340 views17 pages

Atlas of Major Thoracoscopic Pediatric Lung Resection For Congenital Pulmonary Airway Malformation Full Book Download

The document is an atlas detailing thoracoscopic pediatric lung resections for congenital pulmonary airway malformations, authored by Arnaud Bonnard. It provides a comprehensive guide for pediatric surgeons, including techniques, anatomical considerations, and postoperative care, aimed at improving surgical outcomes and minimizing complications. The atlas is supported by illustrations and videos to enhance understanding and reproducibility of the procedures described.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Atlas of Major Thoracoscopic Pediatric Lung Resection for

Congenital Pulmonary Airway Malformation

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Arnaud Bonnard
Robert Debre Children Univ. Hospital
Paris, France

ISBN 978-3-031-07936-8    ISBN 978-3-031-07937-5 (eBook)


https://doi.org/10.1007/978-3-031-07937-5

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Foreword

Over the last 30 years minimally invasive surgery has taken an ever-expanding and
important role in pediatric surgery. Not only does it decrease the pain, scaring, and
recovery associated with any given operation, but it minimizes the long-term mor-
bidity associated with these procedures. This is especially important in thoracic
surgery in infants and children where it is known that an open thoracotomy is asso-
ciated with a high degree of chest wall deformity, scoliosis, and muscle girdle weak-
ness. One of our major tasks as pediatric surgeons must be to decrease or eliminate
the surgical consequences of our incisions for the benefit of our patients.
Perhaps no procedure offers more of a challenge and creates more angst in the
heart of pediatric surgeons than performing complex lung surgery, especially lobec-
tomies. The concerns are many and involve anesthetic issues, a lack of volume of
these cases and thus comfort with the anatomy and techniques involved, and the real
possibility of major bleeding from the pulmonary vessels. For this reason, I have
spent much of my career trying to develop techniques, instruments, and learning
tools to help other surgeons overcome these obstacles.
In 2016 I had the great honor of having Arnaud Bonnard come to Denver with his
family for a 6-month observership. That time allowed me to come to know him as a
great friend, fellow adventurer, and surgical pioneer. Since then, he has clearly dis-
tinguished himself as one of the leading MIS surgeons in Europe, and one of the top
thoracoscopists in the world.
This Atlas is a gift from Arnaud to all pediatric surgeons who wish to perform
thoracoscopic lobectomy. It is a detailed and well-thought-out guide to thoraco-
scopic lobectomy. His step-by-step approach and illustrations will help with under-
standing the anatomy, the techniques required, and the preoperative and postoperative
care for patients undergoing thoracoscopic lobectomy. While there are always some
mild variations between surgeons, Arnaud’s in-depth descriptions, illustrations, and
thoughtful approach will aid all surgeons attempting these complex and difficult
procedures.

Rocky Mountains Children Hospital Steven Rothenberg


Denver, Colorado, USA

v
Warning

This manuscript reports a major pulmonary resection technique in children but does
not intend to replace all the other techniques described and used by other surgeons.
A work of standardization and homogeneity of the technique was developed for the
different resections in order to introduce automatisms for the operator, allowing to
repeat the procedures and to be able to adapt in the occurrence of peroperative com-
plications. The techniques described make it possible to overcome difficulties
related to the anatomy itself and allow a reproducible gesture, in complete safety.
The videos you will be able to watch have been mostly recorded during proce-
dures performed by a fellow or a senior surgeon in the process of acquiring the
technique, in order to show that this technique can be easily transmitted and is
reproducible. Please note that these videos are speechless showing only the proce-
dure without any comment or image stop.
The techniques described are performed by exclusive thoracoscopy, without
assistance by mini-thoracotomy as described in adults by some authors.

vii
Preface

There are surgeries of which one makes a mountain... it is by succeeding for the first
time in your career that you can realize that the mountain was actually a molehill.
To climb a mountain, you need performant equipment and instruments, tips that you
will have gleaned from the sandstone of your career, and, of course, good physical
condition but which we will not talk about in this book.
I acquired the tips by observing and working with the pioneers of minimally
invasive pediatric surgery. In 2006, when I arrived in Toronto to do a fellowship in
neonatal surgery at the Hospital for Sick Children, I still lacked the tricks to be able
to perform thoracoscopic lung surgery. Thanks to my mentor, Professor de Lagausie,
I had already acquired solid foundations in minimally invasive surgery from the
beginning of the 2000s. However, some elements were still missing to be able to
treat pulmonary malformations using a thoracoscopic approach in a safe and repro-
ducible way. Looking back, I can now identify what I lacked: audacity, a bit of luck,
and a book that described a surgical technique making this procedure reproducible
and reliable. Back from Toronto, I performed my first thoracoscopic lobectomy,
which was an upper right lobectomy. Thanks to Peter Kim and Jack Langer, who
gave me the audacity to start ... I never stopped. Over the years, by accumulating
crucial details, this procedure has become simple, reproducible, and most impor-
tantly successful in avoiding conversion to open surgery.
This book was designed to provide all the tools and steps necessary to success-
fully perform thoracoscopic lung resections in children. I do not claim to replace
this technique and procedure with another. I simply claim that this technique works
and will give you the keys to making thoracoscopic lung resection a relatively sim-
ple surgery. The positioning of the patient, surgeon, and laparoscopic column, as
well as the trocar placement are identical, regardless of the location of the lesion to
resect. Difficulties you may be encountered during the procedure are discussed, as
well as solutions to overcome them. Postoperative consequences and complications
and their management are also reviewed. The different surgical stages of each
lobectomy are supported by numerous photos, anatomical pictures, and videos.
Some may already be old, but it is hoped for a second edition with higher and
improved quality videos. The instruments used remain 5-mm, although 3-mm

ix
x Preface

instruments have now been developed to perform this surgery. These 3-mm instru-
ments are unfortunately not available in all centers, which is why I believe it is
crucial to initially perform and master the technique with 5-mm instruments.
Finally, I would like to thank Dr. Steve Rothenberg. I had the chance to spend
7 months at Rocky Children Hospital in Denver. He is an exceptional and outstand-
ing surgeon and gave me the honor of writing the foreword to this book. He has also
helped me improve the thoracoscopic lung surgery technique described in this book,
by developing the 5-mm endo-stapler.
I hope this book will meet the readers’ expectations. It is one of a kind and I
aimed to provide them with exactly the book that I wished I had when I began prac-
ticing thoracoscopic lung surgery. Happy reading and re-reading!

Paris, France Arnaud Bonnard


Acknowledgments

Since 2007, pulmonary resections in children have been performed at Robert-Debré


University Hospital by thoracoscopy. This would not have been possible without
Prof. El Ghoneimi, head of the Department of Pediatric Digestive, Thoracic, and
Urology Surgery, who has always been a support for the development of innovative
surgery in his department. In addition, I want to thank the people in the operating
room. Each and every one has participated in the development of this technique
which has now become a routine procedure at Robert-Debré University Hospital. Of
course, without the help of the anesthesiologists with specific techniques required
during surgery and especially the contribution and progress of postoperative analge-
sia, this surgery could not have been performed and the concept of early rehabilita-
tion and enhanced recovery would not have been introduced.
At last, I would like to thank Dr. Louise Montalva who has been working with us
since November 2020 as a fellow in our department. She is subspecializing in tho-
racic, digestive, and neonatal surgery. She has been kind to review this book and its
translation in English.

xi
Contents

1  ediatric Considerations and Anatomy ����������������������������������������������������


P 1
1.1 Introduction�������������������������������������������������������������������������������������������� 1
1.2 The Timing of the Surgery �������������������������������������������������������������������� 2
1.3 Anatomy and Variations to Consider Before Thoracoscopic
Pulmonary Resections���������������������������������������������������������������������������� 3
References������������������������������������������������������������������������������������������������������ 9
2  echnical Considerations and Postoperative Analgesia �������������������������� 11
T
2.1 Patient Positioning, Preparation, and Room Setup�������������������������������� 11
2.2 Instrumentation�������������������������������������������������������������������������������������� 13
2.2.1 Thoracoscopy Instruments���������������������������������������������������������� 13
2.2.2 Hemostasis Instruments�������������������������������������������������������������� 16
2.2.3 Mechanical Stapler���������������������������������������������������������������������� 17
2.2.4 Endobag�������������������������������������������������������������������������������������� 18
2.3 Placement and Positioning of the Trocars���������������������������������������������� 18
2.4 Vascular Control: Bleeding Management���������������������������������������������� 19
2.5 Bronchial Control: Management of Air Leaks �������������������������������������� 20
2.6 Drainage ������������������������������������������������������������������������������������������������ 21
References������������������������������������������������������������������������������������������������������ 22
3 “Tips and Tricks” and Management of Peroperative Difficulties
and Complications �������������������������������������������������������������������������������������� 23
3.1 I Need to Ventilate because the Child Is Desaturating �������������������������� 23
3.2 I Have No Space to Work ���������������������������������������������������������������������� 24
3.3 My Fissure Is Complete ������������������������������������������������������������������������ 24
3.4 It Is Bleeding and I Cannot See�������������������������������������������������������������� 25
3.5 I Cannot Find My Artery������������������������������������������������������������������������ 26
3.6 I Don’t Recognize the Anatomy������������������������������������������������������������ 26
3.7 I Cannot Find My Minor Fissure������������������������������������������������������������ 26
3.8 My Remaining Lobe Is Not Ventilating Well ���������������������������������������� 26
Reference������������������������������������������������������������������������������������������������������ 27

xiii
xiv Contents

4  ostoperative Management: Chest-X-Ray—Management of


P
Complications and Postoperative Pain—Follow-Up�������������������������������� 29
4.1 Postoperative Chest X-Ray�������������������������������������������������������������������� 29
4.2 Immediate Complications (Recovery Room)���������������������������������������� 30
4.2.1 Bubbling in the Chest Tube �������������������������������������������������������� 30
4.2.2 Bleeding or Oozing of Postoperative Secretions
Through the Openings of the Trocars������������������������������������������ 30
4.2.3 Subcutaneous Emphysema (Clinical and Radiological)�������������� 30
4.2.4 Accidental Removal of the Nasogastric Tube ���������������������������� 30
4.2.5 Postoperative Pneumothorax (PNO)������������������������������������������� 31
4.3 Complications During the Hospital Stay������������������������������������������������ 31
4.3.1 Persistent Bubbling���������������������������������������������������������������������� 31
4.3.2 Persistent Pneumothorax Despite Drainage�������������������������������� 31
4.3.3 Bloody Drainage�������������������������������������������������������������������������� 32
4.4 Pain Management ���������������������������������������������������������������������������������� 33
4.5 Follow-Up���������������������������������������������������������������������������������������������� 33
References������������������������������������������������������������������������������������������������������ 34
5 Lobectomies�������������������������������������������������������������������������������������������������� 35
5.1 Upper Lobectomy���������������������������������������������������������������������������������� 35
5.1.1 Right Upper Lobectomy�������������������������������������������������������������� 36
5.1.2 Left Upper Lobectomy���������������������������������������������������������������� 44
5.2 Middle Lobectomy �������������������������������������������������������������������������������� 50
5.2.1 Anatomic Findings���������������������������������������������������������������������� 50
5.2.2 First Step: Controlling the Inferior Root of the
Superior Pulmonary Vein������������������������������������������������������������ 51
5.2.3 Second Step: The Middle Lobe Bronchus
or the Medial Artery�������������������������������������������������������������������� 53
5.2.4 Third Step: Controlling the Lateral Artery���������������������������������� 54
5.2.5 Fourth Step: Completing the Fissure ������������������������������������������ 55
5.2.6 Lower Lobectomy������������������������������������������������������������������������ 56
5.2.7 Right Lower Lobectomy�������������������������������������������������������������� 56
5.2.8 Left Lower Lobectomy���������������������������������������������������������������� 66
Further Reading �������������������������������������������������������������������������������������������� 72
6 Segmentectomy�������������������������������������������������������������������������������������������� 73
6.1 Anatomical Segmentectomy������������������������������������������������������������������ 73
6.1.1 Prerequisite: A 3D Imaging Planner�������������������������������������������� 73
6.1.2 Isolating the Artery with an Antegrade Dissection���������������������� 75
6.1.3 Controlling the Segmental Bronchus������������������������������������������ 79
6.1.4 Sectioning the Vein���������������������������������������������������������������������� 83
6.1.5 Sectioning the Parenchyma �������������������������������������������������������� 83
Further Reading �������������������������������������������������������������������������������������������� 84

Conclusion������������������������������������������������������������������������������������������������������������ 85
Pediatric Considerations and Anatomy
1

1.1 Introduction

The establishment of a thoracoscopic surgery program in children, and in particular


regarding congenital pulmonary malformations (CPAM), must be considered early,
well before the first eligible patients. It is necessary to study, for example, the num-
ber of patients that this can represent. Indeed, if it speaks to little more than one
patient per year, it does not have to be. On the other hand, we must be able to inte-
grate the fact that such a program can allow the development of minimally invasive
thoracic surgery in the broad sense by including other malformations such as diges-
tive duplications, bronchogenic cysts, and even surgery for aortic malformations.
However, surgery for pulmonary malformations must of course be performed safely
and requires advanced training. This training can be done through organized teach-
ing (university courses, specific conference courses, IRCAD), by learning from a
colleague, by fellowships or observerships, abroad, or in another department.
In addition, the implementation of such a program cannot be done without the
establishment of a close collaboration with the anesthesia team on one hand, and the
operating room (OR) team on the other hand. Indeed, everything should not be
stammered but thought before. From the installation, through the preparation of the
child, to the anesthesia, all this sequence must become “a routine,” which is the only
guarantee of optimal safety. The “check-list” must obviously be carried out, but
most of all, the surgeon must meticulously verify all the prepared instruments, the
forceps, and coagulation systems, and must check the parameters of the laparoscopy
column with the OR nurse.
In Europe, only half of the pediatric surgeons consider thoracoscopy for surgical
treatment of lung malformations [1]. This can be in part explained by the small
volume of malformations to be operated on, which makes it difficult to learn the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 1


A. Bonnard, Atlas of Major Thoracoscopic Pediatric Lung Resection for Congenital
Pulmonary Airway Malformation, https://doi.org/10.1007/978-3-031-07937-5_1
2 1 Pediatric Considerations and Anatomy

technique and make it reproducible. The aim of this atlas is therefore to help over-
come this difficulty.
This atlas will not talk about the combined open-thoracoscopic approach
which can nevertheless be an intermediate step between the exclusively open
and the exclusively minimally invasive approach. In fact, exposure can be facili-
tated by making a 5–6 cm incision, if necessary, with the help of an Alexis
retractor [2]. However, this technique requires a learning curve, a thoracotomy
incision, and thus joins the criticisms that can be made with fully open
techniques.

1.2 The Timing of the Surgery

The timing of surgery has often been a matter of debate. Many people still believe
that the older the child, the easier the surgery. Although I would like to be able to
show them otherwise, such evidence is lacking in the published literature. The two
main arguments for early surgery are the occurrence of complications related to
these malformations, such as infections, which is significant in the first years of life
(up to 34% of the children develop symptoms of infection during the first year of
life as published by Khosa et al. in 2004) [3] and increased lung overgrowth after
resection in the young child [4]. In addition, anatomic fissures are often complete
in infants, which facilitates the dissection, and postoperative recovery is improved.
In our institution’s cohort of patients, the decrease in the age at surgery over the
last decade from 9 months to 4 months did not modify postoperative morbidity and
even allowed the development of enhanced recovery after surgery, with early reha-
bilitation [5]. However, Langer et al. recently reported the absence of difference in
terms of respiratory function between patients operated on early (3 days) or later
(56 months) [4]. However, bias in this latter study might be related to the surgical
approach used, as a thoracotomy in 1985 certainly does not have the same impact
on growth as a thoracoscopy in 2002. Finally, Boubnova et al. reported no differ-
ence in terms of length of hospitalization, duration of drainage, and rate of postop-
erative complications between a population of children operated on before
6 months after 6 months [6]. In addition, nowadays, more than 90% of pulmonary
malformations are diagnosed prenatally. In fact, it can already be sometimes diffi-
cult to explain to parents the presence of a lesion at risk of developing complica-
tions that will be managed expectantly during the first months of life.
For these reasons, we recommend early surgery, as early as the third month of
age (it is even performed earlier by some authors). A CT scan is performed between
1 and 3 months of age, and often offers high-quality images, with the rapid acquisi-
tions of recent CTs, in a sleeping infant [7]. This usually allows the identification of
the lesion, its location within a segment, one or several lobes, as well as the possible
coexistence of a malformation such as a sequestration with a cystic lesion.
Performing a CT scan between 1 and 3 months of age allows accurate surgical plan-
ning. This atlas will not discuss the well-debated indication of lobectomy vs conser-
vative segmentectomy. Our main focus will be major lobectomies, with a short
section on segmentectomy techniques.
1.3 Anatomy and Variations to Consider Before Thoracoscopic Pulmonary Resections 3

1.3 Anatomy and Variations to Consider Before


Thoracoscopic Pulmonary Resections

Pulmonary anatomy should be well known before considering a pulmonary resec-


tion. Indeed, surgical planification is mandatory and many anatomical landmarks
should be identified before surgery. A 3D CT scan reconstruction (3D modeling)
can be used to help the surgeon. It can be especially useful for sparing surgery for
bilateral lesions or multiple locations within a lung. Even for lobectomies, 3D mod-
eling can facilitate the surgery by showing the number and location of the arteries
that need to be controlled. Indeed, anatomic variations are numerous in lung and 3D
modeling can be very helpful for the surgeon. A solution like Visible Patient (and
the software VP Planning), distributed by Ethicon Johnson and Johnson (France,
Issy-les-Moulineaux), is one the best tools for such preoperative planning [8].
As detailed below for each lobectomy, the right lung has 3 lobes, divided in 10
segments, 3 in the right upper lobe, 2 in the middle lobe, and 5 in the right lower
lobe. The left lung has 2 lobes, each divided in 5 segments. The superior left lobe
contains the culmen (3 segments) and the lingula (2 segments). Each segment
receives a main bronchus (B1 to B10—Figs. 1.1, 1.2 and 1.3), artery (A1 to A10—
Figs. 1.4 and 1.5), and vein (V1 to V10—Figs. 1.6 and 1.7).

Fig. 1.1 Anatomy of the bronchi—frontal view (Visible Patient™ software)


4 1 Pediatric Considerations and Anatomy

a b

Fig. 1.2 Anatomy of the left bronchus—(a) frontal view; (b) lateral view (Visible Patient™
software)

a b

Fig. 1.3 Anatomy of the right bronchus—(a) frontal view; (b) lateral view (Visible Patient™
software)
1.3 Anatomy and Variations to Consider Before Thoracoscopic Pulmonary Resections 5

Fig. 1.4 Anatomy of the right pulmonary artery—lateral view (Visible Patient™ software)
6 1 Pediatric Considerations and Anatomy

Fig. 1.5 Anatomy of the left pulmonary artery—lateral view (Visible Patient™ software)
1.3 Anatomy and Variations to Consider Before Thoracoscopic Pulmonary Resections 7

Fig. 1.6 Anatomy of the right pulmonary vein—lateral view (Visible Patient™ software)
8 1 Pediatric Considerations and Anatomy

Fig. 1.7 Anatomy of the left pulmonary vein—lateral view (Visible Patient™ software)

When performing a lobectomy, only one bronchus (superior, middle, or lower)


and one vein (superior or inferior) usually needs to be controlled. For middle lobec-
tomies, the vein that needs controlling is the inferior branch of the superior pulmo-
nary vein.
Although pulmonary arteries present many variations in location and number,
this should not represent a problem when a lobectomy is considered. Indeed, all the
arteries coming straight into the lobe should be dissected. Cautiously preserving the
vascularization for the remaining lobe is crucial, especially for a proximal lobec-
tomy (upper or middle). In fact, a distal lobectomy (lower) will be technically less
challenging than any other lobectomy.

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