Name:
FOCUS25824video8
Description:
FOCUS25824video8
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/59a0b42a-c2b6-4ebb-8d93-34dab6ffbc66/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=ERFV8FyDBAfQHBXSJtuJ0DKN4LWzgxL2yOoz2Jd311E%3D&st=2026-05-13T19%3A52%3A24Z&se=2026-05-13T23%3A57%3A24Z&sp=r
Duration:
T00H07M46S
Embed URL:
https://stream.cadmore.media/player/59a0b42a-c2b6-4ebb-8d93-34dab6ffbc66
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/59a0b42a-c2b6-4ebb-8d93-34dab6ffbc66/8. 25-14.mp4?sv=2019-02-02&sr=c&sig=RKOiIrE%2FRbTPAA9VHDmDo46l96xJXCmyjWwHjEOQexQ%3D&st=2026-05-13T19%3A52%3A25Z&se=2026-05-13T21%3A57%3A25Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: Hello, and welcome to this operative video detailing
SPEAKER: the stage resection of a right upper lobe lung adenocarcinoma with vertebral invasion into the upper thoracic spine. This case highlights the technical challenges of an en bloc resection, including a ventral dural violation encountered intraoperatively and its staged repair. Our patient is a 68-year-old woman, a former smoker, who quit in January of 2024.
SPEAKER: She initially presented with a dry cough and was subsequently found to have a large right upper lung mass. Further evaluation confirmed poorly differentiated adenocarcinoma staged as T4 due to vertebral invasion. She reported upper chest rib pain and thoracic radiculopathy, but had no neurological deficits. On exam, she was fully intact with 5/ 5 strength throughout.
SPEAKER: Here, we see the patient's PET CT at the time of diagnosis. The imaging reveals a large hypermetabolic right upper lung lobe mass with direct extension centered on the T2–3 vertebral bodies and neural foramina. Given the large volume of the tumor, the patient underwent neoadjuvant chemotherapy and radiation to facilitate surgical resection, with posttreatment CT scans showing treatment response with noticeable tumor volume reduction seen here on MRI.
SPEAKER: While there is foraminal invasion, there is no evidence of direct spinal cord compression. The surgical plan was for a two-stage en bloc resection with curative intent. Stage 1: a posterior approach with instrumentation, T2–4 root ligation, sagittal osteotomies, and tumor mobilization. Stage 2: a right thoracotomy for completion of osteotomies, specimen delivery, and anterior spinal column reconstruction.
SPEAKER: While staged en bloc resection provides the best chance for long-term oncologic control, it is an extensive and high-risk procedure with multiple considerations. Radiation-induced scarring will make both dural and vascular dissection significantly more challenging. The patient's bone quality is expected to be poor due to demographics, as well as prior radiation exposure, increasing the risk of fixation failure.
SPEAKER: There is an increased risk of delayed wound healing, infection, and soft tissue breakdown. T2–4 right nerve root sacrifice has a small but nonzero risk of spinal cord ischemia. Further risks include sagittal vertebral body osteotomies requiring precise execution while working around the spinal cord, which does not tolerate retraction. Pleural adhesions from prior radiation complicate dissection and increase the difficulty of the transthoracic approach.
SPEAKER: Pulmonary function is expected to be poor postoperatively, placing the patient at high risk of respiratory failure and prolonged ventilatory support. Proximity to the great vessels in the esophagus increases the potential for catastrophic injury. Given these challenges, a staged approach with multidisciplinary involvement is essential to optimize safety and outcomes. Here, intraoperative imaging demonstrates C7–T4 instrumentation with cement augmentation.
SPEAKER: The surgical field shows the exposed thecal sac and skeletonized left T2, T3, and T4 nerve roots. On the right, the tumor remains attached, with T2–4 nerve roots having been ligated to facilitate the en bloc resection. In this intraoperative video, we attempt to pass a Silastic sheath into the ventral epidural space as a protective barrier and dissection marker. However, as we pass a right-angle clamp, a gush of clear fluid is encountered, indicating a high-flow ventral dural tear.
SPEAKER: Given the location, immediate primary repair was not feasible. Instead, we packed the defect with TachoSil, achieving partial control. We proceeded with the rest of stage 1, planning definitive repair during stage 2 via lateral thoracotomy, when visualization of the defect would be better. These intraoperative images demonstrate the final placement of the Silastic sheath within the ventral epidural space.
SPEAKER: A second sheath was positioned over the specimen on the right side to aid tumor delivery in stage 2. Between stages, a CT scan confirms completion of her sagittal osteotomies, indicating no bony tethers remain aside from the ribs, which will be cut during the thoracotomy. The right thoracotomy after specimen delivery provides direct visualization of the spinal cord and posterior instrumentation.
SPEAKER: Given the ventral dural defect from stage 1, the plastic surgery team preemptively raised the latissimus dorsi flap to reinforce the dura and minimize the risk of CSF pleural fistula. A zoomed-in view highlights the ligated thoracic nerve roots and the site of the ventral durotomy. With improved visualization, we performed a primary dural repair. Final spinal reconstruction was achieved using an expandable titanium cage and anterior plating.
SPEAKER: The latissimus dorsi flap was then interposed to seal off any communication between the spine and pleural spaces, reducing the likelihood of CSF pleural fistula. The final en bloc specimen consists of the right upper lung lobe— T2, T3, T4, partial vertebral bodies— and surrounding tumor. Final pathology confirmed negative margins throughout, ensuring oncologic control.
SPEAKER: The patient was managed in the ICU with a lumbar drain carefully titrated to minimize CSF pressure and reduce leak risk. All surgical drains were left off suction to prevent excess CSF siphoning. Postoperatively, the patient remained neurologically intact. Her main challenges were respiratory in nature. She was discharged home on postop day 23 with home physical therapy on room air.
SPEAKER: Follow-up CT confirms intact spinal hardware and properly positioned latissimus dorsi flap. The patient remains disease free at last follow-up. Let's analyze what went wrong and the key lessons learned. Three critical factors converge to create this complication. First, while we knew radiation-induced adhesions would be challenging, we didn't adequately anticipate how 8 hours of surgical fatigue would compound the technical difficulty.
SPEAKER: Second, performing a ventral epidural dissection late in the case, when precision is most critical, was poor surgical planning. Third, we didn't sufficiently modify our dissection technique when encountering unexpectedly dense adhesions. Based on this experience, we've identified specific improvements for future cases. First, schedule high-risk dissection within the first 4–6 hours when fatigue is lower.
SPEAKER: Second, consider implementing a formal time-out with a fresh team perspective before beginning ventral or high-risk work. Third, when encountering dense adhesions in irradiated fields, accept sharp elevation of scar tissue with dura, rather than pursuing complete separation. Finally, ready all repair materials and specialized instruments for immediate action so that you are fully prepared should complications occur. This case taught us several clinically actionable lessons.
SPEAKER: Surgeon fatigue increases significantly after 6 hours, something we should more actively factor into case planning. Thoracic CSF leaks require more aggressive management than traditional approaches due to negative pleural pressure, such as 15 ml/ hr lumbar drainage and keeping chest tubes off suction. When dealing with prior radiated tissues, dense fibrosis may make complete tissue separation impossible, requiring technique modification.
SPEAKER: And finally, early plastic surgery involvement is essential to have muscle flap options readily available if needed.
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