Name:
07 Lung
Description:
07 Lung
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e5148bb2-177a-4d04-a76e-58e93d49fc07/thumbnails/e5148bb2-177a-4d04-a76e-58e93d49fc07.jpg?sv=2019-02-02&sr=c&sig=mHksoBWbIfUZYc5qej4%2FLKYVaGkIFbQzb9pP6ciPJmo%3D&st=2025-07-04T00%3A33%3A47Z&se=2025-07-04T04%3A38%3A47Z&sp=r
Duration:
T00H06M41S
Embed URL:
https://stream.cadmore.media/player/e5148bb2-177a-4d04-a76e-58e93d49fc07
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e5148bb2-177a-4d04-a76e-58e93d49fc07/0720Lung.mov?sv=2019-02-02&sr=c&sig=WjWQSe9oJ4f6Hzzf0EZZ6Np186PKc5WZwhQrM%2FJkC5U%3D&st=2025-07-04T00%3A33%3A48Z&se=2025-07-04T02%3A38%3A48Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, we will discuss the proper technique to perform the various procedures required to treat the damaged lung.
Segment:1 Objectives.
We will begin by reviewing the anatomy, discussing the instruments and positioning, the exposure and techniques, and, finally, the tips and pitfalls of managing the injured lung.
Segment:2 Anatomy.
The trachea divides into the right and left main bronchi at the level of the sternal angle. On the right, the bronchi divides into the three lobes, while the left bronchi divides into just two.
Within the hilum, the bronchus can be found most posteriorly, the pulmonary veins anteriorly, and the pulmonary artery superiorly.
Segment:3 Instrumentation and Positioning.
The patient should be in a supine position with the arms out at a 90 degree angle or above the patient's head. Preparation of the patient should include the chin, all the way down to the groin, with emphasis on the chest. Anesthesia should be prepared for single lung ventilation. Instruments necessary will include a standard vascular tray, the Finochietto retractor, Duval clamps, Allison lung retractor, and a sternal saw or Lebsche knife.
The skin incision is made boldly from the left lateral border of the sternum at the fourth intercostal space and continue laterally along the curvature of the rib towards the axilla. Carry this incision to the depth of the intercostal muscles. Using the scissors, incise along the upper border of the rib, being careful not to injure the lung underneath. Place the Finochietto retractor so that the handle is positioned inferiorly to allow for extension of the thoracotomy incision to a clamshell incision should the situation arise.
However, when opening the retractor, be careful not to catch the axillary skin in the ratchets. Once inside the thoracic cavity, the lung should be retracted superiorly and the inferior pulmonary ligament identified so that it can be divided to mobilize the lung to expose the hilum.
Once the hilum is exposed, it can be encircled with the surgeon's fingers to control the hemorrhage and a large vascular clamp can be placed across it. If a large vascular clamp is not available, the hilar twist can be performed, though not advocated due to high likelihood of injury to the vessels.
Pneumonorrhaphy is a simple suture of the laceration in the lung. If the injury is found peripherally, this can be accomplished with the simple suture. Deeper injuries with hemorrhage or blowing air leaks should have a tractotomy performed to avoid enclosing the cavity, which can lead to pseudoaneurysms or air emboli. The tractotomy is easily performed with a GIA stapler, using a 3.5 to 3.8 blue load.
If a stapler is not available, two clamps are placed on either side of the injury, the tract is opened, and the injury oversewn. Once the tractotomy is performed, the injury is easily identified and can be oversewn. If there is extensive damage to the peripheral lung, a wedge resection can be performed using a GIA stapler with the blue load, or, alternatively, clamp and suture.
If the injury is not amenable to simple repair or tractotomy, a lobectomy may be performed. The injured lobe and the fissure are identified. Once isolated, the bronchopulmonary pedicle is exposed. Using a TA stapler, the bronchus pulmonary artery and pulmonary vein can be divided and blocked.
Before removing the stapler, a stitch on either side of the STUMP should be placed in order to prevent retraction in the event that additional sutures are required to control residual bleeding or air leak. Alternatively, a clamp can be placed across the pedicle prior to division. If a clamp is utilized in resection, the STUMP is oversewn. Rarely will a pneumonectomy need to be performed, keeping in mind that the mortality rate increases with amount of lung resected.
The hilum of the lung is identified, encircled, and the lung retracted. Similar to the lobectomy described previously, a TA stapler is placed across the hilum and the lung stapled off. Once the lung is removed, the structures of the hilum are easily identified to include the bronchus, pulmonary artery, and pulmonary vein. Again, stitches should be placed on either end of the hilum for control of the vessels, should the staples not achieve hemostasis.
LEAVE IN ALL THE: sutures to STOP: this rapidly oversewn easily and efficiently.
Segment:4 Tips and Pitfalls.
LEAVE IN ALL THE: Tips to remember and pitfalls to avoid for a relatively easier lung resection includes assuring that the thoracotomy is not too low. The fourth intercostal space for the thoracotomy is recommended, which is at the nipple level for men and the inframammary line for women. Be wary that the inferior pulmonary ligament terminates at the pulmonary vein, so be careful not to take the dissection too far.
LEAVE IN ALL THE: Should a stapler be used, the 3.5 to 3.8 mm stapler is recommended. And lastly, stay sutures, when performing a lobectomy or pneumonectomy, is key to control the hilum when there is poor hemostasis. Thank you.
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