Raffaele J. Marchigiani, M.D., presents a surgical case where he performs a video assisted thoracic surgery on a 83 year-old male. This patient had a prior skin cancer on his scalp, and then a reoccurrence as a lump on his neck and a nodule on his lung. Dr. Marchigiani walks us through the case and why this conservative approach was needed for the patient to then proceed with definitive treatment for his head and neck cancer.
So I'm Dr Marco John M. A thoracic surgeon here at Sentara, and I just wanted to briefly discuss a case that I have here for everyone. This is an 83 year old gentleman who has a history of a scalp skin cancer over the years he found to have a recurrence as a lump on his neck. Um, during that work up, he was also found to have a lung nodule at the very top of his right lung. And he was sent to me for consideration of resection prior to receiving definitive therapy for his skin cancer. At that point, we had a lengthy discussion in the clinic. We opted for a more conservative reception for this patient boast on age pulmonary function as well as quick recovery so he can receive definitive therapy for his head and neck cancer. This is a situation where, although we usually recommend a low back to me, they're all situations where a more conservative or prank and sparing operation is appropriate. This is one of those situations where I felt it was in the best interest of the patient, So we ended up proceeding with a right Dorcus Coptic Upper low budget section. At the same time, we did do a lymph node dissection for further staging. He was able to recover fairly quickly from this operation. Move on to definitive therapy for his head and neck cancer. Here we are in the operating room suite. Currently, we are marking our locations on the right side of his body. He is positioned with the right chest up as we begin to mark the locations for our incisions were also communicating with anesthesia and the surrounding nurses to make sure that we in a good state to start. We mark our places with a skin marker. We confirm the anesthesia is happy, and now here we are getting ready to place our ports. As you can see, the camera port is already in place, and that is done by palpitation and isolation of an inter space. Now, with the camera in the body, you can see on the screen, the lung is present and it's collapsed away from the chest wall. We use a needle and localize the inner space that we want to go into, which puts us at a proper position to perform the operation. Both identify the lesion and safely do the operation itself. This is us placing the port within the inner space. The muscle is transected. The ribs are not transacted or broken in these situations. We cauterize all the muscle to make sure it's him a static. We'd be sure to preserve the nerve by staying closer to the rib on the bottom. And now here we are placing a wounded tractor. This helps prevent further damage to the muscle, any ongoing bleeding and protects the tissue, both removing things and placing things into the chest. It's secured in place, and once that is done, we can actually start the operation. So here I am, preparing to begin. We now place are retractors into the chest. These are specialized instruments to help retract lung without tearing. In some circumstances, we can actually see the lesion. In this circumstance, we had to feel it being that it was fairly small, so we palpate it with our finger. Once we identify it, we use the lung grasshopper to grab below it. And then typically I'll come into the chest with an additional grasshopper and I go below my first grasp or to make sure I have a negative. Gross negative margin. We want to try to get as much margin as possible. That's safe once we are below that lesion. And I'm happy with the margin. We come in with the stapler. The staple goes below the grasshopper to obtain an additional one or two centimeter margin. This stapler is a specialized surgical stapler. It both staples and transect the tissue all in one. Go. As you can see there, the lung has been transected away from the remainder of the upper lobe. We continue doing this until we are completely across the specimen again, Keeping in mind that we're looking for a gross negative margin. We are far away from the nodule based on where my grasshopper is. And that grasshopper does not move throughout this part of the procedure. Finally, we come in with our last staple line. We have a little bit left, so the last stapler will come in here in a second. And here we are completing it. You can actually see the little staples they're forming at the very end. The specimen is now removed. Here is where that wound protector is very useful. It protects the skin from any type of infection or seating or any kind of damage when removing the specimen. Now we're measuring it and palpate in it to make sure we have it successfully. And then it's sent down a pathology for further analysis. We're back in the chest here. It's called the Parametric. You'll space doing our lymph node dissection. This is a planned part of the procedure for every lung cancer case. The trick is on the left. The superior vena cava is on the right. This is at the very top of the chest, and we're dissecting out what we call the pair trachea. Lymph nodes again. Standard part for any type of lung cancer resection. Here. You can see that darker. No, this is called a parametric hell. For our lymph node, we carefully dissected as much as possible again for lung cancer. Staging. The prognosis is not changed. By removing the entire note, however, it's more important to sample a number of different nodes within the chest cavity. With that said, we do our best to remove the note in its entirety, and here I am removing a part of that note, and I come back later and move the rest of it for further staging. Now we're down by the bottom of the chest. On the left hand side is the diaphragm. The right hand side is the lower lobe being retracted upward. That tissue you see connected there is called the inferior pulmonary ligament that connects the lower lobe to the diaphragm. As we begin to take up that inferior pulmonary ligament, it leads us to the inferior pulmonary vein, which is a landmark for lung resection for the lower lobe. Other structures nearby are the spine at the very back of the screen, and below is the esophagus. The heart is right to the very bottom right of the screen, and that's where you'll find the pericardium, which is a sac around the heart. We complete this dissection here and take it up to the very end of the ligament, and that helps the lung further expand after removing a segment of the right upper lobe. Now, here we are making sure we have good human synthesis. These surgical powders are safe to be left behind, and they assure that we have good human Stasis prior to closing. You see here we're just double checking to make sure everything looks good, sucking out any additional powder and making sure everything looks good and that is the completion of the case after placing a chest tube.