Movie Night: Thoracic

TM01

Esophageal Lengthening in Paraesophageal Hernia Repair: When and How

Sadia Tasnim, Siva Raja, Sudish Murthy, Monisha Sudarshan. Cleveland Clinic Foundation, Cleveland, OH, USA.

In this video, we discuss esophageal lengthening in paraesophageal hernia repair: when and how. Determination of intra-abdominal esophageal length is a key step in a paraesophageal hernia repair. Ideally 2.5-3cm of intra-abdominal esophageal length is desired after mediastinal mobilization. A short intra-abdominal esophageal length contributes to hernia recurrence. There are certain predictors for short esophagus, however, the diagnosis is made intraoperatively. There are multiple techniques of esophageal lengthening: open, minimally invasive, transthoracic. Wedge gastroplasty is a common transabdominal technique and requires standard port placement. Transthoracic stapling is another technique that can be performed from the right or left side but requires the placement of an intrathoracic port. We demonstrate 2 videos for wedge gastroplasty and left transthoracic stapling. Finally, we compare the pros and cons of each approach.

TM02

Ivor Lewis Esophagectomy and Endoscopic Management of Anastomotic Leak

Jaclyn R. Dempsey, Gal Levy. University of Texas Medical Branch, Galveston, TX, USA.

Objective: Anastomotic leak after esophagectomy occurs in 4-26% of cases [1,2]. We present a case of anastomotic leak in which source control was achieved by performing endoscopic drainage of the mediastinum and stenting over nasogastric tube drainage for source control. Methods: 58-year-old male with stage IIIa (T3N1M0) esophageal squamous cell carcinoma post neoadjuvant chemotherapy with carboplatin plus paclitaxel and concurrent radiation underwent robotic-assisted Ivor Lewis esophagectomy. The procedure was uncomplicated with negative margins on frozen section of resected tumor and good perfusion of the conduit confirmed by fluorescence imaging. Anastomosis was performed with a stapler in side-to-side fashion and sewn with barbed suture. The patient initially progressed well postoperatively until postoperative day five, at which point he had increasing leukocytosis and developing respiratory failure leading to intubation. A posterior mediastinal air-fluid collection was demonstrated on subsequent CT, concerning for anatomic dehiscence. The patient returned to the OR where endoscopy was performed revealing an anterior anastomotic breakdown approximately 9mm in diameter. The mediastinal collection was drained using a nasogastric tube guided across the dehiscence into the mediastinum prior to placement of a covered esophageal stent to close the defect. Results: Patient status improved with ongoing trans-defect drainage of mediastinum and stent exclusion for source control. Conclusions: Nasogastric tube placement for drainage across anastomotic dehiscence with endoscopic stenting presents a potential option for nonoperative source control of post-esophagectomy anastomotic leaks.

TM03

Using 3D Virtual Reality in Preoperative Planning - Robotic Bronchogenic Cyst Resection

Brian D. Cohen, Adam D. Reese, Whitney P. Sutton, John F. Lazar. MedStar Georgetown/Washington Hospital Center, Washington, DC, USA.

Objective: An essential aspect of pre-operative planning for the resection of mediastinal lesions is diagnostic imaging. In this video abstract, we aim to demonstrate the use of three-dimensional (3D) virtual reality (VR) modeling during pre-operative workup and surgical planning. Methods: We applied 3D VR modeling technology to a case study of a 50-year-old female with a bronchogenic cyst undergoing resection. Results: The use of 3D VR allowed the surgical team to build a model of the bronchogenic cyst and its surrounding structures. With this model, the anatomy could be manipulated to better appreciate structures that were not as apparent on traditional imaging. Conclusions: The use of 3D VR modeling may assist the thoracic surgical team in identification and avoidance of key anatomic structures, and serve as another tool for surgical planning.

TM04

Robotic Tracheobronchoplasty Technique and Tips

Kyle W. Riggs¹, Julissa Jurado², Jason Karp¹, Lawrence Glassman², Kevin Hyman², David Zeltsman², Paul C. Lee². ¹Northwell Health, Manhasset, NY, USA, ²Northwell Health, Great Neck, NY, USA.

Objective: Tracheobronchomalacia is a prevalent, debilitating disease with few surgical options and for that reason is often not addressed surgically. Methods: In our video, we demonstrate our minimally invasive, robotic technique of tracheobronchoplasty with clear demonstration of Stop, Drop, and Roll of the endotracheal tube to facilitate safe exposure for suture placement. Results: The video shows pre-operative bronchoscopy followed by the key steps in exposure and securing the posterior mesh for patent, dynamic airway restoration. Conclusions: This technique is reproducible and could be adopted by more minimally invasive thoracic surgeons in the country to provide surgical correction for the numerous patients suffering from tracheobronchomalacia.

TM05

Right Pancoast Tumor: A Robotic-Assisted Thoracoscopic Right Upper Lobectomy With En Bloc With Chest Wall Resection

Daniel J. Gross, Karishma Kodia, Dao M. Nguyen, Nestor R. Villamizar. University of Miami, Miami, FL, USA.

Objective: To demonstrate a novel approach to treat superior sulcus tumor by induction chemo-immunotherapy followed by hybrid robotic thoracoscopic rescetion combined with a limited paraspinal incision. Methods: We present a patient, post induction chemo-immunotherapy, who underwent a hybrid robotic approach for resection of his superior sulcus tumor. Results: We obtained an R0 resection with a short length of stay, minimal post operative pain and a good functional outcome. Conclusions: In carefully selected cases a robotic hybrid approach is a viable strategy for the resection of superior sulcus tumors.