VATS Wedge resection + Lobectomy (흉강경 폐엽 절제술 + 쐐기절제술)

 

 

 

 

 

 

 Wedge resection +- Lobectomy RUL

 

 

 

 

 

5mm 30도 thoracoscope

*10mm scope 보다 less torque on the intercoastal nerve (reducing pain)

*0도 scope보다 주변 structures을 더 잘 볼 수 있다

light cable

VATS 부속 기구(3단kelly, 3단sponge fcp, suction tip, long kelly, nodule fcp)

andrew suction

hook bovie (tape으로 line과 고정)

 

 

 

 

 

 

1.Approach

8th ICS midaxillary line - 5mm camera scope

5th ICS Antaxillary line - working window (wound protect medium)

15mess incision -> bovie -> mosqutio(-), kelly opening

intercosatal nerve block 시행안함

 

2.Wedge resection of RUL

VATS 용 3단 Sponge fcp, Wolf fcp(locking) 으로 wedge 부분 잡고 

Endo GIA Stapler 60

->Frozen biopsy 

side상에 large utility 깔고, mosquito, metz, mosq, 15mess

 

3.Dissected pulmonary ligament and LN #9

Wolf fcp, 3단 sponge fcp

andrew suction tip / 얇은 lg suction tip

black metz 

 

4.dissected LN#7

5.dissected posterior hilar lesion 

 

6.divided major fissure

bovie long tip 으로 major fissure 박리

 

7.dissected inferiorbar PA

Rt angle 과 mixter로 widely 하게 PA를 통과한 후 GIA Stapler TAN 

(때때로 vessel을 lift 하기 위해 sling을 걸기도함)

 

8.disected minor fissure 

harmonic scaple

 

9.disected RULobar vein and divided with GIA Stapler TAN 

 

10.Dissected anterior hilar lesion and LN 10

 

11.Dissected anterior truncus and dived with EndoGIA 45

 

12.Dissected and divided posterior PA

Hemoloc ML (초록)

 

13.dissected RULobar bronchus with EndoGIA 45

Dissected LN #11

 

14.Retieved Rt upper lobe

endo bag XL

->증류수 준비 

 

15.Dissected LN #2, 4R,10

Surgicel 5*35cm 4등분 한것 사용 

 

 

*lymph node dissection 순서 : 11-9-7-10-2,4

 

 

16.irrgated pleural cavity 

yangkeur suction tip 굵은걸로 변경

 

17.air leakage test , bleeding control

<suturing>

suture 3/0 prolene + set내의 제일 긴 needle holder 

-endoscopic needle holder 는 필요 없음

-knot pusher말고 finger로 knot

*목적: mobile lung can be moved so that the tissue is aligned for suturing (Middle lobe의 torsion 가능성이 있어 tagging suture)

<neovil apply>

 

18.close

24Fr chest tube insertion + 2/0 nylon suture (forward)

2/0 J safil -> 4/0 safil -> steri strip

 

 

 

 

 

1.Fissure (major fissure) :  bovie로 dissection

2.PA (Posterior ascedning PA) : Hem-o-lok ML 

  Truncus anterior : Endo GIA stapler tan 45 

3.PV (RULobar vein of SPV) : Endo GIA tan 45

4.Bronchus (RULobar bronchus) : Endo GIA tan 45 

 

 

 

 

 

 

<참고문헌>

 

1.lung lymph node 그림출처

https://med.stanford.edu/content/dam/sm/ctsurgery/images/clinical-care/thoracic-images/lung-cancer/lymph-nodes.jpg

 

2.lung artery anatomy 그림출처

https://radiologykey.com/anatomy-2/