Pediatric VATS Segmentectomy

The video describes a VATS segmentectomy for a left upper lobe cavitating nodule in a 22-month-old child. The child was waiting for a bone marrow transplant, following failed chemotherapy for chronic myeloid leukemia. After non-invasive methods of obtaining a diagnosis failed, the child was referred for surgical biopsy. In view of the central proximity of the nodule to the segmental bronchus, a VATS (apicoposterior and anterior) segmentectomy was performed.

The VATS procedure uses an anterior approach, where the surgeon and assistant stand in front of the patient, while the other assistant and scrub nurse stand behind the child. Single lung isolation is obtained by blocking the left main bronchus with a bronchial blocker under bronchoscopic guidance. Further rapid intra-operative collapse of the lung is obtained by CO₂ insufflation at 5mm Hg pressure at 1L/min flow rate after introduction of the first camera port. Good lung isolation is essential in pediatric VATS procedures due to the limited surgical space available for performing VATS. However, when insufflating CO₂, it is essential for the anesthesiologist to monitor for possible tension pneumomediastinum.

For pediatric VATS lobectomy or segmentectomy, three to four 5mm working ports are needed. A 5mm 30-degree camera port is placed over the major fissure in the 5th intercostal space in the anterior axillary line. As most of the dissection will be at the fissures, the camera is always placed over it. Triangulation for ergonomic dissection is obtained by placing a 5mm working port above the camera port in the 3rd intercostal space in the anterior axillary line. Similarly, another 5mm working port is placed below the camera in the 7th intercostal space in the anterior axillary line. In bigger children, it is through this enlarged (10-15mm) port that an endostapler is introduced for dividing the bronchus and for specimen removal. For upper lobectomy/segmentectomy, an extra 5mm working/retraction port, in the 7th intercostal space behind and inferior to the scapula, is needed for retraction of the upper lobe when dissecting the pulmonary veins.

Dissection usually commences in the fissures, with the pulmonary arterial branches ligated first before the vein to prevent congestion of the lobe/segment. It is imperative to identify, dissect, and incise the vascular sheath over the arterial and venous branches for safe dissection and ligation. Although many pediatric VATS surgeons use an energy source for sealing/division of the small vascular branches, for safety reasons, we tend to ligate with 3-0 silk sutures prior to further sealing and dividing with an energy source. For pediatric VATS, our preferred energy sealant device is the bipolar sealant, Ligasure™, due to its ability to seal vessels up to 7mm in size with little radial thermal injury. In children, the Ligasure™ also gives good pneumostasis when dividing incomplete lung fissures, as the airway pressure generated during coughing does not exceed the bursting sealing pressure of the seal of the Ligasure™.

The bronchus can be clipped or suture ligated in very small children. In bigger children, the lower most 5mm working port can be enlarged to 12-15mm for introduction of a white reload vascular stapler (Ethicon ATW35 vascular) for stapling of the bronchus. The specimen is then removed through this enlarged incision, either in an endobag or piecemeal for benign conditions. Endoscopic suction during VATS in children will cause rapid expansion of the lung with loss of operative exposure. This can be overcome by ensuring meticulous hemostasis of the operative field, or by enlarging the lowermost 5mm port right from the beginning and using low pressure suction. Buttressing of the bronchus in children is generally not necessary. However, when needed, in our practice we use tissue glue applied endoscopically.

Reference

T.Agasthian. Pediatric VATS left upper lobectomy for infected CCAM. CTSNET Aug 11 2011.