VATS Right Lower Lobe Lobectomy (Nonedited)

Hello, don't like to be critical but I don't think that this is a great learning video for trainees and junior surgeons. The focus on how quickly it is done is in no way a metric for quality surgery. Accepting that it was done for a secondary there are a number of issues that require pointing out - the forceful pushing of the instrument to 'complete' the anterior fissure was eye watering- was the middle lobe vein safe?, how much bleeding was there going to be from the medial basal segmental artery which often has an atypical origin and never considered, there was nodal tissue incorporated in the stapler in the posterior fissure, the arterial division and in the bronchial closure. Oncologically this video was, for me somewhat disappointing. The time taken to do a lobectomy is totally irrelevant if it is not done safely and to a high oncologic standard and trainees and junior surgeons should be very aware of this and not be subjected to any time pressure or comparison when doing cases...… my thoughts only

Hi Morgan, thank you for your comments. There is more than one way to do any operation. I don't think I was rushed in any way through the entire operation. I do take my time getting around the hilar structures. William Walker did all his VATS lobes for 30 years with this posterior approach safely. In my experience of more than 1000 cases using the Edinburgh Posterior Approach, I have never injured the pulmonary artery when developing the anterior fissures using the same approach. This is the way I train my trainees in Sydney. The technique is quite reproducible and easy to teach indeed. One of the major advantages of the posterior approach is the fact you can see the tips of your instruments at all times, as the instruments are coming towards you, and not going away from you. Here are some important steps to point out, but may not be evident in the video, as these movements were very subtle. The operator needs to pass a "blunt" dissector from the anterior access incision towards the anterior hilum gently. He/she must "feel" the bronchus with the tips of the blunt dissector (02'30'') and then move the dissector over the anterior aspect of the bronchus. This is a very subtle, but an important movement. The operator should not push the dissector through blindly, but instead, try to brush on the tips of the dissector with a peanut swab, until the tips are clearly seen. Please do not push. Never force things to happen. Use the dissector to spread over the pulmonary artery gently. One should not use any sharp dissector or sharp instruments doing this step. Of course, if not confident, one should try to visualise the hilum with the anterior approach. I routinely perform systematic ipsilateral lymph node dissection for primary lung cancers, sometimes at the beginning and sometimes at the end of the operation. This patient had an isolated 3.5 cm melanoma metastasis in the central portion of the right lower lobe. So the oncological clearance of this tumour is adequate. Hope I have clarified a few things. Cheers, TDY

Hi Morgan, thank you for your comments. There is more than one way to do any operation. I don't think I was rushed in any way through the entire operation. I do take my time getting around the hilar structures. William Walker did all his VATS lobes for 30 years with this posterior approach safely. In my experience of more than 1000 cases using the Edinburgh Posterior Approach, I have never injured the pulmonary artery when developing the anterior fissures using the same approach. This is the way I train my trainees in Sydney. The technique is quite reproducible and easy to teach indeed. One of the major advantages of the posterior approach is the fact you can see the tips of your instruments at all times, as the instruments are coming towards you, and not going away from you. Here are some important steps to point out, but may not be evident in the video, as these movements were very subtle. The operator needs to pass a "blunt" dissector from the anterior access incision towards the anterior hilum gently. He/she must "feel" the bronchus with the tips of the blunt dissector (02'30'') and then move the dissector over the anterior aspect of the bronchus. This is a very subtle, but important movement. The operator should not push the dissector through blindly, but instead, try to brush on the tips of the dissector with a peanut swab, until the tips are clearly seen. Please do not push. Never force things to happen. Use the dissector to spread over the pulmonary artery gently. One should not use any sharp dissector or sharp instruments doing this step. Of course, if not confident, one should try to visualise the hilum with the anterior approach. I routinely perform systematic ipsilateral lymph node dissection for primary lung cancers, sometimes at the beginning and sometimes at the end of the operation. This patient had an isolated 3.5 cm melanoma metastasis in the central portion of the right lower lobe. So the oncological clearance of this tumour is adequate. Hope I have clarified a few things. Cheers, TDY