VATS LOBECTOMY MORRISTOWN MEMORIAL HOSPITAL, MORRISTOWN, NJ Broadcast January 14, 2005

NARRATOR VATS LOBECTOMY MORRISTOWN MEMORIAL HOSPITAL, MORRISTOWN, NJ Broadcast January 14, 2005 Welcome to the live webcast from Morristown Memorial Hospital in Morristown, NJ. During this live webcast, thoracic surgeon Dr. Mark D. Widmann will perform a minimally invasive right VATS and mediastinal mass excision procedure. VATS procedures can be performed for early stage lung cancer with excellent short-term and long-term results. Today s program is part of Morristown Memorial Hospital s ongoing educational efforts to bring the latest information in health care to patients and physicians. During the program, you may send your questions to the surgeons at any time. Just click the MDirectAccess button on the screen. Good afternoon. We re here at Morristown Memorial Hospital in operating room #7, where Dr. Mark Widmann is just starting a video thoracic operative procedure. Before we go into the details of the operation itself, let s take a minute to find out what is wrong with the patient and why he is here in the operating room in the first place. This 57-year-old man had a heart attack a few years ago, from which he made a good recovery, but in the course of being in the hospital, they found that he had a mass in his chest. They did some preliminary studies, but because he was just recovering from his heart attack, it was thought best to do nothing more invasive and, as we say in medicine, to observe him, to see how he did without any further intervention. Unfortunately, he began to have fits of coughing and, in one of those fits, his heart rhythm became disturbed. It required medication and then he had recurrent bouts of coughing and further investigations were done. We ll go over to the x-rays now and take a look at what you folks can see as being his problem. On these x-rays, it s probably easiest to appreciate his overall chest. This actually is his swallowing tube, the esophagus, going into the stomach and we see a density that shouldn t be there, this white area. We also see some indentation of the esophageal wall. This does not look like the problem is primarily from the esophagus, but rather from the extrinsic pressure on the esophagus. In these views, which we have on these three sets of films, the patient is lying on his back and, much as you might slice a salami and look at each of the slices, we have displayed here the various views so that we see the structures of the chest progressively lower down

until we reach the belly over here. This is the liver, the spleen, the stomach, and the intestines. The abnormality that we re interested in is this white-gray area. This should not be there. It should be all lung tissue. Instead, this is what we call a cystic structure. It appears to be full of fluid. It doesn t appear to be invading or damaging any of the adjacent structures, but we can see that it presses on the back of the heart. This is the atrium on this side. We can see that it presses against but does not appear to be damaging the adjacent bony structures that are seen down here. This falls into the general category of a mediastinal mass. When we say mass, it just means that there s something there. We could say tumor. There s something there that shouldn t be there. In the mediastinum, we divide it anatomically into three different areas, the very front, near the front of the chest. Here s the breast bone. This is called the anterior mediastinum. The mid mediastinum has the major blood vessels and the heart. The posterior mediastinum has the space between the heart and the vertebrae. The types of masses that develop are very much dependent on where in the mediastinum the mass originates. We don t know the exact nature of the mass that Dr. Mark Widmann is operating on, but we know statistically that when they re in the front, when they re anterior, they most typically arise from the thymus gland. This patient s thymic area appears normal and there s no reason for us to think that this is a thymic tumor. Also, in this area we might see enlarged lymph nodes, such as might occur with the malignancy lymphoma, and again there are no signs of that. In this area, the most common things are cystic lesions and they can have various sites of origin. They can be from what we call the foregut; that is, the esophagus or the stomach. They can also be from the posterior aspect, in which case they re called neurogenic cysts. Neurogenic cysts don t really communicate with nerves. It s just a name that is applied to them when they originate posteriorly, toward the back, over here. We ll go back to review of the techniques to be used in just a minute. This is Dr. Mark Widmann. I m just going to show everybody what we ve got here for starters and welcome our audience. I understand the patient s family is watching as well. This is the view of the inside of the chest. Very briefly, you re looking at the ribs over here on the lateral side. The lung is up here. We ve retracted it superiorly a little bit. The area of concern is here, looking at our cystic lesion in what s called the posterior mediastinum, with the lung draped over it. Well, we ve just been able to see in actual living time the structure that we saw only on the x-rays and CT scan a minute ago. When we looked at the x-rays of the esophagus, we noted that there was some extrinsic, outside of the esophagus, impression. That was concerned by checking the esophagus itself by putting down a flexible tube. If we can just run the piece of the video that we took when the scope was in the esophagus, you folks will be able to see that we re going down and then back up. That s the normal

esophageal lining, so we know now for sure what we suspected from the x-ray and the CT scan, that the esophagus clearly... We re at the point right now on the inferior ligament of the lung. We re looking at some attachments here. We re going to take this with a stapler. It doesn t look like it s vascularized. Usually it s not, but when you re dealing with abnormal cysts in the posterior thorax, you can have aberrant vessels feeding them, sometimes coming from below the diaphragm, and I don t want to take a risk with this. It s a little bit prominent and should be easily handled with a stapler. At this point, Dr. Widmann has pointed out that the concern might be that this is a sequestration of the stomach and that could be a cystic structure that we hadn t discussed because the x-ray and CT scan appearance for that was not typical. Because of that unlikely possibility, Dr. Widmann has just divided and stapled the communication down to the diaphragm, just in case an abnormal blood vessel was in that piece of tissue. While they re getting things further set, it looks like he s going to be dividing the ligaments that are holding the lung down low and against the mediastinum. While he s doing that, we could just discuss the access to the chest. We have a PowerPoint slide here which shows thoracic access; that is, how the surgeon gains entry into the chest. We see in that slide that thoracoscopy is one way, on the left hand side of the screen. That is looking into the chest. Thoracotomy, meaning opening the chest, is the other way that we gain access into the chest. The dotted line we see is video assisted thoracic surgery, which is what this procedure is called. This procedure was markedly advanced by Dr. Ralph Lewis in New Brunswick 14-15 years ago, when he coupled just looking into the video assisted technique, which made it possible for the surgeon to work with assistants because instead of one operator just looking through a scope, which is called thoracoscopy, we now have the option of the whole operating team looking at a magnified view on the TV screen. At this point, if we do pan to the TV screen, you can see Dr. Widmann... This is the phrenic nerve, which is the nerve that enervates the diaphragm, coming down the long side of the pericardium, going toward the diaphragm, and that s the inferior pulmonary vein over here in front of me. It looks like the inferior pulmonary ligament has been divided and the lower lobe of the lung is being lifted up and the cystic mass is going to be further exposed. The phrenic nerve is intact and the dissection is proceeding.

One of the things that a surgeon has to become accustomed to when he does video assisted thoracic surgery is that the bleeding looks much greater than it actually is because, in fact, it s a magnified view. However, with careful attention to blotting, suctioning out, and control of even the small bleeding points, it turns out that with video assisted thoracic surgery, the blood loss is much less than with open surgery. Those are not the only advantages of video assisted thoracic surgery. If we go to the slide called the Benefits of VATS, we see that no only is it less invasive, which means that smaller incisions are needed, but there s a decrease of morbidity and mortality; that is, the risks of the operation are less, both in the patient discomfort and in the actual complications that develop after full opening of the chest. When the chest is fully opened, the ribs are spread apart and there s a lot of pain from the stretching of the muscles and nerves to gain access to the chest. We now see the view of the operative field. You ll notice that there are very small incisions, in total, perhaps 3, sometimes 4, and they amount to very little in the way of postoperative pain. In addition, Dr. Widmann frequently does what s called a nerve block at the end of the procedure for pain and he uses a non-narcotic analgesic pre-emptively so there will be less pain after surgery. With the VATS procedure, there s frequently less operative time because a lot of time is not spent opening and closing the chest, as with the open thoracotomy. Because the patients have much less pain, they go to intermediate or floor care, rather than requiring intensive care stays. Of all the rooms in the hospital, it isn t the private rooms that are the most expensive; it s the intensive care rooms, where patients who can t care for themselves get the intensive, highly patient ratio nursing that s necessary after major operations on the chest. When the procedures are done with less invasive techniques, the patients are able to go to step-down intermediate care units or very frequently to floor care because they re not having the kind of pain that has traditionally been associated with chest surgery. This translates into much better utilization of hospital resources, the health care dollar, and the only important thing is that the operation be done as safely, if not more safely than with the older techniques. Also, the surgeon has to maintain a very healthy respect for the occasional need to convert to open thoracotomy, such as if there is an increase in bleeding or inaccessibility of the lesion to the approach to the video technique. For those situations, the surgeon should freely open and, in fact, a full operative kit is kept available in the operating room for that eventuality. While the conversion rate is very small, just a few percent, it s not a failure of the technique but a wise application when the surgeon switches from video approach to the open approach. Because of the rapid recovery, the patient is out of the hospital in much shorter times, typically 1/3 or ¼ of the time in the hospital. When he goes home, he doesn t feel rushed out of the hospital; rather, he is in better shape than patients with the open operations who stay in 5, 7, and 10 days. This is really one of the times where technology and advances in technique are winners all around, a win-win situation for the health care dollar, a winwin situation for the patient as well. Not only do they get home quicker, but they get back

to their routine activities quicker and back to work, so all around, this is a technique that, when appropriate, is very cost-effective and very much appreciated by the patients. We do have the opportunity for the audience to submit some questions as we go along. At this point we can see that the operative procedure is progressing with the division of what s called adhesions, the structures that are binding the tumor mass to the lining of the chest cavity. These structures are being divided right now with the use of cautery, which is an electrical current that actually coagulates and cuts at the same time and is allowing Dr. Widmann to mobilize the lung tissue and ultimately the mass from the surrounding tissues. The instruments look quite large in the picture that s being projected, but this is, in fact, a very much magnified view. The operating team is not looking at the patient s chest. They are looking at the video screen and all the members of the team are able to see the TV screen and to participate, move the camera, and help the operation proceed in a safe, orderly fashion. Here we have a view of the whole team. On your left is the back of the scrub nurse. She s a young woman who is responsible for handing the instruments as they re requested, for taking them back from the operating field. To her right is a nurse clinician who is a critical care nurse who has taken surgical training. She works with Dr. Widmann as a nurse practitioner. Now on the screen we re seeing the surgical resident assisting on the right hand side of the screen and Dr. Widmann is looking at the TV Screen, along with the surgical resident, and progressing with the dissection. Now we re looking back into the chest and we re seeing some further mobilization. From time to time, we see blurry things going across the screen. Those are the instruments. Right there, now, toward the top of the screen, we re seeing a suction device. At this point they re still dividing the adhesions. These adhesions have resulted from prior episodes of inflammation, in which the cystic mass may very well have had some degree of infection within it and that would have caused an inflammatory reaction which is binding the lung to the chest wall. In the absence of this lesion, this mass, the lung would have come completely free of the chest wall and there would not be this tedious division of structure after structure. One doesn t just pull them apart because adhesions typically get their blood supply not from the lung, but from the wall of the chest. As some of you may know, the blood supply to the lung, in general, is a low pressure blood supply and low pressure things don t bleed very much, but since the adhesions get their blood supply from the chest wall, it s at the full arterial blood pressure and there has to be a lot of respect for them because if they re not adequately controlled and cauterized, the patient may have postoperative bleeding. We re seeing a fairly close-up view. At this point the team is working on the further identification of these structures and moving forward, hoping to start isolating the mass from the adjacent tissue. Actually, the email questions are coming in and somebody has asked, it s well and good for me to say what are the benefits of VATS, but what is the meaning of VATS? I didn t

make that clear. VATS means video assisted thoracic surgery. It s just an acronym. That s what VATS means. There s another question here and apparently the question relates to my use of the words mass and tumor. The questioner wants to know does this mean that the patient has cancer? Well, the word mass can be used interchangeably with the word tumor and it just means something that s taking space inside the body. It can be benign or it can be, in some cases, malignant. In this case, it is most likely to be benign; that is, not cancerous and not malignant. Here we re seeing a view of the overall field. Dr. Widmann is on the left and you ll see that he s concentrating on the video screen straight in front of him. Here s an interesting question, actually. We didn t discuss the various ways that these things can be treated, but somebody wants to know why he didn t just stick a big needle in and suck it out. Well, the reason for not just sticking a big needle in and sucking it out is that this lesion is pretty close in and deep to the center of the chest. You certainly couldn t do it from the front or side without going through a vital structure, but theoretically you could go through the back. The reason for not just sucking it out is that s not approved and recognized therapy for this type of mass, for a couple of reasons. When you stick the needle in, even if you don t injure an adjacent structure, you d be doing something that wouldn t really alter the proper course of treatment for this type of a mass. The recognized tried and true treatment for this type of a mass is to get it out, if possible, with the full wall. If not possible, leaving a little bit of the wall in place but as little as possible to avoid injuring any vital structure. If you leave the mass in place indefinitely, the dangers are that will happen just what happened in this case. The patient went from having no symptoms to symptoms as the mass enlarged over the past couple of years. Those symptoms can be insidious and slow, such as the enlargement of the mass. They can be sudden if there s hemorrhage into the mass. Then, very low on the list of possibilities is that the mass itself could develop malignancy within it. We don t have any indication of that, but of course, only once it s out and in the hands of a pathologist will that be known. There s a question here about what are the surgeon s charges for a VATS procedure as opposed to an open thoracotomy. The general policy that s followed is that it s what s done that determines the charge, not the technique with which the goal is achieved. Therefore, the surgical fees are set by the nature of the pathology that s operated on, not the technique of getting to that pathology, so the VATS procedures are charged at the same rate as the open procedures. In fact, when they go quicker than the open, that decreases charges overall for the anesthesiologist, but not for the surgeon. If it takes longer, the fee is the same because in surgery, in general, the charge is for what is accomplished, not for how long it takes nor for the approach used. Here is a question about whether the dissection of lymph nodes is easier by the VATS technique or by the open. This is a very interesting question because VATS is in some ways like laparoscopy; that is, operation on the abdominal cavity. Only now is the hard

data coming through that tells us that not only is VATS more comfortable for the patient, but it is also at least the equivalent of the open procedures when it comes to removing lymph nodes and having an operation that is truly meeting the oncologist s, that is the cancer surgeon s needs. In abdominal surgery, this has already been studied and produced level evidence 1, that is the best of evidence in medicine as we currently use the term prospective randomized controlled study and that shows that the VATS technique is at least as effective. I d like to stop discussing lymph nodes for a minute and just have us concentrate on what Dr. Widmann has accomplished so far. He s now dissecting upward in the posterior mediastinum and we can see the azygous vein right near that sucker tip. That s a rather major vein that takes blood from the lower portion of the body and connects to the superior vena cava. We often think of blood from the lower portion of the body coming back to the heart through the inferior vena cava, but there is this alternative route. The azygous vein is frequently the upper limit of the dissection for masses like this because it s pretty much a marker of where the extent of any lower and posterior mediastinal mass is likely to extend. Now we are seeing the pleural membranes being stripped free from the mass and that s called the parietal pleura when it s on the chest wall. It s called the visceral pleura when it s on the lung. When it s over the mass itself, I think we ll just call it pleura. That membrane actually does have a fairly good blood supply and frequently you ll see that he uses cautery as he dissects along it. We also should comment for a minute that just prior to starting the surgery, Dr. Widmann passed a flexible esophagoscope into the patient s stomach. He did that not only to check the lining of the esophagus, but he did it also so there s a marker inside the patient to help identify the esophagus and to keep it in view and not have it subject to misidentification and also as an aid in the anatomic dissection. While this mass is most likely arising from the bronchial tubes in some fashion, being what we would call a bronchogenic cyst, it may equally well have arisen from the esophagus, in which case it would be called an enteric cyst. Some people use the terminology in which it s interchangeable. What makes it pretty clear that it comes from the intestinal or GI tract is if it has stomach lining and it produces acid, but that s relatively rare in these. More likely it would have a lining that would be squamous in type if it were from the esophagus, in which case that might be a helpful clue as to the origin of it, but if it has what we call ciliated epithelium, then certainly we d call it a bronchogenic cyst, coming from the bronchial tree, and it would mimic the structures of the lung, rather than the structures of the intestinal track. We see now that they re dividing some more pleura. They re reflecting the lung and the mass up and they re making some good progress. The case is progressing well. There s some more pleura being divided now. We still don t know the nature of this lesion, but interestingly, if it is a bronchogenic cyst, although it looks like it had fluid on the inside and nothing much but the wall of it, under the microscope they may even find bits of cartilage and sometimes even muscle because there may be embryologic remnants of the primitive structures of the adjacent organs.

Mark, can you tell us how things are going with the procedure? You can see, this is a lot of inflammation here. We re just trying to develop some safe planes of entry to start mobilizing this. I think we re getting there, but we keep trying to circumnavigate this process to find the easiest way in. Mark, is it possible at this point to point out the esophagus? It s actually a very good time to do it because we re reorienting. The esophagus actually is right below. I m just going to clean up a little bit of this blood clot that s sitting here. Remember that it always looks like a lot more blood on the video screen. It s over here. This is the esophagus, between my sucker and this cotton dissector that I m pointing with. That s the esophagus running right down there. Although you can t feel with your fingers, you can tell that the esophagoscope is still there by the resistance? I can feel the resistance and I could see it before, before I made the field a little wetter. A bit earlier, we were able to see the azygous vein and it looked like there was no extension up to the level of the azygous vein. No, it was free from that. We re just taking a little bit more of the pleura here anteriorly and then we re going to reorient.

The patient is on his side and the front of him is facing Dr. Widmann. When the cameras go back in, you ll see that the back of the patient is currently on your left and the front of the patient is on your right. It looks like it s raining in there. Indeed, outside it s raining, but it s raining inside the chest too. That rain is the irrigation fluid. Outside I think the water is from the sky. Here, it s from a bottle of saline. They do that to clean up the field and make it easier to see. We have a whole bunch of questions that have accumulated. As they continue the dissection, let s run through them. A questioner wants to know, when we say inflammation, are we referring to pulmonary edema? The answer to that is no, pulmonary edema is more a reflection of heart failure. The inflammation is probably the result of possible infection in the adjacent lung tissue, to which the cystic structure has been attached. In fact, these cysts, although I didn t mention it, can have small microscopic connections to the lung itself and bacteria can enter from the lung into the cyst, so if the patient had an episode of, say, pneumonia, the cyst could have gotten infected, certainly the wall of it, and that could lead to this type of adhesion. We have some more questions here. Is it true to say that the visualization of the surgeon is better than compared to open thoracotomy? Well, let s take a look at the screen right now. Certainly if we were standing with the chest open, we could see these same structures, but they would not be as big as they appear to the surgeon on the screen in the operating room, so yes, visualization is better, but the down side is that you do lose, to a degree, the concept of the three-dimensional view because the screen is flat and clearly is not three-dimensional. There are experimental screens that are being made with types of hoods where the image is simulated in three dimensions and that may be in the future, but as yet it hasn t appeared to have sufficient advantages that it s being used clinically. I think now they re above the lesion. There s the sucker right along the esophagus. Here s the esophagus, the longitudinal fibers of it, right here. What I m going to try to do is separate the esophagus from the cyst back here. I ve been looking for a plane to get around this. If we can just separate one end of it, it sometimes is easier than continuing circumferentially. You can see there s this broad area where it s very much fused to the esophagus and that s actually very much my concern. One of our issues was making sure there was no communication with the esophagus on our preoperative studies and there didn t appear to be, either on the barium swallow or the esophagoscopy, but the other is to externally make sure that there s not a vascular attachment. There may be from some small blood vessels coming off the esophagus, but it certainly looks intimately adherent here and that s one of our biggest concerns of the lesion, making sure that the esophagus stays intact throughout the procedure.

When the esophagus is entered, the surgeon repairs it and prudently covers it with what we call a patch. He might use pleura from the chest wall to reinforce an enclosure. One of the students who is watching asked us to name some of the instruments. The names of instruments in surgery are actually kind of interesting. They re sometimes named by their use, things like a right angle scissor. It s an instrument that has a right angle in it and it cuts. They re sometimes named after the surgeon who developed the instrument, such as a Mixter clamp. I didn t see a Mixter being used, but the reason I mention the name Mixter is that he is the surgeon who about 50 years ago was one of the first...make that more like 60-70 years ago...was one of the first to describe this procedure. I can ask the scrub nurse if they have any Mixters in the field. No, I don t see a Mixter up there. Let s go to the other instruments. We sometimes name an instrument, if not after the person who developed it, then by what they look like. Now, see that instrument going back and forth with a blood-soaked piece of gauze? They call that a cherry. Not surprisingly, it looks like a cherry and it s being held in a ring forcep. No, that s a sponge that s being held in a diamond forcep. That s so named because it looks like a diamond shape. Let s see if we can see some of the others. There s the suction catheter. Suction catheters are sometimes named after the person or by the company that produces it or the person who designed it. These suction catheters have multiple holes in them so they don t plug with clot or tissue easily. Earlier you saw staplers being used. That s an advance that helps, especially with video assisted technique, because you don t have to put in as many stitches. Here s a question right on target. This is from a young lady named Alana who wants to know if we got permission from the patient to videotape this surgery. Indeed, that is a requirement, not only of the hospital and not only of the video team, but also as part of what is called informed consent. Informed consent means that the patient is fully aware of what is going to be done, who is going to do it, why the procedure is done, what would happen if he didn t have the procedure done, what the risks of doing it are, and what the risks of not doing it are. When it comes to the permission to videotape, the patient is doing that in good part out of altruism because the patient is aware that this video will be used for educational purposes. In fact, when a patient comes to a teaching hospital, such as Morristown Memorial, he knows that doctors in training will be observing and participating in the operations, but always under the direct supervision of the attending surgeon. When some people say, I want the surgeon to do everything, they really don t understand that the surgeon is directing a team and different team members have different responsibilities. As you saw when the operative field was panned, the team here consists of four people, the surgical resident, the nurse practitioner, Dr. Widmann, and also the scrub nurse. What you don t see is the rest of the crew, which includes a circulating nurse; an anesthesiologist at the head of the bed, who is keeping the patient under anesthesia, free of pain, and comfortable; and then the occasional technicians who are called in for equipment needs. It s a whole orchestrated event when an operation is done. Now, here we have a question from a very informed observer who wants to know the size of the trochars that are being used. Now, trochars are the hollow tubes that are put in

through the chest wall to allow the instruments to go in and out of the chest. I ll have to ask Mark. They look to me like they re 12 or 14 mm. That would be about ½ in size. Mark, can you tell us what the size of the trochars used were? We re using only one trochar for the camera port. One of the differences between thoracic surgery and most other laparoscopic procedures in the abdomen is that we don t have to maintain a seal with carbon dioxide, so we re only using one port and I believe it s a 14 mm. It s a 10, 12, or 14. It s an adjustable trochar, so it can accommodate a number of different sizes. It s about 1/2. 2.54 cm is the size of an inch. I m going to just brush those with a cherry. That s not going to really be a cherry. It s going to be an instrument holding a little ball of gauze that looks like a cherry. It starts out white. That s the suction going down. The cherry did not come down yet. There it is. When it gets red, it s going to look more like a regular cherry. It s a white cherry now, maybe from Washington State, but it s going to be a red cherry pretty soon. Now we see the structure being dissected away from the esophagus. It s quite adherent to the esophagus, quite adherent, so it s not a piece of cake as yet. It still is adherent to the adjacent structures. Let s see if there s another question here. When operating on the lung, the questioner wants to know, since you re losing tactile sensation, how can you proceed? That s exactly one of the issues. You have to learn the feel of the tissue and the pressure has to be exerted cautiously because you don t have your finger at the tip of the instrument. You must remember that when we operate open, we also don t have our finger at the tip of the instrument. It s at the handle of the instrument and it s the transmitted pressure. Now there s some question as to whether the esophagus is actually connected by a diverticulum. It looks to me, at least at this point, that those are adhesions to it, rather than an actual outpouching of the esophagus. The esophagram did not suggest that there was a diverticulum. In just a few minutes, I think that question that the surgical resident raised is going to be answered, as the esophagus is now being pushed posteriorly to the left side of the screen and soon I think the mass will be free from the esophagus. There s the diamond shaped grasper in the field.

At this point there s still adhesions that are being dissected away and at the top of the field we see the collapsed lung tissue that also has been...the azygous vein, the vessel we were talking about, is above the area of concern and we re seeing the field again, with the lung and the mass being reflected to your right and the esophagus to your left. Again now, the dissection has really made a lot of progress in the last few minutes, as we see the mass being progressively separated from the esophagus, those fibers being separated, the muscle fibers that are being separated now and the mass is being reflected to the right side of the screen. When we talk about right, it s right as you re looking at the TV screen and the left is where the esophagus is, on the left hand side of the screen. This is a good view of that azygous vein. You ll see one thing that s very interesting about the azygous vein, that it connects the blood supply from the lower part of the body, which is in the bottom of the screen, and returns blood to the superior vena cavum, but it also drains blood from the head and neck and the chest wall, so you could see some of those connections a minute ago. At this point, the mass is being further reflected anteriorly. Dr. Widmann has made a fair amount of progress in the last few minutes and now the dissection has really brought the mass much more to the right. It s not at all uncommon for these things to break in the course of the dissection. That s not ideal, but it s also not uncommon for the wall to break, especially if it s adherent to a vital structure, because the surgeon will want to spare the vital structure and risk rupturing the cyst much more than he would want to harm the vital structure just to keep the cyst wall intact. You saw some bleeding from a little point where they did that dissection. They may end up cauterizing that little spot, maybe putting in a stitch. There have been some more questions. Here is one by...two people have asked this question, looks like Zach and Sara, and they want to know can you live with one lung? The answer to that is yes, indeed, but that one lung has to be functioning well. We do have operations in which we remove the whole entire lung. While people have 2 lungs and we think the right and the left are equal, actually the right lung does more function for the body than the left. The right does a little more than half of the function, 55%. The left only does the remaining 45% of function. Also, when people have problems with their lungs, say a lung cancer, the function of that portion of the lung is frequently lost, so the patient is living on less than two full lungs when he has something wrong with one lung, so there are people walking around who have two lungs in them but maybe only one working, so the brief answer to the question, can you live with one lung, the answer is yes, providing that lung has well preserved, pretty normal function. There s a questioner here that wants to know how many of these procedures has Dr. Widmann done. The answer to that is well over 1,000. I believe it s over 2,000 at this point. The VATS procedures are done for a variety of different operations. As they proceed with the dissection, I m going to flip up another one of the slides here and put down current indications for VATS. If we could look at that slide as they continue the

dissection, then you ll see that it can be done for problems with the lung itself. That s interstitial lung disease, a fancy word for saying something wrong with the lung. Nodule or mass, remember with the word mass or tumor, it just means something s there that shouldn t be. It could be a cyst or fluid. It could be solid. It could be benign, which is not cancerous, or it could be malignant. It could be a cyst filled with a lump of air, in which case it would be called bolus disease. It s also done for lesions or problems with the pleural cavity, in which there is fluid in the chest cavity or masses in the chest wall or pus building up in the chest, typically after pneumonia. Now we re looking back at the operative field. The esophagus again is off to the left and the mass is being dissected off to the right. It looks like there s still a layer, possibly, of some of the esophagus on that mass, but Dr. Widmann is freeing it. As he does so, the mass is going to become a lot more evident as it s separated from the attachments to the surrounding structures. Now that they re making such good progress, I don t want to go back to the slide, but other indications for VATS are operations on the mediastinum, and indeed this is an operation on the mediastinum. The slide, you might recall, told us that it s for bronchogenic, neurogenic, or enteric lesions. Those are the different kinds of cysts that it could be done for. Also, operations on the esophagus are done with the VATS technique and we see how easily that could be done because the esophagus has been in the field for a good portion of the operation. Also we can operate on the nerves of the chest. The nerves you operate on are not the usual nerves that make muscles move or that you feel pain with, but what we call the sympathetic nervous system. There are some rare conditions that cause excessive sweating or clamping down of blood vessels, as in Raynaud s disease, and those operations can be done through the VATS technique as well. Now once again we see the field at work. You ll notice Dr. Widmann isn t looking down at the chest. He s looking ahead of himself, right at that TV screen. Now we re back into the chest and the operation is proceeding with a clamp that s teasing off the tissue from the adjacent structures. That s our friend, the azygous vein. I call it our friend because it s intact and it s not bleeding. I know we re running almost out of our hour here, but we re looking right now at the back wall of the airway, the bronchus. This is actually the cartilaginous bronchus that you can see poking through. We re trying to define the superior border here. We ve already freed this from the esophagus. Basically our goal is to separate this cystic structure from all the adjacent known anatomical structures, so we re going from known structures to follow them down as far as we can. You know, we ve cleared the esophagus. You can see there s a lot of inflammation there, but I d say we re still making progress, so we re going to continue with our approach, as you ve been watching us do today, until we feel like it s not safe to make any headache. I think we haven t done anything untoward at this point. We ve been exploring.

At this point, if I had to make a guess what the pathologist is going to find as the lining of the cyst, my guess is that he might fund that it has the same lining of the esophagus, because it was so intimately adherent to the esophagus, but that s a guess only at this point, before we see how adherent it is to the bronchus. Certainly the muscles of the esophageal wall blended in with the covering of this cystic structure and that could well mean that its origin embryologically is from the esophagus. The collapsed lung is seen at the top. As I ve used the word collapsed, I think people could say oh my gosh, does that mean something bad? Just now is the time for me to talk about that because the anesthesia tube has moved a bit back in the trachea and now you re seeing the lung expand and the tube may need to be repositioned. Now we see the lung expanded on the screen and that s what a normal lung looks like. It s that collapsed purplish structure, but it s all fluffy and pink. We didn t mention it, but this patient has what s called a double lumen tube in his airway, in his trachea, and that double lumen tube makes it possible for the anesthesiologist to have the patient breathing with just one lung. When the tube slips a bit, the lung that previously was inflated deflates and at times like this, the anesthesiologist has to reposition things and make sure that he s giving the gas flow, the oxygen and the anesthetic agent, only to the left side. Now the lung is back down. The anesthesiologist is making the patient s oxygen go in and carbon dioxide come out just from the left side. That questioner earlier who asked can a patient live with just one lung, actually for a good portion of this procedure the patient is living with just one lung. The patient s left lung is doing all the work, as his right lung has been mostly collapsed during the operation. They re making good progress now as they move the cystic structure forward. Now the remaining portion of the operation will be the separation of the cyst from the bronchial tree and the lung tissue. That usually proceeds a little faster because the risk of injury is much less than the risk of injury to the esophagus, but right now they still have some adhesions. There they are. They re poking at them right now. He has asked for a right angle clamp, which he s probably going to introduce through that area of adhesion and then divide it in an effort to keep separating the mass from the adjacent structures. The overall length of time that it takes...there s the right angle clamp going underneath. I m not going to second guess, but I would believe he s either going to cauterize that or staple it or put clips on it. Now it looks like the cautery is coming in and the tissue is going to be cauterized and that will then free it up a little bit further and then we ll have some further mobilization of the mass to follow. This patient is somewhat older than the usual patient who has a cystic structure. This mass may have been congenital and actually in the patient all of his life, but until it enlarged sufficiently to cause these bouts of coughing and probably trigger the

arrhythmia, the abnormal heart rhythm, it caused him no symptoms and wasn t brought to anybody s attention. Until he had symptoms or another problem, in his case a mild heart attack, he would not necessarily have had a chest x-ray, which would have been the first way to find out about this. You might ask, why don t we x-ray patients all the time, looking for things before they become a problem? The reason for that is, we don t do anything in medicine unless it matches the risk:benefit ratio and doing a bunch of x-rays in a whole lot of people would be giving a fair amount of radiation to the general public and the returns of finding things that aren t causing problems wouldn t justify it. However, once something becomes symptomatic, the patient does indeed have to have studies done. At this point, those who are pretty good at seeing things will notice that a small blood vessel has been divided and they re going to have to gain control of it, probably with a combination of clamping and cautery or suture technique. That s probably one of the small arteries that connects the main blood vessel in the body, the aorta, to the esophagus. That would make it a small esophageal arterial branch. They just have to do some suctioning in order to isolate the source of the bleeding and then they ll clip it or clamp it or cauterize it as necessary. Again, with the video technique, the amount of bleeding looks very brisk and prominent, but in fact it s a magnified view and it does help bring our attention to these sources of bleeding so that we re careful to get them well controlled before the patient leaves the operating room. At this point they re probably going to suction the area free and see about controlling that blood vessel. At this point there s some air that has gotten back into the lung and they re going to push the lung out of the way and now they re dissecting down toward the site of the bleeding, putting pressure on it and then they ll decide how they re going to control that vessel. It looks like it s going to rain in the chest again. I heard Dr. Widmann ask for some irrigation and a cherry. There goes the irrigation. You re seeing an outside view of the chest and I believe Dr. Widmann is able to see inside as he suctions it free and will attend to that bleeding. The other things that we think about with video assisted thoracic surgery include a consideration of how many incisions are made. Can we flip over to that VATS incisions slide at this point? While they re working away, let s just take a look over here at the VATS incisions. This shows us the four cuts that are usually made. It actually is a diagram and the cuts are not quite as large as they re shown on this picture. The VATS incisions, labeled 1, 2, 3, and 4, are positioned so that with the camera in place through any one of the ports, there s always the option of looking, working, and manipulating from a triangle aimed at where the camera is pointing, so if the camera goes through 1, the triangle is 2, 3, and 4. If the camera goes in through the cut marked 4, the triangle is 1, 2, and 3. One of the questioners asked how many trochars are used. Dr. Widmann moves the trochar so the camera is inserted through the trochar so it doesn t get blood and fluid on it as it goes in and out of the chest, but the camera can go through any one of these incisions. At the end of the operation, Dr. Widmann is going to leave a drainage tube in the chest through one of these cuts. All the others will be sewn tight and one of them will have the drainage tube which is going to go to a suction device and that drainage tube

will suck out any continued oozing of fluid that occurs and also will help the lung to remain expanded after the operation. The suction is put to relatively low force; that is, 20 cm of water. That s not a heck of a lot of suction. That s as much suction as it takes to suck up fluid in about a 10 straw. The reason we use the suction, as I said, is to encourage drainage of fluid from the chest and also any air leakage. You notice that the lung has been up and down in this field. If the operation were done on lung tissue itself, when the lung is cut, it would leak air. As the lung has been manipulated, there might be some minor air leaks, so there will be this tube to do drainage at the end of the procedure and that tube typically stays in overnight to 2-3 days, depending upon how long there is air leaking out or significant volumes of fluid leaking out. The incisions, 1, 2, 3, and 4, will be closed. As I said, one of them will have the drainage tube, usually 3 or 4. When these incisions are closed, they re closed in layers and then no external stitches are put in place, so the patient doesn t have to return specifically for suture removal from these incisions. The removal of the chest tube is done with the patients actually awake. It s done a few days after surgery. With the patient awake, he may get a pain pill or a shot, but it s been shown that most patients prefer just to have the tube removed without anything because once it s out, they feel fine and the discomfort is usually not that much. At this point the team is checking on the hemostasis, that is the control of oozing from the artery, and then they ll get back to the dissection. I think there may be some more questions coming in at this point. Someone wants to know what testing was done in this patient before the surgery. That s an interesting point because there s no standard of what tests have to be done, other than a simple blood count. In this particular patient tests were done to make sure his heart function was good. That would be an electrocardiogram as well as an echocardiogram, since he had some history of heart disease. Additionally, a blood count was done. We already know that he had the esophagram and the CT scan. There are other tests that could be done. That would be an MRI or sonogram. An MRI is much more expensive than a CT scan and, in cases like this, wouldn t add anything to the information we already had with the CT scan, so it was not necessary to do it. However, if this structure were much closer to the spine and solid, might have been a tumor of nerve origin. In those cases, we would do an MRI because it s the best test for looking at the nerve structures as they lead to the spinal cord. If it were an anterior mediastinal mass, it might involve the thymus gland and it s been shown that tumors of the thymus gland are associated with a condition called myasthenia gravis and some tests for that might have been done. Also, if it were solid, there might have been tests for markers of what are called germ cell tumors. These are tumors that elaborate abnormal chemical compounds called alpha fetoprotein and beta HCG and these would be indicative of a tumor that had origin from germ cells that are reproductive cells. Mark, at this point can you tell us what plans you have for the completion of the procedure, as we re getting close to the end of the hour?

We got diverted there by that little tiny bleeder, which is not active, but we ve got other little small vessels which when you do certain operations in the chest, we often don t even identify, but since we ve got such great magnification, we sort of need to control them just so we can see our field. Do you think some of these vessels are the result of prior inflammation? Absolutely because these are not main vessels and there s a lot more of them than you normally encounter here. So that makes the operation a little more tedious, but your goal is to keep freeing this mass from the adjacent tissue. Yeah. We ve done actually a lot of progress in the last few seconds here. Once this is separated from the other structures, this will be sent to the pathologist. Are we going to wait for the results or... Well, when we re done it ll be out, so it s certainly not appropriate to do a bigger operation, so we ll continue to do our operation, but the patient certainly would like to know at least a preliminary result on what he has and so would we. I guess the audience might want to know when the pathologist can give us a definite answer. The answer to that is that the pathologist will have a preliminary idea of what s in this mass, but he will do multiple slides and examine multiple areas, but a preliminary diagnosis will probably be forthcoming. We really doubt that it s malignant and one could say why use resources to have the pathologist identify it. The reason for that is, if there is an unexpected finding of malignancy, then Dr. Widmann would likely put in some markers, some clips in specific locations so if radiation therapy were necessary at a later date, they d be able to direct it exactly to the bed where the tumor was, since when the tumor is gone, we won t know exactly where it was, so there would be some value to