1146 timestamped statements
across 20 topics
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Summaries Steven gave as host are listed separately below.
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
The way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.
I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection
The key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.
The one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.
Once you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.
quoteThe one thing that we can always count on is how, how often this target changes, but I think that with the work done by many of our colleagues over the last 5 to 10 years, we've been able to kind of drill down to certain high risk age groups.↗
▶Ep 1 · 14:30
clinicalOver the last 5–10 years, work by colleagues has allowed age-stratified C-spine protocols; a 13-year-old is not treated like a 2-year-old.↗
▶Ep 1 · 14:30
clinicalFuture work from PECARN will help determine which children do not need any C-spine imaging at all.↗
▶Ep 1 · 16:04
clinicalPlain films are the next step in a 10-year-old with midline tenderness, no distracting injuries, and GCS 15.↗
▶Ep 1 · 16:14
opinionChildren without distracting injuries, without neurologic symptoms, and with minimal or no tenderness have been over-imaged; restraint in imaging this group is an area for improvement.↗
▶Ep 1 · 16:14
clinicalThe degree of midline tenderness, believability of tenderness, and neck muscle spasm guide the astute clinician in deciding whether to proceed to MRI or observe in a collar.↗
▶Ep 1 · 16:14
quoteWe've over imaged those children. We know it for sure and slowly we'll get better at being able to show restraint in our imaging.↗
Steven's statements about Cervical Spine Injury7 statements
clinicalFuture work from PECARN will help determine which children do not need any C-spine imaging at all.↗
▶Ep 1 · 14:30
clinicalOver the last 5–10 years, work by colleagues has allowed age-stratified C-spine protocols; a 13-year-old is not treated like a 2-year-old.↗
▶Ep 1 · 14:30
quoteThe one thing that we can always count on is how, how often this target changes, but I think that with the work done by many of our colleagues over the last 5 to 10 years, we've been able to kind of drill down to certain high risk age groups.↗
▶Ep 1 · 16:04
clinicalPlain films are the next step in a 10-year-old with midline tenderness, no distracting injuries, and GCS 15.↗
▶Ep 1 · 16:14
quoteWe've over imaged those children. We know it for sure and slowly we'll get better at being able to show restraint in our imaging.↗
▶Ep 1 · 16:14
opinionChildren without distracting injuries, without neurologic symptoms, and with minimal or no tenderness have been over-imaged; restraint in imaging this group is an area for improvement.↗
▶Ep 1 · 16:14
clinicalThe degree of midline tenderness, believability of tenderness, and neck muscle spasm guide the astute clinician in deciding whether to proceed to MRI or observe in a collar.↗
Steven's statements about Congenital Lung Lesions (CPAM)268 statements
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 4 · 1:02
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 4 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 4 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 4 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
▶Ep 4 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 4 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 4 · 10:41
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 4 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 4 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 4 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 4 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 4 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 4 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 4 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 4 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 4 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 4 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 4 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 4 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 4 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 4 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 4 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 4 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 4 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 4 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 4 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 4 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 4 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 4 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 4 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 4 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 4 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 4 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 4 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 4 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 4 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 4 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 4 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 4 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 4 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 4 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 4 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 4 · 23:06
quoteThe hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
▶Ep 4 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 4 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 4 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
▶Ep 4 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012
▶Ep 7 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 7 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 7 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 7 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 7 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
▶Ep 7 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 8 · 3:48
clinicalSerial prenatal ultrasounds every couple of weeks are the best way to follow development of cystic lung lesions - noninvasive, quick, and adequate for monitoring.↗
▶Ep 8 · 4:11
opinionFetal MRI provides little benefit for lung lesions - doesn't change the plan or give much more definition than ultrasound.↗
▶Ep 8 · 5:43
epidemiological6-40% of prenatally diagnosed lung lesions will regress with time, and in some cases appear to completely disappear.↗
▶Ep 8 · 6:11
epidemiologicalFetal intervention for lung lesions is extremely rare - CHOP does less than one open fetal surgery every couple of years for this indication.↗
▶Ep 8 · 7:54
clinicalCyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and indicates cases more prone to need fetal intervention.↗
▶Ep 8 · 8:52
clinicalCongenital lung lesions represent a spectrum - often see hybrid lesions on pathology combining features of CPAM and sequestration.↗
▶Ep 8 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 8 · 14:31
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 8 · 14:44
clinicalMultiple children with prenatal diagnosis and normal postnatal chest X-ray presented later (9 months to 6-7 years) with pneumonia and infected CPAM on further evaluation.↗
▶Ep 8 · 14:44
clinicalA chest X-ray or ultrasound after birth are not adequate to ensure there is absolutely no lung lesion present.↗
▶Ep 8 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life.↗
▶Ep 8 · 15:55
epidemiological20-40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 8 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 8 · 16:58
epidemiologicalThe incidence of malignancy in Rothenberg's series of congenital lung lesions is over 1%, which he considers significant.↗
▶Ep 8 · 18:04
clinicalOperating by 3 months of age avoids the problem of the baby getting an infection before surgery.↗
▶Ep 8 · 18:20
clinicalSurgery is technically easier in smaller infants - with current equipment and instrumentation, smaller vessels make the surgery easier and the anatomy is fresh.↗
▶Ep 8 · 18:46
clinicalEven in asymptomatic children, by around one year of age there are significantly enlarged lymph nodes in fissures and peribronchial spaces, and sometimes inflammation in the fissure, suggesting low-grade infections.↗
▶Ep 8 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection↗
▶Ep 8 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery time, and operative time were all significantly less in patients under 5 kg compared to those under 10 kg.↗
▶Ep 8 · 19:46
clinicalMost children are discharged within 48 hours after lobectomy, and by one month post-op on chest X-ray, you cannot tell they had anything done due to compensatory lung growth.↗
▶Ep 8 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room↗
▶Ep 8 · 23:31
quoteI think that, you know, it's important to have an anesthesiologist who's comfortable doing this with you.↗
▶Ep 8 · 23:38
clinicalMost asymptomatic children on room air will tolerate single lung ventilation without problem.↗
▶Ep 8 · 26:02
clinicalAfter lung collapse, babies initially desaturate for a few minutes (low 90s to high 80s) because they're still shunting blood to the collapsed lung; saturations come up once they stop shunting to that lung.↗
▶Ep 8 · 27:41
clinicalEnd-tidal CO2 in the mid-40s during thoracoscopic surgery is not a problem and doesn't cause significant acidosis or deleterious effects.↗
▶Ep 8 · 30:02
clinicalThere is more room to work from the front of the chest towards the hilum than from the patient's back during thoracoscopic surgery.↗
▶Ep 8 · 35:01
clinicalThe 3mm vessel sealer will seal vessels at least up to 5mm in diameter.↗
▶Ep 8 · 35:15
clinicalThe technique for vessel control is to make two separate seals on the vessel at least 4-5mm apart, then cut partway between the seals - if you see lumen with no bleeding, it's safe to complete the division.↗
▶Ep 8 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything. You really want to maximize the downside.↗
▶Ep 8 · 36:22
quoteIf you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe. If you get into the lumen and you start to see some bleeding, you have the ability to compensate and recover.↗
▶Ep 8 · 37:44
opinionUsing energy devices that seal and cut simultaneously on major vessels is a huge mistake and sets you up for trouble - every device can fail at some point.↗
▶Ep 8 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble↗
▶Ep 8 · 38:30
quoteMy supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 8 · 39:04
clinicalRothenberg had one case where he used a seal-and-cut device in another country, it didn't seal properly, there was bleeding, and they had to convert to open.↗
▶Ep 8 · 43:13
clinicalWhen completing an incomplete fissure, work layer by layer like finger fracturing during liver lobectomy, gradually exposing the pulmonary artery.↗
▶Ep 8 · 44:06
clinicalIn a lower lobe, the pulmonary artery usually has a main trunk that bifurcates into four branches to the basal segments, plus a superior segmental branch that comes off higher and more posteriorly.↗
▶Ep 8 · 45:23
clinicalThe bronchus sits right underneath the pulmonary artery - you can feel it and use it to help dissect behind the artery.↗
▶Ep 8 · 48:37
clinicalWhen dissecting behind the bronchus to reach it, the pulmonary vein is right behind - must stay hard on the backside of the bronchus and be aware the vein is there.↗
▶Ep 8 · 50:33
quoteYou cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 8 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium↗
▶Ep 8 · 50:33
clinicalCritical rule: do not take the pulmonary vein trunk near the pericardium - if your device fails, it will retract into the pericardium and the child will bleed to death before you can do anything. Must have enough length for proximal control.↗
▶Ep 8 · 51:03
clinicalRight lower lobe is the exact opposite of left lower lobe - just switch hands and flip sides - but must be careful that middle lobe branches come off just above the lower lobe artery.↗
▶Ep 8 · 52:11
clinicalFor upper lobectomy, retract the lung apex inferiorly to expose the pulmonary artery as it comes into the upper lobe near the apex, then work from top down around the front and up through the fissure.↗
▶Ep 8 · 54:06
clinicalThe lingula is almost always taken with an upper lobectomy on the left; on the right, the middle lobe is usually preserved.↗
▶Ep 8 · 57:38
clinicalIf you have a lung with large cysts and limited space, use the sealing device to pop the cysts and decompress them at the beginning of the procedure - do a lung reduction to get room to work.↗
▶Ep 8 · 58:42
clinicalSystemic vessels to sequestrations can number up to 6, and Rothenberg has seen vessels as large as 15mm in diameter.↗
▶Ep 8 · 59:45
clinicalCritical warning: do not use sealing technology and clips on the same vessel - the sealing changes the vessel nature, causing necrosis, and clips can lose secure footing and fall off, causing delayed bleeding.↗
▶Ep 8 · 59:45
quoteDo not use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed↗
▶Ep 8 · 1:00:15
quoteI believe that's because as the vessel, the nature of the vessel changes, that the clip no longer has secure footing, that the the vessel sort of necrosis a bit and the clip falls off, and you can get late bleeding.↗
▶Ep 8 · 1:01:07
opinionExtra-lobar sequestrations can become infected and cause problems, which is why Rothenberg removes them all rather than watching or embolizing.↗
▶Ep 8 · 1:01:23
opinionEmbolization of sequestrations requires general anesthetic and significant arterial intervention - Rothenberg believes thoracoscopic removal has almost no morbidity with no chest tube and next-day discharge.↗
▶Ep 8 · 1:03:27
clinicalRothenberg has performed approximately 20 segmentectomies in cases where disease appeared confined to superior segment of lower lobe or lingula on CT, with good follow-up and no recurrent disease, but cannot widely recommend yet.↗
▶Ep 8 · 1:05:27
clinicalAverage length of stay for lobectomy in patients who come in the morning is about 2.5 days, and even shorter for patients under 5 kg.↗
Thoracoscopic Right Lower Lobe Cystic Lesion Excision: Update Course 2014
▶Ep 11 · 0:06
clinicalThe patient is a 3-month-old, 5 kg infant undergoing thoracoscopic right lower lobectomy for a cystic lesion with an unseen sequestration.↗
▶Ep 11 · 0:06
clinicalThe patient is a 3-month-old, 5 kg infant undergoing thoracoscopic right lower lobectomy for a cystic lesion with an unseen sequestration.↗
▶Ep 11 · 0:11
clinicalThree-millimeter instruments are used for the procedure, and space is not an issue in a 3-month-old infant.↗
▶Ep 11 · 0:11
clinicalThree-millimeter instruments are used for the procedure, and space is not an issue in a 3-month-old infant.↗
▶Ep 11 · 0:36
clinicalAt 3 months of age, enlarged lymph nodes are already visible in the major fissure.↗
▶Ep 11 · 0:36
clinicalAt 3 months of age, enlarged lymph nodes are already visible in the major fissure.↗
▶Ep 11 · 0:40
clinicalIn asymptomatic children aged 9 months to 1 year, lymph nodes are often massive and inflammation in the fissure is extensive, making the operation more difficult.↗
▶Ep 11 · 0:40
clinicalIn asymptomatic children aged 9 months to 1 year, lymph nodes are often massive and inflammation in the fissure is extensive, making the operation more difficult.↗
▶Ep 11 · 1:21
clinicalThe operation with a fellow assisting took approximately 90 minutes.↗
▶Ep 11 · 1:21
clinicalThe operation with a fellow assisting took approximately 90 minutes.↗
▶Ep 11 · 1:26
clinicalA 3 mm sealer can safely take vessels up to 5 mm in diameter.↗
▶Ep 11 · 1:26
clinicalA 3 mm sealer can safely take vessels up to 5 mm in diameter.↗
▶Ep 11 · 1:44
clinicalWhen asymptomatic children are operated on around 1 year of age, dissection becomes much tougher due to inflammation, even in children who have never had a cold or chest infection.↗
▶Ep 11 · 1:44
clinicalWhen asymptomatic children are operated on around 1 year of age, dissection becomes much tougher due to inflammation, even in children who have never had a cold or chest infection.↗
▶Ep 11 · 2:21
clinicalAt 3 months of age, clips can be safely used at the segmental level.↗
▶Ep 11 · 2:21
clinicalAt 3 months of age, clips can be safely used at the segmental level.↗
▶Ep 11 · 3:02
clinicalThe specimen is morcellated through the trocar site and removed piecemeal because it is difficult to use a bag with a large specimen in a small infant.↗
▶Ep 11 · 3:02
clinicalThe specimen is morcellated through the trocar site and removed piecemeal because it is difficult to use a bag with a large specimen in a small infant.↗
▶Ep 11 · 5:39
opinionIf cystic disease is seen in the lower part of the upper lobe, an anatomic segmental resection should be performed.↗
▶Ep 11 · 5:39
opinionIf cystic disease is seen in the lower part of the upper lobe, an anatomic segmental resection should be performed.↗
▶Ep 11 · 5:48
clinicalOne child who had a segmental resection that appeared limited to an anatomic segment on CT and at surgery has shown evidence of recurrent cystic disease.↗
▶Ep 11 · 5:48
clinicalOne child who had a segmental resection that appeared limited to an anatomic segment on CT and at surgery has shown evidence of recurrent cystic disease.↗
▶Ep 11 · 6:15
clinicalOne child with no fissure (one giant lobe) required a bi-segmental resection and subsequently developed recurrent cystic disease because an anatomic resection could not be performed.↗
▶Ep 11 · 6:15
clinicalOne child with no fissure (one giant lobe) required a bi-segmental resection and subsequently developed recurrent cystic disease because an anatomic resection could not be performed.↗
▶Ep 11 · 6:54
clinicalThe chest tube was removed on postoperative day 2 and could have been removed on postoperative day 1; the child went home on postoperative day 3.↗
▶Ep 11 · 6:54
clinicalThe chest tube was removed on postoperative day 2 and could have been removed on postoperative day 1; the child went home on postoperative day 3.↗
▶Ep 11 · 7:02
clinicalPathology showed lung tissue with CPAM type 1 and type 2 changes with exuberant neoplastic mucinous proliferations; bronchial margin was negative. This is a finding not previously reported by the speaker.↗
▶Ep 11 · 7:02
clinicalPathology showed lung tissue with CPAM type 1 and type 2 changes with exuberant neoplastic mucinous proliferations; bronchial margin was negative. This is a finding not previously reported by the speaker.↗
▶Ep 11 · 7:22
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the speaker has identified two pulmonary blastomas and one adenocarcinoma.↗
▶Ep 11 · 7:22
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the speaker has identified two pulmonary blastomas and one adenocarcinoma.↗
▶Ep 11 · 7:36
clinicalThe neoplastic mucinous proliferations may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 11 · 7:36
clinicalThe neoplastic mucinous proliferations may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 11 · 7:47
epidemiologicalAt Columbia, pathologists reviewing cases have found four others with exuberant neoplastic mucinous proliferations.↗
▶Ep 11 · 7:47
epidemiologicalAt Columbia, pathologists reviewing cases have found four others with exuberant neoplastic mucinous proliferations.↗
▶Ep 11 · 8:03
epidemiologicalThe literature shows that 30–40% of children with cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 11 · 8:17
clinicalOnce cystic lesions become infected, they are much more difficult to resect.↗
▶Ep 11 · 8:17
clinicalOnce cystic lesions become infected, they are much more difficult to resect.↗
▶Ep 11 · 8:21
opinionAll lobectomies for cystic lung disease should be done thoracoscopically, and if a center cannot perform them thoracoscopically, patients should be referred to a center that can.↗
▶Ep 11 · 8:21
opinionAll lobectomies for cystic lung disease should be done thoracoscopically, and if a center cannot perform them thoracoscopically, patients should be referred to a center that can.↗
▶Ep 11 · 8:37
opinionGood long-term pulmonary function studies are needed to document that if a lobe is removed in infancy, the rest of the lung will grow and compensate without significant disability.↗
▶Ep 11 · 8:37
opinionGood long-term pulmonary function studies are needed to document that if a lobe is removed in infancy, the rest of the lung will grow and compensate without significant disability.↗
▶Ep 11 · 9:02
epidemiologicalIn the speaker's personal series, the incidence of malignancy is almost 2%, certainly 1%, but may be 2%.↗
▶Ep 11 · 9:02
epidemiologicalIn the speaker's personal series, the incidence of malignancy is almost 2%, certainly 1%, but may be 2%.↗
▶Ep 11 · 9:51
clinicalHematologist-oncologists have stated that morcellating the specimen does not upgrade the tumor, does not change treatment, and no patient has received chemotherapy, but these children are being watched.↗
▶Ep 11 · 10:07
clinicalIt is difficult to place a large specimen in a bag in young infants undergoing early lobectomy.↗
▶Ep 11 · 10:07
clinicalIt is difficult to place a large specimen in a bag in young infants undergoing early lobectomy.↗
▶Ep 11 · 10:30
epidemiologicalThree tumors in 300 cases represents a 1% incidence of cancer.↗
▶Ep 11 · 10:30
epidemiologicalThree tumors in 300 cases represents a 1% incidence of cancer.↗
▶Ep 11 · 11:11
clinicalThe three malignancies (blastomas and adenocarcinoma) were all diagnosed at 1 year of age.↗
▶Ep 11 · 11:11
clinicalThe three malignancies (blastomas and adenocarcinoma) were all diagnosed at 1 year of age.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 23 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 23 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 23 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 23 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 23 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 23 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 23 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 23 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 23 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 23 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 23 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 23 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 23 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 23 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 23 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 23 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 23 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 23 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 23 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 23 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 23 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 23 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 23 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 23 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 23 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 23 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 23 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 23 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 23 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 23 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 23 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 23 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 23 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 23 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 23 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 23 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 23 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 23 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 23 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 23 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 23 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 23 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 23 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 23 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 23 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 23 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 23 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 23 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 23 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 23 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 23 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 23 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 23 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 23 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 23 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 23 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 23 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 23 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 23 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 23 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 23 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 23 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 23 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 23 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 23 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 23 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 23 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 23 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 23 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 23 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 23 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 23 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 23 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 23 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 23 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 23 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 23 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 23 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 23 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 23 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 23 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 23 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 23 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 23 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 23 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 23 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 23 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 23 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 23 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 23 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 25 · 36:43
clinicalSingle lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures.↗
▶Ep 25 · 36:43
clinicalSingle lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures.↗
▶Ep 25 · 39:02
clinicalFor thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox.↗
▶Ep 25 · 39:02
clinicalFor thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox.↗
▶Ep 25 · 41:39
clinicalWhen completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery.↗
▶Ep 25 · 41:39
clinicalWhen completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery.↗
▶Ep 25 · 43:09
clinicalVascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division.↗
▶Ep 25 · 43:09
quoteVascular control in these cases is everything.↗
▶Ep 25 · 43:09
quoteVascular control in these cases is everything.↗
▶Ep 25 · 43:09
clinicalVascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division.↗
▶Ep 25 · 44:13
clinicalThe bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy.↗
▶Ep 25 · 44:13
clinicalThe bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy.↗
▶Ep 25 · 46:57
clinicalWhen dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it.↗
▶Ep 25 · 46:57
clinicalWhen dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it.↗
▶Ep 25 · 48:44
clinicalDo not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control.↗
▶Ep 25 · 48:44
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 25 · 48:44
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 25 · 48:44
clinicalDo not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control.↗
Steven's statements about Congenital Pulmonary Airway Malformation210 statements
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 3 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 3 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 3 · 10:41
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 3 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 3 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 3 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 3 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 3 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 3 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 3 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 3 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 3 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 3 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 3 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 3 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 3 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 3 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 3 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 3 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 3 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 3 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 3 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012
▶Ep 6 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 6 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 6 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 7 · 3:48
clinicalSerial prenatal ultrasounds every couple of weeks are the best way to follow development of cystic lung lesions - noninvasive, quick, and adequate for monitoring.↗
▶Ep 7 · 4:11
opinionFetal MRI provides little benefit for lung lesions - doesn't change the plan or give much more definition than ultrasound.↗
▶Ep 7 · 5:43
epidemiological6-40% of prenatally diagnosed lung lesions will regress with time, and in some cases appear to completely disappear.↗
▶Ep 7 · 6:11
epidemiologicalFetal intervention for lung lesions is extremely rare - CHOP does less than one open fetal surgery every couple of years for this indication.↗
▶Ep 7 · 8:52
clinicalCongenital lung lesions represent a spectrum - often see hybrid lesions on pathology combining features of CPAM and sequestration.↗
▶Ep 7 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 7 · 14:31
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 7 · 14:44
clinicalMultiple children with prenatal diagnosis and normal postnatal chest X-ray presented later (9 months to 6-7 years) with pneumonia and infected CPAM on further evaluation.↗
▶Ep 7 · 14:44
clinicalA chest X-ray or ultrasound after birth are not adequate to ensure there is absolutely no lung lesion present.↗
▶Ep 7 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life.↗
▶Ep 7 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 7 · 16:58
epidemiologicalThe incidence of malignancy in Rothenberg's series of congenital lung lesions is over 1%, which he considers significant.↗
▶Ep 7 · 18:04
clinicalOperating by 3 months of age avoids the problem of the baby getting an infection before surgery.↗
▶Ep 7 · 18:20
clinicalSurgery is technically easier in smaller infants - with current equipment and instrumentation, smaller vessels make the surgery easier and the anatomy is fresh.↗
▶Ep 7 · 18:46
clinicalEven in asymptomatic children, by around one year of age there are significantly enlarged lymph nodes in fissures and peribronchial spaces, and sometimes inflammation in the fissure, suggesting low-grade infections.↗
▶Ep 7 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection↗
▶Ep 7 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery time, and operative time were all significantly less in patients under 5 kg compared to those under 10 kg.↗
▶Ep 7 · 19:46
clinicalMost children are discharged within 48 hours after lobectomy, and by one month post-op on chest X-ray, you cannot tell they had anything done due to compensatory lung growth.↗
▶Ep 7 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room↗
▶Ep 7 · 23:31
quoteI think that, you know, it's important to have an anesthesiologist who's comfortable doing this with you.↗
▶Ep 7 · 23:38
clinicalMost asymptomatic children on room air will tolerate single lung ventilation without problem.↗
▶Ep 7 · 26:02
clinicalAfter lung collapse, babies initially desaturate for a few minutes (low 90s to high 80s) because they're still shunting blood to the collapsed lung; saturations come up once they stop shunting to that lung.↗
▶Ep 7 · 27:41
clinicalEnd-tidal CO2 in the mid-40s during thoracoscopic surgery is not a problem and doesn't cause significant acidosis or deleterious effects.↗
▶Ep 7 · 30:02
clinicalThere is more room to work from the front of the chest towards the hilum than from the patient's back during thoracoscopic surgery.↗
▶Ep 7 · 35:01
clinicalThe 3mm vessel sealer will seal vessels at least up to 5mm in diameter.↗
▶Ep 7 · 35:15
clinicalThe technique for vessel control is to make two separate seals on the vessel at least 4-5mm apart, then cut partway between the seals - if you see lumen with no bleeding, it's safe to complete the division.↗
▶Ep 7 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything. You really want to maximize the downside.↗
▶Ep 7 · 36:22
quoteIf you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe. If you get into the lumen and you start to see some bleeding, you have the ability to compensate and recover.↗
▶Ep 7 · 37:44
opinionUsing energy devices that seal and cut simultaneously on major vessels is a huge mistake and sets you up for trouble - every device can fail at some point.↗
▶Ep 7 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble↗
▶Ep 7 · 38:30
quoteMy supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 7 · 39:04
clinicalRothenberg had one case where he used a seal-and-cut device in another country, it didn't seal properly, there was bleeding, and they had to convert to open.↗
▶Ep 7 · 43:13
clinicalWhen completing an incomplete fissure, work layer by layer like finger fracturing during liver lobectomy, gradually exposing the pulmonary artery.↗
▶Ep 7 · 44:06
clinicalIn a lower lobe, the pulmonary artery usually has a main trunk that bifurcates into four branches to the basal segments, plus a superior segmental branch that comes off higher and more posteriorly.↗
▶Ep 7 · 45:23
clinicalThe bronchus sits right underneath the pulmonary artery - you can feel it and use it to help dissect behind the artery.↗
▶Ep 7 · 48:37
clinicalWhen dissecting behind the bronchus to reach it, the pulmonary vein is right behind - must stay hard on the backside of the bronchus and be aware the vein is there.↗
▶Ep 7 · 50:33
clinicalCritical rule: do not take the pulmonary vein trunk near the pericardium - if your device fails, it will retract into the pericardium and the child will bleed to death before you can do anything. Must have enough length for proximal control.↗
▶Ep 7 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium↗
▶Ep 7 · 50:33
quoteYou cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 7 · 51:03
clinicalRight lower lobe is the exact opposite of left lower lobe - just switch hands and flip sides - but must be careful that middle lobe branches come off just above the lower lobe artery.↗
▶Ep 7 · 52:11
clinicalFor upper lobectomy, retract the lung apex inferiorly to expose the pulmonary artery as it comes into the upper lobe near the apex, then work from top down around the front and up through the fissure.↗
▶Ep 7 · 54:06
clinicalThe lingula is almost always taken with an upper lobectomy on the left; on the right, the middle lobe is usually preserved.↗
▶Ep 7 · 57:38
clinicalIf you have a lung with large cysts and limited space, use the sealing device to pop the cysts and decompress them at the beginning of the procedure - do a lung reduction to get room to work.↗
▶Ep 7 · 58:42
clinicalSystemic vessels to sequestrations can number up to 6, and Rothenberg has seen vessels as large as 15mm in diameter.↗
▶Ep 7 · 59:45
quoteDo not use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed↗
▶Ep 7 · 59:45
clinicalCritical warning: do not use sealing technology and clips on the same vessel - the sealing changes the vessel nature, causing necrosis, and clips can lose secure footing and fall off, causing delayed bleeding.↗
▶Ep 7 · 1:00:15
quoteI believe that's because as the vessel, the nature of the vessel changes, that the clip no longer has secure footing, that the the vessel sort of necrosis a bit and the clip falls off, and you can get late bleeding.↗
▶Ep 7 · 1:01:07
opinionExtra-lobar sequestrations can become infected and cause problems, which is why Rothenberg removes them all rather than watching or embolizing.↗
▶Ep 7 · 1:01:23
opinionEmbolization of sequestrations requires general anesthetic and significant arterial intervention - Rothenberg believes thoracoscopic removal has almost no morbidity with no chest tube and next-day discharge.↗
▶Ep 7 · 1:03:27
clinicalRothenberg has performed approximately 20 segmentectomies in cases where disease appeared confined to superior segment of lower lobe or lingula on CT, with good follow-up and no recurrent disease, but cannot widely recommend yet.↗
▶Ep 7 · 1:05:27
clinicalAverage length of stay for lobectomy in patients who come in the morning is about 2.5 days, and even shorter for patients under 5 kg.↗
Thoracoscopic Left Lower Lobectomy Technique by Dr. Steven Rothenberg: How I...
▶Ep 8 · 0:23
clinicalThe procedure uses 3mm sealer and 5mm stapler for thoracoscopic left lower lobectomy in an infant with CPAM↗
▶Ep 8 · 1:30
clinicalRight mainstem intubation is used to obtain left lung collapse↗
▶Ep 8 · 1:35
clinicalCamera port is placed anterior to tip of scapula in approximately 5th intercostal space in posterior axillary line↗
▶Ep 8 · 2:30
quoteIn lower lobectomies, we always look for a systemic artery, even if one is not identified on CT scan. It is not unusual for there to be a hybrid lesion of a sequestration in CPAP, and occasionally these large vessels are missed.↗
▶Ep 8 · 2:30
clinicalIn lower lobectomies, always look for systemic artery even if not identified on CT scan, as hybrid sequestration-CPAM lesions with large vessels are occasionally missed↗
▶Ep 8 · 2:45
clinicalSeal-and-tear technique eliminates need for sharp dissection when mobilizing inferior pulmonary ligament↗
▶Ep 8 · 2:45
quoteThe sealing and tearing technique works quite well in where the tissues are this thin.↗
▶Ep 8 · 4:00
clinicalChanging camera angle 30 degrees gives better orientation during fissure dissection↗
▶Ep 8 · 5:00
clinicalIn incomplete fissures, lung parenchyma is gone through layer at a time to expose pulmonary artery↗
▶Ep 8 · 7:00
clinicalSuperior segmental artery usually comes off separately from basal trunk and is best isolated alone↗
▶Ep 8 · 8:00
clinicalChar buildup on sealer should be intermittently removed and cleaned by scrub nurse↗
▶Ep 8 · 10:00
clinicalDouble-seal technique: make two separate seals 3-4mm apart (one proximal, one distal) and cut between them to ensure no bleeding or leak↗
▶Ep 8 · 10:30
quoteWe use this approach in case the seal is not complete or there is some other issue. By making two separate seals and only partially dividing the vessel, we can ensure that there is no bleeding or leak.↗
▶Ep 8 · 11:00
clinicalBy making two seals and only partially dividing vessel, control is maintained if bleeding occurs before vessel ends separate and retract↗
▶Ep 8 · 11:00
quoteIf we were to encounter any bleeding by using this method, we still have control of the vessel before the two ends separate and retract.↗
▶Ep 8 · 13:30
quoteOne of the reasons for performing these procedures earlier rather than later, I believe, is that even in asymptomatic patients, we often see these enlarged inflamed lymph nodes because of chronic inflammation secondary to the CPA.↗
▶Ep 8 · 13:30
clinicalEven in asymptomatic CPAM patients, enlarged inflamed lymph nodes are often seen due to chronic inflammation↗
▶Ep 8 · 13:45
clinicalIn asymptomatic patients one year of age, it is not unusual to have fissure obliterated by inflammation and enlarged lymph nodes↗
▶Ep 8 · 13:48
quoteIt is not unusual in a patient one year of age to have the fissure obliterated by inflammation and enlarged lymph nodes, even though the patient has been completely asymptomatic.↗
▶Ep 8 · 14:30
clinicalBronchus can be used as tactile landmark to help dissect out pulmonary artery due to segmental anatomy of lung↗
▶Ep 8 · 15:15
clinicalTaking superior segmental artery first before main trunk gives more length on main trunk for safe ligation and division↗
▶Ep 8 · 16:15
clinicalStapler is compressed and held for count of 10 seconds to allow staples to completely form↗
▶Ep 8 · 17:00
clinicalIn thoracoscopic approach, it is often easier to take bronchus first, which leaves pulmonary vein well exposed, unlike open surgery sequence of artery-vein-bronchus↗
▶Ep 8 · 17:00
quoteIn open surgery, we often took the pulmonary artery and then the pulmonary vein, uh, and then the bronchus. But I find, uh, because of the thoracoscopic approach, it is often easier to take the bronchuss first.↗
▶Ep 8 · 17:30
clinicalIn children over 2-3 months of age, separating superior segmental bronchus from basal bronchi is preferable due to bronchus size to ensure adequate division and seal with stapler↗
▶Ep 8 · 17:45
clinicalBronchus is compressed before stapler insertion to ensure adequate fit and aid in staple formation↗
▶Ep 8 · 17:55
clinical5mm stapler works well in children under 10kg; in larger children bronchi may be too large and surgeon must evaluate case by case↗
▶Ep 8 · 18:00
clinicalThis minimally edited procedure took 45 minutes in real time↗
▶Ep 8 · 18:05
clinicalPatient had chest tube removed on first postoperative day and was discharged that evening↗
▶Ep 8 · 18:15
clinicalSealer works extremely well on lung tissue for completing incomplete fissures and performing segmental resections with no problems with bleeding or air leak↗
clinicalWhen taking pulmonary vein trunk, staple line must be well away from base of vein and pericardium (at least 2cm), with ability to grasp trunk proximal to stapler in case of leak↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 20 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 20 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 20 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 20 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 20 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 20 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 20 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 20 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 20 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 20 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 20 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 20 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 20 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 20 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 20 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 20 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 20 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 20 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 20 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 20 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 20 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 20 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 20 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 20 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 20 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 20 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 20 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 20 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 20 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 20 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 20 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 20 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 20 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 20 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 20 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 20 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 20 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 20 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 20 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 20 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 20 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 20 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 20 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 20 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 20 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 20 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 20 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 20 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 20 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 20 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 20 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 20 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 20 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 20 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 20 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 20 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 20 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 20 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 20 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 20 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 20 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 20 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 20 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 20 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 20 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 20 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 20 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 20 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 20 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 20 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 20 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 20 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 20 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 20 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 20 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 20 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 20 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 20 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 20 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 20 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 20 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 20 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 20 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 20 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 20 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 20 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 20 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 20 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 20 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 20 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 21 · 36:43
clinicalSingle lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures.↗
▶Ep 21 · 39:02
clinicalFor thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox.↗
▶Ep 21 · 41:39
clinicalWhen completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery.↗
▶Ep 21 · 43:09
quoteVascular control in these cases is everything.↗
▶Ep 21 · 43:09
clinicalVascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division.↗
▶Ep 21 · 44:13
clinicalThe bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy.↗
▶Ep 21 · 46:57
clinicalWhen dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it.↗
▶Ep 21 · 48:44
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 21 · 48:44
clinicalDo not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control.↗
Steven's statements about Congenital Pulmonary Airway Malformation210 statements
opinionFetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids.↗
▶Ep 3 · 1:16
quoteI find that more and more are being, being obtained, but they really don't change what I do at all.↗
▶Ep 3 · 9:44
epidemiologicalApproximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management.↗
quoteThere's no question, and we've actually published a side study now that shows the operative time is less, the complication rate is less when you do these patients earlier.↗
▶Ep 3 · 10:41
clinicalOperative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data.↗
▶Ep 3 · 10:51
clinicalAsymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery.↗
▶Ep 3 · 10:55
quoteThe difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes is significant and can make the procedure significantly more difficult.↗
▶Ep 3 · 13:55
quoteI will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult.↗
▶Ep 3 · 14:40
clinicalA 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery.↗
▶Ep 3 · 15:02
clinicalEven in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult.↗
▶Ep 3 · 15:12
quoteYou will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with.↗
▶Ep 3 · 16:01
clinicalAt 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor.↗
▶Ep 3 · 18:55
clinicalAnatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease.↗
▶Ep 3 · 19:08
clinicalOne child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up.↗
▶Ep 3 · 20:36
epidemiologicalIn a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma.↗
▶Ep 3 · 20:50
clinicalNeoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer.↗
▶Ep 3 · 21:02
clinicalColumbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature.↗
▶Ep 3 · 21:17
epidemiological30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 3 · 21:32
clinicalOnce congenital cystic lung lesions become infected, they are much more difficult to resect surgically.↗
▶Ep 3 · 21:35
opinionAll thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity.↗
▶Ep 3 · 21:35
quoteI think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy.↗
▶Ep 3 · 21:51
opinionLong-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability.↗
▶Ep 3 · 23:06
clinicalMorsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance.↗
▶Ep 3 · 24:27
epidemiologicalAll three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age.↗
Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012
▶Ep 6 · 11:24
opinionFor a superior-segment lower-lobe CPAM, the morbidity of segmentectomy is extremely low.↗
▶Ep 6 · 35:52
quoteI don't like talc. I think you're doing a random massive chemical pleurodesis and you don't know if anybody's ever going to need to be in their chest again.↗
▶Ep 6 · 36:03
clinicalPerforming apical pleurectomy limited to the third interspace avoids whole-chest adhesions, unlike talc pleurodesis.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 7 · 3:48
clinicalSerial prenatal ultrasounds every couple of weeks are the best way to follow development of cystic lung lesions - noninvasive, quick, and adequate for monitoring.↗
▶Ep 7 · 4:11
opinionFetal MRI provides little benefit for lung lesions - doesn't change the plan or give much more definition than ultrasound.↗
▶Ep 7 · 5:43
epidemiological6-40% of prenatally diagnosed lung lesions will regress with time, and in some cases appear to completely disappear.↗
▶Ep 7 · 6:11
epidemiologicalFetal intervention for lung lesions is extremely rare - CHOP does less than one open fetal surgery every couple of years for this indication.↗
▶Ep 7 · 8:52
clinicalCongenital lung lesions represent a spectrum - often see hybrid lesions on pathology combining features of CPAM and sequestration.↗
▶Ep 7 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 7 · 14:31
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 7 · 14:44
clinicalA chest X-ray or ultrasound after birth are not adequate to ensure there is absolutely no lung lesion present.↗
▶Ep 7 · 14:44
clinicalMultiple children with prenatal diagnosis and normal postnatal chest X-ray presented later (9 months to 6-7 years) with pneumonia and infected CPAM on further evaluation.↗
▶Ep 7 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life.↗
▶Ep 7 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 7 · 16:58
epidemiologicalThe incidence of malignancy in Rothenberg's series of congenital lung lesions is over 1%, which he considers significant.↗
▶Ep 7 · 18:04
clinicalOperating by 3 months of age avoids the problem of the baby getting an infection before surgery.↗
▶Ep 7 · 18:20
clinicalSurgery is technically easier in smaller infants - with current equipment and instrumentation, smaller vessels make the surgery easier and the anatomy is fresh.↗
▶Ep 7 · 18:46
clinicalEven in asymptomatic children, by around one year of age there are significantly enlarged lymph nodes in fissures and peribronchial spaces, and sometimes inflammation in the fissure, suggesting low-grade infections.↗
▶Ep 7 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection↗
▶Ep 7 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery time, and operative time were all significantly less in patients under 5 kg compared to those under 10 kg.↗
▶Ep 7 · 19:46
clinicalMost children are discharged within 48 hours after lobectomy, and by one month post-op on chest X-ray, you cannot tell they had anything done due to compensatory lung growth.↗
▶Ep 7 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room↗
▶Ep 7 · 23:31
quoteI think that, you know, it's important to have an anesthesiologist who's comfortable doing this with you.↗
▶Ep 7 · 23:38
clinicalMost asymptomatic children on room air will tolerate single lung ventilation without problem.↗
▶Ep 7 · 26:02
clinicalAfter lung collapse, babies initially desaturate for a few minutes (low 90s to high 80s) because they're still shunting blood to the collapsed lung; saturations come up once they stop shunting to that lung.↗
▶Ep 7 · 27:41
clinicalEnd-tidal CO2 in the mid-40s during thoracoscopic surgery is not a problem and doesn't cause significant acidosis or deleterious effects.↗
▶Ep 7 · 30:02
clinicalThere is more room to work from the front of the chest towards the hilum than from the patient's back during thoracoscopic surgery.↗
▶Ep 7 · 35:01
clinicalThe 3mm vessel sealer will seal vessels at least up to 5mm in diameter.↗
▶Ep 7 · 35:15
clinicalThe technique for vessel control is to make two separate seals on the vessel at least 4-5mm apart, then cut partway between the seals - if you see lumen with no bleeding, it's safe to complete the division.↗
▶Ep 7 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything. You really want to maximize the downside.↗
▶Ep 7 · 36:22
quoteIf you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe. If you get into the lumen and you start to see some bleeding, you have the ability to compensate and recover.↗
▶Ep 7 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble↗
▶Ep 7 · 37:44
opinionUsing energy devices that seal and cut simultaneously on major vessels is a huge mistake and sets you up for trouble - every device can fail at some point.↗
▶Ep 7 · 38:30
quoteMy supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 7 · 39:04
clinicalRothenberg had one case where he used a seal-and-cut device in another country, it didn't seal properly, there was bleeding, and they had to convert to open.↗
▶Ep 7 · 43:13
clinicalWhen completing an incomplete fissure, work layer by layer like finger fracturing during liver lobectomy, gradually exposing the pulmonary artery.↗
▶Ep 7 · 44:06
clinicalIn a lower lobe, the pulmonary artery usually has a main trunk that bifurcates into four branches to the basal segments, plus a superior segmental branch that comes off higher and more posteriorly.↗
▶Ep 7 · 45:23
clinicalThe bronchus sits right underneath the pulmonary artery - you can feel it and use it to help dissect behind the artery.↗
▶Ep 7 · 48:37
clinicalWhen dissecting behind the bronchus to reach it, the pulmonary vein is right behind - must stay hard on the backside of the bronchus and be aware the vein is there.↗
▶Ep 7 · 50:33
clinicalCritical rule: do not take the pulmonary vein trunk near the pericardium - if your device fails, it will retract into the pericardium and the child will bleed to death before you can do anything. Must have enough length for proximal control.↗
▶Ep 7 · 50:33
quoteYou cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 7 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium↗
▶Ep 7 · 51:03
clinicalRight lower lobe is the exact opposite of left lower lobe - just switch hands and flip sides - but must be careful that middle lobe branches come off just above the lower lobe artery.↗
▶Ep 7 · 52:11
clinicalFor upper lobectomy, retract the lung apex inferiorly to expose the pulmonary artery as it comes into the upper lobe near the apex, then work from top down around the front and up through the fissure.↗
▶Ep 7 · 54:06
clinicalThe lingula is almost always taken with an upper lobectomy on the left; on the right, the middle lobe is usually preserved.↗
▶Ep 7 · 57:38
clinicalIf you have a lung with large cysts and limited space, use the sealing device to pop the cysts and decompress them at the beginning of the procedure - do a lung reduction to get room to work.↗
▶Ep 7 · 58:42
clinicalSystemic vessels to sequestrations can number up to 6, and Rothenberg has seen vessels as large as 15mm in diameter.↗
▶Ep 7 · 59:45
clinicalCritical warning: do not use sealing technology and clips on the same vessel - the sealing changes the vessel nature, causing necrosis, and clips can lose secure footing and fall off, causing delayed bleeding.↗
▶Ep 7 · 59:45
quoteDo not use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed↗
▶Ep 7 · 1:00:15
quoteI believe that's because as the vessel, the nature of the vessel changes, that the clip no longer has secure footing, that the the vessel sort of necrosis a bit and the clip falls off, and you can get late bleeding.↗
▶Ep 7 · 1:01:07
opinionExtra-lobar sequestrations can become infected and cause problems, which is why Rothenberg removes them all rather than watching or embolizing.↗
▶Ep 7 · 1:01:23
opinionEmbolization of sequestrations requires general anesthetic and significant arterial intervention - Rothenberg believes thoracoscopic removal has almost no morbidity with no chest tube and next-day discharge.↗
▶Ep 7 · 1:03:27
clinicalRothenberg has performed approximately 20 segmentectomies in cases where disease appeared confined to superior segment of lower lobe or lingula on CT, with good follow-up and no recurrent disease, but cannot widely recommend yet.↗
▶Ep 7 · 1:05:27
clinicalAverage length of stay for lobectomy in patients who come in the morning is about 2.5 days, and even shorter for patients under 5 kg.↗
Thoracoscopic Left Lower Lobectomy Technique by Dr. Steven Rothenberg: How I...
▶Ep 8 · 0:23
clinicalThe procedure uses 3mm sealer and 5mm stapler for thoracoscopic left lower lobectomy in an infant with CPAM↗
▶Ep 8 · 1:30
clinicalRight mainstem intubation is used to obtain left lung collapse↗
▶Ep 8 · 1:35
clinicalCamera port is placed anterior to tip of scapula in approximately 5th intercostal space in posterior axillary line↗
▶Ep 8 · 2:30
clinicalIn lower lobectomies, always look for systemic artery even if not identified on CT scan, as hybrid sequestration-CPAM lesions with large vessels are occasionally missed↗
▶Ep 8 · 2:30
quoteIn lower lobectomies, we always look for a systemic artery, even if one is not identified on CT scan. It is not unusual for there to be a hybrid lesion of a sequestration in CPAP, and occasionally these large vessels are missed.↗
▶Ep 8 · 2:45
quoteThe sealing and tearing technique works quite well in where the tissues are this thin.↗
▶Ep 8 · 2:45
clinicalSeal-and-tear technique eliminates need for sharp dissection when mobilizing inferior pulmonary ligament↗
▶Ep 8 · 4:00
clinicalChanging camera angle 30 degrees gives better orientation during fissure dissection↗
▶Ep 8 · 5:00
clinicalIn incomplete fissures, lung parenchyma is gone through layer at a time to expose pulmonary artery↗
▶Ep 8 · 7:00
clinicalSuperior segmental artery usually comes off separately from basal trunk and is best isolated alone↗
▶Ep 8 · 8:00
clinicalChar buildup on sealer should be intermittently removed and cleaned by scrub nurse↗
▶Ep 8 · 10:00
clinicalDouble-seal technique: make two separate seals 3-4mm apart (one proximal, one distal) and cut between them to ensure no bleeding or leak↗
▶Ep 8 · 10:30
quoteWe use this approach in case the seal is not complete or there is some other issue. By making two separate seals and only partially dividing the vessel, we can ensure that there is no bleeding or leak.↗
▶Ep 8 · 11:00
quoteIf we were to encounter any bleeding by using this method, we still have control of the vessel before the two ends separate and retract.↗
▶Ep 8 · 11:00
clinicalBy making two seals and only partially dividing vessel, control is maintained if bleeding occurs before vessel ends separate and retract↗
▶Ep 8 · 13:30
clinicalEven in asymptomatic CPAM patients, enlarged inflamed lymph nodes are often seen due to chronic inflammation↗
▶Ep 8 · 13:30
quoteOne of the reasons for performing these procedures earlier rather than later, I believe, is that even in asymptomatic patients, we often see these enlarged inflamed lymph nodes because of chronic inflammation secondary to the CPA.↗
▶Ep 8 · 13:45
clinicalIn asymptomatic patients one year of age, it is not unusual to have fissure obliterated by inflammation and enlarged lymph nodes↗
▶Ep 8 · 13:48
quoteIt is not unusual in a patient one year of age to have the fissure obliterated by inflammation and enlarged lymph nodes, even though the patient has been completely asymptomatic.↗
▶Ep 8 · 14:30
clinicalBronchus can be used as tactile landmark to help dissect out pulmonary artery due to segmental anatomy of lung↗
▶Ep 8 · 15:15
clinicalTaking superior segmental artery first before main trunk gives more length on main trunk for safe ligation and division↗
▶Ep 8 · 16:15
clinicalStapler is compressed and held for count of 10 seconds to allow staples to completely form↗
▶Ep 8 · 17:00
clinicalIn thoracoscopic approach, it is often easier to take bronchus first, which leaves pulmonary vein well exposed, unlike open surgery sequence of artery-vein-bronchus↗
▶Ep 8 · 17:00
quoteIn open surgery, we often took the pulmonary artery and then the pulmonary vein, uh, and then the bronchus. But I find, uh, because of the thoracoscopic approach, it is often easier to take the bronchuss first.↗
▶Ep 8 · 17:30
clinicalIn children over 2-3 months of age, separating superior segmental bronchus from basal bronchi is preferable due to bronchus size to ensure adequate division and seal with stapler↗
▶Ep 8 · 17:45
clinicalBronchus is compressed before stapler insertion to ensure adequate fit and aid in staple formation↗
▶Ep 8 · 17:55
clinical5mm stapler works well in children under 10kg; in larger children bronchi may be too large and surgeon must evaluate case by case↗
▶Ep 8 · 18:00
clinicalThis minimally edited procedure took 45 minutes in real time↗
▶Ep 8 · 18:05
clinicalPatient had chest tube removed on first postoperative day and was discharged that evening↗
clinicalSealer works extremely well on lung tissue for completing incomplete fissures and performing segmental resections with no problems with bleeding or air leak↗
▶Ep 8 · 18:35
clinicalWhen taking pulmonary vein trunk, staple line must be well away from base of vein and pericardium (at least 2cm), with ability to grasp trunk proximal to stapler in case of leak↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 20 · 3:48
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 20 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 20 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 20 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 20 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 20 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 20 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 20 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 20 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 20 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 20 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 20 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 20 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 20 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 20 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 20 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 20 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 20 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 20 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 20 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 20 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 20 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 20 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 20 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 20 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 20 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 20 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 20 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 20 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 20 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 20 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 20 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 20 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 20 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 20 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 20 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 20 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 20 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 20 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 20 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 20 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 20 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 20 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 20 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 20 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 20 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 20 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 20 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 20 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 20 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 20 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 20 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 20 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 20 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 20 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 20 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 20 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 20 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 20 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 20 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 20 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 20 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 20 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 20 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 20 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 20 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 20 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 20 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 20 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 20 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 20 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 20 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 20 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 20 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 20 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 20 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 20 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 20 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 20 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 20 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 20 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 20 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 20 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 20 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 20 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 20 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 20 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 20 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 20 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 20 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 21 · 36:43
clinicalSingle lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures.↗
▶Ep 21 · 39:02
clinicalFor thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox.↗
▶Ep 21 · 41:39
clinicalWhen completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery.↗
▶Ep 21 · 43:09
quoteVascular control in these cases is everything.↗
▶Ep 21 · 43:09
clinicalVascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division.↗
▶Ep 21 · 44:13
clinicalThe bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy.↗
▶Ep 21 · 46:57
clinicalWhen dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it.↗
▶Ep 21 · 48:44
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 21 · 48:44
clinicalDo not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control.↗
Steven's statements about CPAM (congenital Pulmonary Airway Malformation)99 statements
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 3 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 3 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 3 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 3 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 3 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 3 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 3 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 3 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 3 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 3 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 3 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 3 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 3 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 3 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 3 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 3 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 3 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 3 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 3 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 3 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 3 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 3 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 3 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 3 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 3 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 3 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 3 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 3 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 3 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 3 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 3 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 3 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 3 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 3 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 3 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 3 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 3 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 3 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 3 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 3 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 3 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 3 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 3 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 3 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 3 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 3 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 3 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 3 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 3 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 3 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 3 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 3 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 3 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 3 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 3 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 3 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 3 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 3 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 3 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 3 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 3 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 3 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 3 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 3 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 3 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 3 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 3 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 3 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 3 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 3 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 3 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 3 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 3 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 3 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 3 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 3 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 3 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 3 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 3 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 3 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 3 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 3 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 3 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 3 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 3 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 3 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 3 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 3 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 3 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 4 · 36:43
clinicalSingle lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures.↗
▶Ep 4 · 39:02
clinicalFor thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox.↗
▶Ep 4 · 41:39
clinicalWhen completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery.↗
▶Ep 4 · 43:09
quoteVascular control in these cases is everything.↗
▶Ep 4 · 43:09
clinicalVascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division.↗
▶Ep 4 · 44:13
clinicalThe bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy.↗
▶Ep 4 · 46:57
clinicalWhen dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it.↗
▶Ep 4 · 48:44
clinicalDo not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control.↗
▶Ep 4 · 48:44
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
Steven's statements about Esophageal Atresia50 statements
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 3 · 1:31
quoteThere's a huge difference between esophageal resia and TEF, and every resident calls it TEF when they mean esophageal tree. So please, that's precision is got↗
▶Ep 3 · 12:35
quoteI think the big thing here is that we're eliminating the thoracotomy, and I think that is the primary reason for doing this.↗
▶Ep 3 · 12:40
opinionThe primary reason for doing thoracoscopic TEF repair is eliminating the thoracotomy and its associated morbidity.↗
▶Ep 3 · 12:55
opinionNo matter what kind of thoracotomy is performed, there is morbidity associated with having a thoracotomy as an infant.↗
▶Ep 3 · 12:55
quoteno matter what kind of thoracotomy you do, and, and I was a pioneer of the muscle sparing thoracotomy. I wrote the first paper on it in pediatrics, there is morbidity associated with having a thoracotomy as an infant↗
▶Ep 3 · 13:15
quoteif we can avoid that incision and end up with an equivalent operation. Then I think as pediatric surgeons who are looking for the long term care of our children not only as postoperatively but for the rest of their lives, we need to be committed to that↗
▶Ep 3 · 13:40
quoteI personally think you can see the operation better. I mean, I, I think you know watching this operation on a big magnified high definition screen. You can see things better than you can see when we're all trying to look through small incisions with loops and all of that↗
▶Ep 3 · 14:00
quoteI am shocked that 45% of the audience does this operation thoracoscopically.↗
▶Ep 3 · 16:33
opinionThoracoscopic TEF repair requires surgeons who are skilled in MIS to perform it and pass that skill on to trainees.↗
▶Ep 3 · 16:35
quoteIt requires people who are skilled to do this and then pass that on to the trainees. It takes a while for those trainees who get that experience to then come back around and actually teach the faculty wherever they go how to do it.↗
▶Ep 3 · 17:45
quoteyou actually have less of a diverticulum thoracoscopically than you do open because you get, I'll show it, you, you get a perpendicular view. And so you, because I've had to resect a number of diverticulums and they were all done open. I've never had to resect the diverticulum thoracoscopically.↗
▶Ep 3 · 17:50
clinicalRothenberg reports he has never had to resect a diverticulum after thoracoscopic TEF repair, whereas he has had to resect a number of diverticulums that were all done open.↗
▶Ep 3 · 18:10
clinicalThoracoscopically, the fistula is seen coming in directly at 90 degrees perpendicular, which is not seen when the operation is done open.↗
Update Course Rewind: Magnet Therapy for Esophageal Atresia
▶Ep 27 · 4:44
quoteI'm not convinced that there's not a role for magnets in this, but I thought it important to people be aware of some of the issues.↗
▶Ep 27 · 4:59
clinicalOne contraindication for using the Flourish device is the presence of a fistula.↗
▶Ep 27 · 6:06
clinicalDr. Rothenberg ligates all upper pouch fistulas and H-type fistulas thoracoscopically because the view is excellent and provides good control.↗
▶Ep 27 · 6:54
quoteI would argue that a patient who's got less than a 4 centimeter gap should be amenable to a primary anastomosis, and we would of course do it thoracoscopically.↗
▶Ep 27 · 6:54
clinicalThe indications for the magnet require a gap of less than 4 centimeters, and there is an incredibly high stricture rate with multiple strictures.↗
▶Ep 27 · 6:54
opinionA patient with less than a 4 centimeter gap should be amenable to a primary anastomosis, which Dr. Rothenberg would do thoracoscopically.↗
▶Ep 27 · 6:54
guidelineBy classification of the International Esophageal Atresia Group, a gap must be at least 4 centimeters to be considered a long gap.↗
Update Course 2021: MAGNET THERAPY FOR ESOPHAGEAL ATRESIA
▶Ep 30 · 10:00
clinicalIn the presented case, a full-term male with pure EA had gap study at 3 months showing 2.6 cm gap, and Flourish device was placed.↗
▶Ep 30 · 11:20
clinicalThe patient was heavily sedated for 12 days during magnet treatment.↗
▶Ep 30 · 11:40
clinicalFour days after esophageal ends came together, patient had acute decompensation and was transferred to another hospital where large fistula between esophagus and left main stem bronchus was identified.↗
▶Ep 30 · 12:20
clinicalAt emergency surgery, the surgeon found severe inflammation, divided the fistula, and divided the esophagus again, resulting in a 5 cm gap.↗
▶Ep 30 · 14:10
clinicalSubsequent workup revealed an upper pouch fistula that had not been previously diagnosed, which is a contraindication to using the Flourish device.↗
▶Ep 30 · 16:50
quotethis child had a gap at one point of two and a half centimeters that I think any any certainly anybody on the panel, whether you did it scopically or open could have fixed.↗
▶Ep 30 · 17:20
guidelineBy International group classification, a gap of 4 centimeters or more is required to be considered long gap esophageal atresia.↗
▶Ep 30 · 17:35
quoteI have some concerns. I'm not completely against magnets, but I would argue that a patient who's got less than a 4 centimeter gap uh should be amenable to a primary anastomosis and we would of course do it scopically as I think most of the people on the panel would uh with maybe a 20% stricture rate.↗
▶Ep 30 · 17:35
opinionDr. Rothenberg's opinion: a patient with less than 4 cm gap should be amenable to primary anastomosis, which he would do thoracoscopically with maybe 20% stricture rate.↗
▶Ep 30 · 18:10
quotethis device had not been available, this patient would have been transferred to a center that could have treated it and you know, and and had all the modalities. So I'm concerned more around the ethics of the device and and how it's being applied than necessarily using the device↗
▶Ep 30 · 21:28
clinicalDr. Rothenberg describes potential magnet candidate: 23-week premature infant, 340 grams at birth, pure atresia, who decompensates for two weeks after each thoracoscopic attempt to approximate ends.↗
▶Ep 30 · 22:20
opinionDr. Rothenberg's opinion: if a surgeon cannot sew together a 2-3 cm gap, the patient should be sent to a center that can, as that is the best outcome for the child.↗
▶Ep 30 · 22:38
quoteI do think that that I'm concerned that I don't even know how a device like this could end up in the hands of the people who it ended up in↗
▶Ep 30 · 23:00
quoteIt's not a license for people who say, well, you know, I'm not comfortable doing the operation but if I can put in magnets, I can do that and we can just keep the baby here. I think that's doing those kids a disservice.↗
Ladd Medal Award Presentation Honoring Dr. Steven Rothenberg's Pioneering Minimally Invasive Pediatric Surgery
▶Ep 73 · 10:00
quoteIt's better to be lucky than good, even better if you can be a bit of both, and take advantage of unexpected opportunities.↗
▶Ep 73 · 11:40
clinicalDuring thoracic fellowship in Liverpool, Rothenberg developed muscle-sparing thoracotomy technique and observed improved recovery in patients who received bilateral procedures with this approach compared to traditional thoracotomy.↗
▶Ep 73 · 15:00
clinicalRothenberg performed the first laparoscopic Nissen fundoplication at Texas Children's Hospital in 1990.↗
▶Ep 73 · 15:50
clinicalRothenberg collaborated on one of the first successful gene therapy projects, performing 80% hepatectomy in factor VIII deficient dogs using only eye cautery, which cured factor VIII deficiency and was published in Science.↗
▶Ep 73 · 20:50
clinicalRothenberg pioneered thoracoscopic lung biopsies in children with interstitial lung disease, changing care by making tissue diagnosis accessible when previously the morbidity of open biopsy prevented diagnosis.↗
▶Ep 73 · 25:00
clinicalRothenberg performed the first thoracoscopic TEF repair in Berlin in 1999 during the IPEG meeting, operating live in front of 100 people on a patient with pure esophageal atresia whose ends had been brought together by metal bougie dilation.↗
▶Ep 73 · 27:30
clinicalAlmost a year after the Berlin case, Rothenberg performed the first thoracoscopic type C esophageal atresia repair in a healthy large baby (Connor) who is now a chemist.↗
clinicalRothenberg's initial thoracoscopic TEF series of approximately 15 cases was rejected by ABSA but published in JPS through Jay Grosfeld's support.↗
▶Ep 73 · 29:10
clinicalRothenberg presented a series of 220 consecutive thoracoscopic TEF repairs, after which the nature of audience questions shifted from critiquing the technique to asking why more surgeons were not adopting it.↗
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 2 · 1:31
quoteThere's a huge difference between esophageal resia and TEF, and every resident calls it TEF when they mean esophageal tree. So please, that's precision is got↗
▶Ep 2 · 12:35
quoteI think the big thing here is that we're eliminating the thoracotomy, and I think that is the primary reason for doing this.↗
▶Ep 2 · 12:40
opinionThe primary reason for doing thoracoscopic TEF repair is eliminating the thoracotomy and its associated morbidity.↗
▶Ep 2 · 12:55
quoteno matter what kind of thoracotomy you do, and, and I was a pioneer of the muscle sparing thoracotomy. I wrote the first paper on it in pediatrics, there is morbidity associated with having a thoracotomy as an infant↗
▶Ep 2 · 12:55
opinionNo matter what kind of thoracotomy is performed, there is morbidity associated with having a thoracotomy as an infant.↗
▶Ep 2 · 13:15
quoteif we can avoid that incision and end up with an equivalent operation. Then I think as pediatric surgeons who are looking for the long term care of our children not only as postoperatively but for the rest of their lives, we need to be committed to that↗
▶Ep 2 · 13:40
quoteI personally think you can see the operation better. I mean, I, I think you know watching this operation on a big magnified high definition screen. You can see things better than you can see when we're all trying to look through small incisions with loops and all of that↗
▶Ep 2 · 14:00
quoteI am shocked that 45% of the audience does this operation thoracoscopically.↗
▶Ep 2 · 16:33
opinionThoracoscopic TEF repair requires surgeons who are skilled in MIS to perform it and pass that skill on to trainees.↗
▶Ep 2 · 16:35
quoteIt requires people who are skilled to do this and then pass that on to the trainees. It takes a while for those trainees who get that experience to then come back around and actually teach the faculty wherever they go how to do it.↗
▶Ep 2 · 17:45
quoteyou actually have less of a diverticulum thoracoscopically than you do open because you get, I'll show it, you, you get a perpendicular view. And so you, because I've had to resect a number of diverticulums and they were all done open. I've never had to resect the diverticulum thoracoscopically.↗
▶Ep 2 · 17:50
clinicalRothenberg reports he has never had to resect a diverticulum after thoracoscopic TEF repair, whereas he has had to resect a number of diverticulums that were all done open.↗
▶Ep 2 · 18:10
clinicalThoracoscopically, the fistula is seen coming in directly at 90 degrees perpendicular, which is not seen when the operation is done open.↗
Steven's statements about Esophageal Atresia7 statements
Update Course Rewind: Magnet Therapy for Esophageal Atresia
▶Ep 4 · 4:44
quoteI'm not convinced that there's not a role for magnets in this, but I thought it important to people be aware of some of the issues.↗
▶Ep 4 · 4:59
clinicalOne contraindication for using the Flourish device is the presence of a fistula.↗
▶Ep 4 · 6:06
clinicalDr. Rothenberg ligates all upper pouch fistulas and H-type fistulas thoracoscopically because the view is excellent and provides good control.↗
▶Ep 4 · 6:54
opinionA patient with less than a 4 centimeter gap should be amenable to a primary anastomosis, which Dr. Rothenberg would do thoracoscopically.↗
▶Ep 4 · 6:54
clinicalThe indications for the magnet require a gap of less than 4 centimeters, and there is an incredibly high stricture rate with multiple strictures.↗
▶Ep 4 · 6:54
guidelineBy classification of the International Esophageal Atresia Group, a gap must be at least 4 centimeters to be considered a long gap.↗
▶Ep 4 · 6:54
quoteI would argue that a patient who's got less than a 4 centimeter gap should be amenable to a primary anastomosis, and we would of course do it thoracoscopically.↗
Steven's statements about Fetal Surgery99 statements
clinicalSerial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.↗
▶Ep 14 · 4:11
opinionFetal MRI for lung lesions provides little additional benefit and does not change the management plan.↗
▶Ep 14 · 5:43
epidemiologicalAnywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.↗
▶Ep 14 · 6:11
epidemiologicalFetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.↗
▶Ep 14 · 6:31
clinicalFetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.↗
▶Ep 14 · 7:13
clinicalSteroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.↗
▶Ep 14 · 7:54
clinicalA cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.↗
▶Ep 14 · 8:52
clinicalCongenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.↗
▶Ep 14 · 9:37
clinicalSequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.↗
▶Ep 14 · 11:43
clinicalIf a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.↗
▶Ep 14 · 12:37
quoteI think it can be a mistake. A lot of people say, Well, if you get a chest X-ray and it doesn't show anything, don't worry about it, especially if it looked like the lesion was regressing on, on prenatal ultrasound. But, but I don't think that's right.↗
▶Ep 14 · 12:39
clinicalA chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.↗
▶Ep 14 · 12:51
quoteSome of these lesions do regress and go completely away, but I think you need to prove it, and a chest X-ray is not an adequate way to evaluate that.↗
▶Ep 14 · 14:29
quoteI have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.↗
▶Ep 14 · 14:44
clinicalSome children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.↗
▶Ep 14 · 15:47
epidemiologicalDepending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.↗
▶Ep 14 · 15:47
quoteI feel that the morbidity of these lesions goes up significantly if they're not treated early in life. Depending on the series you read, 20-40% of these will get a significant infection at some point. Um, and then there's always the consideration of malignancy.↗
▶Ep 14 · 16:56
epidemiologicalThe incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.↗
▶Ep 14 · 16:58
quoteThe incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant.↗
▶Ep 14 · 17:49
opinionRothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.↗
▶Ep 14 · 17:59
quoteI like to do these by 3 months of age, and, and there's a number of reasons. Um, one is, is I think you avoid, um, Running into the problem where the baby gets an infection before you operate, so you avoid that pneumonia or severe respiratory infection. 2, honestly, I think the surgery is technically easier.↗
▶Ep 14 · 18:46
quoteI often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection.↗
▶Ep 14 · 18:46
clinicalEven in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.↗
▶Ep 14 · 19:19
clinicalIn Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.↗
▶Ep 14 · 19:37
quoteThe hospital stay, the chest tube duration, and the recovery was actually and the operative time was much less in the smaller patients.↗
▶Ep 14 · 19:46
clinicalMost infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.↗
▶Ep 14 · 21:13
clinicalThe key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.↗
▶Ep 14 · 21:13
quoteThe key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room.↗
▶Ep 14 · 22:36
clinicalBlood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.↗
▶Ep 14 · 22:44
quoteI do think, you know, if you do get into bleeding, it can be significant, um, and you want to have blood available.↗
▶Ep 14 · 23:38
quoteMost kids, especially those kids who are asymptomatic and are on room air, will tolerate single lung ventilation without problem.↗
▶Ep 14 · 23:38
clinicalMost asymptomatic children on room air tolerate single-lung ventilation without problem.↗
▶Ep 14 · 24:06
clinicalSingle-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.↗
▶Ep 14 · 26:02
clinicalAfter lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.↗
▶Ep 14 · 26:02
quoteOnce you collapse the lung, they're going to desaturate for a few minutes. Sometimes it's just the low 90s, sometimes it's in the high 80s, because they're still shunting blood to that collapsed lung, and it's not being oxygenated. Once they quit shunting, once they quit pumping blood to that lung and are pumping just to the contralateral lung. Uh, the SATs tend to come up.↗
▶Ep 14 · 26:36
clinicalAnesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.↗
▶Ep 14 · 27:41
clinicalEnd-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.↗
▶Ep 14 · 28:59
clinicalThe surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.↗
▶Ep 14 · 30:39
clinicalThe camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.↗
▶Ep 14 · 32:28
clinicalA fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.↗
▶Ep 14 · 33:01
clinicalRothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.↗
▶Ep 14 · 33:56
clinicalLow-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.↗
▶Ep 14 · 35:01
clinicalA 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.↗
▶Ep 14 · 35:15
clinicalThe dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.↗
▶Ep 14 · 35:37
quoteThe thing that scares everybody about doing a thoracoscopic lobectomy is that, oh my gosh, you know, what if I get into bleeding? How am I going to control it, you know, I, I can't get my hand in there. What am I going to do? And I agree with that. That's, that's the frightening thing. And so I think vascular control in these cases is everything.↗
▶Ep 14 · 35:52
clinicalVascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.↗
▶Ep 14 · 36:01
quoteThe way I've done that is to dissect out the vessels and get enough length on the vessel that I can make a seal. Um, approximately on the vessel and then distally on the vessel, and then I can cut between the two seals, and as I, and I just cut partway because if you cut all the way across and it starts to bleed, you can't get control, but if you cut just a little bit till you see a lumen and then there's no bleeding, then you know it's safe.↗
▶Ep 14 · 36:47
quoteYou only lose control once you've completely divided the vessel.↗
▶Ep 14 · 36:59
opinionClips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.↗
▶Ep 14 · 37:44
quoteI think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble.↗
▶Ep 14 · 37:46
opinionUsing energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.↗
▶Ep 14 · 38:12
quoteI think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover.↗
▶Ep 14 · 38:30
quoteMy, it's my supposition is, is that every device can fail at some point. And so you wanna set yourself up to, to be able to recover, um, if at all possible.↗
▶Ep 14 · 39:09
clinicalRothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.↗
▶Ep 14 · 39:09
quoteIn fact one of the few cases I've had in my career. I was operating in another country that didn't have anything, and I used a device like that, and it sealed and cut it and in fact didn't seal it, and there was bleeding, and we ended up having to convert to open.↗
▶Ep 14 · 42:01
clinicalThe first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.↗
▶Ep 14 · 42:54
clinicalThe ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.↗
▶Ep 14 · 42:54
quoteThe ease of the operation really depends on how complete the fissure is.↗
▶Ep 14 · 44:06
clinicalIn a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.↗
▶Ep 14 · 45:23
clinicalThe bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.↗
▶Ep 14 · 45:35
clinicalIf the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.↗
▶Ep 14 · 46:25
clinicalWhen using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.↗
▶Ep 14 · 47:35
clinicalRothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.↗
▶Ep 14 · 47:35
quoteWhen I think about doing a lobectomy thoracoscopically, I often talk to people about the fact that it's kind of like reading a book and turning a page at a time.↗
▶Ep 14 · 48:04
clinicalAfter dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.↗
▶Ep 14 · 48:31
quoteThe key here is that if you dissect behind that, you have to remember that the pulmonary vein is right behind that. You're still looking in the same plane. You're still looking down on the fissure. You just have to very carefully, just as when you dissected. Behind the artery and you use, um, you could feel the bronchus. Now you have to stay hard on the backside of the bronchus and be aware that the pulmonary vein's there.↗
▶Ep 14 · 49:11
clinicalIn children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.↗
▶Ep 14 · 49:46
clinicalAfter dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.↗
▶Ep 14 · 50:33
quoteThe key thing, whether you're doing an infant, uh, uh, you know, a 1 year old or a 15-year-old, is you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 14 · 50:33
clinicalIf a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.↗
▶Ep 14 · 51:03
clinicalRight lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.↗
▶Ep 14 · 52:02
clinicalFor left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.↗
▶Ep 14 · 53:23
clinicalAfter taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.↗
▶Ep 14 · 54:06
clinicalIn left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.↗
▶Ep 14 · 54:30
clinicalWorking through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.↗
▶Ep 14 · 55:47
clinicalFor right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.↗
▶Ep 14 · 57:38
clinicalIf the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.↗
▶Ep 14 · 57:38
quoteIf you have a lung that has large cysts and so you have limited space or you know it's difficult to manipulate the lung, use the sealing device to pop the cysts to basically decompress them.↗
▶Ep 14 · 58:40
clinicalExtralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.↗
▶Ep 14 · 58:58
clinicalFor sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).↗
▶Ep 14 · 59:45
quoteThe one thing that everybody needs to remember, it's not a good idea to use sealing technology and clips on the same vessel. And the reason is that the sealing technology changes the nature of the vessel, and there are more than a couple of reports of where people have used clips on one side. And a sealer, a vessel sealer on the other and cut it and it was fine and then there's a delayed bleed.↗
▶Ep 14 · 59:45
clinicalNever use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.↗
▶Ep 14 · 1:00:43
clinicalSystemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.↗
▶Ep 14 · 1:01:07
opinionExtralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.↗
▶Ep 14 · 1:01:07
quoteI worry about these things becoming infected, whether or not extra, extra lobar sequestrations. Have any malignant potential or not, I'm, I'm not sure. Um, but I do know that they become infected and can cause problems.↗
▶Ep 14 · 1:01:35
quoteI believe that we can go in thoracoscopically and remove these with Almost no morbidity, um, you know, when we do a, when we do an extra lobar sequestration, we don't leave a chest tube in after the procedure, um, and the kids all go home the next day.↗
▶Ep 14 · 1:02:05
quoteI think there's absolutely no indication to embolize these. If you feel like you need to do something about it, then go take it out. Why, why, you know, embolize it and have it necrosis and risk the problems from an embolization either with the access vessel or, you know, if a coil pokes through or something. That just doesn't make any sense to me.↗
▶Ep 14 · 1:02:42
clinicalRothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.↗
▶Ep 14 · 1:04:46
clinicalA chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon.↗
▶Ep 14 · 1:05:33
clinicalAverage length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg.↗
The Full Story on CPAMs
▶Ep 17 · 36:43
clinicalSingle lung ventilation for thoracoscopic lobectomy is obtained by mainstem intubation of the contralateral bronchus, preventing the lung from overinflating during dissection of key vessels or structures.↗
▶Ep 17 · 39:02
clinicalFor thoracoscopic lobectomy, the scope port should be placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula, to allow working from front to back and avoid working in paradox.↗
▶Ep 17 · 41:39
clinicalWhen completing an incomplete fissure during lobectomy, work through it layer at a time like finger fracturing during liver lobectomy, starting at the front and working posteriorly until exposing the pulmonary artery.↗
▶Ep 17 · 43:09
quoteVascular control in these cases is everything.↗
▶Ep 17 · 43:09
clinicalVascular control in thoracoscopic lobectomy is everything; dissect out vessels to get enough length to make a seal proximally and distally, then cut partway between seals to check for bleeding before completing division.↗
▶Ep 17 · 44:13
clinicalThe bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery during lobectomy.↗
▶Ep 17 · 46:57
clinicalWhen dissecting behind the bronchus during lobectomy, stay hard on the backside of the bronchus and be aware that the pulmonary vein is right behind it.↗
▶Ep 17 · 48:44
quoteYou cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.↗
▶Ep 17 · 48:44
clinicalDo not take the pulmonary vein trunk near the pericardium during lobectomy, because if the device fails, the vessel will retract into the pericardium and the child will bleed to death before you can do anything; ensure enough length away from pericardium for proximal control.↗
Steven's statements about Long Gap Esophageal Atresia14 statements
Update Course 2021: MAGNET THERAPY FOR ESOPHAGEAL ATRESIA
▶Ep 4 · 10:00
clinicalIn the presented case, a full-term male with pure EA had gap study at 3 months showing 2.6 cm gap, and Flourish device was placed.↗
▶Ep 4 · 11:20
clinicalThe patient was heavily sedated for 12 days during magnet treatment.↗
▶Ep 4 · 11:40
clinicalFour days after esophageal ends came together, patient had acute decompensation and was transferred to another hospital where large fistula between esophagus and left main stem bronchus was identified.↗
▶Ep 4 · 12:20
clinicalAt emergency surgery, the surgeon found severe inflammation, divided the fistula, and divided the esophagus again, resulting in a 5 cm gap.↗
▶Ep 4 · 14:10
clinicalSubsequent workup revealed an upper pouch fistula that had not been previously diagnosed, which is a contraindication to using the Flourish device.↗
▶Ep 4 · 16:50
quotethis child had a gap at one point of two and a half centimeters that I think any any certainly anybody on the panel, whether you did it scopically or open could have fixed.↗
▶Ep 4 · 17:20
guidelineBy International group classification, a gap of 4 centimeters or more is required to be considered long gap esophageal atresia.↗
▶Ep 4 · 17:35
opinionDr. Rothenberg's opinion: a patient with less than 4 cm gap should be amenable to primary anastomosis, which he would do thoracoscopically with maybe 20% stricture rate.↗
▶Ep 4 · 17:35
quoteI have some concerns. I'm not completely against magnets, but I would argue that a patient who's got less than a 4 centimeter gap uh should be amenable to a primary anastomosis and we would of course do it scopically as I think most of the people on the panel would uh with maybe a 20% stricture rate.↗
▶Ep 4 · 18:10
quotethis device had not been available, this patient would have been transferred to a center that could have treated it and you know, and and had all the modalities. So I'm concerned more around the ethics of the device and and how it's being applied than necessarily using the device↗
▶Ep 4 · 21:28
clinicalDr. Rothenberg describes potential magnet candidate: 23-week premature infant, 340 grams at birth, pure atresia, who decompensates for two weeks after each thoracoscopic attempt to approximate ends.↗
▶Ep 4 · 22:20
opinionDr. Rothenberg's opinion: if a surgeon cannot sew together a 2-3 cm gap, the patient should be sent to a center that can, as that is the best outcome for the child.↗
▶Ep 4 · 22:38
quoteI do think that that I'm concerned that I don't even know how a device like this could end up in the hands of the people who it ended up in↗
▶Ep 4 · 23:00
quoteIt's not a license for people who say, well, you know, I'm not comfortable doing the operation but if I can put in magnets, I can do that and we can just keep the baby here. I think that's doing those kids a disservice.↗
Steven's statements about Osteosarcoma8 statements
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 2 · 7:29
clinicalDr. Rothenberg's institution reported almost 20 years ago that survival didn't change when there were only 3 to 4 nodules per side.↗
▶Ep 2 · 7:41
quoteThe argument about that you needed to put your hand in to feel all the granules, then you automatically should do a bilateral thoracotomy because this is a systemic disease. It's not a unilateral disease↗
▶Ep 2 · 7:52
opinionBecause osteosarcoma is a systemic disease, the argument that manual palpation is necessary would logically require bilateral thoracotomy, not unilateral.↗
▶Ep 2 · 8:02
clinicalEven with the best CTs, only 1 to 2 millimeter nodules can be visualized, and some are still missed.↗
▶Ep 2 · 8:02
quoteSo there's no question that tumor clearing is, is. Improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel.↗
▶Ep 2 · 8:05
clinicalThere are nodules that can be felt but not seen, and nodules that cannot be felt at all.↗
▶Ep 2 · 8:12
clinicalDr. Rothenberg's practice is to use thoracoscopy when there are only 3 to 4 nodules per side that are amenable to thoracoscopic resection, in order to reduce morbidity.↗
▶Ep 2 · 8:23
clinicalFor bilateral oligometastatic disease, Dr. Rothenberg performs bilateral thoracoscopy.↗
Steven's statements about Pectus Excavatum58 statements
quoteMy, my biggest issues with it were the added time. The other is concerned about the neuralgia and the complications that I'd heard about.↗
▶Ep 25 · 4:59
quoteMy, my biggest issues with it were the added time. The other is concerned about the neuralgia and the complications that I'd heard about.↗
▶Ep 25 · 5:08
quoteI will tell you that it took me about 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable.↗
▶Ep 25 · 5:08
quoteI will tell you that it took me about 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable.↗
▶Ep 25 · 5:08
opinionAfter approximately 4 cases, Dr. Rothenberg observed that cryoanalgesia changed not just when patients go home but how they feel when they go home, describing the results as unbelievable.↗
▶Ep 25 · 5:08
opinionAfter approximately 4 cases, Dr. Rothenberg observed that cryoanalgesia changed not just when patients go home but how they feel when they go home, describing the results as unbelievable.↗
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 25 · 5:23
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 25 · 5:23
opinionDr. Rothenberg agrees with Dr. Garcia's concerns and supports the need for a registry to track long-term cryoanalgesia outcomes.↗
▶Ep 25 · 5:23
opinionDr. Rothenberg agrees with Dr. Garcia's concerns and supports the need for a registry to track long-term cryoanalgesia outcomes.↗
▶Ep 25 · 6:59
opinionDr. Rothenberg believes bar flippage is completely a surgical issue, not related to pain management technique.↗
▶Ep 25 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 25 · 6:59
opinionDr. Rothenberg believes bar flippage is completely a surgical issue, not related to pain management technique.↗
▶Ep 25 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 25 · 8:19
quoteI use a sternal elevator in about 10% of the cases.↗
▶Ep 25 · 8:19
clinicalDr. Rothenberg uses a sternal elevator in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.↗
▶Ep 25 · 8:19
quoteI use a sternal elevator in about 10% of the cases.↗
▶Ep 25 · 8:19
clinicalDr. Rothenberg uses a sternal elevator in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.↗
▶Ep 25 · 8:22
clinicalIn average younger patients, thoracoscopy provides adequate visualization without needing a sternal elevator.↗
▶Ep 25 · 8:22
clinicalIn average younger patients, thoracoscopy provides adequate visualization without needing a sternal elevator.↗
▶Ep 25 · 8:22
quoteI think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it.↗
▶Ep 25 · 8:22
quoteI think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it.↗
opinionWith cryoanalgesia, it is not just when patients go home but how they feel when they go home that has changed dramatically.↗
▶Ep 26 · 5:08
quoteIt took me about 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable.↗
▶Ep 26 · 5:08
quoteIt took me about 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable.↗
▶Ep 26 · 5:08
opinionWith cryoanalgesia, it is not just when patients go home but how they feel when they go home that has changed dramatically.↗
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 26 · 5:23
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 26 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 26 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 26 · 6:59
opinionBar flippage is completely a surgical issue.↗
▶Ep 26 · 6:59
opinionBar flippage is completely a surgical issue.↗
▶Ep 26 · 8:19
quoteI use a sternal elevator in about 10% of the cases.↗
▶Ep 26 · 8:19
clinicalA sternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.↗
▶Ep 26 · 8:19
quoteI use a sternal elevator in about 10% of the cases.↗
▶Ep 26 · 8:19
clinicalA sternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.↗
▶Ep 26 · 8:22
clinicalIn the average younger patient, thoracoscopy provides adequate visualization without needing a sternal elevator.↗
▶Ep 26 · 8:22
quoteI think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it.↗
▶Ep 26 · 8:22
quoteI think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it.↗
▶Ep 26 · 8:22
clinicalIn the average younger patient, thoracoscopy provides adequate visualization without needing a sternal elevator.↗
▶Ep 26 · 8:27
quoteHaving The sternum elevated in those really deep stiff pectuses allows you less tissue damage and have a better repair.↗
▶Ep 26 · 8:27
quoteHaving The sternum elevated in those really deep stiff pectuses allows you less tissue damage and have a better repair.↗
Steven's statements about Pediatric Oncology8 statements
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 376 · 7:29
clinicalDr. Rothenberg's institution reported almost 20 years ago that survival didn't change when there were only 3 to 4 nodules per side.↗
▶Ep 376 · 7:41
quoteThe argument about that you needed to put your hand in to feel all the granules, then you automatically should do a bilateral thoracotomy because this is a systemic disease. It's not a unilateral disease↗
▶Ep 376 · 7:52
opinionBecause osteosarcoma is a systemic disease, the argument that manual palpation is necessary would logically require bilateral thoracotomy, not unilateral.↗
▶Ep 376 · 8:02
quoteSo there's no question that tumor clearing is, is. Improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel.↗
▶Ep 376 · 8:02
clinicalEven with the best CTs, only 1 to 2 millimeter nodules can be visualized, and some are still missed.↗
▶Ep 376 · 8:05
clinicalThere are nodules that can be felt but not seen, and nodules that cannot be felt at all.↗
▶Ep 376 · 8:12
clinicalDr. Rothenberg's practice is to use thoracoscopy when there are only 3 to 4 nodules per side that are amenable to thoracoscopic resection, in order to reduce morbidity.↗
▶Ep 376 · 8:23
clinicalFor bilateral oligometastatic disease, Dr. Rothenberg performs bilateral thoracoscopy.↗
Steven's statements about Sarcoma (Ewing/Rhabdo)8 statements
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 8 · 7:29
clinicalDr. Rothenberg's institution reported almost 20 years ago that survival didn't change when there were only 3 to 4 nodules per side.↗
▶Ep 8 · 7:41
quoteThe argument about that you needed to put your hand in to feel all the granules, then you automatically should do a bilateral thoracotomy because this is a systemic disease. It's not a unilateral disease↗
▶Ep 8 · 7:52
opinionBecause osteosarcoma is a systemic disease, the argument that manual palpation is necessary would logically require bilateral thoracotomy, not unilateral.↗
▶Ep 8 · 8:02
clinicalEven with the best CTs, only 1 to 2 millimeter nodules can be visualized, and some are still missed.↗
▶Ep 8 · 8:02
quoteSo there's no question that tumor clearing is, is. Improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel.↗
▶Ep 8 · 8:05
clinicalThere are nodules that can be felt but not seen, and nodules that cannot be felt at all.↗
▶Ep 8 · 8:12
clinicalDr. Rothenberg's practice is to use thoracoscopy when there are only 3 to 4 nodules per side that are amenable to thoracoscopic resection, in order to reduce morbidity.↗
▶Ep 8 · 8:23
clinicalFor bilateral oligometastatic disease, Dr. Rothenberg performs bilateral thoracoscopy.↗
Steven's statements about Shortness of Breath On Exertion26 statements
opinionDr. Rothenberg's initial concerns about cryoanalgesia were the added operative time and concerns about neuralgia and complications.↗
▶Ep 1 · 4:59
quoteMy, my biggest issues with it were the added time. The other is concerned about the neuralgia and the complications that I'd heard about.↗
▶Ep 1 · 5:08
opinionAfter approximately 4 cases, Dr. Rothenberg observed that cryoanalgesia changed not just when patients go home but how they feel when they go home, describing the results as unbelievable.↗
▶Ep 1 · 5:08
quoteI will tell you that it took me about 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable.↗
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 1 · 5:23
opinionDr. Rothenberg agrees with Dr. Garcia's concerns and supports the need for a registry to track long-term cryoanalgesia outcomes.↗
▶Ep 1 · 6:59
opinionDr. Rothenberg believes bar flippage is completely a surgical issue, not related to pain management technique.↗
▶Ep 1 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 1 · 8:19
clinicalDr. Rothenberg uses a sternal elevator in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.↗
▶Ep 1 · 8:19
quoteI use a sternal elevator in about 10% of the cases.↗
▶Ep 1 · 8:22
clinicalIn average younger patients, thoracoscopy provides adequate visualization without needing a sternal elevator.↗
▶Ep 1 · 8:22
quoteI think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it.↗
quoteIt took me about 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable.↗
▶Ep 2 · 5:08
opinionWith cryoanalgesia, it is not just when patients go home but how they feel when they go home that has changed dramatically.↗
quoteI accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients.↗
▶Ep 2 · 6:59
opinionBar flippage is completely a surgical issue.↗
▶Ep 2 · 6:59
quoteI do think that bar flippage is completely a surgical issue.↗
▶Ep 2 · 8:19
quoteI use a sternal elevator in about 10% of the cases.↗
▶Ep 2 · 8:19
clinicalA sternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.↗
▶Ep 2 · 8:22
clinicalIn the average younger patient, thoracoscopy provides adequate visualization without needing a sternal elevator.↗
▶Ep 2 · 8:22
quoteI think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it.↗
▶Ep 2 · 8:27
quoteHaving The sternum elevated in those really deep stiff pectuses allows you less tissue damage and have a better repair.↗
Steven's statements about Spontaneous Pneumothorax6 statements
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 1 · 1:31
quoteThere's a huge difference between esophageal resia and TEF, and every resident calls it TEF when they mean esophageal tree. So please, that's precision is got↗
▶Ep 1 · 12:35
quoteI think the big thing here is that we're eliminating the thoracotomy, and I think that is the primary reason for doing this.↗
▶Ep 1 · 12:40
opinionThe primary reason for doing thoracoscopic TEF repair is eliminating the thoracotomy and its associated morbidity.↗
▶Ep 1 · 12:55
opinionNo matter what kind of thoracotomy is performed, there is morbidity associated with having a thoracotomy as an infant.↗
▶Ep 1 · 12:55
quoteno matter what kind of thoracotomy you do, and, and I was a pioneer of the muscle sparing thoracotomy. I wrote the first paper on it in pediatrics, there is morbidity associated with having a thoracotomy as an infant↗
▶Ep 1 · 13:15
quoteif we can avoid that incision and end up with an equivalent operation. Then I think as pediatric surgeons who are looking for the long term care of our children not only as postoperatively but for the rest of their lives, we need to be committed to that↗
▶Ep 1 · 13:40
quoteI personally think you can see the operation better. I mean, I, I think you know watching this operation on a big magnified high definition screen. You can see things better than you can see when we're all trying to look through small incisions with loops and all of that↗
▶Ep 1 · 14:00
quoteI am shocked that 45% of the audience does this operation thoracoscopically.↗
▶Ep 1 · 16:33
opinionThoracoscopic TEF repair requires surgeons who are skilled in MIS to perform it and pass that skill on to trainees.↗
▶Ep 1 · 16:35
quoteIt requires people who are skilled to do this and then pass that on to the trainees. It takes a while for those trainees who get that experience to then come back around and actually teach the faculty wherever they go how to do it.↗
▶Ep 1 · 17:45
quoteyou actually have less of a diverticulum thoracoscopically than you do open because you get, I'll show it, you, you get a perpendicular view. And so you, because I've had to resect a number of diverticulums and they were all done open. I've never had to resect the diverticulum thoracoscopically.↗
▶Ep 1 · 17:50
clinicalRothenberg reports he has never had to resect a diverticulum after thoracoscopic TEF repair, whereas he has had to resect a number of diverticulums that were all done open.↗
▶Ep 1 · 18:10
clinicalThoracoscopically, the fistula is seen coming in directly at 90 degrees perpendicular, which is not seen when the operation is done open.↗
Ladd Medal Award Presentation Honoring Dr. Steven Rothenberg's Pioneering Minimally Invasive Pediatric Surgery
▶Ep 31 · 10:00
quoteIt's better to be lucky than good, even better if you can be a bit of both, and take advantage of unexpected opportunities.↗
▶Ep 31 · 11:40
clinicalDuring thoracic fellowship in Liverpool, Rothenberg developed muscle-sparing thoracotomy technique and observed improved recovery in patients who received bilateral procedures with this approach compared to traditional thoracotomy.↗
▶Ep 31 · 15:00
clinicalRothenberg performed the first laparoscopic Nissen fundoplication at Texas Children's Hospital in 1990.↗
▶Ep 31 · 15:50
clinicalRothenberg collaborated on one of the first successful gene therapy projects, performing 80% hepatectomy in factor VIII deficient dogs using only eye cautery, which cured factor VIII deficiency and was published in Science.↗
▶Ep 31 · 20:50
clinicalRothenberg pioneered thoracoscopic lung biopsies in children with interstitial lung disease, changing care by making tissue diagnosis accessible when previously the morbidity of open biopsy prevented diagnosis.↗
▶Ep 31 · 25:00
clinicalRothenberg performed the first thoracoscopic TEF repair in Berlin in 1999 during the IPEG meeting, operating live in front of 100 people on a patient with pure esophageal atresia whose ends had been brought together by metal bougie dilation.↗
▶Ep 31 · 27:30
clinicalAlmost a year after the Berlin case, Rothenberg performed the first thoracoscopic type C esophageal atresia repair in a healthy large baby (Connor) who is now a chemist.↗
clinicalRothenberg's initial thoracoscopic TEF series of approximately 15 cases was rejected by ABSA but published in JPS through Jay Grosfeld's support.↗
▶Ep 31 · 29:10
clinicalRothenberg presented a series of 220 consecutive thoracoscopic TEF repairs, after which the nature of audience questions shifted from critiquing the technique to asking why more surgeons were not adopting it.↗
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 1 · 1:31
quoteThere's a huge difference between esophageal resia and TEF, and every resident calls it TEF when they mean esophageal tree. So please, that's precision is got↗
▶Ep 1 · 12:35
quoteI think the big thing here is that we're eliminating the thoracotomy, and I think that is the primary reason for doing this.↗
▶Ep 1 · 12:40
opinionThe primary reason for doing thoracoscopic TEF repair is eliminating the thoracotomy and its associated morbidity.↗
▶Ep 1 · 12:55
quoteno matter what kind of thoracotomy you do, and, and I was a pioneer of the muscle sparing thoracotomy. I wrote the first paper on it in pediatrics, there is morbidity associated with having a thoracotomy as an infant↗
▶Ep 1 · 12:55
opinionNo matter what kind of thoracotomy is performed, there is morbidity associated with having a thoracotomy as an infant.↗
▶Ep 1 · 13:15
quoteif we can avoid that incision and end up with an equivalent operation. Then I think as pediatric surgeons who are looking for the long term care of our children not only as postoperatively but for the rest of their lives, we need to be committed to that↗
▶Ep 1 · 13:40
quoteI personally think you can see the operation better. I mean, I, I think you know watching this operation on a big magnified high definition screen. You can see things better than you can see when we're all trying to look through small incisions with loops and all of that↗
▶Ep 1 · 14:00
quoteI am shocked that 45% of the audience does this operation thoracoscopically.↗
▶Ep 1 · 16:33
opinionThoracoscopic TEF repair requires surgeons who are skilled in MIS to perform it and pass that skill on to trainees.↗
▶Ep 1 · 16:35
quoteIt requires people who are skilled to do this and then pass that on to the trainees. It takes a while for those trainees who get that experience to then come back around and actually teach the faculty wherever they go how to do it.↗
▶Ep 1 · 17:45
quoteyou actually have less of a diverticulum thoracoscopically than you do open because you get, I'll show it, you, you get a perpendicular view. And so you, because I've had to resect a number of diverticulums and they were all done open. I've never had to resect the diverticulum thoracoscopically.↗
▶Ep 1 · 17:50
clinicalRothenberg reports he has never had to resect a diverticulum after thoracoscopic TEF repair, whereas he has had to resect a number of diverticulums that were all done open.↗
▶Ep 1 · 18:10
clinicalThoracoscopically, the fistula is seen coming in directly at 90 degrees perpendicular, which is not seen when the operation is done open.↗
Summaries Steven gave as host
· 23 summaries
Recaps of what the experts said, with Steven as narrator — not Steven's own clinical position, and never cited in answers.
Summaries Steven gave as host · Congenital Lung Lesions (CPAM)3 summaries
host summarySteven Rothenberg summarizing the discussion: The hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
Thoracoscopic Right Lower Lobe Cystic Lesion Excision: Update Course 2014
▶Ep 11 · 8:03
host summarySteven Rothenberg summarizing the discussion: The literature shows that 30–40% of children with cystic lung disease will have a significant pulmonary infection at some point during their life.↗
▶Ep 11 · 9:51
host summarySteven Rothenberg summarizing the discussion: Hematologist-oncologists have stated that morcellating the specimen does not upgrade the tumor, does not change treatment, and no patient has received chemotherapy, but these children are being watched.↗
Summaries Steven gave as host · Congenital Pulmonary Airway Malformation3 summaries
host summarySteven Rothenberg summarizing the discussion: The hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 7 · 7:54
host summarySteven Rothenberg summarizing a resource: Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and indicates cases more prone to need fetal intervention.↗
▶Ep 7 · 15:55
host summarySteven Rothenberg summarizing a resource: 20-40% of untreated congenital lung lesions will develop a significant infection at some point.↗
Summaries Steven gave as host · Congenital Pulmonary Airway Malformation3 summaries
host summarySteven Rothenberg summarizing the discussion: The hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids.↗
Neonatal Lung Lesions with Dr. Steven Rothenberg
▶Ep 7 · 7:54
host summarySteven Rothenberg summarizing a resource: Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and indicates cases more prone to need fetal intervention.↗
▶Ep 7 · 15:55
host summarySteven Rothenberg summarizing a resource: 20-40% of untreated congenital lung lesions will develop a significant infection at some point.↗
Summaries Steven gave as host · Esophageal Atresia1 summary
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 2 · 14:30
host summarySteven Rothenberg summarizing the discussion: A recent study from the Midwest Consortium of approximately 10 hospitals showed less than 15% of TEF cases were done thoracoscopically in major US training centers.↗
Summaries Steven gave as host · Esophageal Atresia6 summaries
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 3 · 14:30
host summarySteven Rothenberg summarizing the discussion: A recent study from the Midwest Consortium of approximately 10 hospitals showed less than 15% of TEF cases were done thoracoscopically in major US training centers.↗
Ladd Medal Award Presentation Honoring Dr. Steven Rothenberg's Pioneering Minimally Invasive Pediatric Surgery
▶Ep 73 · 5:00
host summarySteven Rothenberg summarizing a resource: We have to push the industry to do better.↗
▶Ep 73 · 22:30
host summarySteven Rothenberg summarizing a resource: A mother reported that her son who underwent muscle-sparing thoracotomy for esophageal atresia developed noticeable chest asymmetry and spinal curve.↗
▶Ep 73 · 23:20
host summarySteven Rothenberg summarizing a resource: Martin Larker's study demonstrated that even muscle-sparing thoracotomy results in significant diminished chest wall movement and chest wall asymmetry with smaller lung volumes compared to thoracoscopy.↗
▶Ep 73 · 31:40
host summarySteven Rothenberg summarizing a resource: According to the newest consortium data, less than 11% of 500 TEF repairs are performed thoracoscopically and less than 50% of CPAM resections are performed thoracoscopically.↗
▶Ep 73 · 32:50
host summarySteven Rothenberg summarizing a resource: Mastering the art of life draws no sharp distinction between work and play, their labor and leisure, their mind and body, their education and recreation. They hardly know which is which. They simply pursue their Excellence through whatever they're doing and leave others to determine whether they are working or playing. To them, they are always doing both, and to me this is the definition of a pediatric surgeon.↗
Summaries Steven gave as host · Tracheoesophageal Fistula6 summaries
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 1 · 14:30
host summarySteven Rothenberg summarizing the discussion: A recent study from the Midwest Consortium of approximately 10 hospitals showed less than 15% of TEF cases were done thoracoscopically in major US training centers.↗
Ladd Medal Award Presentation Honoring Dr. Steven Rothenberg's Pioneering Minimally Invasive Pediatric Surgery
▶Ep 31 · 5:00
host summarySteven Rothenberg summarizing a resource: We have to push the industry to do better.↗
▶Ep 31 · 22:30
host summarySteven Rothenberg summarizing a resource: A mother reported that her son who underwent muscle-sparing thoracotomy for esophageal atresia developed noticeable chest asymmetry and spinal curve.↗
▶Ep 31 · 23:20
host summarySteven Rothenberg summarizing a resource: Martin Larker's study demonstrated that even muscle-sparing thoracotomy results in significant diminished chest wall movement and chest wall asymmetry with smaller lung volumes compared to thoracoscopy.↗
▶Ep 31 · 31:40
host summarySteven Rothenberg summarizing a resource: According to the newest consortium data, less than 11% of 500 TEF repairs are performed thoracoscopically and less than 50% of CPAM resections are performed thoracoscopically.↗
▶Ep 31 · 32:50
host summarySteven Rothenberg summarizing a resource: Mastering the art of life draws no sharp distinction between work and play, their labor and leisure, their mind and body, their education and recreation. They hardly know which is which. They simply pursue their Excellence through whatever they're doing and leave others to determine whether they are working or playing. To them, they are always doing both, and to me this is the definition of a pediatric surgeon.↗
Summaries Steven gave as host · Tracheoesophageal Fistula1 summary
Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
▶Ep 1 · 14:30
host summarySteven Rothenberg summarizing the discussion: A recent study from the Midwest Consortium of approximately 10 hospitals showed less than 15% of TEF cases were done thoracoscopically in major US training centers.↗
