The patient is a 60 plus year old with a biopsy proven adenocarcinoma of the lung who presents for resection.
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Cardiothoracic Surgery Specialty
Thoracic Surgery Subspecialty
NYU Langone Lung Cancer Center
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Past Notes
Hi, I'm Robertsport Folio here
at NYU Langone and our incredible
world class facilities, one point
two billion dollar brand new
hospital with the best Doha's
and really the best team in the
world. I'm honored to be a small
part of it.
We're about to do now is a
complicated type of segment to
me on a biopsy, proven
adenocarcinoma and a 60
some odd old female
who got this discovered actually in
the motor vehicle crash has already
been biopsy proven, flew in
from another state to have surgery
today. Now, what makes this
complicated is sort of in between
the lingo and the anterior segment.
So the question is, are we going to
do a tri segment ectomy
and spare the Lingala?
Are we going to do an extended
lingling resection and what
march along the bronchus of the
anterior segment and take some of
the anterior segment with the
Lingoa?
I really would prefer the second
course, but we'll see.
Of course, it's all about doing the
good lymph node dissection
and really show you how this is a
team sport, how our anesthesiologist
and us put the double woman
bind together and 30 to 40 seconds
how we positioned the patient.
We're going to start with a Naveh
Bronk to the table will be flipped.
We don't flip the table because we
don't want to waste three or four
minutes and you can still
bump patients with just an
IV bag.
We don't use an axillary roll.
We don't use it in a line or a
central line.
We don't type in screen, don't type
in cross and do this all with a
peripheral IV.
And we expect the patient to go home
tomorrow at eight a.m.
So there'll be no air leaks
and we have to be very careful
handling the lung.
So we're honored to have you.
We'll have fun today.
Looking forward to it.
And now he's navigating to the left
upper lobe
posterior
segment, apical segment.
OK.
Switch over to peripheral fluid.
So the goal here is for me to just
get as close as I can to the Lesin.
And I'm going to take that right,
there is one 8th grade
and you're inferior to
it.
I think so.
That is the.
Then you turn it in once
you were the.
OK.
Yeah, then you plushie
with the.
But this is one of the most
important parts of what we do in the
development and we work as a team.
So notice that patient patient has
been elevated.
The surgical team is here or not
outside.
They are complaining, but
we're here helping now.
We put this in now this
patient, we just promptly the navvy
Bronk with most of the patients.
We haven't lowered the bed, but
there is you're right.
There's your left.
It's got a small airway.
Slide it and then slide it down
like a
good day like this.
Let's go down the right side.
Please hold please hold the.
Please give me my glove.
So there is your right size, pull
back just a little right there.
Perfect.
You can hang out if you want to
inflate under direct.
She's got all this water from what
we just did. Let's clear this out.
Yeah, it was hard to see.
OK, now inflate.
You see, the top of the blue car was
sliding in just a
little very
little hole this good.
So we have a routine every time this
is a left.
So we grab the arms and that person
goes up top on
the right side of the patient.
I'm usually on the side going up.
We make sure we have the patient
correctly position on the bed.
If we don't, then we just use
a bump to create the brake.
All right. You ready?
You have the head.
One, two, three, turn.
Then we bring her all the way to the
back.
That's good.
So what we do now is we hit one
button flex, and ideally
when you're doing a thoracotomy,
which you do once, maybe every
five years, now you want
to break the fifth or sixth rib.
When you're doing a robotic case,
you want to break them over maybe
the ninth and tenth rib
so you can see this bed is
positioned correctly, the breaks
there. So it'll be just fine.
So if your brake is wrong or the
beds in position, all you have to do
is put a little IV pad or a little
I mean, a little IV bag or something
underneath it to act as the brake.
And then the way to get the hip out
of the way is just to put the
patient in reverse trendelenburg,
put the head a little higher and
then flex a little more.
That opens that up.
So we will need something here.
So let's get a little roll.
Let's put it right here.
So you want to put that roll?
Probably right there.
Hold it for a second.
One, two, three.
That's it.
Not an axillary roll.
You don't have to use that in 20
years.
Now, gloves come off.
When the tape comes on, the gloves
come off on. The tape comes out
very efficient.
No wasting moves.
Now, notice how the double
woman goes,
this is important, how the face
is protected, the sheets
aren't in her mouth.
We can start even prepping the
patient here in a second.
So you want to make this tight, but
not too tight on that arm.
So this is the way to do this with
no arm board, no beanbag, none of
that stuff.
No airline, no centerline, no folino
hyphen screen doesn't have
any value.
That's the middle of a table body
and that's the lateral pedicle of
the vertebral bodies.
This is the tip of the scapula.
It's pretty thin patient
here, actually, today.
Now we can feel the ribs, 12,
11, 10.
I keep moving my head, but I turn
the lights off, please.
Nine,
eight. So here is the ninth rib.
Four left out plugs often go over
eight if
you have a room and it looks like we
will today. So we're not too low in
this expansive chest.
On the right side, we go over nine
for everybody.
Left side will go over nine for
lower lobes, usually eight for the
upper torso. Now, remember, this is
an X I robot.
So Jan's going to tell you what is
our measurements for an exercise
starting not from the vertebral
body, but from the lateral pedicle
go for four
centimeters, eight centimeters,
eight centimeters. And if I had an
ESSI, what would it be?
Two, ten, nine.
So this is an EXI.
So we go right there.
There's the lateral vertical and
make this very precise.
We put a mark there, a mark
that's orthogonal to the traversing
of the rib,
eight there and
eight there. And look, that doesn't
give me enough room.
So I'm going to go probably four
seven seven.
Because I want a lot of room in my
space, my R.A.
space here.
She looks great.
So where do we go, we go not
in the back port or the next
move with a camera for which is this
guy. So right over the top of the
rim and notice we saw
look what we're doing here.
I hope you can see where sawing, not
cutting.
We don't. Bovey Everywhere I go, I
watch people burn and burn a burn.
Makes no sense. Right.
What do you bogeying?
All you do is going to burn the skin
that bleeds a little.
You just make the incision not too
big and put the port in.
It'll stop and we induce in the
method. Actor Mike Servoz showed us
that technique.
Dr. Zavos, it's
a nice letter. We call it the
service maneuver, so you don't get
into the lung.
Now you add CO2 only now
when you're sure a preemptive
analgesia. Hold this.
We should be able to see our mark
right here. You can see your finger,
see what we're doing. And you can
see one or two rows below the
fissure.
You can see that she's pretty
thin. You try not to go through the
pleura, so is going to show it to me
so I don't go through.
And I really injector well, this
woman is going to already
has some pain issues, so we want to
do a real nice injection.
Now, the other thing that we can do
is we can actually wait and see if
we can see the dye as
well with that camera.
So we inject all this.
This is just marking.
This patient got gabapentin
900 milligrams and a thousand
milligrams of Tylenol before coming
into the car because she wanted
to be about two hours below the
fisher. And I am well, it's
actually really good, right where my
marcus' knife, we don't
hand the knife back six times.
I'm feeling the rib.
You can see this.
I like this. I feel like an athlete
and I'm a nice athletic position
with my feet.
And I'm going right over the river
here.
So if this bleeds, Tami Tyler,
put your finger here and holds it
because she knows what to do.
I'm going to go through this port
and this is really important.
Take a look here that I am
perpendicular.
I'm not going up hurting the nerve
or going down hurting the nerve,
but I'm on a right angle
to that rib so I don't
hurt the patient in a bleeds
a little. You just put the port in a
stop. Don't BOVEY
There's no reason to.
Bovey Now the next two snowsports
are put in with a ruler.
These next two ports are placed
more dynamically.
So you want to maximize your
triangle.
So we don't like to go over the
eighth rib here.
We'd rather go over the seventh,
but we also don't want to get her
rectus. So I think sometimes nine
is two is OK.
You go over eight today.
Eight is clearly going into
practice.
So we'll go over the top probably of
seven, but we don't want to go in
her breast tissue.
That's why we make sure we can see
the breast in the nipple.
So probably right there.
And Tammy is going to show us our
finger by coming out and
showing us our finger.
Thank you. Now put it in right
there. Go knife
to me.
Now, this would be a twelve, so we
will put a twelve in gunmaker.
We'll.
Again, parallel to the red,
Dr. Jan Nishimura is our robotic
fellow. Look how good she is
now. We want to create a triangle
here
just like this.
And the better the triangle we can,
the bigger the triangle, the better.
This is where our testing goes and
we take our Chastity's tubes out the
day of surgeries.
This hopefully think they're going
to come out in five hours after
surgery, maybe six.
They don't spread that too much.
So now after the
pair of vertebral sub plural block,
we now do a field block of all the
ports.
Good work, guys.
So we want to start fire
flying
and rolling the lung.
There's a little bit up there.
And let me just take that adhesion
down.
You don't think that's natural, that
you
might it
might be
there is the mammary vein.
Let's just see.
Come on for a minute. Yeah, looks
like
there's say it.
That is right there.
Right below it. So that actually
could be the actual nodule.
But I think in case this is
anything, I'm going to come get all
this.
And I'd rather put a little hole in
a memory than leave any tumor
and there's memory.
So let's get all this.
Just in case you stuff here, Mike.
It looks better, that
looks better.
There's a memory vein.
There's phrenic there, it is good to
see well, this is interesting little
case normally you're not doing us
watching in the memory lane mammary
artery,
getting all the pleura off.
Nice Saajan, the
nice little demonstration
of how you want to make sure you're
going to look for parietal pleural
invasion, not just visual.
Right.
And there is a branch.
See it.
So I don't know.
We'll need a suture today because I
think we're going to have a mark on
this with this pleural tag on it.
You know,
this could act like our suture.
Jenya, with me,
you
see there is Dr. Zavos is perfectly
placed, Mark, like that.
Mike, what do you think?
I think that's it.
It's not really it looks more like
the Lingala, though.
But we want to save.
So the important point is, if I'm
going to do a segment,
I got to go get an in one node,
right, Jen?
So we're going to send this refrozen
frozen right now, Timofey.
And you give this counterreaction.
I'll do this if we're going to send
this off. Here comes a frozen
the number 11 lymph node,
beautiful anatomy again.
So this is more of the Lingala
node.
See what I mean, like that was my
question in conference, why not do
an extended
Lindel ectomy?
And we said, well, it wasn't in the
Lingle's more ratings that apical
angular segment,
you
guys review that and give me your
thoughts.
I think we should do an extended
length that I think will take less
long if we do an extended
legal activity.
There's
yet.
Well, then, how much of the Lindela
can I spare my take a look at where
that's going to be taken?
Well, then what we're looking at is
not the nodule that puts
up plural and.
I take this out and as Mike and I
review this as a great case,
but that is not going to be my mark.
The nodule is not
there, Mike, because that's Lingala.
That's all I'm saying.
Take a look.
Yeah. So your point is when
I divide, I could divide here.
Yeah.
So where is the nodule?
Let's see if we can palpate it.
Here's the contrast.
Say it.
The nodule is probably above that
here.
But then when I complete the
Lengyel, I see there's not that much
Lingala I'm saving, I got
to come like this.
Look, your point is we're going to
be taking a staple here normally,
and I do a regular sparing.
I'm like this.
I'm saving all of this Lingala
up here
in the nodules up here.
Yeah. Let's put a suture then where
we think it is.
We put a suture there and then take
everything that's like your stapler
above it.
Some of the other
things we like to do is really
flatten the lung
out, really
feel it hard as part of the case
is to identify where the nodule
is.
Yeah,
and so this is such a great case, so
the question is, what's a better
operation for her to do a long and
extended Lingala resection
and taking some of the apical
segment or to do a posterior?
Apical a.m.
leave the Lingala, I think if we do
an extended Lingala, like I'm going
to I'm going to leave me alone.
Cut here long,
so we think the nodule is above
this.
Take this out,
the doctors are not going to make a
decision along with Jen.
My thought is if I
I take the Lingala and I just take
my stapler like this, I'm going to
save all of this.
All posterior segment, apical
segment and some of
the anterior, if I
do a tri segment activity, I'm going
to have to bring my sleep.
I'm only saving a part of the
Lingala.
So Dr. Zerwas is going to do
now is going to try to palpate the
nodule.
Notice how we put this under
traction here.
This is the team we're going to go
get our little nuts
because our number nine
10, the hardest part of the case is
finding the nodule.
I think once you've found the
nodule, the rest
of it is pretty straightforward with
the robot
ceiling
number
nine, two of them.
All right. You ready?
Yes.
Jan, take down, girl.
Go get me some X C
don't get confused with the other
lung. That's their right to hold it
like this.
Remember, no air leaks.
Patient going home tonight or
tomorrow.
No.
Good after long, no
bleeding,
OK,
stop. So once you start
getting
here now, you turn the camera and
make this big point with the camera.
Turn three goes
up right here.
Grab the lung.
There's no air leaks.
You pull it like this, you come
back and twist your camera.
OK.
OK, now let's get in the correct
plane,
so
this
goes up like this.
Looking for an eight
there,
got one up here.
Now you're coming into 70s and 80s,
right?
A big plumpy nose, doesn't she?
And again, look look how I'm helping
myself, right, look how I'm
grabbing, I'm not tearing,
I'm dissecting, I'm pushing the
vagus nerve down and identify the
artery that goes.
This note, it's always there.
Right when I set off the bronchus,
keep it nice and boring, I'm not
burning the aorta, I'm all
the way down there, look all the way
down, there's the esophagus.
So this is a seven and an eight sort
of rolled up in one.
One big nice reception.
OK.
OK, here's one
eight right there.
You can see it.
Maybe that's
an area that's a seven.
Take it
three sevens.
There is two.
Eight.
All right. And then a couple more
sevens there.
Maybe it looks like two more two
more sevens.
Now we really want to identify all
of our things.
And I Tammy, put your soccer like
this, pin it back and suck at
the same time and suck
up top.
Good. Now pin it back.
That's nice.
Very nice.
Yeah, we're doing an extended
Lindela, right?
Yeah, that's what I thought.
He's got to make sure we got to only
take it now.
So what would you call this, John?
It's above the bronchus and by the
way, so it's a 10
hold that back, the
nerve
vagal nerve.
And again, I'm pulling with my
letter, but not so much that it's
bleeding
and
I'm just sweeping stuff away,
sweeping away, there's the P.A.,
you know, the bronchial artery goes
right here. It's really big, goes
right on the bronchus.
Right.
What I believe is there is PR right
there.
I set out the pulmonary artery, the
base of it bronchodilator,
it's right there, right
always there.
There's the bronchus, right?
Make sure we don't have to pay, you
should be able to see it well,
just dissect it all off.
You can even dissect it here if you
want to see it a little better.
All this time, we'll come up here
and make it really easy, because
she's making it pretty easy with her
anatomy today.
No, we're going to do this, Fisher,
today, whatever we're doing today,
because we're doing a segment,
so we've got to dissect all that
out, you just pull all this off.
Another element, which you got a lot
of big notes, but again, it's all
just blunt dissection.
Now, all
this comes off. This is an 11
three of them.
Tamela pinback the bronchus so
we can show you the bronchial
pulmonary artery
junction. That's a beautiful shot of
it.
So you come right here, especially
if you're doing a soup segment.
This is a really nice technique.
And as six.
This is what you do when there is a
difficult fissure.
Crossing, they might be a little bit
careful, we can have a little
crossing vein right there.
Now we're in the upper lobe today,
so we don't need to go so crazy here
right now, again, we don't want an
air leak
and
we want to see again, Jen, look how
I'm pulling out of trouble right
hand over hand.
But I'm not pulling too hard.
I'm just pulling out of trouble.
And I get the whole note out.
Tammy's give me the counter
traction.
Number ten,
three of them, and we're going to
complete our fisher, and I think
we'll just do an extended
Lingga, like a really
aggressive posterior dissection
way down, I'm not sure we need to be
this aggressive back here.
But this is the beautiful lymph node
you can do with the robot, just
unbelievable.
All right, more 10 or 11, excuse
me, three more.
All right, let's take a look at our
fish. Now, that's lower.
Low. That's pretty.
Well, dissect it out and think we
did a good lymph node dissection.
Hold that back like this, if you
would.
Great. Move Vagisil.
Posterior phishers right here.
Not even sure we need to do this,
actually,
but we'll
get the notes now.
Let's take one more look.
Really hasn't diffused very much
today.
I think we do an extended line.
You elected me. All right, let's do
it. The is what we're going to we're
going to complete the A.
Fisher first again
right
here. Right.
We have to staple some of this.
We will. What you could do actually.
Let's even do it later.
Let's just take the note out
so you can get around the Lingala.
Can you remember this is the second
since is the second bloodiest lymph
node in the
chest. The first is a submarine
on this guy. Second, because of the
branch that goes right, there
is always a branch.
Yeah.
What might you talk to me
myself?
Not just right in front of the
of.
And yeah, can't
pull that back.
Yeah, that's nice.
What number would you call this,
John?
That's the Denver Broncos, right,
wanted to get that little bit
better, but all right.
Behind there can be the rain, right?
They were going to be a staple in
your artery next, we're not
going to use ICG because I'm not
sure it's really
going to
matter what we do here.
All right. Boy, her nodes are just
so cool that I 11
three more.
I can go get the regular artery.
I think you're in good shape and see
what we can do to make it a little
bit easier for you.
Posterior segment.
The artery is back there.
See it.
So
if you have lots of room, OK,
come around it, get it and
stabilize. See the little bit of
hematoma. There should be a little
bit careful.
All right, you do it.
Use your left hand bluntly
to get around. It
can rest up against the Broncos.
Yeah, that's nice, Jenn.
That's pretty damn good,
should have pulled your camera
back when you when you did that
movie so you could have seen.
All right. Like I just said, grab
it.
All right.
Open up the space so you
can make it really look smooth.
And it's going to be simple and easy
and even come out with that open.
I like that trick.
All right. Robotic ski up 30
millimeters in one.
Now, remember, you bring your tips
up, you're going to have great
respect to post your segments that
you're going to put your tip up,
scale up, up, slide
in. You can even reposition for
and hold that back to the post.
Your segments driven down,
but it's sitting here would be to
hurt the posterior segment.
Step up now,
take the now take your other hand
and push it along.
Let me show you
what I mean. This can go like this,
OK?
And now you can slide this in like
this gives you a little better
control system, I'm using this arm.
So I want you to use both arms.
Sometimes when you're bringing the
staple and you get focused, you
forget that three and four
interchangeable, see,
and then you don't have to touch it.
And, you know, again, it's about not
having your leaks.
So remember, we're doing an extended
when you elected me,
so we're going to be there.
So we got to keep going
to
like Dr. Zavos makes a great point
that we've got to go get that
bronchus. So what I'm going to do
now, change out my stapler.
I'm going to dissect out
the anterior segment of bronchus
and angular bronchus and get that
regional. No doubt.
I think that's the key to this.
There is your vein, remember I told
you the vein comes up really closely
on the bronchus when you're doing
this? We talked about it last night
and there it is right there, OK?
So you want to get all this off,
you'd rather not get into your
staple line so it doesn't matter
if you leave that they're 13,
not
a 13 to 12, take it
too much in the upper level.
So here is your upper lip, because
we'll go get the Lingala vein in a
minute.
There's your Lingala right there.
All right. We're going to take that.
You spread the rain off, so it makes
us boring.
I don't think we have to take all of
the bronchus.
Mike and I can do this right.
Dissect it out.
So we'll come right here like
this. There is the plain see, John.
But that's what you want this to
look like. Now, what we do is we're
going to dive in the front,
go dive in the front.
We're going to take the rain.
But that's not a whole a.
bronchus. See it.
What a nice shot of it.
Gorgeous.
I could have the rain there.
Right. I said to be a little bit
careful,
but it looks OK.
And looks pretty good.
All right, so why don't we go do
this, let's do the fisher quickly,
let's do the Lingala vein
and then we'll decide what to do.
So there were a couple of ways
to do the fisher and then just bring
your staple right in here like this.
We've already cleaned it off.
Now, you could go dive in the front
and go see the vein, but you don't
have all the room in the world
because you did a nice job there.
See the vein, see it right there.
You take the note out.
The veins always exposed.
I think he can go to the front and
take the blame.
We just want to get all the
knowledge of.
You're in great shape now.
All right,
why don't you lay a staple in there
and just take that, OK, 45
below.
I can take it, Jan,
take this and we'll flip it along.
Then we'll take the V for violent
weather vane and then we'll see
what we can do with the rest of
the stapler. Maybe the key
is that lymph nodes, all
of the regular and anterior
bronchus. And we've done a pretty
good lymph node dissection.
And I think
that's the key to segments to
prevent recurrence is really to
get the nodes.
You know, what you're going to do?
You're going to pin this lung back.
No Airlink, you're going to spin it
back, put your stapler in there.
Doesn't matter if there's any
arterial branches
coming from the lower lobe to the
blood because they're in the fish
you're going to take. It's irrelevant.
Slide it in
all the way right there a little
more.
Know you're safe.
Trust me.
Trust me. Yep.
Yep.
This is they're going to have long
to take.
So I would have put my hand here and
push this off.
So you didn't have that in there?
I would have pushed this down a
little. That's what I was telling
you. To use your right hand to push
the lung down.
You would have seen the fissure
better. That's right.
We operate with traction
counterreaction.
Take it out, OK, now
what we're going to do while we're
waiting for that to come in, we're
going to flip this up like this
might even do the dogeared trick.
Let's see
what you got. Make sure there's two
veins, but you can be pretty.
You know, you're not taking the
venous.
And we saw the lower level than
before, but there's a lower level,
Tammy, is that back like that for a
minute? You spin it?
Yeah, that shows you
the lower level than just what we
call the looks like a dog.
Your trick.
Everyone here likes dogs.
I call it the beagle maneuver.
It's like a beagle.
There you can see one vein
right there. So, you know, you have
a vein going to
take all this out, exposing your.
Apolo van.
She just got her lymph nodes and
lymph nodes.
That's all in the lower lobe, I'm
just not sure I need them.
Obsessed with the nodes a little bit
here.
So one thing you can do, you can
actually use this arm to get the
whole come off
of their maneuver, get the whole
lung.
Like this, I'm not sure we need
to do it today, but OK.
Amy.
Tamara, let's hold this back, this
idea so the audience can see the
lower loving.
So there's your lower level than if
you were doing something there.
These are all lower lobe lymph
nodes,
which I'm going to try to
not be so obsessed with because
she's got big plump nodes are like
potato chips.
You want to see the rest of her
upper low vein and make sure you're
preserving that.
Always find your your phrenic.
And Divya can get really close in
here, some fives and sixes, which
can take maybe right now.
These are some
fives, probably
real, real,
real interior.
We still got to go in the back
bacto.
Now she's plumpy.
There is there
so turmoil that there should be a
time that you could not pin the
upper little vein back and let go of
the lower lobe where you
are,
and again, be just a little more
dynamic
seeing what I'm
doing.
OK, for fives.
So here's your fisher
right here.
There's your vein with a very
aggressive holding the vein, the
vein, we don't have too many
problems, that there could be a
little branch American bleed, but it
doesn't matter because it's coming
out.
So there is your age for a five.
I think we'll just take this.
You've in a really nice dissection
of the nodes in the back.
That's why you do all that work.
You clean everything out.
And the question is, do you want to
take that branch to
or just this one?
I don't know. Let's see.
We could start off just taking this
and then see.
All right.
Hard for me to leave notes, I just
can't.
All right, take this out.
This is like a 12.
Pinback that broke the artery,
please see it.
This is way down on the lower
lobe
right
now, let's go get the vein, OK,
12.
All right, Tammy, let's just take
this one right here.
Another note, come get
it,
so we didn't take the whole fish.
That's what's holding you up.
Is Dr. Zavos sustainability going
like this? You can come get at least
three, four of five, right?
See it
right here. Let's get this out of
the way. Keep it boring.
I think he'd rather get it from that
port. We'll see. I don't really want
to double cannulate.
It might be hard to get from the
entire airport.
You're right.
We took them.
If you took the official line could
be easy enough.
Let's take the
the fisher
here. Now, this is a blue.
Take the fisher, complete your
fisher and then we'll see.
But we may have to put a 12
in the back anyhow.
Generally, we finish the operation
unless we use a handheld, which we
could do.
You want to make sure you avoid the
artery,
get your tip in that plane.
Yep. That's nice.
Slide it in Tamil I think.
Come out. Let me see your tip.
Slide along with your
right hand.
Just push it along.
OK, that's it.
Yeah.
Little more
all the way, and you're safe, you're
safe, take it,
and I would have taken maybe just a
little bit more.
There's a long personally,
I would have just slowed it down a
little bit, not left out, but OK.
So now what I'm thinking is we can
take the Lingala bronchus because we
have the vein, dissect it out behind
it, see.
Yeah, it's a nice shot of it.
Yeah. The vein.
Yeah, that's the idea.
So we don't have to put a 12
millimeter port port number three
in an eight millimeter.
And if we put a robotic stapler in
there, we'll make it a 12 until
we get five millimeters or
eight millimeter staplers we have to
upstage.
We don't want to upstage and hurt
patients. We'd rather just have one
12 rather than two.
So what we're trying to do here is
if we can is just
do all our stapling from the back.
Usually we've taken the rain by now
or not. So we're trying to show a
little different way to do it.
We could have taken the vein with a
posterior
port, we're trying not to.
Just try to take the vein off the
bronchus like this.
See if we can get the bronchus.
I think we just have to push
you got lymph nodes galore.
There a vein in there, I don't think
so. All right, give me a vessel,
please.
OK, take the oil and give it
bronchus.
Can tell me if you just closed your
instrument and just pushed the lower
lobe. No, not there on the state
line.
There, yeah, that's the move to
push that link.
Yep, that's the move.
See that?
Yep, see how that helps her
good,
slide it and slide it in slightly.
Take it.
Yep, it's a good move, take it
good,
I was well done to get to know I
know you're fine.
Take it now. Encroaching on
anything.
Now, maybe you can take the Lingala
vein, I think you can.
I think he got to take Balzary as
might see on ice.
That shows us where we have to go
see that. That's just a nice
advantage. See, I
think he got to take both of these.
Yeah, it's harder to see from the A.
Yeah, whenever
you divide the bronchus, everything
opens up.
It's amazing.
The divided bronchus is your friend,
a divided bronchus is here to tell
me how many times have I said that?
Now you can look from the front and
see what you're leaving.
We want to see we're trying to
identify the space, right, so we
don't nail anything.
So it's just traction, counter
traction, right.
The Resolute.
So you still have the rain left, see
the rest of the rain?
All right, take it.
Let her take it.
Soon as you engage, you let her take
it before you push it, it adds
resistance, take
it to understand.
I'm pretty good.
Now we got to make some decisions,
so I think now we just
step away up here and we'll have a
good margin.
I really do
think we just take it like this, but
I think we're going to need a posterior
port to do that.
The question is the vein, Mike.
You know, when you do this, where is
the vein? See, the vein is the thing
that's going to be at risk.
And so I think we just have to be a
little bit careful as we come up
here with this.
Yeah.
So just maybe as a little vessel
there, maybe.
So I think if we just come in here,
hug the vein
at the branch of the bronchus right
there, maybe. Yep, yep,
yep. That's perfect.
Only.
Yes.
You don't get to see it like this
every day. This is a nice shot of it
and nerviness anatomy,
you
see it right there, too.
People get confused on
this and they see.
Apical A.
say these
segments.
So I think we can display a staple
right alongside that Mike.
That's my thought, right?
You agree? Yeah, yeah.
Let's do a hand out from the back.
You want to scrub in, Jen?
Oh, yeah.
I got to go get six lymph nodes to
let me do that while you're doing
this
to hold that back like that.
Just gently.
Want to be way off for recurrent
laryngeal.
There is or pay.
So maybe those were five and six
guys, looks like they're just all
popped out.
I mean, like it looks like we got
them all.
Yeah, I want to dig in.
Yeah. So those fives make some of
those five, six guys split them.
All right. All right.
So take a look.
Here comes ICG now by.
Look at that.
And so there's your profusion.
Yeah, looks nice.
Yeah, there it is right there.
Yeah. Yeah.
All right, we're going to go.
All right then. Bring your stapler.
And this is real important
because she's now bringing in a
handheld stapler
as opposed to a robotic one just to
show the other ways to do that.
So why don't you start right
like that?
That's good. And slide it and go
right to the bronchus.
What's your tip this way, the flair
you go now we're talking.
Yeah, take that to start
then.
I need you to take a little bit more
of my.
OK, now I need you to take a little
more of an angle like this now
we need all this to go.
Yeah, I said so you're going to
slide in the
tip down, get your tip around
the whole long wiggle.
There you go.
That's an athlete.
Yep. That's nice.
Stay down.
We take it.
Nice move.
That should have it, don't you
think, Mike?
But what?
Take unless
you're saying
that that's got take it and the I
think are pretty close to the now
teenagers should be
there.
Take it.
I'll be really interested to see the
specimen.
Yappers calls
it fire.
And I'll take a little bipolar in my
hand now, unfortunately, and then
let's bag all right,
then get your bag ready in that one
hand.
Take out a robotic arm one
and three to one
go.
You just got to.
So when the bad comes in, we have
several moves out.
One, I grabbed the bag and hold it
under the diaphragm like this
stopped and I grab
just to make sure we don't get that
crease in there and we don't have a
little constriction point like a
belt around the bag, lift up
the bag and wiggle it.
So now it's open.
Three goes up, four drops
it in.
Foregoes goes out of the way three,
make sure it's in your clothes, and
then when you don't pull back and
we're sure it's not on any state
line now you pull.
The rain does not look to look
perfect,
so that's correct.
Just look at this, it looks funny,
deflated.
All right. Why don't you pull the
specimen out now, give it to Dr.
Zavos.
So just a quick point on this.
When you're completing a segment
or some lobar section for this
thing, it's always a good idea
to actually take a look at the
specimen at the back table and cut
into it A because you want to
confirm.
Your findings confirm the findings
that you have in the specimen with
your CAT scan findings and also
make sure that you have a negative
margin so you can actually.
Investigate and confirm all
three of those things when you're
doing this, so doctors will follow
you and I always like to do this on
the back table and confirm that.
OK, now let's
take this out
at.
All right, CO2 off
now you can dock,
then I'm going to want to watch this
one come up
all this year.
Now, I got a sucker to me,
right, just to put it in
my own.
Where are you
confident in bringing in.
That's good. Stop right there.
OK, now I want
you to bring the lung up.
I want to watch that come up with no
twist.
That looks good.
That looks nice.
Big breath and all.
I want to see the whole upper lobe
come up.
There you go. Hold it.
That's it.
That's what I want to see.
Another breath hold.
Yeah. Yeah.
There you
go. There you go.
Now it's up to
you. Be hypervigilant.
And you see that, Jency, what we did
and now we know there's no Twist's,
OK? That's how you prevent volvulus
and weird cases like this.
All right. Just in you put in.
So let's show you how we put our
chest if we take a great big giant
bite, because
even though we're hoping the tube
comes out in six hours, you might go
home with this tube tomorrow,
a good 10 or 12 percent.
Do you make giant
bites here loose on
the skin
just like this?
Nice move.
And then we do a half inch hole, the
tube up. This comes like this.
This goes the other direction and
around it. And another half a turn.
Now, look how tight that is.
You don't have the knot on top of
the other, not the knots actually on
your tube or whatever it is you're
showing in.
Nothing will ever come out this way.
You make this short so it doesn't
dangle on them, OK?
Small bites here, not big bites.
There's a one using.
She did I get it there,
I got there a little bit.
So you want to lift this up?
That's what I mean, you can't have
that stuff that has to be free like
that. She brought a patient away
from me. Please take the break out
now.
The level of patient, you know, very
important to take a big bite.
There's no not.
This is a really important technique
we use.
No, not technique makes a big
difference.
One.
So take a look how nice that look.
See, this is all the patient sees,
and if you don't use Knot's, they
love it.
You don't come back with problems.
And we get these bandaids, we
just put bandaids on them and we
actually take them off tonight if we
can, or first thing in the morning.
They don't get tape burns.
It's nothing worse than tape burns.
You do this beautiful, perfect
operation.
And what we do now is we cut them a
little bit long until we wash all
the soap off and wash her up.
Then we cut them at the skin before
she leaves the oh, or now we
take all this off so
they can get to work on the double
and we wash everything off.
This is important,
all this.
So when she wakes up, she doesn't
have this soap all over her
back one more time.
This matters, this is
the best time to wash this soap now
as it hurts or later
easier for us to do while she's
asleep.
OK, thank you, guys.
All right, good
job.
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