The vessels that supply and drain blood from the lung tissue are identified and carefully dissected away from the heart, ensuring that no damage occurs to the heart itself. Once adequately separated, the vessels are divided, allowing the lung tissue to be removed. Ensuring proper hemostasis (control of bleeding) is crucial to prevent excessive blood loss. Throughout the process, the vessels are gently handled to avoid injury to adjacent structures.
The lobar bronchi are the primary branches that supply air to each lobe of the lung. These divide further into segmental bronchi. During lung resection, the lobar and segmental bronchi are carefully identified and divided. Precise division of these structures ensures successful removal of the affected lung tissue while preserving adjacent healthy segments. Surgeons must be aware of variations in bronchial anatomy to minimise complications and achieve optimal outcomes.
During anatomical lung resections, the division of lobar or segmental lung parenchyma is a critical step. Real time visualisation of blood flow can be achieved using a near-infrared camera and Indocyanine Green (ICG), a fluorescent dye which can be injected intravenously to assess vascular perfusion. ICG-guided division minimises the risk of ischaemia (lack of blood flow) to the remaining lung tissue, and ensures preservation of lung function and optimal oncological outcomes.
A thymectomy is a surgical procedure to remove the thymus gland; it is often performed to treat disorders such as myasthenia gravis or thymoma. During surgery, the phrenic nerves, the only source of motor innervation to the diaphragm, are identified and preserved to prevent diaphragmatic paralysis. Care must also be taken to safely divide the vessels from the brachiocephalic vein; this is typically achieved through careful dissection and use of specialised surgical instruments.
The procedure is performed via three 1-centimetre incisions between the ribs on the side of the paralysed diaphragm. The diaphragm, which has been paralysed or is lax, is folded onto itself and then sewn into place. This is done to tighten the diaphragm and increase its tension. This technique of plication effectively reduces the volume of the paralyzed hemidiaphragm, thereby increasing the volume of the thoracic cavity and improving respiratory function.
The parietal pleura overlying the lesion is excised using a robotic electrocautery. This step exposes the lesion and the underlying structures. The intercostal muscles are carefully divided to allow access to the lesion. The intercostal nerves and vessels are identified and carefully divided. The lesion is then carefully dissected away from the surrounding lung tissue. The dissection continues until the lesion is completely freed. The resected lesion is placed in a retrieval bag and removed from the thoracic cavity through one of the port sites.
The surgeon uses the robotic camera to visualise the ribs and identify the intercostal space, which is the space between two adjacent ribs. A needle driver is used to advance a needle into the identified intercostal space. The needle is carefully positioned between the intercostal muscles and the parietal pleura. Once the needle is in the correct position, a local anesthetic is administered through the needle. This blocks the intercostal nerves that run in this space, providing pain relief during and after the procedure.
Dr Periklis Perikleous, Consultant in Thoracic Surgery at St George's University Hospitals NHS Foundation Trust in London, United Kingdom
With practicing privileges at Spire St Anthony's Hospital in London, United Kingdom
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