Page 216 - Clinical Manual of Small Animal Endosurgery

204 Clinical Manual of Small Animal Endosurgery

In some cases of partial lobectomy it is possible to exteriorise the
affected portion of the lung lobe by conversion to a mini-thoracotomy
of one of closest port sites, with no rib retraction to reduce postoperative
pain. After the affected region and a margin of normal lung have been
exteriorised, standard stapling or suture techniques are used before resec-
tion just as in open thoracic surgery, and the remaining lung then replaced
in the chest at the end. Using this technique it is possible to utilise recently
available hydrolysable lung sealants (PleuraSeal, Covidien) to help
prevent air leakage postoperatively, should this be judged a risk.
Port-site selection is based on preoperative radiographs of the specific
patient’s anatomy, as well as the lobe to be removed. Patients are posi-
tioned in lateral recumbency. For lobectomy of the caudal lobes, a ventral
and two dorsally placed ports, in a triangle, allow the best visualisation,
manipulation and dorsal access to the hilus, although the ergonomics
may be awkward. For the other lobes, ports are best placed some dis-
tance caudo-ventral to the intended hilus or resection site, to allow an
adequate operating space and visualisation, ergonomic triangulation of
instruments and sufficient lead-in distance for the insertion of the endo-
scopic stapler, if the procedure is to be performed thoracoscopically.
When performing partial or complete lobectomy, hilar lymph node
biopsy is highly recommended and should always be performed in cases
of suspected neoplasia. Cup biopsy forceps can sometimes result in
tearing loose of the lymph node and associated haemorrhage, and, if
access allows, biopsy is best performed with stabilisation of the lymph
node with atraumatic grasping forceps. Incision of the overlying medi-
astinum or capsule also results in fewer histological artefacts.
Whereas some authors favour single-lung ventilation for lung lobec-
tomy (Lansdown et al., 2005; Laksito et al., 2010), this increases anaes-
thetic time as well as having effects on anaesthesia (see above), and
requires attentive monitoring throughout. Single-lung ventilation requires
bronchial intubation or endobronchial blockers inserted in the operated
lung side. Levionnois et al. (2006) reported the accidental entrapment of
an endobronchial blocker tip by staples during a lobectomy, and recom-
mended the removal of the guidewire before staple placement, if this
mode of single-lung ventilation is used. However, there is a learning curve
to both techniques.
The use of a pericardial fat pedicle to reinforce the bronchial stump
in humans undergoing a video-assisted lobectomy to reduce the risk of
the postoperative development of a bronchial fistula has been reported.
This perhaps merits further evaluation, as does endosurgical application
of lung sealants such as PleuraSeal, to help prevent air leakage, in selected
veterinary patients such as those undergoing pneumolobectomy.

Thymoma resection

Mayhew and Friedberg (2008) described the thoracoscopic resection of
modestly sized, non-invasive thymomas in two dogs in which preopera-