Page 191 - BSAVA Manual of Canine and Feline Head, Neck and Thoracic Surgery, 2nd Edition

BSAVA Manual of Canine and Feline Head, Neck and Thoracic Surgery

Initial placement of the telescope and blunt probe can
assist the surgeon in visualization of the target lesion and
VetBooks.ir lobes or accessory lobes are being resected, the pulmo-
in examination of any lymphadenopathy. If caudal lung
nary ligament must first be sectioned, which the authors
prefer to do using a J-hook monopolar electrosurgical
probe. An endoscopic stapler (e.g. EndoGIA, Covidien Inc.,
Mansfield, MA, USA) is mandatory for VATS lobectomy
and will place three lines of staples on either side of the
cut line, thus providing very secure closure of all airways
and blood vessels within the lung tissue. Several cartridge
lengths (30, 45 and 60 mm) and staple sizes (2.0, 2.5, 3.5
and 4.8 mm) are available. The 3.5 mm staple leg length is
generally recommended for endoscopic lung stapling in
dogs and appears to be very effective for a wide variety of
patient sizes. Some stapler cartridges incorporate an
‘articulating’ tip, allowing the surgeon to angulate the
Port placement for VATS lung lobectomy of the caudal lung direction of the staple line to suit their needs.
14.2 lobes. VATS = video-assisted thoracoscopic surgery. VATS tracheobronchial lymph node resection is pos-
sible and can be performed through a three-port approach
(Steffey et al., 2015).

Complications
Several important intra- and postoperative compli -
cations can be associated with VATS lung lobectomy.
Haemorrhage from intercostal vessels has been reported,
causing significant postoperative blood loss (Lansdowne
et al., 2005; Mayhew et al., 2013). Haemorrhage or air leak-
age from the pulmonary hilus can also occur if the stapler
does not function correctly or is incorrectly placed.
Iatrogenic damage to surrounding structures (especially
lung) can occur, and great care should be taken when
passing instruments through thoracic cannulae. The most
common reasons for conversion of a VATS lung lobectomy
to an open approach are failure of OLV and haemorrhage
(Lansdowne et al., 2005; Mayhew et al., 2013). Conversion
to an open approach was necessary in 4/9 and 1/23 dogs
Port placement for VATS lung lobectomy of the cranial lung
14.3 lobes. VATS = video-assisted thoracoscopic surgery. operated on in two studies (Lansdowne et al., 2005;
Mayhew et al., 2013). When resection of primary lung lobe
tumours was compared between VATS and open
approaches, there was no difference in the ability to obtain
VATS-assisted lung lobectomy – surgical a clean margin of resection for these tumours with either
technique approach (Mayhew et al., 2013).
Once the lesion has been visualized from the telescope
portal, an ‘assist’ incision is created one to two spaces
caudodorsal (for cranial lobe lesions) or craniodorsal (for
caudal lobe lesions) to the lesion. The length of this inci- Postoperative considerations
sion is generally made in proportion to the size of the
lesion to be exteriorized, but in one report varied from 2 to Appropriate postoperative management of the thoracic
7 cm (Wormser et al., 2014). It is helpful at this point surgery patient is essential for success (see also Chapter
to insert a commercially available wound retraction device 1). Problems include: hypoventilation; haemorrhage;
(e.g. Alexis wound retractor, Applied Medical Inc., Rancho hypoxaemia; hypothermia; postoperative pain; acidosis;
Santa Margarita, CA, USA) into the intercostal incision to oliguria; shock; and death (Figure 14.4). Patients should be
facilitate lung lobe exteriorization without causing iatro- in a facility that is staffed with trained personnel 24 hours a
genic damage to the tissues. Once exteriorized, the lung day to allow close monitoring and optimal outcome.
lobe can be resected using either endoscopic staplers or Postoperative hypothermia is common and is treated
traditional surgical stapling devices used for open thoracic by slowly warming the patient with warm blankets or
surgery. The resulting thoracotomy incision is then closed forced hot air patient-warmers. Hypothermia exacerbates
in routine fashion. acidosis and hypotension and can potentiate oliguria. The
surgery, postoperative haemorrhage, fluid losses, pain,
anaesthetic drugs and hypothermia can lead to hypo -
VATS lung lobectomy – surgical technique vol aemic shock. Intravenous fluids should be administered
For VATS lung lobectomy, OLV is mandatory to enable and urine output carefully monitored. Hypovolaemia and
sufficient visualization of the pulmonary hilus. OLV can decreased urine output should be corrected early.
be induced using a variety of modalities, including endo- Hypoventilation results in respiratory acidosis and
bronchial blockers, double-lumen endobronchial tubes can worsen hypoxaemia. Hypoventilation may result from
and selective intubation. anaesthetic medications, postoperative pain, thoracic

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