Clinical Challenges in Thoracic Surgery: Robotic Segmentectomy - Lessons From 30 Years in the OR with Hopkins’ Dr. Stephen Yang

Welcome to Behind the Knife. I'm Kyler Ozzi, a PGY three general surgery resident at Johns Hopkins. And today I'm thrilled to be joined by an expert in thoracic surgery, professor of surgery at Johns Hopkins, Dr. Stephen Yang. Dr. Yang is extremely clinically active, a fierce medical student and resident advocate and master surgical educator. It is a distinct privilege to get to learn from and work with you, Dr. Yang. Thank you for being here. Well, thanks Kyle. This is really a great honor and a thrill for me to be on Behind The Knife. I've listened to a handful of these. I'm very excited to do this. Hopefully we can do another one and for the audience out there, Kyle is a great resident, so you'll be hearing more from her in the future. So don't recruit her away from me, please. Thanks Dr. Yang. I'm pretty excited to be here with you too. Today we're gonna be discussing robotic segmentectomy. To provide a brief historical

context, segmentectomies weren't always used in lung cancer surgery as they are today. Oncologic thoracic surgery has been evolving over the years. Back in 1912, Dr. Davies performed the first lobectomy specifically for lung cancer. After that, in 1933, Dr. Graham did the first pneumonectomy. This maximally invasive approach was the standard for years until the 1950s and sixties when Dr. Kahan popularized the radical lobectomy. Then the management of early stage lung cancer, specifically, those as small peripheral tumors got more controversial into the 1990s when the idea of using a more limited subar resection entered the scene in 1995, the lung cancer study group published a randomized control trial that found because of higher death rate in local regional recurrence rates associated with more limited resection. Lobectomy should still be considered standard of care for peripheral T one N zero non-small cell lung cancer. This was accepted for years until

advancements in CT imaging reignited the conversation about sub low resections, which resulted in J Cogo 8 0 2 and Cal gb, which together gave rise to the use of sub lobar resections for these early stage peripheral tumors. What was it like practicing through some of those changes? What advice do you have for surgeons in general with regards to the need to constantly adapt and evolve? Yeah, so thanks Kyle. It's, I did, I've been in practice for 30 years now and if you had another 10 years during my training practice has really changed from a pretty radically, I might give a Hopkins plug for Dr. Rain William Roff. So he was a thoracic surgeon here at Hopkins and also performed the first pneumonectomy for lung cancer. And a patient that eventually survived chronologically. He did it before Dr. Graham, which is some debate, but he didn't get credited for it. Dr. Aranoff actually did what's called individual ligation of the artery and the vein of

the bronchus, which is what we use these days. Dr. Graham and his colleagues all did a big tie around the hilum, so you can see even from that, we've evolved technically in actually how we take out the different sections of the lung. Yeah, so it has changed and what I usually tell folks is that what you're practicing now will probably not be what you're gonna be doing in 20, 30 years. And if you're still teaching what you're doing that you trained in residency, you're going to be behind the time. It's good to be open, you're going to go through this lifelong learning. So techniques will change, but it's also important to really know. Everything. So just because we're doing mostly robotic doesn't mean you can't, you shouldn't know how to do thoracotomy or vats. So I think it's important to know all the techniques and you all are gonna be challenged. 'cause as technology changes, you're gonna have to know that as well as know some of the old techniques. It has been game changing as far as the different techniques

from open to robotic. When I was training, we were doing big posterial thoracotomies, even for wedge resections. Most of our lung resections now obviously are lobectomies, but they did do quite a few open segmentectomies, and I've always felt that segments were appropriate for smaller tumors and we were part of the C-A-L-G-B trial, and that took about 14 years to get the final results. But I think it's important that you should know where we came from in order to progress in the future, but. That's why I spend a lot of time on history. I love teaching history. So the other thing is that when you first start your practice, yes, segmentectomies are pretty sexy and you gotta do what's right and do what you're comfortable with. So when you first start out, don't do a complex robotic segmentectomy, which will take hours. But what I do tell folks that your first case when you start your practice will

define you. So if you do a complex operation for your first case and. And it takes hours and you may have complications that will unfortunately define your practice. Start out easy, do a quick wedge, and if you wanna do a segment, you can always do an open, or if you're more comfortable with vats, if you haven't had any robotic experience, just do something that you can get done easily so that people know that you're a competent surgeon. Um. And the other is that as you start moving forward, make sure that you would hear the standard oncologic principles that sample the nodes or dissect out the nodes that you check the margins, and that you look at your long-term results. So you know, not only see the patients for their first post-op visit, you should be seeing them long term to make sure that if you are doing segmentectomies for these peripheral nodules, that your outcomes are good. Because if your outcomes. Aren't as good as

lobectomies and you're doing something wrong, and obviously we need to serve the public properly and not do something fancy just because we want to do it. Excellent. As a resident, I do think it's exciting to latch onto all the technology and the beauty that is the robot, but it's important that we don't lose those open skills in the process. You referenced a little bit of the different complexity of the cases. Not every segmentectomy is created equal, that's for sure. A more complex segmentectomy versus a simple one is a resection where more than one inner segmental plane is divided. Segmentectomies require a really good 3D understanding of anatomy, and that's great. In the robotic world, advances in MDCT and volume rendering reconstruction software have allowed us to prepare for the highly variable thoracic anatomy, which can be encountered. Specifically important is the identification of inner segmental veins as these are the landmarks we use during segmentectomy to define the boundaries of the target. Dr. Yang,

when preparing for a case with imaging, what are the most important things to consider? Well, I think just the basic standard 3D reconstructions of the CT scans are important. I study the scans, I look at the sagittal cuts, I look at the coronal cuts. I try to follow on all the. Vessels these days with high resolution CT scans, you could see all the, you can differentiate the PA segmental vessels from the pulmonary vein. So if you do that, and I think, again, I grew up the old fashioned way. You just do it these days. There's a lot of other techniques used in the or. If you divide the artery early, you can give ICG and see where it's not profused. And certainly the old time when you cut the bronch. As you can see what part of the lung deflates, I don't use the inflation technique just because there is collateralization between the different segments. Those are called the pores of con. Those of you

studying, if you're board exam, you better know that sometimes you can actually see the intra segmental uh, fissures. Intraoperatively, you can see some lines where the, especially if there's anthropos in the lungs, you can actually see where it stops. So after I do the CAT scans, I try to make sure I know which segment it's in. Then I'll do the bronchoscopy to make sure the endoscopic anatomy is normal if I'm not quite sure which segment it's in. But I do use the ion, the robotic ion, and we will bring the interventional pulmonary team. IP team comes in to. Mark the nodule A. It is good to find where the nodule is, but B, it actually tells me which segment it's in. So specifically if I have trouble with the segment six, if it's in six or say nine 10, they can tell me which segment it's in, and obviously they're using Firefly to find the nodule is important. So those are little things that I do to try to

figure out these tiny nodules and inner segmental. Planes. And maybe just to step back a little bit, why is Segmentectomy important these days? We're being much more aggressive, especially patients with borderline lung function, at least here we have a lot of patients who have mets to the lung and if they have failed systemic therapy and we can actually afford them a good survival with metastas ectomies. Not all mets are come out with wedges and some do require. A small segment, and so we have extended segmentectomies for pulmonary metastas ectomies for certain patients when treating mets to the lung. Preserving post-op lung function is of particular importance as the patients may have recurrences, which require reoperation. Segmentectomy also allows us to evaluate lymph nodes, which can offer valuable data to inform prognostication for the

patient. So now you've reviewed all the imaging, thought about the patient, and decided that segmentectomy is the correct operation. Now, you're in the or. Positioning generally involves a left lateral decubitus with a flex bed to open up the intercostal spaces. Can you walk us through your setup when performing a robotic segment? Text me. What are the most important considerations when positioning? How do you think about where you want to place reports? I always prep for lobectomy. I'm a very simple surgeon. I don't wanna have specific port placements for specific segments. The general rule for upper lobes I'll, I go above the ninth rib through the eighth intercostal space for the middle and the lower lobes. I will go through the ninth intercostal space or above the 10th rib. I like to put all my ports through basically the same inner space to prevent a lot of neurologists. So. I align all the ports up to the

usual hook and horn. So the ports are about four or five centimeters apart. And then I'll usually use an air seal port for extraction. Sometimes I can get by with just four arms, especially if the resident's not there. I use fifth port just for teaching, but they can usually get by without an air seal port. So that's how I start where I put my port sites. Again, in general, for upper lobes, I'll use. Two 12 on the right hand side, there'll be on arm two and arm four on the left hand side there, and arm one and three. And I think it's important, like on the right hand side, I always put my Maryland dissector. So if some people like to use cautery, I always put it in the fourth arm. So I'm using my, my right hand. On the left hand side, I actually like to use my left hand, so I'm coming through. Port one to do all my dissection. A lot of people still use their right hand through port four. You know, we're all, we should be

bimanual. So I encourage you all, if you're doing left sided surgery to use your left arm because it's actually a lot easier to go up that fisure on the left hand side through port one. I don't modify the size ports so. Now there's an eight millimeter stapler, so you don't need as many 12 millimeter ports. If it's a very complicated segment, I usually do use two 12 ports for two so I can, so I can have all options for doing the stapler. So I'd rather be safe and have options as opposed to try to do what I usually do for a lobectomy. That's my port placement, and then we just start the dissection. Then we get in there. You do a hilar. Nodal sampling or dissection if there's nodes that you're concerned about. The protocol said you do frozen sections in there, but I'm pretty comfortable with negative PET scans and negative ebus that I just proceed and do my sampling and staging. It

won't do intraoperative Frozen sections, I consider three levels. The segmentectomies, there's the easy, the moderate, the most difficult, easy ones are superior segment. Posterior segment. I think the most difficult one is the left lower lobe segment nine 10, because you have to bisect the superior segment from the basar segment safely without damaging the descending pulmonary artery. And then you just take out post the posterior lateral segment. I think all the other ones are intermediate or moderately, a difficult segmentectomy. When you're. In starting out, do the easier segmentectomies and always make sure you're ready for disaster. Have small clips ready, have sutures ready in case you have trouble with bleeding. Make sure how to convert to an open operation. Quickly put a sponge or something to

put pressure on the bleeder. Now the other thing I tell people, don't push as hard as you can. 'cause the harder you push, the more you'll tear the pulmonary artery. So just. Enough pressure to keep the bleeding from making it audible bleeding and make sure that whichever arm that you're going to control with that bleeding is that if out of the way, it can control and can keep the tampon nod as you convert to an open thoracotomy. I think a lot of surgery residents out there can recall a time or two. Their left hand has been reminded to get in the game a bit more, myself included. And that tip about moderating pressure with bleeding. That's a good one. I can imagine the stress of that situation could cause someone to wanna put a lot of pressure, but more isn't always better. I am curious, Dr. Yang, I know you're all about challenge. Do you have a favorite type of segmentectomy? What gets you most excited? I do do

like those complex ones. I figured those difficult ones over time. As you, when you get to my age or. You are tired of doing the same lobectomies and you start veering how you and I, and again, this is just another teaching point. If you're doing lobectomies, you, I am sure there's one way of doing it that people tell you, you vary it a little bit just because there are some times that you know you have to change the approach. Like most people say for a right upper, upper lobe, you go from posterior to anterior, but sometimes that posterior part is so stuck, so you do have to go anterior to posterior or say you don't have a fissure. Some people will do a fishless lobectomy. Yeah, I think all segment techies are challenging. You know, with the software you should be able to predict the anatomy. I'm still an old time search and destroy, but I do study the CT scans pretty carefully, so any segmentectomy is actually my favorite segment tech. I love doing segments. It's just we're, I think we do, I think last time I heard we do the most here in the United States.

I think it's important, you know, don't do it just to do it, but I'm, again, make sure you do it for the right purpose. I always double, double and triple check myself. I think the other point, maybe related to a previous question is that when you're not quite sure what instruments you're going to use, you know, make sure you do think about it and let your team know. I sent an email to the team the night before to make sure they know which instruments I specifically want, how many ports, what size ports I want. Do you want the eight millimeter or the 12 millimeter stapler? There's clearly a lot of thoughtful preparation and technique that goes into these cases, but sometimes despite these efforts, complications including more common one like air leaks do happen. Is there anything specific that you feel is a technique or an approach that keep your postoperative air leaks particularly low? I think one is the meticulous dissection in the fissure. So I preferably like to get

the PA first. I like to devascularize it so that lobe or segment doesn't get congested if you take the vein first. So I do take great care in trying to stay in the plane between the lobes. So that's one point I think that does minimize some of our air leaks. And then when you're dissecting out the segmental bronchis to stay right on the airway. And again, I was classically taught not to do that because it devascularize the bronchus. But again, knock on, we haven't had a lot of problems with broncho pulmonary fistulas, so you just stay right on the plane of the bronchus so you don't violate that visceral pleura. When you staple, you make sure you use the appropriate thickness stapler. I try not to cross the staples. One thing I, I do for, specifically for the, the superior segment and the basler segment, I'll

actually cut the superior segment like a pyramid, so like a little, I guess what you call the samosa. And so I'll, I'll cut it like a little pyramid so it's, you're not just going straight across the basin making that suture line so tight, so. I'll actually take one stapler along the fissure where it's nice and thin, and then I'll come almost at 90 degree angles from the back and from the front to make it like a little pyramid. So I do that if I'm doing a basar segmentectomy, if I'm doing a, a superior segmentectomy. And I try to do that with some of the other segments as well. I think a lot of people think they just guillotine right across the base, but I think the thickness of the tissue. It can tear away from the staple lines that way. So again, if those of you are doing this and you are using the black loads and you know when you close it and it takes a while for it to properly close all the way, I think if you take it from different directions and make it, try to

make it not so thick. And I think the other thing from when you properly close the bronchus, classically, when we, when Ray Roff, where I talked about earlier. When you do the individual closing of the bronchus, you always want to close it from the cartilaginous rings to the posterior membrane because if you close it at a different angle, then the cartilage is gonna fracture. So I always try to make sure that when I fire the stapler, that I close it like an an anterior to posterior direction so that the cartilaginous rings come down toward the posterior membrane. Wow. Lots of pitfalls, lots of tips and tricks there. Dr. Yang, one of these days, I'm gonna convince you that this should be a video recording. You talk with your hands there. I think the people need to see it, but I know you're not about that too much. And I'm sure amongst everything that you just said, nothing's more valuable in avoiding catastrophe in the or. There's complications than experience, which I know you just have so much of. So it's really

been a pleasure talking with you, Dr. Yang. Last question. What excites you most about the future of robotic surgery? Where are we going from here? So I think that technology will continue to get better. Just in my 20 years of doing robotics, I've already gone through five platforms. A new platform will come out and there's different ways of doing it. There's gonna be feedback, there's gonna be ways that you don't have to stick your head out of the console. Everything will be a automatic and the images will overlay the lung. I know there's programs right now, so that. Hopefully it develops a hologram of the lung so you can see the nodule as you're looking inside the monitor. It's, it sounds like science fiction, but that's where I think it's headed, and I think robotic surgery's just gonna be getting better and better. So again, I think the sky's the limit with surgery. I love Thoracic just because we do so many different things. We have a very wide range of procedures that we offer

robotic surgery, and Segmentectomies is just a small portion of that, but that I, as I said, I love teaching you all how to do robotic surgery, and you know that it'll just get better. Dr. Yang, this was fantastic. Your passion is evident. Some quick hits as we wrap up here. Number one. Reflect about where we've come from and be willing to adapt and evolve into the future. Number two, preparation builds confidence. Use CT scans and 3D recons to create a map to your lesion. And number three, vary your operative approach. Perform meticulous dissection and be sure to follow your outcomes. This is how we improve. So thanks so much for being here and reviewing robotic segmentectomies. It's been really special. Thanks, Dr. Yang. This has been Johns Hopkins thoracic surgery team signing off. Until next time, be sure to dominate the day. Dominate

the day.