Left Lower Lobectomy Research Articles

A rare presentation of aorto-bronchial fistula and the relevance of open repair in endovascular era

Aorto-bronchial fistula is a rare but potentially fatal condition due to torrential bleeding from erosion of aneurysmal wall into bronchial wall or lung parenchyma. It is usually associated with infection, lung transplantation, pulmonary malignancies, atherosclerotic and mycotic aneurysms, and anastomotic pseudoaneurysms after open or endovascular surgery. The typical presentation usually manifested by haemoptysis, but rarely the patient also can be presented with hematemesis and this will delay the definitive treatment. Surgical or endovascular repair is mandatory because non-operative management will lead to a poor prognosis due to massive bleeding from the fistula. We would like to present a unique case of an elderly man presented with intermittent haematemesis, in which he later developed profound haemoptysis and diagnosed with ABF. Although in the era of endovascular, the ABF was successfully treated via open thoracotomy, resection of thoracic aorta aneurysm, left lower lobe lobectomy, and completed with aortic repair using Gelweave aortic graft.

SUN-491 A Diagnosis of Thyroid Cancer Reveals a Triple Threat

Introduction: The risk of secondary malignancies is increased in patients with papillary thyroid cancer (PTC). It is not completely clear if this risk is due to radioactive iodine treatment or due to other causes. We present a case of a patient diagnosed with papillary thyroid cancer (PTC) found to have lung cancer and small lymphocytic lymphoma which appear to be unrelated to radioactive iodine treatment.Case Presentation: A 72 yo woman with a history of Graves’ disease, atrial fibrillation, and hyperparathyroidism initially presented to care for weight loss. She was found to have hyperthyroidism and was treated with methimazole. Thyroid ultrasound revealed multiple nodules including a 17mm right lower pole nodule with irregular borders for which she underwent FNA. Pathology demonstrated atypical-cells of undetermined significance (AUS), but thyroseq revealed a BRAF V600E mutation. She underwent total thyroidectomy with pathology showing multifocal thyroid cancer, 12mm and 0.8mm with 3/11 involved lymph nodes and right parathyroid adenoma. Given a questionable lower left lung nodule on preop CXR, she underwent CT chest which revealed a 2cm lung nodule. She had video assisted thoracoscopic (VATS) left lower lobe wedge resection with completion left lower lobectomy for a 3 cm lung adenocarcinoma with negative margins and 33 negative lymph nodes. She was subsequently treated with RAI after recovery from VATS procedure. Pretreatment thyroglobulin was 0.8 ng/ml with negative thyroglobulin antibodies. One month after her RAI treatment, ultrasound of the neck revealed suspicious bilateral level IV lymph nodes which increased in size during short term follow up. Serum thyroglobulin was 0.3ng/ml with negative antibodies and TSH 0.29 mIU/L. Biopsy of right level IV lymph node was positive for PTC with thyroglobulin washout >5000 while left level IV lymph node was negative for PTC and Tg washout was 0.1. She subsequently underwent right-sided modified radical neck dissection, with lymph nodes revealing PTC also involved by small lymphocytic lymphoma. She had repeat RAI ablation for thyroid cancer and is being actively monitored for her small lymphocytic lymphoma and lung adenocarcinoma.Conclusion: We present a patient with no known history of malignancy who presented with 3 de novo primary malignancies. This case may demonstrate an increased risk of malignancy in patients with thyroid cancer not necessarily related to radioactive iodine treatment.

VATS lobectomy outcomes in octogenarian patients: a retrospective series

: The proportion of octogenarian patients is growing over years. Nowadays video-assisted thoracoscopic surgery (VATS) permits to treat old age patients, even with limited pulmonary function, not otherwise suitable for surgery. The aim of our study is to analyse the factors influencing short and long terms outcome of the octogenarian patients underwent VATS lobectomy. Between January 2013 and March 2019 we performed 292 VATS lobectomies of which 26 patients were octogenarian. The patients’ population were divided in two groups according to patient’s age (group 1: patient younger than 80 years old; group 2: older than 80 years old). The octogenarian patients had higher post-operative complication (POC) rate and hospital stay than the younger patients. Surgeon’s learning curve was significantly associated to higher POC in both group of patients (group 1: P<0.002, group 2: P<0.001). Patients of both groups who underwent VATS lobectomy performed by resident surgeon supported by a skilled tutor had a significantly lower risk of POC (group 1 and group 2: P<0.001). Right upper lobectomy was significantly associated to higher risk of POC in both groups [group 1: P<0.008, relative risk (RR) =1.7 and group 2: P<0.032, RR =1.5] whereas left lower lobectomy showed higher risk of POC only in group 1 (P<0.03, RR =1.9). Hospital stay was significantly influenced by POC (group 1: P<0.001, group 2: P<0.03) and by post-operative atrial fibrillation in octogenarian group (P<0.04). Overall survival was influenced by lung cancer’s stage but not by age and POC in both groups. In conclusion octogenarian patients should undergo surgery after a completed pre-operative assessment due to their comorbidities. Post-operative outcome and overall survival of elderly patients are comparable with younger patients.

Surgical outcomes of segmental bronchial sleeve resection in central non-small cell lung cancer.

BackgroundThe purpose of this study was to present the clinical and surgical results in patients who underwent segmental bronchial sleeve reconstruction.MethodsThe clinical and pathological data of 16 patients with central non‐small cell lung cancer (NSCLC) who underwent segmental bronchial sleeve resection from April 2015 to May 2019 were retrospectively analyzed.ResultsAccording to the type of segmental bronchial reconstruction, procedures were divided into four types: right upper S6 sleeve lobectomy in three cases (type A); left lower lingular sleeve lobectomy in 10 cases (type B); left upper S6 sleeve lobectomy in two cases (type C); and left lower propriolateral superior sleeve lobectomy in one case (type D). A total of three patients (18.75%) experienced anastomotic complications, including two with anastomotic stenosis and one with anastomotic fistula. All patients achieved R0 resection. Apart from one patient who died of acute lung infection after surgery, the rest were successfully discharged. The average follow‐up time was 28 months, and the overall survival rates of patients at one, two, and three years were 80.0%, 53.3%, and 40.0%, respectively.ConclusionsSegmental bronchial sleeve resection is complex in technique and may have an increased risk of complications compared to a standard sleeve resection, but it is an effective and safe procedure, especially for selected patients with central lung cancer.

Perioperative chemoimmunotherapy in a patient with stage IIIB non-small cell lung cancer.

We present a case of a 56-year-old male patient with stage IIIB (T3N2M0) poorly differentiated squamous cell carcinoma of the lung. Four cycles of chemotherapy were first applied, and the patient had stable disease. However, the patient refused to receive radiotherapy, therefore second-line treatment chemotherapy combined with anti-PD-1 immunotherapy was applied. Partial response was reached at the 4th cycle of chemotherapy combined with anti-PD-1 immunotherapy. The neoadjuvant strategy was prolonged to 10 cycles but no significant change was observed on tumor size. The patient then underwent video-assisted thoracoscopic left lower lobectomy. Eight cycles of adjuvant PD-1 immunotherapy were applied postoperatively. Perioperative immunotherapy demonstrated good curative effect in this patient and no recurrence was observed at the clinic 40 months following surgery. Here we intend to explore the concept of immunotherapy combined with chemotherapy and surgery in neoadjuvant and adjuvant setting, and to investigate the possibility of extending this strategy in patients with stage IIIB non-small cell lung cancer (NSCLC).

Intravenous drug use causing Enterococcus Faecalis bacteraemia, mycotic pulmonary artery aneurysm and suspected Mucormycosis

Background 33 year old previously fit and well lady with a history of previous drug use presented generally unwell with shortness of breath and cough. Methods Initial investigations demonstrated marked inflammatory response with bilateral pneumonia on chest xray. She was initially treated for severe community acquired pneumonia. On day 3 of admission blood cultures isolated Enterococcus faecalis, which was later also isolated in sputum. Results Transthoracic echo demonstrated no evidence of vegetations to suggest endocarditis. Despite appropriate antibiotic switch inflammatory markers increased, and a groin abscess was suspected on clinical examination leading to CT angiogram in addition to CT thorax. Imaging demonstrated left ileofemoral DVT and a large pulmonary artery aneurysm with multiple cavitating pulmonary lesions. Following discussion with cardiothoracics the patient was transferred to a cardiothoracic centre for left lower lobectomy and lingulectomy. Histopathological perioperative samples showed branching fungal hyphae within multiple blood vessels, although 18s PCR returned as negative. The patient had a good clinical response with IV Amoxicillin and antifungal therapy - Oral Posaconazole was used as she suffered an adverse reaction to liposomal Amphotericin B. Discussion Final impression was of mycotic pulmonary artery aneurysm caused by Enterococcus faecalis with suspected mucormycosis as result of intravenous drug use. This case highlights the increased risk of mucormycosis in people who inject drugs.

Efficacy and safety of thoracoscopic bronchial sleeve lobectomy for central non-small cell lung cancer

Objective To explore the efficacy of thoracoscopic bronchial sleeve lobectomy for central non-small cell lung cancer (NSCLC), and to evaluate the safety of this operation. Methods The clinical data of 29 patients who underwent thoracoscopic bronchial sleeve lobectomy at Shanxi Provincial Cancer Hospital from May 2015 to September 2018 were retrospectively analyzed, and the surgical effect and safety were analyzed. Results Twenty-nine cases underwent thoracoscopic bronchial sleeve lobectomy. The types of resection included 13 cases of right upper, 10 cases of left upper, and 6 cases of left lower sleeve lobectomy. The operation time was 180-400 min, and the median time was 240 min. The bronchial anastomosis time was 35-60 min, and the median time was 48 min. The intraoperative blood loss was 150-460 ml, and the median blood loss was 220 ml. The number of lymph node dissection was 12-39 lymph nodes per patient, with a median of 19.6 lymph nodes per patient. The thoracic drainage tube was placed for 4-16 days after operation, with a median of 6 days; the postoperative hospital stay was 6-16 days, with a median of 9 days. The postoperative complication rate was 24.1% (7/29), including 1 case with pulmonary air leakage (> 7 days), 2 cases with pulmonary infections, 3 cases with arrhythmia, and 1 patient discharged from the hospital on the 7th day after surgery, but died of anastomotic fistula bleeding on the 40th day. The rest of the patients recovered smoothly after surgery. The median follow-up time was 6 months (3-12 months). No tumor recurrence or anastomotic stenosis was observed. Conclusion Thoracoscopic bronchial sleeve lobectomy is a safe and feasible surgical treatment for central NSCLC. Key words: Carcinoma, non-small-cell lung; Thoracoscopes; Sleeve lobectomy

Pulmonary artery reconstruction using a common basal artery wall flap in completion left lower lobectomy after S&lt;sup&gt;6&lt;/sup&gt; segmentectomy

Pulmonary artery reconstruction using a common basal artery wall flap in completion left lower lobectomy after S&lt;sup&gt;6&lt;/sup&gt; segmentectomy

A rare ectopic ACTH secreting atypical pulmonary carcinoid- case report

Pulmonary carcinoids are rare pulmonary neoplasms which account for 1-2% of all lung neoplasms. Pulmonary carcinoid tumors are a rare cause of ectopic ACTH secretion. The incidence of Cushing's syndrome in pulmonary carcinoid tumor is approximately 1%. A case of 25-year-old young male with typical cushingoid appearance presented with headache on and off and episodes of hypertension since 1year.Thoracic CT revealed a nodular region in left lower lobe. The patient underwent left lower lobectomy and histopathology revealed an atypical carcinoid tumor. On immunohistochemistry, tumor cells were positive for CK PAN9, CD117, S100, TTF-1, synaptophysin, chromogranin and negative for P40, CK7, Her-2 and CD99.This case is presented for its rarity.

Emergent Left Lower Lobectomy Under ECMO for Massive Hemoptysis During TBB

Emergent Left Lower Lobectomy Under ECMO for Massive Hemoptysis During TBB

How thoracoscopic left lower lobectomy with systematic mediastinal lymph node dissection is performed using 4K video-thoracoscopy

How thoracoscopic left lower lobectomy with systematic mediastinal lymph node dissection is performed using 4K video-thoracoscopy

Left middle and lower sleeve lobectomy for lung cancer in a patient with complete situs inversus

Left middle and lower sleeve lobectomy for lung cancer in a patient with complete situs inversus

Trousseau's syndrome associated with pulmonary pleomorphic carcinoma exhibiting aggressive features: A case report.

Trousseau's syndrome is characterized as an unexpected, cancer-related thrombotic event, such as a cerebral infarction or a deep vein thrombosis/pulmonary embolism. We describe the first reported case of Trousseau's syndrome with pulmonary pleomorphic carcinoma and aggressive features. A 74 year-old man presenting with a pulmonary mass, which was identified as pleomorphic carcinoma with extensive lymph node involvement, in the left lower lobe, underwent a left lower lobectomy. Immunohistochemical analysis revealed that neoplastic cells exhibited an extensive expression of tissue factors with a mucin-producing adenocarcinoma component. Three months postoperatively, diffuse infiltration rapidly appeared in the left lung, which was identified as lymphangitic carcinomatosis via bronchoscopy. Prior to treatment for cancer recurrence, the patient presented with a left hemiplegia due to a cerebral infarction via multiple thromboses, with no evidence of atherosclerotic or cardiogenic thrombi. Elevated D-dimer and carbohydrate antigen 125 levels and the presence of a fibrin thrombus retrieved from the occluded vessel suggested Trousseau's syndrome as the etiology of the brain infarction. A hypercoagulable state associated with the aggressive recurrence of pulmonary pleomorphic carcinoma, accompanied by cancer cell production of mucin and tissue factors may be a potential mechanism for cancer-related thrombosis.

Obstructive pneumonia owing to migration of a Teflon pledget at 8\u2009years after surgery for a pulmonary carcinoid tumor: a case report

BackgroundIt is uncommon for a bronchial stump-related complication to develop during the remote postoperative period in a case of obstructive pneumonia owing to migration of the suture material. Here, we describe a case of bronchial obstructive pneumonia that developed owing to migration of the suture material in the airway 8 years after pulmonary resection.Case presentationA 34-year-old woman underwent left lower lobectomy for a pulmonary carcinoid tumor (pT1bN0M0-stage IA) in 2010. She experienced obstructive pneumonia, and chest computed tomography revealed a mass protruding from the bronchial stump to the bronchial lumen in 2018. After treatment for pneumonia, flexible bronchoscopy showed the presence of a fibrous suture material (Teflon pledget) completely obstructing the left second carina. A week later, the Teflon pledget obstructing the bronchial lumen was removed using a flexible bronchoscope with the patient under general anesthesia. The procedure was completed without removing the small amount of granulation tissue because the bronchial lumen opened after removing the Teflon pledget. She has remained asymptomatic for 1 year after removal.ConclusionsIn this case, the complication of obstructive pneumonia developed owing to migration of the non-absorbable suture materials used to suture the bronchial stump. Bronchoscopic management of this rare complication comprised endobronchial removal with the patient under general anesthesia. Given our experience with this case, we believe that such conservative management should allow for excellent results in most instances and avoid the need for reoperation.

Variations and surgical management of pulmonary vein in living-donor lobectomy.

In a living-donor lobectomy, the donor undergoes a right or left lower lobectomy. The surgical procedures for living-donor lobectomy are sometimes influenced by the anatomical variations of the pulmonary vein (PV). The goal of this study was to analyse the PV variations in living donors and to review the influence of these variations on the surgical procedures used. Between June 2008 and September 2018, 154 living donors underwent right or left lower lobectomy. The PV variations were analysed using 3-dimensional computed tomography (3D-CT), and the surgical management of these variations was reviewed. Among 154 donors, 21 PV variations that could influence the surgical procedure for a right lower lobectomy were found in 19 (12.3%) donors, whereas no such variations for a left lower lobectomy were found. Detected PV variations were dorsal branch of the right upper PV (n = 12), middle PV draining into the right lower PV (n = 6) and the superior segment branch of the right lower PV draining into the right upper PV (n = 3). Among 96 donors undergoing right lower lobectomy, 9 (9.4%) donors had PV variations that could influence the surgical procedure. In 2 donors, sparing of PV branches with multiple vascular clamps was required. Pulmonary venoplasty was not required in any donor, whereas pulmonary venoplasty in recipient surgery was required in 4 recipients. There were no complications related to the surgical procedures performed on the PV. Living-donor lobectomy was performed safely owing to the preoperative evaluation of PV on 3D-CT and the use of appropriate surgical approaches to PV.

2492 Everolimus-Induced Transaminitis in the Setting of Stage IV Carcinoid Tumor With Liver Metastasis

INTRODUCTION: Everolimus may lead to mild and asymptomatic liver enzymes elevation in up to a quarter of the patients taking it, but it rarely leads to symptomatic and significant transaminitis. We describe a case of everolimus induced transaminitis in the setting of stage IV carcinoid tumor with liver metastasis. CASE DESCRIPTION/METHODS: A 58-year-old female with a history of stage IV carcinoid tumor with liver metastasis presented with fatigue and worsening epigastric pain. She was first diagnosed with atypical bronchial carcinoids S/P left lower lobe lobectomy and lymph node dissection. Liver metastasis was diagnosed by biopsy two years later. She was started on everolimus one month earlier, and she reports sharp epigastric pain every time she takes the medication. On presentation, patient's vital signs were within normal limits. Physical exam revealed right upper quadrant and epigastric tenderness. Laboratory findings revealed elevated liver enzymes. AST was 723 U/L, ALT was 580 U/L, and alkaline phosphatase was 513 U/L. Total bilirubin was 1.2 mg/dl. To note, liver function tests were normal two weeks earlier. CT scan of the abdomen showed prominent intrahepatic biliary tracts and gallbladder wall thickening. Hepatitis panel and acetaminophen level were negative. Everolimus was discontinued on presentation. On the second day, bilirubin trended up to 1.6 mg/dl. Afterwards, patient's liver enzymes started to trend down and her bilirubin has normalized. Her abdominal pain has resolved. There was no indication at the time for endoscopic intervention. DISCUSSION: The trend of the liver enzymes is most consistent with a drug- induced liver injury. Patient was recently started on everolimus which was held on presentation. Liver enzymes started to trend down afterwards. AST and ALT were rapidly improving. Bilirubin became normal. It is important to consider everolimus as a cause of hepatocellular injury when other causes are ruled out.

INTRAPULMONARY SEQUESTRATION IN AN ADULT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: An intrapulmonary sequestration is defined as nonfunctioning lung tissue that is not in normal continuity with the tracheobronchial tree and derives its blood supply from systemic vessels[1]. Pulmonary sequestration is considered a childhood disease; however, the condition can continue into adolescence and sometimes adulthood[2]. Here, we present a middle-aged female presenting with pneumonia, found to have intrapulmonary sequestration and underwent lobectomy. CASE PRESENTATION: 43-year-old female with past surgical history of diaphragmatic hernia repair in childhood presented with persistent cough of two weeks duration with clear rhinorrhea and sharp left lower chest pain. Chest radiography revealed a left lower lobe consolidation suspicious for pneumonia. Patient was admitted for suspected pneumonia, and initial vital signs showed temperature 99F, heart rate 134, respiratory rate 25, blood pressure 97/75, and oxygen saturation of 99% on room air. Laboratory studies were significant for WBC count of 9.60, Hgb 10.5, and platelet count 69,000, with a d-dimer of 722. A CT angiogram to rule out a pulmonary embolism displayed a complete collapse of the left lower lobe with abnormal systemic arterial branch extending to the left lower lobe consistent with sequestration. Subsequently, patient underwent bronchoscopy that was noted to be normal with negative cultures and washings. The patient signed out against medical advice after the procedure, but returned to the hospital five days later with non-resolution of her cough and left sided chest pain. Chest radiograph and CT angiography performed showed unchanged findings of left lower lung infiltrate and suspected sequestration. Cardiothoracic surgery was consulted and patient was taken for a left lower lobectomy. The procedure and pathology confirmed the diagnosis of intrapulmonary sequestration. The patients’ symptoms resolved after surgery and she was discharged home in stable condition. DISCUSSION: Pulmonary sequestration, a disease of childhood, most commonly presents as pneumonia but may also present with chest pain, cough, shortness of breath and hemoptysis [3,4]. The condition may also be found incidentally in asymptomatic adults. Most pulmonary sequestrations arise in the left lung with two-thirds arising in the lower left lung lobe with the blood supply coming from systemic circulation, usually the thoracic or abdominal aorta. The treatment for a pulmonary sequestration involves surgical resection of the effected lung lobe to avoid infection and damage to the lung parenchyma. Our case is made unique by the advanced age of our patient with no prior history of recurrent infections or underlying respiratory symptoms prior to this presentation[5]. CONCLUSIONS: Pulmonary sequestration should be in the differential even in advanced age without prior history of underlying respiratory symptoms or recurrent infections. Reference #1: 1. "Congenital Malformations and Genetic Disorders of the Respiratory Tract.” American Review of Respiratory Disease, 120(1), pp. 151–185 Reference #2: 2. Petty, L., Joseph, A., & Sanchez, J. (2018). Case report: Pulmonary sequestration in an adult. Radiology Case Reports,13(1), 21-23. https://doi.org/10.1016/j.radcr.2017.09.029 Reference #3: 3. Frazier, A. A., Christenson, M. L., Stocker, J. T., & Templeton, P. A. (1997). Intralobar sequestration: Radiologic-pathologic correlation. RadioGraphics, 17(3), 725-745. https://doi.org/10.1148/radiographics.17.3.9153708 4. Hertzenberg, Casey & Daon, Emmanuel & Kramer, Jeffrey. (2012). Intralobar pulmonary sequestration in adults: Three case reports. Journal of thoracic disease. 4. 516-9. 10.3978/j.issn.2072-1439.2012.06.07. 5. Alsumrain, M., & Ryu, J. H. (2018). Pulmonary sequestration in adults: A retrospective review of resected and unresected cases. BMC Pulmonary Medicine, 18(1) DISCLOSURES: No relevant relationships by Anas Al-khateeb, source=Web Response No relevant relationships by Sharath Bellary, source=Web Response No relevant relationships by Michael Ellis, source=Web Response No relevant relationships by Muqueet Kadri, source=Web Response No relevant relationships by William Meng, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Hari Sharma, source=Web Response No relevant relationships by Euclid St.Hill, source=Web Response

Targeted sequencing identifies the mutational signature of double primary and metastatic malignancies: a case report

BackgroundThe accurate identification of the tissue of origin is critical for optimal management of cancer patients particularly those who develop multiple malignancies; however, conventional diagnostic methods at times may fail to provide conclusive diagnosis of the origin of the malignancy. Herein, we describe the use of targeted sequencing in distinguishing the primary and metastatic tumors in a patient with metachronous malignancies in the lung, colon and kidney.Case presentationIn December 2016, a 55-year-old Chinese male was diagnosed with stage IB lung adenosquamous carcinoma and treated with left lower lobectomy and 4 cycles of platinum-based chemotherapy. After being disease-free for 3.5 months, three colonic polyps were discovered and were diagnosed as invasive adenocarcinoma after polypectomy. Within 5.4 months from the polypectomy, squamous cell renal carcinoma was identified and was managed by radical nephrectomy. Immunohistochemistry results were inconclusive on the origin of the kidney tumor. Hence, the three archived surgical tissue samples were sequenced using a targeted panel with 520 cancer-related genes. Analysis revealed similar mutational signature between the lung and kidney tumors and a distinct mutational profile for the colon tumor, suggesting that the lung and colon malignancies were primary tumors, while the kidney tumor originated from the lung, revealing a diagnosis of metastatic double primary cancer – lung carcinoma with renal cell metastasis and second primary colon carcinoma.ConclusionMutational profiling using targeted sequencing is valuable not only for the detection of actionable mutations, but also in the identification of the origin of tumors. This diagnostic approach should be considered in similar scenarios.

A case of large spontaneous hemothorax in patient with pulmonary arterio-venous malformation of left lung

Spontaneous hemothorax is an uncommon condition that often requires immediate radical surgery. Pulmonary arteriovenous malformations (PAVM) is a rare lung vascular anomaly that progresses in time and in 8% of cases leads to either pulmonary hemorrhage or massive hemothorax as potentially fatal complications. We present a clinical case of spontaneous large hemothorax, which developed on PAVM and leaded to huge aneurysm of the lower lung lobe. The patient underwent left lower lobectomy successfully. Nowadays to prevent life-threatening complications of PAVM, all patients should undergone miniinvasive planned surgical technique - endovascular occlusion (embolization) of PAVM.

Left lower lobectomy: steps and technical tricks

Left lower lobectomy: steps and technical tricks