Imaged Thoracic Lobectomy: Should It Be Done? Ralph J. Lewis, MD, Glenn E. Sisler, MD, and Robert J. Caccavale, hAD Department of Surgery, UMDNJ-The Robert Wood Johnson Medical School, Robert Wood Johnson Hospital, Piscataway, New Jersey
Imaged thoracic surgery is a new modality that is rapidly gaining acceptance from thoracic surgeons. Procedures that traditionally required a thoracotomy can now be done successfully using this technique in some patients. Three patients with primary carcinoma of the lung have undergone lobectomy using imaged thoracic surgery. (Ann Thoruc Surg 2992;54:80-3)
I
n the past, thoracotomy and thoracoscopy were the two techniques available for operating within the thoracic cavity. Only simple procedures could be performed with traditional thoracoscopy because access and exposure are severely restricted [l,21. Access and exposure are much better with a thoracotomy. Nevertheless, this procedure can cause patients to experience a greater degree of pain, have a higher morbidity, and require intensive medical services. Recently, with the development of video optics, a new modality has evolved. Transfer of intrathoracic images to a screen has permitted complex operations to be performed within the chest without making the traditional thoracotomy incision. Using this new technique, major resectional pulmonary operations were successfully performed for primary carcinoma of the lung in 3 patients.
For editorial comment, see page 2.
intensive medical services, and was discharged on her fifth postoperative day (Fig 2). Pathological examination revealed a bronchoalveolar carcinoma. All lymph nodes were negative for malignancy.
Patient 2 A 71-year-old man was admitted to the hospital with melena. Evaluation revealed a small duodenal ulcer as the cause of bleeding. Because of a strong family history of colon cancer, a colonoscopy was performed. A lesion was identified in the descending colon; the lesion was removed and found to have a small focus of adenocarcinoma at the end of the stalk. The base was free of tumor. While the patient was still in the hospital, a chest roentgenogram revealed a noncalcified 2.5-cm mass in the right mid lung field. Computed tomographic scan confirmed this finding. There was no evidence of mediastinal, liver, or adrenal abnormalities. Bronchoscopy and mediastinoscopy were negative. An imaged thoracic surgical exploration revealed a lesion in the middle lobe. An imaged thoracic lobectomy was performed. The lesion was a poorly differentiated non-small cell carcinoma. Margins and hilar lymph nodes were free of tumor. Other than a persistent air leak, he had an uneventful postoperative course. Discharge was on the ninth postoperative day. Even though discharge was delayed because of an air leak, the patient had markedly reduced pain postoperatively and returned to full activity by the 14th postoperative day.
Case Presentations
Patient 3
Patient 1
A 60-year-old woman had a small nodular lesion found in the right middle lobe of her lung on chest roentgenogram. Computed tomographic scan confirmed the presence of a noncalcified, irregular lesion suspected to be carcinoma. The patient had a history of tuberculosis and smoked 1% packs of cigarettes each day. Bronchoscopy and mediastinoscopy were both negative. Imaged thoracic surgical exploration revealed a small lesion in the fissure. A wedge resection was performed, however, the pathologist could not give a definitive diagnosis on frozen section. Because the lesion was ill defined, and deep in the fissure, right middle lobectomy seemed necessary for complete removal. This was accomplished using imaged thoracic surgery. Immediately after the lobe was removed, the pathologist performed an examination of the specimen and found no residual lesions. Because our operative findings did not result in a confirmed diagnosis on frozen section, it was decided to perform an open thoracotomy for further evaluation and exploration. After a thoracotomy and complete examination, no other lesions could be
A 55-year-old woman in excellent health had a routine chest roentgenogram for anticipated minor plastic surgery. A noncalcific, nodular lesion was noted in the left upper lobe and confirmed by computed tomographic scan (Fig 1). Twenty-one years ago a melanoma was removed from her right foot. At that time, a right groin dissection was negative for metastases. Her physical examination was unremarkable, and all other studies were negative. The patient was admitted for surgical excision of the lung lesion. Bronchoscopy and mediastinoscopy were unremarkable. Using imaged thoracic surgery, a wedge resection could not be satisfactorily performed. Hilar lymph nodes were examined by frozen section, and a left upper lobectomy was performed by this technique. The patient had an uneventful postoperative course, did not require Accepted for publication Jan 27, 1992 Address reprint requests to Dr Lewis, 185 Livingston Ave, New Brunswick, NJ 08901.
0 1992 by The Society of Thoracic Surgeons
0003-4975/92/$5.00
LEWISETAL IMAGED LOBECTOMY
A n n Thorac Surg 1992;54:8&3
81
Fig 1 . Computed tomographic scan reveals a lesion in the left upper lobe.
identified within the remaining lobes. The patient’s postoperative course was unremarkable. The permanent pathological diagnosis from the initial wedge resection was bronchoalveolar carcinoma. The patient was discharged home on the seventh postoperative day.
Technique The following procedure was used for the left upper lobe. Under endotracheal anesthesia using a left bronchus double-lumen Mallinckrodt bronchocatheterization tube (Critical Care, St. Louis, MO), the left lung was allowed to collapse spontaneously. The patient was then placed in the right lateral position with the right side up. After antiseptic preparation, a 2-cm incision was made in the sixth intercostal space in the mid axillary line. Finger palpation confirmed the absence of adhesions and verified deflation of the lung. A 12-mm trocar was inserted into the thorax, and a 10-mm Panoview 0 Storz (Culver City, CA) scope was passed through it. Visual Of the intrathoracic cavity was performed’ No
Fig 2. Postoperative chest roentgenogram.
B
Fig 3 , (A) Linear stapler inserted into chest cavity; lung clamps retracting lung fields. ( B ) Linear stapler dividing fissure.
other lesions could be detected. A 3-cm incision entering into the chest was next made in the anterior axillary line in the fourth intercostal space, and another 2-cm incision in the postaxillary line in the fourth intercostal space. Because visual surveillance did not reveal the lesion in the left upper lobe, digital palpation was used through these incisions. The lesion was identified; however, it was found to be deeper in the lung parenchyma then was revealed by the roentgenogram and could not be satisfactorily excised. Lobectomy was considered the procedure of choice. Biopsy of the lymph nodes identified in the parabronchial and hilar areas was performed, and the nodes were reported to be free of tumor on frozen section. No other lymph nodes could be identified. Using lung clamps, the lobes were separated, exposing the fissure. Gauze pledgets on clamps, digital palpation with blunt dissection, and staplers were used to complete the fissure (Fig 3). The pulmonary arteries in the fissure
82
LEWIS E T A L IMAGED LOBECTOMY
Ann Thorac Surg 1992;54:8&3
A
Fig 4 . Linear stapler dividing bronchus to the left upper lobe.
were exposed and protected. The anterior hilar area was next exposed and dissected, allowing identification of the superior pulmonary vein. The left upper lobe was retracted anteriorly, exposing the bronchus posteriorly. Because the lingular artery partially concealed the segmental bronchus to the lingula, the vessel was secured with Liga Clips (Ethicon, Cincinnati, OH) and divided. After appropriate dissection, a 1-0 black silk suture was placed around the left upper lobe bronchus and used for retraction. One leg of the Ethicon Proximate Linear Stapler 75 (regular tissue) was passed behind the bronchus as the other leg was placed in front of the bronchus. The stapler was closed and fired. The bronchus was divided, and both ends were completely sealed (Fig 4). Careful observation of the proximal bronchial stump revealed excellent staple line formation. Further hilar dissection exposed all of the remaining vessels to the upper lobe. Retraction and elevation of the upper lobe allowed an Ethicon Proximate RL 60 stapler to enclose all of the vessels (Fig 5). Two applications of this stapler were made to ensure hemostasis [ 3 ] .The vessels were divided with the stapler in place, and the specimen was excised. The staple line was carefully evaluated, and all staples were determined to be in perfect alignment. There was no evidence of any bleeding. The lobe was easily removed through the 60-mm intercostal incision used for introduction of the stapler. The right middle lobe was removed using a comparable technique. The fissures were fully developed. The right middle lobe bronchus was identified, stapled, and divided. Pulmonary arteries and veins to the right middle lobe were next stapled and divided. Any incomplete fissure was then completed by stapling and dividing. The lobe could now be removed. The chest cavity was irrigated with saline solution, and the lung was inspected for air leaks as it was expanding. Number 28 and 32 chest tubes were inserted, and the wounds were closed.
B Fig 5 . ( A ) Stapler inserted into the thorax; lung clamps and scope in thorax. (B) Stapler enveloping only vessels to left upper lobe (superior pulmona y vein and segmental arteries).
Comment We have used imaged thoracic surgery to perform a multitude of procedures, eg, lung biopsy, bullous ablation, partial lung resection for benign and malignant neoplasms, resection of metastatic lesions, bronchogenic cysts, esophageal cysts, pericardial windows, exploration and biopsy of the aortopulmonary window, parietal pleurectomy, and pleural sclerosiij [ P 6 ] . In each of these cases, the intrathoracic portion of the operation is very similar to the technique used when the traditional thoracotomy incision is made. Lobectomy is a complex, intricate, major surgical procedure requiring various skills, experience, and knowledge to have a successful outcome. In carefully selected
LEWISETAL IMAGED LOBECTOMY
Ann Thorac Surg 1992;54:80-3
patients, imaged thoracic surgery may eventually become a realistic option for such major resectional surgical procedures as lobectomy or pneumonectomy. Patients with a compromised pulmonary reserve may have a more benign postoperative course after resection using this technique, because chest wall mechanics are less disturbed when compared with the thoracotomy incision. Although major resectional pulmonary surgery can be successfully performed by imaged thoracic surgery in its present form, extreme care and prudence must be used before its application. This procedure is in its embryonic stages and requires further refinements in technique, advances in optics, and better instrumentation before it can be considered an alternative to the thoracotomy for major surgery. At this time, standards and criteria for the use of imaged thoracic surgery in patients with primary carcinoma of the lung are nonexistent. Until more information is accumulated and evaluated, thoracic surgeons should proceed cautiously and with great concern for the welfare of their patients. Currently, the thoracotomy incision has proved to be very reliable for the evaluation and resection of primary malignancies of the lung. As a large body of information exists concerning the thoracotomy incision and its application to major pulmonary resections, it must be considered the proven technique for the treatment of primary pulmonary malignancies. Even though major pulmonary resections can be performed using imaged thoracic surgery, we have used this technique very infrequently and with great discretion. In almost every patient who is explored using imaged thoracic surgery, if a lobectomy is indicated, we will now proceed to a traditional open thoracotomy. Imaged thoracic lobectomy seems to offer the benefits of less pain, less interference with ventilatory mechanics, and more rapid return to preoperative levels of activity. The first patient who had only imaged thoracic surgery could have been discharged earlier; however, we still have concerns about this new technique and continue to be very conservative in patient care. Certainly our conservatism was manifested by the thoracotomy after lobectomy to completely evaluate the thorax in the third
83
patient. Because this technique is so new, we must continue to rely on the traditional thoracotomy whenever any uncertainty presents itself. As optics, instrumentation, and techniques evolve and improve, major pulmonary resectional surgery could become more feasible in the future. Presently, imaged thoracic lobectomy is a unique procedure, and it should not be considered a replacement for the standard thoracotomy. We have gained experience from using imaged thoracic surgery in more than 100 patients. Some operations can be tedious and require more time to perform using this technique than the same operation using a formal thoracotomy incision. Even though imaged thoracic surgery can be more difficult and time-consuming, benefits derived by patients are becoming readily apparent. Hospitalization and recovery times have been shortened for some patients, and postoperative pain seems largely related to the chest tubes. Most of these patients do not require intensive care services. On some occasions, it is becoming more evident that imaged thoracic surgery, even at this early stage of development, can be used for benign lesions that have always required the traditional thoracotomy incision. One can only speculate on the eventual value of this new modality; however, early successes seem to indicate that imaged thoracic surgery will find a permanent place in the armamentarium of the thoracic surgeon.
References 1. Lewis RJ, Kunderman PJ, Sisler GE, et al. Direct diagnostic
thoracoscopy. Ann Thorac Surg 1976;21:536-9. 2. Jacobeaus HC. Cauterization of adhesions in artificial pneumothorax. Am Rev Tuberc 1922;6:871-96. 3. Gaskin RJ, Bergmann M. Pneumonectomy by "en masse" stapling of hilar vessels. Ann Thorac Surg 1975;19:242-7. 4. Lewis RJ, Caccavale RJ, Sisler GE. Video-endoscopic thoracic surgery. N J Med 1991;88:473-5. 5. Miller JI, Hatcher CR Jr. Thoracoscopy: a useful tool in the diagnosis of thoracic disease. Ann Thorac Surg 1978;26:6%72. 6. Rusch VW, Mountain C. Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease. Am J Surg 1987;154:274-8.
Imaged thoracic surgery is a new modality that is rapidly gaining acceptance from thoracic surgeons. Procedures that traditionally required a thoracotomy can now be done successfully using this technique in some patients. Three patients with primary carcinoma of the lung have undergone lobectomy using imaged thoracic surgery. (Ann Thoruc Surg 2992;54:80-3)
I
n the past, thoracotomy and thoracoscopy were the two techniques available for operating within the thoracic cavity. Only simple procedures could be performed with traditional thoracoscopy because access and exposure are severely restricted [l,21. Access and exposure are much better with a thoracotomy. Nevertheless, this procedure can cause patients to experience a greater degree of pain, have a higher morbidity, and require intensive medical services. Recently, with the development of video optics, a new modality has evolved. Transfer of intrathoracic images to a screen has permitted complex operations to be performed within the chest without making the traditional thoracotomy incision. Using this new technique, major resectional pulmonary operations were successfully performed for primary carcinoma of the lung in 3 patients.
For editorial comment, see page 2.
intensive medical services, and was discharged on her fifth postoperative day (Fig 2). Pathological examination revealed a bronchoalveolar carcinoma. All lymph nodes were negative for malignancy.
Patient 2 A 71-year-old man was admitted to the hospital with melena. Evaluation revealed a small duodenal ulcer as the cause of bleeding. Because of a strong family history of colon cancer, a colonoscopy was performed. A lesion was identified in the descending colon; the lesion was removed and found to have a small focus of adenocarcinoma at the end of the stalk. The base was free of tumor. While the patient was still in the hospital, a chest roentgenogram revealed a noncalcified 2.5-cm mass in the right mid lung field. Computed tomographic scan confirmed this finding. There was no evidence of mediastinal, liver, or adrenal abnormalities. Bronchoscopy and mediastinoscopy were negative. An imaged thoracic surgical exploration revealed a lesion in the middle lobe. An imaged thoracic lobectomy was performed. The lesion was a poorly differentiated non-small cell carcinoma. Margins and hilar lymph nodes were free of tumor. Other than a persistent air leak, he had an uneventful postoperative course. Discharge was on the ninth postoperative day. Even though discharge was delayed because of an air leak, the patient had markedly reduced pain postoperatively and returned to full activity by the 14th postoperative day.
Case Presentations
Patient 3
Patient 1
A 60-year-old woman had a small nodular lesion found in the right middle lobe of her lung on chest roentgenogram. Computed tomographic scan confirmed the presence of a noncalcified, irregular lesion suspected to be carcinoma. The patient had a history of tuberculosis and smoked 1% packs of cigarettes each day. Bronchoscopy and mediastinoscopy were both negative. Imaged thoracic surgical exploration revealed a small lesion in the fissure. A wedge resection was performed, however, the pathologist could not give a definitive diagnosis on frozen section. Because the lesion was ill defined, and deep in the fissure, right middle lobectomy seemed necessary for complete removal. This was accomplished using imaged thoracic surgery. Immediately after the lobe was removed, the pathologist performed an examination of the specimen and found no residual lesions. Because our operative findings did not result in a confirmed diagnosis on frozen section, it was decided to perform an open thoracotomy for further evaluation and exploration. After a thoracotomy and complete examination, no other lesions could be
A 55-year-old woman in excellent health had a routine chest roentgenogram for anticipated minor plastic surgery. A noncalcific, nodular lesion was noted in the left upper lobe and confirmed by computed tomographic scan (Fig 1). Twenty-one years ago a melanoma was removed from her right foot. At that time, a right groin dissection was negative for metastases. Her physical examination was unremarkable, and all other studies were negative. The patient was admitted for surgical excision of the lung lesion. Bronchoscopy and mediastinoscopy were unremarkable. Using imaged thoracic surgery, a wedge resection could not be satisfactorily performed. Hilar lymph nodes were examined by frozen section, and a left upper lobectomy was performed by this technique. The patient had an uneventful postoperative course, did not require Accepted for publication Jan 27, 1992 Address reprint requests to Dr Lewis, 185 Livingston Ave, New Brunswick, NJ 08901.
0 1992 by The Society of Thoracic Surgeons
0003-4975/92/$5.00
LEWISETAL IMAGED LOBECTOMY
A n n Thorac Surg 1992;54:8&3
81
Fig 1 . Computed tomographic scan reveals a lesion in the left upper lobe.
identified within the remaining lobes. The patient’s postoperative course was unremarkable. The permanent pathological diagnosis from the initial wedge resection was bronchoalveolar carcinoma. The patient was discharged home on the seventh postoperative day.
Technique The following procedure was used for the left upper lobe. Under endotracheal anesthesia using a left bronchus double-lumen Mallinckrodt bronchocatheterization tube (Critical Care, St. Louis, MO), the left lung was allowed to collapse spontaneously. The patient was then placed in the right lateral position with the right side up. After antiseptic preparation, a 2-cm incision was made in the sixth intercostal space in the mid axillary line. Finger palpation confirmed the absence of adhesions and verified deflation of the lung. A 12-mm trocar was inserted into the thorax, and a 10-mm Panoview 0 Storz (Culver City, CA) scope was passed through it. Visual Of the intrathoracic cavity was performed’ No
Fig 2. Postoperative chest roentgenogram.
B
Fig 3 , (A) Linear stapler inserted into chest cavity; lung clamps retracting lung fields. ( B ) Linear stapler dividing fissure.
other lesions could be detected. A 3-cm incision entering into the chest was next made in the anterior axillary line in the fourth intercostal space, and another 2-cm incision in the postaxillary line in the fourth intercostal space. Because visual surveillance did not reveal the lesion in the left upper lobe, digital palpation was used through these incisions. The lesion was identified; however, it was found to be deeper in the lung parenchyma then was revealed by the roentgenogram and could not be satisfactorily excised. Lobectomy was considered the procedure of choice. Biopsy of the lymph nodes identified in the parabronchial and hilar areas was performed, and the nodes were reported to be free of tumor on frozen section. No other lymph nodes could be identified. Using lung clamps, the lobes were separated, exposing the fissure. Gauze pledgets on clamps, digital palpation with blunt dissection, and staplers were used to complete the fissure (Fig 3). The pulmonary arteries in the fissure
82
LEWIS E T A L IMAGED LOBECTOMY
Ann Thorac Surg 1992;54:8&3
A
Fig 4 . Linear stapler dividing bronchus to the left upper lobe.
were exposed and protected. The anterior hilar area was next exposed and dissected, allowing identification of the superior pulmonary vein. The left upper lobe was retracted anteriorly, exposing the bronchus posteriorly. Because the lingular artery partially concealed the segmental bronchus to the lingula, the vessel was secured with Liga Clips (Ethicon, Cincinnati, OH) and divided. After appropriate dissection, a 1-0 black silk suture was placed around the left upper lobe bronchus and used for retraction. One leg of the Ethicon Proximate Linear Stapler 75 (regular tissue) was passed behind the bronchus as the other leg was placed in front of the bronchus. The stapler was closed and fired. The bronchus was divided, and both ends were completely sealed (Fig 4). Careful observation of the proximal bronchial stump revealed excellent staple line formation. Further hilar dissection exposed all of the remaining vessels to the upper lobe. Retraction and elevation of the upper lobe allowed an Ethicon Proximate RL 60 stapler to enclose all of the vessels (Fig 5). Two applications of this stapler were made to ensure hemostasis [ 3 ] .The vessels were divided with the stapler in place, and the specimen was excised. The staple line was carefully evaluated, and all staples were determined to be in perfect alignment. There was no evidence of any bleeding. The lobe was easily removed through the 60-mm intercostal incision used for introduction of the stapler. The right middle lobe was removed using a comparable technique. The fissures were fully developed. The right middle lobe bronchus was identified, stapled, and divided. Pulmonary arteries and veins to the right middle lobe were next stapled and divided. Any incomplete fissure was then completed by stapling and dividing. The lobe could now be removed. The chest cavity was irrigated with saline solution, and the lung was inspected for air leaks as it was expanding. Number 28 and 32 chest tubes were inserted, and the wounds were closed.
B Fig 5 . ( A ) Stapler inserted into the thorax; lung clamps and scope in thorax. (B) Stapler enveloping only vessels to left upper lobe (superior pulmona y vein and segmental arteries).
Comment We have used imaged thoracic surgery to perform a multitude of procedures, eg, lung biopsy, bullous ablation, partial lung resection for benign and malignant neoplasms, resection of metastatic lesions, bronchogenic cysts, esophageal cysts, pericardial windows, exploration and biopsy of the aortopulmonary window, parietal pleurectomy, and pleural sclerosiij [ P 6 ] . In each of these cases, the intrathoracic portion of the operation is very similar to the technique used when the traditional thoracotomy incision is made. Lobectomy is a complex, intricate, major surgical procedure requiring various skills, experience, and knowledge to have a successful outcome. In carefully selected
LEWISETAL IMAGED LOBECTOMY
Ann Thorac Surg 1992;54:80-3
patients, imaged thoracic surgery may eventually become a realistic option for such major resectional surgical procedures as lobectomy or pneumonectomy. Patients with a compromised pulmonary reserve may have a more benign postoperative course after resection using this technique, because chest wall mechanics are less disturbed when compared with the thoracotomy incision. Although major resectional pulmonary surgery can be successfully performed by imaged thoracic surgery in its present form, extreme care and prudence must be used before its application. This procedure is in its embryonic stages and requires further refinements in technique, advances in optics, and better instrumentation before it can be considered an alternative to the thoracotomy for major surgery. At this time, standards and criteria for the use of imaged thoracic surgery in patients with primary carcinoma of the lung are nonexistent. Until more information is accumulated and evaluated, thoracic surgeons should proceed cautiously and with great concern for the welfare of their patients. Currently, the thoracotomy incision has proved to be very reliable for the evaluation and resection of primary malignancies of the lung. As a large body of information exists concerning the thoracotomy incision and its application to major pulmonary resections, it must be considered the proven technique for the treatment of primary pulmonary malignancies. Even though major pulmonary resections can be performed using imaged thoracic surgery, we have used this technique very infrequently and with great discretion. In almost every patient who is explored using imaged thoracic surgery, if a lobectomy is indicated, we will now proceed to a traditional open thoracotomy. Imaged thoracic lobectomy seems to offer the benefits of less pain, less interference with ventilatory mechanics, and more rapid return to preoperative levels of activity. The first patient who had only imaged thoracic surgery could have been discharged earlier; however, we still have concerns about this new technique and continue to be very conservative in patient care. Certainly our conservatism was manifested by the thoracotomy after lobectomy to completely evaluate the thorax in the third
83
patient. Because this technique is so new, we must continue to rely on the traditional thoracotomy whenever any uncertainty presents itself. As optics, instrumentation, and techniques evolve and improve, major pulmonary resectional surgery could become more feasible in the future. Presently, imaged thoracic lobectomy is a unique procedure, and it should not be considered a replacement for the standard thoracotomy. We have gained experience from using imaged thoracic surgery in more than 100 patients. Some operations can be tedious and require more time to perform using this technique than the same operation using a formal thoracotomy incision. Even though imaged thoracic surgery can be more difficult and time-consuming, benefits derived by patients are becoming readily apparent. Hospitalization and recovery times have been shortened for some patients, and postoperative pain seems largely related to the chest tubes. Most of these patients do not require intensive care services. On some occasions, it is becoming more evident that imaged thoracic surgery, even at this early stage of development, can be used for benign lesions that have always required the traditional thoracotomy incision. One can only speculate on the eventual value of this new modality; however, early successes seem to indicate that imaged thoracic surgery will find a permanent place in the armamentarium of the thoracic surgeon.
References 1. Lewis RJ, Kunderman PJ, Sisler GE, et al. Direct diagnostic
thoracoscopy. Ann Thorac Surg 1976;21:536-9. 2. Jacobeaus HC. Cauterization of adhesions in artificial pneumothorax. Am Rev Tuberc 1922;6:871-96. 3. Gaskin RJ, Bergmann M. Pneumonectomy by "en masse" stapling of hilar vessels. Ann Thorac Surg 1975;19:242-7. 4. Lewis RJ, Caccavale RJ, Sisler GE. Video-endoscopic thoracic surgery. N J Med 1991;88:473-5. 5. Miller JI, Hatcher CR Jr. Thoracoscopy: a useful tool in the diagnosis of thoracic disease. Ann Thorac Surg 1978;26:6%72. 6. Rusch VW, Mountain C. Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease. Am J Surg 1987;154:274-8.
