JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 6, 1992 Mary Ann Lieben, Inc., Publishers
Preliminary Experience With Thoracoscopic Surgery FREDERICK K. TOY, M.D., F.A.C.S., F.C.C.M. and ROY T. SMOOT, Jr., M.D., F.A.C.S.
ABSTRACT
Thoracoscopic surgery was accomplished in 12 patients utilizing thoracoscopic instruments and a stapler. Five patients were treated for recurrent, spontaneous pneumothoraces, for which blebectomies were done; three patients for pulmonary nodules, for which wedge resections were done; one patient for cryptogenic pleural effusion; one patient for debridement of an empyema cavity; one patient for traumatic bronchopleural fistula; and one patient with AIDS for interstitial lung disease. All patients were done under general anesthesia in the lateral decubitus position and were prepped and draped for a standard thoracotomy. They underwent endobronchial double-lumen ventilation so that the ipsilateral lung could be deflated to create a working space. In addition, insufflation of 4 to 5 m m H g was also used. Trocars were placed using a blunt technique. The mid-axillary trocar was at about the eighth intercostal space and was used for the endoscope, and then additional trocars were placed, usually on the anterior axillary line and posterior axillary line at about the lift h intercostal space. If adhesions were encountered, the lung was grasped atraumatically with a clamp or retractor used to give countertraction, and the adhesions were lysed with shears or electrocautery. After a thorough exploration of the hemithorax involved, the area of pathology was grasped with the clamp, which was used for countertraction. Through a 12 mm trocar, a stapler was introduced and fired. This staples and also transects on a 3 cm length. Several firings were usually necessary to remove the pathology, which, if malignant, was placed in a retrieval bag. When mechanical pleurodesis was felt necessary, this was accomplished using a 2 dry gauze was placed and used to abrade the parietal sponge stick clamp, into which a 2 pleura. The patients then had a chest tube placed under direct vision through one of the trocars. The patients experienced only moderate pain in the immediate postoperative period, with essentially no pain by the fourth postoperative day. There were no significant complications noted and
no
deaths occurred.
Department of Surgery,
Nanticoke Memorial
Hospital, Seaford, DE, University
MD.
303
of
Maryland Hospital, Baltimore,
TOY AND SMOOT
INTRODUCTION done 80 years ago, although the procedure never gained extensive Over the past several years, there has been a tremendous surge in the field of endoscopie surgery. The era of video-guided surgery began in 1986 with the development of the computer-chip TV camera. Since the first laparoscopic cholecystectomy in 1988, many more advanced laparoscopic procedures have been described. With the recent development of advanced endoscopie instruments and staplers, there has been a resurgence of interest in thoracoscopic surgery. The authors believe that there are a large number of thoracic procedures which can be safely and effectively accomplished thoracoscopically, resulting in diminished pain and cosmetic disfigurement, as well as quicker convalescence. The experience with thoracoscopic surgery on 12 patients is presented, 7 for benign disease and 5 for malignancy. It is believed that the thoracoscopic approach will become the procedure of choice in the near future for many procedures which have required thoracotomy in the past.
Theapplication.
first THORACOSCOPY was
MATERIALS AND METHODS Twelve patients underwent thoracoscopic surgery, including five blebectomies with mechanical pleurodesis for recurrent, spontaneous pneumothoraces; three diagnostic thoracoscopies with pulmonary wedge resection; one pulmonary wedge resection for stage I peripheral bronchogenic carcinoma in a patient with severe pulmonary compromise; one pleural biopsy for cryptogenic pleural effusion with pleurodesis; one thoracoscopic drainage and debridement of a post-pneumonia empyema thoracis; and one thoracoscopic closure of a traumatic bronchopleural fistula. The age range of these patients was 16 to 86 years. One patient had undergone prior thoracotomy. The procedures were performed under general anesthesia with a double-lumen endotracheal tube to permit selective deflation of the ipsilateral lung. The patients were placed in the lateral decubitus position and prepped and draped for a formal thoracotomy. An 11 mm incision was made at approximately the eighth intercostal space mid-axillary line. With blunt dissection through the intercostal muscles, over the superior edge of the rib with a Kelly clamp, the pleural space was entered. A blunt-tipped, 11 mm trocar was introduced into the hemithorax. With careful monitoring of the blood pressure, 02 saturation, and end-tidal C02, the ipsilateral lung was deflated and the hemithorax was insufflated to 5 mmHg pressure. A forward viewing (0°) endoscope was introduced. Two additional 11 mm blunt-tipped trocars were introduced under direct vision at approximately the sixth intercostal space anterior and posterior axillary lines (Fig. 1 ). Through these ports, the Nanticoke Endo-Duval Clamp and the Nanticoke Endo-Retractor (Cabot Medical, Inc., Langhorne, PA) were introduced (Figs. 2, 3). These instruments allow adequate, atraumatic manipulation and retraction of the lung to ensure a thorough exploration of the entire hemithorax. If adhesions were encountered, they were lysed using Endo-Shears (U.S. Surgical Corp., Norwalk, CT). These allow sharp, precise lysis along with simultaneous electrocauterization of any bleeding. After thorough exploration of the hemithorax, the clamp is introduced via whichever trocar is most convenient to grasp the pathology. The other trocar is exchanged for a 12 mm trocar, and the Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT) is introduced. With the clamp allowing atraumatic manipulation and countertraction of the lung, the stapler was positioned and fired (Fig. 4). Several reloads were necessary to complete the pulmonary resection (Fig. 5). The tissue was placed in a Pleatman Sac (Cabot Medical) and easily removed through the 12 mm port. When mechanical pleurodesis was necessary, a 2 x 2 gauze was folded and grasped in a Nanticoke Endo-Forester sponge stick (Cabot Medical) (Fig. 6). This is easily passed through a trocar and the parietal pleura vigorously abraded (Fig. 7). The hemithorax was copiously irrigated with Bacitracin solution, and a #34 Argyl chest tube was placed through the mid-axillary trocar and sutured to the skin. The incisions were closed with 3-0 vicryl subcutaneous sutures, 4-0 vicryl subcuticular sutures, and steri-strips. 304
FIG. 1.
FIG. 2.
Under general anesthesia, the
Thoracoscopic
patient is in lateral decubitus position with trocars inserted.
instrumentation used for retraction of
Seaford, DE).
FIG. 3.
Thorascopic
Seaford, DE).
instrumentation used for
grasping
of
305
lung (Endo-Retractor,
lung (Endo-Retractor,
Endo-Duval
Clamp, Nanticoke,
Endo-Duval
Clamp, Nanticoke,
TOY AND SMOOT
FIG. 4.
Grasping and countertraction of the lung with application of the Endo-GIA stapler (Nanticoke Endo-Duval,
Seaford, DE).
FIG. 5.
Grasping of the lung after first application of Endo-GIA stapler. Multiple firings usually required. (Nanticoke
Endo-Duval, Seaford, DE.)
306
EXPERIENCE WITH THORACOSCOPIC SURGERY
FIG. 6.
Sponge stick used for mechanical pleurodesis. (Nanticoke Forester, Seaford, DE.) DISCUSSION
Thoracoscopy was first described and reported by a Swedish physician, H.C. Jacobaeus, in 1910. His first procedure was performed under local anesthesia using a trocar to enter the pleural space, which was examined with a cystoscope. Initially, this was used to investigate "idiopathic pleurisy", which was largely found to be tuberculosis. ' Later, he used it for "pneumonolysis"—lysis of adhesions preventing pneumothorax therapy for pulmonary tuberculosis—the treatment prior to the discovery of effective antituberculous chemotherapy. Over the next 40 years, thoracoscopy experienced limited utilization. In recent years, there has been a renewed interest in both diagnostic and therapeutic thoracoscopy. To accomplish a successful thoracoscopic procedure, it is essential to adequately visualize the lung and maneuver the thorascopic instruments. This space is acquired through the use of a double-lumen endotracheal
FIG. 7.
Sponge
stick with 2x2 gauze
(Nanticoke Forester, Seaford, DE.)
abrading
the
parietal pleura, accomplishing
307
a
mechanical
pleurodesis.
TOY AND SMOOT Table 1. Indications
for
Thoracoscopy
Diagnostic
Therapeutic
Cryptogenic pleural
effusions
of adhesions Evacuation of hemothorax Pleurodesis: chemical, mechanical Foreign body retraction Debridement of empyema cavity Bronchopleural fistula closure Trauma
Lysis
Pleural based lesions Hormonal receptor determination Interstitial Cancer
pulmonary
disease
Sympathectomy Vagotomy
staging
Pericardial window
Solitary pulmonary
nodule
Blebectomy Pulmonary resection AICD placement
tube or a bronchial blocker to permit selective collapse of the ipsilateral lung and low pressure insufflation. The addition of 5 mmHg pressure insufflation has been found to be safe and very helpful at providing an adequate space to work when partial inflation of the lung is required. All patients are prepared so they can be immediately converted to an open thoracotomy, in the event the procedures cannot be safely completed
endoscopically. Thoracoscopic
surgery is in a state of evolution. With the development of the video camera, advanced and endoscopie stapler devices, the list of indications is growing rapidly (Ta-
thoracoscopic instruments,
ble 1). In the authors' preliminary experience, thoracoscopic surgery has been utilized for the treatment of recurrent, spontaneous pneumothoraces; pulmonary resection, both diagnostically and therapeutically; the evaluation of pleural disease; and the treatment of empyema. Recurrent, spontaneous pneumothoraces have been very successfully managed with a thoracoscopically stapled blebectomy and gauze mechanical pleurodesis, just as surgeons have done via an open thoracotomy for many years. The advantages are minimal incisions and rib retraction, resulting in a better cosmetic result, less postoperative pain, and a rapid convalescence. With non-small cell, stage I, bronchogenic carcinoma, it has been demonstrated that the local recurrence and survival rates are virtually identical between lobectomy and wedge resection. This has largely been confined to the high-risk patient with marked impairment of pulmonary function.2-5 It has been demonstrated by others that the thoracoscopic evaluation of cryptogenic pleural effusions can be very accurately diagnosed.6,7 Boutin6 showed the incidence of idiopathic pleural effusions approximated 20% and could be reduced to 4% with thoracoscopic evaluation. He also showed a 90% resolution of the chronic effusion with thoracoscopic pleurodesis. Thoracoscopic debridement and irrigation of empyema thoracis was demonstrated to be safe and very beneficial by Ridley and Braimbridge.8
CONCLUSIONS Over the past 2 years, there have been tremendous advances and enthusiasm in endoscopie surgery. This has kindled an interest in thoracoscopy among chest surgeons. The recent development of advanced thoracoscopic instruments and stapling devices have made therapeutic thoracoscopy possible, and a new field of thoracoscopic surgery has developed. This new field enables the thoracic surgeon to avoid a formal thoracotomy, with its greater morbidity and mortality. 308
EXPERIENCE WITH THORACOSCOPIC SURGERY
REFERENCES 1. Jacobaeus HC: The practical 296.
importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:289-
2. Errett LE, Wilson J, Chin RC, Munro DD: Wedge resection as an alternative procedure for peripheral carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985;90:656-661. 3. Miller JI, Hatcher CR: Limited resection of bronchogenic carcinoma in the pulmonary function. Ann Thorac Surg 1987;44:340-343. 4. Bennett
patient.
WF, Smith RA: Segmental resection for bronchial carcinoma: A Ann Thorac Surg 1979;27:169-172.
5. Hoffman TH, Ransdell HT: Comparison of Cardiovasc Surg 1980;79:211-217.
lobectomy
and
wedge
patient
with marked
bronchogenic
impairment
of
surgical alternative for the compromised
resection for carcinoma of the
lung.
J Thorac
6. Boutin C, Astoul
PH, Seitz B: The role of thoracoscopy in the evaluation and management of pleural effusions. Lung 1990;1113-1121.
7. Krasna M, Flowers JL:
1991;1:94-97. 8.
Diagnostic thoracoscopy
Ridley PD, Braimbridge MV: Thoracoscopic thoracis. Ann Thorac Surg 1991;51:461-464.
in
a
patient
debridement and
with
a
pleural
pleural irrigation
mass.
Surg Laparosc
Endose
in the management of empyema
Address reprint requests to: Dr. Frederick K. Toy 900 Middleford Road Seaford, DE 19973
309
Preliminary Experience With Thoracoscopic Surgery FREDERICK K. TOY, M.D., F.A.C.S., F.C.C.M. and ROY T. SMOOT, Jr., M.D., F.A.C.S.
ABSTRACT
Thoracoscopic surgery was accomplished in 12 patients utilizing thoracoscopic instruments and a stapler. Five patients were treated for recurrent, spontaneous pneumothoraces, for which blebectomies were done; three patients for pulmonary nodules, for which wedge resections were done; one patient for cryptogenic pleural effusion; one patient for debridement of an empyema cavity; one patient for traumatic bronchopleural fistula; and one patient with AIDS for interstitial lung disease. All patients were done under general anesthesia in the lateral decubitus position and were prepped and draped for a standard thoracotomy. They underwent endobronchial double-lumen ventilation so that the ipsilateral lung could be deflated to create a working space. In addition, insufflation of 4 to 5 m m H g was also used. Trocars were placed using a blunt technique. The mid-axillary trocar was at about the eighth intercostal space and was used for the endoscope, and then additional trocars were placed, usually on the anterior axillary line and posterior axillary line at about the lift h intercostal space. If adhesions were encountered, the lung was grasped atraumatically with a clamp or retractor used to give countertraction, and the adhesions were lysed with shears or electrocautery. After a thorough exploration of the hemithorax involved, the area of pathology was grasped with the clamp, which was used for countertraction. Through a 12 mm trocar, a stapler was introduced and fired. This staples and also transects on a 3 cm length. Several firings were usually necessary to remove the pathology, which, if malignant, was placed in a retrieval bag. When mechanical pleurodesis was felt necessary, this was accomplished using a 2 dry gauze was placed and used to abrade the parietal sponge stick clamp, into which a 2 pleura. The patients then had a chest tube placed under direct vision through one of the trocars. The patients experienced only moderate pain in the immediate postoperative period, with essentially no pain by the fourth postoperative day. There were no significant complications noted and
no
deaths occurred.
Department of Surgery,
Nanticoke Memorial
Hospital, Seaford, DE, University
MD.
303
of
Maryland Hospital, Baltimore,
TOY AND SMOOT
INTRODUCTION done 80 years ago, although the procedure never gained extensive Over the past several years, there has been a tremendous surge in the field of endoscopie surgery. The era of video-guided surgery began in 1986 with the development of the computer-chip TV camera. Since the first laparoscopic cholecystectomy in 1988, many more advanced laparoscopic procedures have been described. With the recent development of advanced endoscopie instruments and staplers, there has been a resurgence of interest in thoracoscopic surgery. The authors believe that there are a large number of thoracic procedures which can be safely and effectively accomplished thoracoscopically, resulting in diminished pain and cosmetic disfigurement, as well as quicker convalescence. The experience with thoracoscopic surgery on 12 patients is presented, 7 for benign disease and 5 for malignancy. It is believed that the thoracoscopic approach will become the procedure of choice in the near future for many procedures which have required thoracotomy in the past.
Theapplication.
first THORACOSCOPY was
MATERIALS AND METHODS Twelve patients underwent thoracoscopic surgery, including five blebectomies with mechanical pleurodesis for recurrent, spontaneous pneumothoraces; three diagnostic thoracoscopies with pulmonary wedge resection; one pulmonary wedge resection for stage I peripheral bronchogenic carcinoma in a patient with severe pulmonary compromise; one pleural biopsy for cryptogenic pleural effusion with pleurodesis; one thoracoscopic drainage and debridement of a post-pneumonia empyema thoracis; and one thoracoscopic closure of a traumatic bronchopleural fistula. The age range of these patients was 16 to 86 years. One patient had undergone prior thoracotomy. The procedures were performed under general anesthesia with a double-lumen endotracheal tube to permit selective deflation of the ipsilateral lung. The patients were placed in the lateral decubitus position and prepped and draped for a formal thoracotomy. An 11 mm incision was made at approximately the eighth intercostal space mid-axillary line. With blunt dissection through the intercostal muscles, over the superior edge of the rib with a Kelly clamp, the pleural space was entered. A blunt-tipped, 11 mm trocar was introduced into the hemithorax. With careful monitoring of the blood pressure, 02 saturation, and end-tidal C02, the ipsilateral lung was deflated and the hemithorax was insufflated to 5 mmHg pressure. A forward viewing (0°) endoscope was introduced. Two additional 11 mm blunt-tipped trocars were introduced under direct vision at approximately the sixth intercostal space anterior and posterior axillary lines (Fig. 1 ). Through these ports, the Nanticoke Endo-Duval Clamp and the Nanticoke Endo-Retractor (Cabot Medical, Inc., Langhorne, PA) were introduced (Figs. 2, 3). These instruments allow adequate, atraumatic manipulation and retraction of the lung to ensure a thorough exploration of the entire hemithorax. If adhesions were encountered, they were lysed using Endo-Shears (U.S. Surgical Corp., Norwalk, CT). These allow sharp, precise lysis along with simultaneous electrocauterization of any bleeding. After thorough exploration of the hemithorax, the clamp is introduced via whichever trocar is most convenient to grasp the pathology. The other trocar is exchanged for a 12 mm trocar, and the Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT) is introduced. With the clamp allowing atraumatic manipulation and countertraction of the lung, the stapler was positioned and fired (Fig. 4). Several reloads were necessary to complete the pulmonary resection (Fig. 5). The tissue was placed in a Pleatman Sac (Cabot Medical) and easily removed through the 12 mm port. When mechanical pleurodesis was necessary, a 2 x 2 gauze was folded and grasped in a Nanticoke Endo-Forester sponge stick (Cabot Medical) (Fig. 6). This is easily passed through a trocar and the parietal pleura vigorously abraded (Fig. 7). The hemithorax was copiously irrigated with Bacitracin solution, and a #34 Argyl chest tube was placed through the mid-axillary trocar and sutured to the skin. The incisions were closed with 3-0 vicryl subcutaneous sutures, 4-0 vicryl subcuticular sutures, and steri-strips. 304
FIG. 1.
FIG. 2.
Under general anesthesia, the
Thoracoscopic
patient is in lateral decubitus position with trocars inserted.
instrumentation used for retraction of
Seaford, DE).
FIG. 3.
Thorascopic
Seaford, DE).
instrumentation used for
grasping
of
305
lung (Endo-Retractor,
lung (Endo-Retractor,
Endo-Duval
Clamp, Nanticoke,
Endo-Duval
Clamp, Nanticoke,
TOY AND SMOOT
FIG. 4.
Grasping and countertraction of the lung with application of the Endo-GIA stapler (Nanticoke Endo-Duval,
Seaford, DE).
FIG. 5.
Grasping of the lung after first application of Endo-GIA stapler. Multiple firings usually required. (Nanticoke
Endo-Duval, Seaford, DE.)
306
EXPERIENCE WITH THORACOSCOPIC SURGERY
FIG. 6.
Sponge stick used for mechanical pleurodesis. (Nanticoke Forester, Seaford, DE.) DISCUSSION
Thoracoscopy was first described and reported by a Swedish physician, H.C. Jacobaeus, in 1910. His first procedure was performed under local anesthesia using a trocar to enter the pleural space, which was examined with a cystoscope. Initially, this was used to investigate "idiopathic pleurisy", which was largely found to be tuberculosis. ' Later, he used it for "pneumonolysis"—lysis of adhesions preventing pneumothorax therapy for pulmonary tuberculosis—the treatment prior to the discovery of effective antituberculous chemotherapy. Over the next 40 years, thoracoscopy experienced limited utilization. In recent years, there has been a renewed interest in both diagnostic and therapeutic thoracoscopy. To accomplish a successful thoracoscopic procedure, it is essential to adequately visualize the lung and maneuver the thorascopic instruments. This space is acquired through the use of a double-lumen endotracheal
FIG. 7.
Sponge
stick with 2x2 gauze
(Nanticoke Forester, Seaford, DE.)
abrading
the
parietal pleura, accomplishing
307
a
mechanical
pleurodesis.
TOY AND SMOOT Table 1. Indications
for
Thoracoscopy
Diagnostic
Therapeutic
Cryptogenic pleural
effusions
of adhesions Evacuation of hemothorax Pleurodesis: chemical, mechanical Foreign body retraction Debridement of empyema cavity Bronchopleural fistula closure Trauma
Lysis
Pleural based lesions Hormonal receptor determination Interstitial Cancer
pulmonary
disease
Sympathectomy Vagotomy
staging
Pericardial window
Solitary pulmonary
nodule
Blebectomy Pulmonary resection AICD placement
tube or a bronchial blocker to permit selective collapse of the ipsilateral lung and low pressure insufflation. The addition of 5 mmHg pressure insufflation has been found to be safe and very helpful at providing an adequate space to work when partial inflation of the lung is required. All patients are prepared so they can be immediately converted to an open thoracotomy, in the event the procedures cannot be safely completed
endoscopically. Thoracoscopic
surgery is in a state of evolution. With the development of the video camera, advanced and endoscopie stapler devices, the list of indications is growing rapidly (Ta-
thoracoscopic instruments,
ble 1). In the authors' preliminary experience, thoracoscopic surgery has been utilized for the treatment of recurrent, spontaneous pneumothoraces; pulmonary resection, both diagnostically and therapeutically; the evaluation of pleural disease; and the treatment of empyema. Recurrent, spontaneous pneumothoraces have been very successfully managed with a thoracoscopically stapled blebectomy and gauze mechanical pleurodesis, just as surgeons have done via an open thoracotomy for many years. The advantages are minimal incisions and rib retraction, resulting in a better cosmetic result, less postoperative pain, and a rapid convalescence. With non-small cell, stage I, bronchogenic carcinoma, it has been demonstrated that the local recurrence and survival rates are virtually identical between lobectomy and wedge resection. This has largely been confined to the high-risk patient with marked impairment of pulmonary function.2-5 It has been demonstrated by others that the thoracoscopic evaluation of cryptogenic pleural effusions can be very accurately diagnosed.6,7 Boutin6 showed the incidence of idiopathic pleural effusions approximated 20% and could be reduced to 4% with thoracoscopic evaluation. He also showed a 90% resolution of the chronic effusion with thoracoscopic pleurodesis. Thoracoscopic debridement and irrigation of empyema thoracis was demonstrated to be safe and very beneficial by Ridley and Braimbridge.8
CONCLUSIONS Over the past 2 years, there have been tremendous advances and enthusiasm in endoscopie surgery. This has kindled an interest in thoracoscopy among chest surgeons. The recent development of advanced thoracoscopic instruments and stapling devices have made therapeutic thoracoscopy possible, and a new field of thoracoscopic surgery has developed. This new field enables the thoracic surgeon to avoid a formal thoracotomy, with its greater morbidity and mortality. 308
EXPERIENCE WITH THORACOSCOPIC SURGERY
REFERENCES 1. Jacobaeus HC: The practical 296.
importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:289-
2. Errett LE, Wilson J, Chin RC, Munro DD: Wedge resection as an alternative procedure for peripheral carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985;90:656-661. 3. Miller JI, Hatcher CR: Limited resection of bronchogenic carcinoma in the pulmonary function. Ann Thorac Surg 1987;44:340-343. 4. Bennett
patient.
WF, Smith RA: Segmental resection for bronchial carcinoma: A Ann Thorac Surg 1979;27:169-172.
5. Hoffman TH, Ransdell HT: Comparison of Cardiovasc Surg 1980;79:211-217.
lobectomy
and
wedge
patient
with marked
bronchogenic
impairment
of
surgical alternative for the compromised
resection for carcinoma of the
lung.
J Thorac
6. Boutin C, Astoul
PH, Seitz B: The role of thoracoscopy in the evaluation and management of pleural effusions. Lung 1990;1113-1121.
7. Krasna M, Flowers JL:
1991;1:94-97. 8.
Diagnostic thoracoscopy
Ridley PD, Braimbridge MV: Thoracoscopic thoracis. Ann Thorac Surg 1991;51:461-464.
in
a
patient
debridement and
with
a
pleural
pleural irrigation
mass.
Surg Laparosc
Endose
in the management of empyema
Address reprint requests to: Dr. Frederick K. Toy 900 Middleford Road Seaford, DE 19973
309
