Surg Today DOI 10.1007/s00595-014-0992-3
Original Article
Single‑incision thoracoscopic surgery using a chest wall pulley for lung excision in patients with primary spontaneous pneumothorax Kenji Tsuboshima · Teppei Wakahara · Yasumi Matoba · Harunori Miyauchi · Chikako Hayashi · Iwao Kobayashi · Hiroaki Oue · Yoshihisa Watanabe · Toru Ono · Yoshimasa Maniwa
Received: 12 January 2014 / Accepted: 30 April 2014 © Springer Japan 2014
Abstract Purpose The aim of the study was to evaluate the feasibility and compare the outcomes of single-incision thoracoscopic surgery using a chest wall pulley for lung excision (PulLE) vs. those of conventional video-assisted thoracic surgery (cVATS) in patients with primary spontaneous pneumothorax (PSP). Methods Sixty-nine patients who underwent PulLE (n = 34) or cVATS (n = 35) between January 2009 and December 2013 were enrolled in this study. PulLE was performed as follows. After making a 17- to 25-mm single incision in the 6th intercostal space (6ICS) at the median axillary line, the visceral pleura near the bulla was sutured for traction. The parietal pleura at 3ICS was then sutured from the thoracic cavity to serve as the chest wall pulley and a traction thread was passed through the pulley. By manipulating the traction thread, it was possible to move the lesion to an arbitrary site for excision. The postoperative scar was nearly invisible. Results The operative time, duration of postoperative drainage, and postoperative hospital stay were equivalent for PulLE vs. cVATS. There was no significant difference in postoperative recurrence rates. K. Tsuboshima (*) · T. Wakahara · Y. Matoba Department of Thoracic Surgery, Takasago Municipal Hospital, 33‑1 Kamimachi, Arai Town, Takasago, Hyogo 676‑8585, Japan e-mail: [email protected] H. Miyauchi · C. Hayashi · I. Kobayashi · H. Oue · Y. Watanabe · T. Ono Department of General Surgery, Takasago Municipal Hospital, Takasago, Japan Y. Maniwa Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
Conclusions PulLE has cosmetic benefits over cVATS and is easy to perform. We believe our novel procedure has the potential to become the standard operative treatment for PSP. Keywords Single-incision thoracoscopic surgery · SITS · Chest wall pulley · PulLE · Primary spontaneous pneumothorax · PSP
Introduction In most institutions, three-port video-assisted thoracoscopic surgery (VATS) is the treatment of choice for primary spontaneous pneumothorax (PSP). While single-incision thoracoscopic surgery (SITS) has been reported recently, it is still relatively uncommon and the procedures have not been standardized. For relatively uncomplicated PSP, we perform SITS using a chest wall pulley for lung excision (PulLE). This innovation was developed at our hospital in February 2012. Our procedure provides a good intraoperative view and favorable cosmetic results. We report this technique and its outcomes vs. those of conventional VATS (cVATS) in an interventional study.
Materials and methods The subjects of this study were consecutive PSP patients who underwent VATS in our hospital between January, 2009 and December, 2013. We retrospectively compared the PulLE and cVATS procedures in terms of operative time, blood loss, the number of autosutures used during surgery, duration of postoperative drainage, postoperative hospital stay, and rate of recurrence of pneumothorax. Two
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surgeons operated on all the patients under the same policy. PulLE was performed for relatively straightforward PSP, based on preoperative computed tomography and intraoperative findings. Thus, this series comprised patients with uncomplicated PSP without adhesion in the thoracic cavity in both groups. This study was approved by the Institutional Review Board of Takasago Municipal Hospital.
Surg Today
Chest wall pulley The parietal pleura at the 3ICS level at the anterior axillary line (AAL) was sutured from the thoracic cavity to serve as the chest wall pulley, again using 2-0 nylon. The traction thread was then passed through this pulley (Figs. 1b, 2). The pulley thread unwound the traction thread out of the thoracic cavity and ligated it in the thoracic cavity with a pusher. The pulley was formed from both threads.
Surgical technique Bulla resection The PulLE procedure Observation of the thoracic cavity The patient was placed in the lateral position under general anesthesia. In principle, a 5.5-mm camera port was inserted through the 6th intercostal space (6ICS) at the median axillary line (MAL). We used a 5-mm 30º or flexible thoracoscope to observe the thoracic cavity, especially the area surrounding the bulla identified on computed tomography. When the lesions were identified easily and adhesions were minimal, we extended the port site to 17–25 (mean 19.8 ± 2.2, median 20) mm and a Lapprotector Mini (Hakko, Japan) was placed at this site. If a chest drainage tube had been inserted preoperatively, we utilized this wound as a camera port.
Manipulating the traction thread allowed the lesion to be moved to an arbitrary site for excision, using autosutures (ENDO-GIA: Covidien) (Figs. 1c, 3). In principle, the staple line of the lung was reinforced with a Surgicel Nu-Knit (Johnson & Johnson, USA). The cVATS procedure Observation of the thoracic cavity In principle, a 5.5- or 11.5-mm camera port was inserted through the 6ICS or 7ICS at the MAL. A 5.5-mm working port was then inserted through the 4ICS at the AAL and a 5.5- or 11.5-mm working port was inserted through the 6ICS or 7ICS at the AAL.
Traction suturing of the lung Bulla resection Using forceps to pull on the lung, we inspected the lesion and the entire thoracic cavity. The visceral pleura near the bulla was sutured for traction using 2-0 nylon (Fig. 1a).
Fig. 1 Schema of single-incision video-assisted thoracoscopic surgery (VATS) using a chest wall pulley for lung excision (PulLE) for primary spontaneous pneumothorax
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Using a 5-mm 30º or flexible thoracoscope inserted through the site of the camera port, we identified the lesion. Using
Surg Today Fig. 2 Intraoperative findings of single-incision video-assisted thoracoscopic surgery (VATS) using a chest wall pulley for lung excision (PulLE) for primary spontaneous pneumothorax
Results Patient characteristics Thirty-four patients underwent PulLE (mean age 22.9 ± 8.7 years) and 35 underwent cVATS (mean age 25.9 ± 8.8 years). The pathology was primary in 30 patients from each group. Table 1 summarizes the other demographic data. There were no significant differences between the PulLE and cVATS groups. Statistical analyses were conducted using the Wilcoxon test and the χ2 test. Significance was set at p
Original Article
Single‑incision thoracoscopic surgery using a chest wall pulley for lung excision in patients with primary spontaneous pneumothorax Kenji Tsuboshima · Teppei Wakahara · Yasumi Matoba · Harunori Miyauchi · Chikako Hayashi · Iwao Kobayashi · Hiroaki Oue · Yoshihisa Watanabe · Toru Ono · Yoshimasa Maniwa
Received: 12 January 2014 / Accepted: 30 April 2014 © Springer Japan 2014
Abstract Purpose The aim of the study was to evaluate the feasibility and compare the outcomes of single-incision thoracoscopic surgery using a chest wall pulley for lung excision (PulLE) vs. those of conventional video-assisted thoracic surgery (cVATS) in patients with primary spontaneous pneumothorax (PSP). Methods Sixty-nine patients who underwent PulLE (n = 34) or cVATS (n = 35) between January 2009 and December 2013 were enrolled in this study. PulLE was performed as follows. After making a 17- to 25-mm single incision in the 6th intercostal space (6ICS) at the median axillary line, the visceral pleura near the bulla was sutured for traction. The parietal pleura at 3ICS was then sutured from the thoracic cavity to serve as the chest wall pulley and a traction thread was passed through the pulley. By manipulating the traction thread, it was possible to move the lesion to an arbitrary site for excision. The postoperative scar was nearly invisible. Results The operative time, duration of postoperative drainage, and postoperative hospital stay were equivalent for PulLE vs. cVATS. There was no significant difference in postoperative recurrence rates. K. Tsuboshima (*) · T. Wakahara · Y. Matoba Department of Thoracic Surgery, Takasago Municipal Hospital, 33‑1 Kamimachi, Arai Town, Takasago, Hyogo 676‑8585, Japan e-mail: [email protected] H. Miyauchi · C. Hayashi · I. Kobayashi · H. Oue · Y. Watanabe · T. Ono Department of General Surgery, Takasago Municipal Hospital, Takasago, Japan Y. Maniwa Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
Conclusions PulLE has cosmetic benefits over cVATS and is easy to perform. We believe our novel procedure has the potential to become the standard operative treatment for PSP. Keywords Single-incision thoracoscopic surgery · SITS · Chest wall pulley · PulLE · Primary spontaneous pneumothorax · PSP
Introduction In most institutions, three-port video-assisted thoracoscopic surgery (VATS) is the treatment of choice for primary spontaneous pneumothorax (PSP). While single-incision thoracoscopic surgery (SITS) has been reported recently, it is still relatively uncommon and the procedures have not been standardized. For relatively uncomplicated PSP, we perform SITS using a chest wall pulley for lung excision (PulLE). This innovation was developed at our hospital in February 2012. Our procedure provides a good intraoperative view and favorable cosmetic results. We report this technique and its outcomes vs. those of conventional VATS (cVATS) in an interventional study.
Materials and methods The subjects of this study were consecutive PSP patients who underwent VATS in our hospital between January, 2009 and December, 2013. We retrospectively compared the PulLE and cVATS procedures in terms of operative time, blood loss, the number of autosutures used during surgery, duration of postoperative drainage, postoperative hospital stay, and rate of recurrence of pneumothorax. Two
13
surgeons operated on all the patients under the same policy. PulLE was performed for relatively straightforward PSP, based on preoperative computed tomography and intraoperative findings. Thus, this series comprised patients with uncomplicated PSP without adhesion in the thoracic cavity in both groups. This study was approved by the Institutional Review Board of Takasago Municipal Hospital.
Surg Today
Chest wall pulley The parietal pleura at the 3ICS level at the anterior axillary line (AAL) was sutured from the thoracic cavity to serve as the chest wall pulley, again using 2-0 nylon. The traction thread was then passed through this pulley (Figs. 1b, 2). The pulley thread unwound the traction thread out of the thoracic cavity and ligated it in the thoracic cavity with a pusher. The pulley was formed from both threads.
Surgical technique Bulla resection The PulLE procedure Observation of the thoracic cavity The patient was placed in the lateral position under general anesthesia. In principle, a 5.5-mm camera port was inserted through the 6th intercostal space (6ICS) at the median axillary line (MAL). We used a 5-mm 30º or flexible thoracoscope to observe the thoracic cavity, especially the area surrounding the bulla identified on computed tomography. When the lesions were identified easily and adhesions were minimal, we extended the port site to 17–25 (mean 19.8 ± 2.2, median 20) mm and a Lapprotector Mini (Hakko, Japan) was placed at this site. If a chest drainage tube had been inserted preoperatively, we utilized this wound as a camera port.
Manipulating the traction thread allowed the lesion to be moved to an arbitrary site for excision, using autosutures (ENDO-GIA: Covidien) (Figs. 1c, 3). In principle, the staple line of the lung was reinforced with a Surgicel Nu-Knit (Johnson & Johnson, USA). The cVATS procedure Observation of the thoracic cavity In principle, a 5.5- or 11.5-mm camera port was inserted through the 6ICS or 7ICS at the MAL. A 5.5-mm working port was then inserted through the 4ICS at the AAL and a 5.5- or 11.5-mm working port was inserted through the 6ICS or 7ICS at the AAL.
Traction suturing of the lung Bulla resection Using forceps to pull on the lung, we inspected the lesion and the entire thoracic cavity. The visceral pleura near the bulla was sutured for traction using 2-0 nylon (Fig. 1a).
Fig. 1 Schema of single-incision video-assisted thoracoscopic surgery (VATS) using a chest wall pulley for lung excision (PulLE) for primary spontaneous pneumothorax
13
Using a 5-mm 30º or flexible thoracoscope inserted through the site of the camera port, we identified the lesion. Using
Surg Today Fig. 2 Intraoperative findings of single-incision video-assisted thoracoscopic surgery (VATS) using a chest wall pulley for lung excision (PulLE) for primary spontaneous pneumothorax
Results Patient characteristics Thirty-four patients underwent PulLE (mean age 22.9 ± 8.7 years) and 35 underwent cVATS (mean age 25.9 ± 8.8 years). The pathology was primary in 30 patients from each group. Table 1 summarizes the other demographic data. There were no significant differences between the PulLE and cVATS groups. Statistical analyses were conducted using the Wilcoxon test and the χ2 test. Significance was set at p
