JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 4, 1992 Mary Ann Liebert, Inc., Publishers

Surgical Thoracoscopy: V. JOHN

A

Preliminary Report

BAGNATO,

M.D.

ABSTRACT

Laparoscopic surgery has demonstrated advantages of less pain, early recovery, and cosmesis. Applying laparoscopic surgical techniques to thoracic procedures may allow for similar advantages. New instrumentation provides for greater versatility in treating thoracic conditions. Described herein is the use of thoracoscopy for a variety of thoracic procedures.

INTRODUCTION surgery has been accepted with unprecedented rapidity by surgeons and patients. The advance of video technology combined with new endoscopie instrumentation has allowed for the development of new operative techniques for the performance of "keyhole" operations which had previously been done through traditional incisions. General surgeons have realized that the short term morbidity of most gastrointestinal operations has been associated with the abdominal incision. The visceral portion of an uncomplicated operation did not limit recovery and was not generally associated with pain. It is the access to the viscera which causes the short term morbidity during most uncomplicated procedures. There is, perhaps, no more painful incision made in surgery than a standard posterolateral thoracotomy. Therefore, thoracoscopy may significantly reduce morbidity more than laparoscopy because of the high morbidity of thoracotomy. Consequently, the adaptation of video endoscopie and laparoscopic surgical techniques to chest surgery is a natural step. The development of new instrumentation, namely the endoscopie stapler GIA (Auto Suture, U.S. Surgical [Norwalk, CT]), allows surgeons to perform operations which are viscerally identical to the traditional procedures. This report outlines the use of thoracoscopy in a private

Laparoscopic

practice setting.

MATERIALS AND METHODS Since August 7, 1990, 39 patients have undergone thoracoscopy at Methodist Hospital and Forrest General

Hospital, Hattiesburg, MS. (Table 1). A variety of thoracoscopic procedures have been performed. The procedures described herein are pulmonary resection for a bronchopleural fistula or bleb (27), lung biopsy (15), wedge resection of peripheral solitary pulmonary nodule (3), mediastinal lymph node biopsy (1), pericardial window (6), cervical sympathectomy (3), biopsy of chest wall lesions which were negative by CT Surgery Clinic of Hattiesburg and University Medical Center, Jackson. 131

MS.

BAGNATO Table 1. Patient Data

Number of Patients

Age

Pneumothorax and Bronchopleural Fistula

27

17-82

2.5

Lung Biopsy

15 6 3 3 2

22-67 54-72 22-38 46-62 54-61

Not applicable 4 days 2 days 6 days 7 days

Diagnosis or

Procedure

Pericardial Window Cervical Sympathectomy SPN

Empyema

Length of Post-op Stay days

guided needle biopsy (3), decortication for empyema (2), and transthoracic marsupialization of liver cyst ( 1 ). All patients were candidates for traditional operative techniques. Patients were placed in a standard lateral decubitus position, as for a posterolateral thoracotomy. Instrumentation was the same as that used for laparoscopy with the exception of a proctotype thoracoscope

used on certain cases. Curved instruments became available midway through this series. All patients received general anesthesia with double lumen endotracheal tube ventilation. Disposable laparoscopic trocars were used to gain access to the chest space in most cases but were not used exclusively. The zero degree laparoscope was inserted and the chest inspected. Insufflation was used to compress the lung and speed collapse. The insufflation pressure was kept to less than 10 mmHg. Insufflation pressure was kept low for evaluation of pulmonary pathology, as it can obscure pulmonary anatomy by "squeezing" the lung too much. Ports are usually placed initially in the mid-axillary line; 5 mm ports can then be placed anteriorly through the pectoralis muscle with minimal bleeding. Likewise, ports can usually be positioned easily through the ausculatory triangle. However, access to the thoracic space is limited by the chest wall; in contrast to laparoscopy where ports can usually be positioned wherever necessary. Occasionally, the operating laparoscope is used, which allows the lung to be manipulated without adding another port. Because of the rib cage and shoulder girdle, use of the operating laparoscope is very convenient under some circumstances. Likewise, use of the 30° and 50° angled telescopes can occasionally provide a different dimension to the field of vision. Sometimes, a procedure cannot be completed without this versatility. This has led to the development of a "new" thoracoscope. A prototype scope (Olympus Corp [Lake Success, NY]) has been used in many cases (Fig. 1). This scope is a rigid scope with a deflectable tip. It combines the accuracy of zero degree scopes with the versatility of angled scopes. Cautery is used exclusively. There seems to be little benefit to using the laser in thoracoscopic surgery. Resection appears preferable to vaporization or ablation and also provides an airtight closure—no postoperative air leaks have been encountered; this contributes significantly to early recuperation. The importance of an endoscopie stapler for pulmonary thoracoscopic surgery cannot be overstated. The endoscopie stapler divides and seals the lung tissue in one step (Fig. 2). Neither bleeding nor air leaks have been identified with the use of this revolutionary instrument. Endoscopie stapling allows the surgeon to perform an acceptable thoracoscopic pulmonary resection because the visceral portion of the procedure is identical to the traditional operation. When manipulating the lung, atraumatic forceps are recommended to minimize lung injury. An unrecognized small tear in the lung due to manipulation could cause a postoperative air leak which would hamper early discharge. To be sure that the staple line is airtight, the air in the thoracic space is sampled using the System for Anesthetic and Respiratory Analysis (SARA) (Fig. 3). Prior to terminating the procedure, the port is attached to the SARA monitor by attaching tubing to the insufflation site on the port and the lung ventilated. Any anesthetic gas present usually indicates a leak. This is a very sensitive technique, but rather non-specific. It has, however, proved valuable in assuring that the pathologic bleb has been resected. A small caliber (20-24F) chest tube was used 24-48 h after surgery; this is dependent on the type of

operation performed. 132

SURGICAL THORACOSCOPY

FIG. 1.

New prototype

thoracoscope.

It has

a

rigid shaft with a deflectable tip.

RESULTS The operative mortality has been zero. Patients with pneumothorax secondary to bleb were followed from 3 weeks to 18 months without recurrence. The average hospital stay was 2.5 days for the pneumothorax. Patients who underwent lung biopsy had no complications. The biopsy specimen was determined to be adequate in all cases. Wedge resection was feasible in two to three patients. In one patient, the lesion could not be satisfactorily localized, therefore, the procedure was converted to a thoracotomy. Adequate resection margins of a small adenocarcinoma was obtained. The other lesion was benign.

FIG. 2.

The

endoscopie stapler divides and seals the lung in one step. 133

BAGNATO

FIG. 3. The System for Anesthetic and Respiratory SARA monitor and the air in the chest space sampled.

Analysis (SARA) monitor. The disposable port is attached to the Any detectable quantity of anesthetic gas indicates a leak.

A thoracotomy was averted by obtaining a mediastinal node which unreachable was lymph by mediastinoscopy. Pericardial malignant biopsy windows were performed in six patients with recurrent pericardial effusions. The pericardial biopsy revealed metastatic carcinoma in two patients who had had negative cytology by pericardiocentesis. No recurrent effusions were noted. Cervical sympathectomy was accomplished thoracoscopically in three patients, with good results. Two patients had causalgia and received immediate relief; one patient had hyperhidrosis. No complications were encountered. One patient who had recurrent liver abscess was found to have empyema. He underwent thoracoscopic decortication with excellent results. His liver abscess has cleared and he is now well after a lengthy illness. He has been followed for 6 weeks after thoracoscopic decortication. A patient with a large painful liver cyst posteriorly in the dome of the right lobe of the liver underwent thoracoscopic marsupialization of the liver cyst. She previously had unsuccessful treatment of this cyst by

Mediastinal

lymph node biopsy was performed on one patient. on a

laparotomy.

DISCUSSION

Thoracoscopy has been used for diagnosis of chest disease since 1910.2 When tuberculosis was widespread, thoracoscopy was used commonly. However, since tuberculosis has now become medically treatable, thoracoscopy is not used as widely. Many thoracic surgeons today have never performed thoracoscopy. Endoscopie surgery proves to be the major technical advance of the 90s. With the success of laparoscopic cholecystectomy and the great advantages to both patients and surgeons recognized through the use of laparoscopy in general surgery, it is not surprising that the same techniques are being applied to thoracic surgery.3 Operative thoracoscopy is thus becoming more popular. Because of the tremendous reduction in morbidity associated with thoracoscopy when compared to thoracotomy, the impact on health care can be anticipated to be very significant. When considering morbidity on an individual basis for each patient, the authors feel that the advantage of thoracoscopy will be far greater than the advantage of laparoscopy. As instrumentation improves and experience broadens, more thoracoscopic procedures can be anticipated. For the treatment of pneumothorax associated with bronchopleural fistula and bleb disease, thoracoscopy is ideally suited4 (Fig. 4). The use of thoracoscopy combined with the use of the endoscopie stapler is revolutionary.5 This combination represents an example of an operation done endoscopically, in which the 134

SURGICAL THORACOSCOPY

FIG. 4.

A bleb

on

the surface of the upper lobe that is located and

grasped prior to excision with the stapler.

visceral portion of the operation is identical to the open procedure. The endoscopie stapler, therefore, allows surgeons to perform thoracoscopic pulmonary resection without uncertainty, due to its similarity to the open

procedure.

Pleurodesis has not been used in combination with thoracoscopic excision of blebs in this series, therefore, patients are being followed closely for possible recurrence. There has been no recurrence thus far, but the follow-up period is too short to make any conclusion regarding pleurodesis. Traditional open lung biopsy is now performed only under unusual circumstances. Thoracoscopic lung biopsy performed with the endoscopie stapler appears to be safer and more accurate. For patients in the ICU on ventilatory support, thoracoscopy is ideal. The endoscopie stapler provides a hemostatic and airtight closure. No postoperative air leaks have been encountered in this series even with positive-end expiratory pressure ventilation. It appears that thoracoscopic lung biopsy is superior to open lung biopsy under most circumstances. The use of the SARA system to detect air leaks is an important step for patients who are ventilator dependent, as any loss of tidal volume from an air leak can be detrimental. The role of thoracoscopy in the staging of carcinoma of the lung needs to be further defined. Patients who may be candidates for resection of lung cancer would perhaps benefit by first receiving thoracoscopy to evaluate mediastinal lymph nodes. If the nodes prove to be positive, then a thoracotomy can be avoided. This is an important issue which needs to be evaluated with a large series of patients to test the feasibility of this type of approach. Pericardial window or pericardiectomy can be performed thoracoscopically with minimal morbidity. Thoracoscopy allows the surgeon to be more thorough in evaluation, as well as technically precise. The operating scope is very useful in performing thoracoscopic pericardial window, since frequently the left chest space is compromised by the enlarged heart. Preoperative pericardiocentesis is usually helpful by reducing the size of the "heart" and making the pericardium easier to grasp. The cautery is used to create a 2-3 cm window. Five cases were performed in this series. The pericardial biopsy resulted in unsuspected diagnosis of cancer in two patients who had negative cytology on the pericardial fluid. A chest tube is used for up to 48 h postoperatively. No recurrent pericardial effusions have been identified. Cervical sympathectomy is an example of a procedure that is better suited to thoracoscopy than performed traditionally. Access to the cervical sympathetic ganglion is tedious and hazardous when performed through an axillary incision. Performed thoracoscopically, cervical sympathectomy is relatively simple and safe. The video endoscopy system provides excellent direct vision with magnification which cannot be compared to an axillary approach. This results in a more precise and safer cervical sympathectomy which also has less morbidity—clearly a technical advance. 135

BAGNATO

Some cases of empyema or chronic pleural effusion may be amenable to thoracoscopic treatment. If the pleural effusion is loculated, thoracoscopy will aid in therapy and diagnosis. Transthoracic upper abdominal procedures can also be performed via thoracoscopic guidance. A large liver cyst was treated by thoracoscopy. Diagnostic thoracoscopy will continue to be used, perhaps more often as surgeons become adroit in its use. Several patients with pleural chest wall lesions have been encountered who had negative CT guided biopsy. Thoracotomy was avoided by using thoracoscopy and frozen section. Obtaining sufficient material was assured and a diagnosis secured prior to terminating the procedure.

CONCLUSIONS

Surgery is in the midst of a renaissance, created by the realization that major operations can be performed under video endoscopie guidance without large incisions. Thereby, the morbidity of surgery is reduced without compromising expected results. Operative thoracoscopy is a "new" technique for which the role in the surgical armamentarium is yet to be defined, although it will be forthcoming as experience is gained and experiences are shared. Traditional surgical principles should still be adhered to at all times. When an operation can be performed in standard fashion through an endoscopie approach, then this has minimized the complications, maximized the benefit to the patient, minimized the recovery time, and created no uncertainty as to the effectiveness of the procedure. It can be predicted then that operative thoracoscopy will make a major impact on health care because of the tremendous reduction in morbidity when compared to thoracotomy. Consequently, thoracoscopy is being enthusiastically embraced. However, while major pulmonary and esophageal resections are feasible thoracoscopically, caution is recommended. Understandably, surgeons can become enamored by this revolutionary technique. To challenge the limits and extend the possibilities of a "new" technology can be both invigorating and rewarding. To "push-back the envelope" and contribute to the science of surgery is an admirable endeavor. However, we are all imperfect men. In the thorax, pitfalls may often prove fatal. It behooves us to remember the axiom, "First do no harm." REFERENCES 1. Dubois F, Icard P, Bertholt G, et al:

1990;211:60-62. 2. Jacobaues HC: The practical 296.

Coelioscopic cholecystectomy: a preliminary report of 36 cases.

Ann

Surg

importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:280-

Diagnostic thoracoscopy: Use of laparoscopic surgical techniques. Surg Endose 1991. Wakabayashi A: Thorascopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax. AnnThorac Surg 1989;48:651-653. Bagnato J: Treatment of recurrent spontaneous pneumothorax. Surg Laparosc 1992;2:100-103. Ridley DD, Brainbridge NW: Thorascopic debridement and pleural irrigation in the management of empyema thoracis. AnnThorac Surg 1991;51:461-464.

3. Krasna MJ, Flower J: 4.

5. 6.

Address reprint requests to: V. John Bagnato, M.D. Surgery Clinic of Hattiesburg, P.A. P.O. Box 16149 105 Asbury Circle Hattiesburg, MS 39404-6149

136

Surgical thoracoscopy: a preliminary report.

Laparoscopic surgery has demonstrated advantages of less pain, early recovery, and cosmesis. Applying laparoscopic surgical techniques to thoracic pro...
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