Surg Endosc (1992) 6:189-192
Surgical Endoscopy © Springer-Verlag New York Inc. 1992
Thoracoscopic wedge resection Rolf Inderbitzi 1, Markus Furrer 1, Christian Klaiber 2, Hans Beat Ris 1, Heinz Striffeler 1, and Ulrich Althaus l l Department of Thoracic and Cardiovascular Surgery, University Hospital of Berne, S-3010 Berne, Switzerland, and 2 Aarberg Hospital, Aarberg, Switzerland
Summary. Thoracoscopic surgery is decidedly expanded by the ability to perform pulmonary wedge resections of the lung by using the Endo-GIA-stapler. In addition to thoracoscopic biopsies, since July 1991 we have carried out wedge resections in 12 patients suffering from spontaneous pneumothorax (nine) or peripheral bronchial carcinoma (three). Postoperatively one air fistula persisted over 9 days. The chest tube was removed within 48 h in all other patients. There was no other major complication. The postoperative hospitalization period lasted 4.6 days (1-9 days). Operating time was 44 min (30-70 min). The benefit for the patient consists in the little-impaired breathing mechanics, the short hospital stay, and the favorable cosmetic result.
present report describes indications and techniques actually applied in our institution.
Key words: Thoracoscopic surgery - Wedge resection - Spontaneous pneumothorax - Peripheral bronchial carcinoma
Thoracoscopy is carried out under general anesthesia by doublelumen endobronchial intubation with the patient in a lateral position. In our hands, this is the most adequate method for thoracoscopic surgery, as it takes all anatomical, pathological, and technical eventualities into consideration. Moreover, it allows one to perform thoracoscopy under conditions comparable to surgical interventions within the open thorax. The equipment can be transferred from one port to another as necessary. Pneumothorax is created by insufflating 500 ml CO2 via a Veres needle. We use the Endo-Pneu-Insufflator (Wolf, Germany), which allows for a continuous control and judgment of the CO2-flow. In a pleural space without adhesions the negative intrapleural pressure pulls the gas through the tube. An increasing flow pressure may be an indication of any adhesions or partially obliterated pleural space. Thus the flow pressure is limited by us to 15 mmHg. The use of such a setup is not mandatory. A pneumothorax apparatus is an adequate alternative to measure the required quantity of gas [4]. CO2 is preferred due to its rapid resorption in view of inadvertent compression of gas into extrapleural structures, especially into the mediastinum. After creating the pneumothorax a straight-viewing telescope connected to the video camera is inserted via a trocar sleeve through the first skin incision in the fourth intercostal space anterior to the edge of the latissimus dorsi muscle. The image produced by the endoscope is transmitted to a TV monitor. With respect to the thoracoscopic findings, now the second and third points of entry are definitively selected, and the trocars are inserted under direct vision. Usually the incisions are made in a triangular fashion between the third and sixth intercostal space with a distance of at least 6 cm between each entry. Should very basally situated lung alterations be explored, lateral entries can be placed down to the eighth intercostal space. All trocars have a 7-mm diameter, allowing for flexibility in the
Diagnostic thoracoscopy, established long ago, has substantially expanded its range in the past two decades [2, 5, 8, 9, 14-16]. The use of video techniques allows for the application of general principles of minimally invasive surgery [11]. Since 1990 we have treated spontaneous pneumothorax by thoracoscopically controlled ligature of a circumscribed leak. In the presence of extended lung alterations, corresponding to stage 4 of Vanderschueren [15], the ligature is combined with the endoscopic parietal pleurectomy [9, 10]. With the introduction of an applicable endoscopic stapler, a pulmonary wedge-resection has also become accessible to thoracoscopy. Likewise, aside from resectioning of altered bullous lung parts, peripherally situated tumors can be thoracoscopically removed in selected cases. Based upon our experience in 12 clinical cases, the
Offprint requests to: R. Inderbitzi
Patients and methods
Patients Patient characteristics are compiled in Table 1. Since July 1991 we have carried out wedge resections in nine patients with spontaneous pneumothorax (mean age 41.6 years) and in three patients suffering from a bronchial carcinoma (mean age 62 years).
Surgical technique
190 Table 1. Clinical data of patients Name
Sex
Age (years)
Diagnosis
Gross pathology
Duration of thoracoscopy (min)
Length of hosp. after operation (days)
Period of pleural drainage (hours)
Complications
1 G.A.
m
21
Recurrent SP
45
3
Surgical Endoscopy © Springer-Verlag New York Inc. 1992
Thoracoscopic wedge resection Rolf Inderbitzi 1, Markus Furrer 1, Christian Klaiber 2, Hans Beat Ris 1, Heinz Striffeler 1, and Ulrich Althaus l l Department of Thoracic and Cardiovascular Surgery, University Hospital of Berne, S-3010 Berne, Switzerland, and 2 Aarberg Hospital, Aarberg, Switzerland
Summary. Thoracoscopic surgery is decidedly expanded by the ability to perform pulmonary wedge resections of the lung by using the Endo-GIA-stapler. In addition to thoracoscopic biopsies, since July 1991 we have carried out wedge resections in 12 patients suffering from spontaneous pneumothorax (nine) or peripheral bronchial carcinoma (three). Postoperatively one air fistula persisted over 9 days. The chest tube was removed within 48 h in all other patients. There was no other major complication. The postoperative hospitalization period lasted 4.6 days (1-9 days). Operating time was 44 min (30-70 min). The benefit for the patient consists in the little-impaired breathing mechanics, the short hospital stay, and the favorable cosmetic result.
present report describes indications and techniques actually applied in our institution.
Key words: Thoracoscopic surgery - Wedge resection - Spontaneous pneumothorax - Peripheral bronchial carcinoma
Thoracoscopy is carried out under general anesthesia by doublelumen endobronchial intubation with the patient in a lateral position. In our hands, this is the most adequate method for thoracoscopic surgery, as it takes all anatomical, pathological, and technical eventualities into consideration. Moreover, it allows one to perform thoracoscopy under conditions comparable to surgical interventions within the open thorax. The equipment can be transferred from one port to another as necessary. Pneumothorax is created by insufflating 500 ml CO2 via a Veres needle. We use the Endo-Pneu-Insufflator (Wolf, Germany), which allows for a continuous control and judgment of the CO2-flow. In a pleural space without adhesions the negative intrapleural pressure pulls the gas through the tube. An increasing flow pressure may be an indication of any adhesions or partially obliterated pleural space. Thus the flow pressure is limited by us to 15 mmHg. The use of such a setup is not mandatory. A pneumothorax apparatus is an adequate alternative to measure the required quantity of gas [4]. CO2 is preferred due to its rapid resorption in view of inadvertent compression of gas into extrapleural structures, especially into the mediastinum. After creating the pneumothorax a straight-viewing telescope connected to the video camera is inserted via a trocar sleeve through the first skin incision in the fourth intercostal space anterior to the edge of the latissimus dorsi muscle. The image produced by the endoscope is transmitted to a TV monitor. With respect to the thoracoscopic findings, now the second and third points of entry are definitively selected, and the trocars are inserted under direct vision. Usually the incisions are made in a triangular fashion between the third and sixth intercostal space with a distance of at least 6 cm between each entry. Should very basally situated lung alterations be explored, lateral entries can be placed down to the eighth intercostal space. All trocars have a 7-mm diameter, allowing for flexibility in the
Diagnostic thoracoscopy, established long ago, has substantially expanded its range in the past two decades [2, 5, 8, 9, 14-16]. The use of video techniques allows for the application of general principles of minimally invasive surgery [11]. Since 1990 we have treated spontaneous pneumothorax by thoracoscopically controlled ligature of a circumscribed leak. In the presence of extended lung alterations, corresponding to stage 4 of Vanderschueren [15], the ligature is combined with the endoscopic parietal pleurectomy [9, 10]. With the introduction of an applicable endoscopic stapler, a pulmonary wedge-resection has also become accessible to thoracoscopy. Likewise, aside from resectioning of altered bullous lung parts, peripherally situated tumors can be thoracoscopically removed in selected cases. Based upon our experience in 12 clinical cases, the
Offprint requests to: R. Inderbitzi
Patients and methods
Patients Patient characteristics are compiled in Table 1. Since July 1991 we have carried out wedge resections in nine patients with spontaneous pneumothorax (mean age 41.6 years) and in three patients suffering from a bronchial carcinoma (mean age 62 years).
Surgical technique
190 Table 1. Clinical data of patients Name
Sex
Age (years)
Diagnosis
Gross pathology
Duration of thoracoscopy (min)
Length of hosp. after operation (days)
Period of pleural drainage (hours)
Complications
1 G.A.
m
21
Recurrent SP
45
3
