Video-assisted thoracoscopic repair of an intercostal pulmonary hernia

Pulmonary hernias are extremely rare. They are usually treated with open surgical procedures. We describe a case in which a large, spontaneously acquired intercostal pulmonary hernia was successfully repaired by video-assisted thoracoscopic surgery (VATS). Received: 12 August 1996/Accepted: 26 November 1996     

Video-assisted thoracoscopic lobectomy in infants

Objective: Congenital lung malformations are often discovered on routine prenatal sonography or postnatal imaging. Lesions such as congenital cystic adenomatoid malformation or pulmonary sequestration may be asymptomatic at birth, and their management is controversial. Thoracoscopy in children has been mainly used for lung biopsy and for the treatment of empyema and recurrent pneumothorax. Very few reports of more technically demanding procedures, such as lobectomy, are currently available. This report evaluates the safety and efficacy of video-assisted thoracoscopic (VATS) lobectomy in infants and small children with asymptomatic prenatally diagnosed lung lesions. Methods: During 2004, six patients underwent VATS lobectomy without a mini-thoracotomy. Mean age was 10 months (range, 6–19 months). Preoperative diagnosis included congenital cystic adenomatoid malformation (n = 5) and an extralobar pulmonary sequestration. All patients were asymptomatic and surgery was performed electively. Three or four 3–5 mm ports were used. Single lung ventilation and controlled low pressure pneumothorax were used in every case. A bipolar sealing device was the preferred mode of vessel ligation and bronchi were closed with interrupted sutures. A chest tube was left in all cases. Results: All the procedures were completed thoracoscopically. Operating times ranged from 70 to 215 min (mean, 130 min). There were five lower lobe and one middle lobe resections. There were no intraoperative complications and chest tubes were left in place 1–4 days. Two patients showed postoperative hemothorax that stopped spontaneously. Hospital stay ranged from 4 to 9 days (mean, 7 days). Conclusions: VATS lobectomy in small infants is a feasible and safe technique. Decreased postoperative pain, a shorter hospital stay, and a better cosmetic result are definite advantages of this minimally invasive procedure. Long-term morbidity due to a major thoracotomy incision is avoided.     

Video-assisted thoracic surgery (VATS) lobectomy for typical bronchopulmonary carcinoid tumors

Background: Indications for the use of video-assisted thoracic surgery (VATS) lobectomy are a controversial matter. This study aims to provide a retrospective evaluation of VATS lobectomy in typical bronchopulmonary carcinoids. Methods: Patient selection criteria for VATS lobectomy were as follows: (a) typical carcinoids with clear diagnosis; (b) centrally located lung tumors not amenable to bronchial resection with bronchoplastic procedures, or tumors located in peripheral lung tissues; (c) no hilar or mediastinal lymph node enlargement; and (d) normal respiratory function. Between January 1995 and December 1999, 12 patients (eight men and four women with a mean age of 57 years) were treated, seven with a peripheral and five with a centrally located tumor. Preoperative examination included chest roentgenograms, computed tomography (CT) of the chest, bronchoscopy, and spirometry; diagnosis was established by direct bronchoscopy in five cases, transbronchial biopsy in two cases, transthoracic biopsy in two cases, and videothorascopic wedge resection in three cases. Eleven VATS lobectomies and one VATS bilobectomy were performed. All patients underwent hilar lymphadenectomy and mediastinal sampling. Results: There were no intraoperative complications. The only postoperative complication, hematothorax (8.3%), required VATS reoperation. Mean postoperative hospital stay was 5.33 days. Pathological examination of the resected specimens confirmed that the procedure was radical in all 12 patients and revealed eight T1N0 and four T2N0. At a mean follow-up of 30 months, no signs of recurrence were recorded. Conclusion: VATS lobectomy in the treatment of selected typical carcinoids, both central and peripheral, seems to yield favorable results and is therefore preferable to thoracotomy since it is less invasive. Received: 21 January 2000/Accepted: 11 May 2000/Online publication: 5 October 2000     

电视胸腔镜下治疗肺叶切除术后支气管胸膜瘘

本文报道 2例肺癌患者行肺叶切除分别于术后第 4、7天出现支气管胸膜瘘。再次手术经VATS直接以无损伤编织线缝合封闭瘘口 ,外用医用合成胶或生物蛋白胶。 2例支气管膜瘘均治愈出院。     

Complete versus assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques

Background Video-assisted thoracoscopic surgery (VATS) lobectomy does not represent a unified approach, but rather a spectrum of operative techniques ranging from a complete endoscopic thoracotomy to a minithoracotomy. A prospective randomized trial was conducted to compare the differences in these techniques and their results to determine the best of VATS lobectomy for lung cancer.Methods This study randomized 39 consecutive patients with clinical stage I lung cancer to undergo either a complete (C-VATS, n = 20) or an assisted (A-VATS, n = 19) VATS approach for pulmonary lobectomy.Results The operating time was longer (p = 0.002) and blood loss was less (p = 0.004) with C-VATS than with A-VATS. Although there was no significant difference in analgesic use or duration of thoracic drainage between the groups, a shorter hospitalization was observed after C-VATS. Serum peak levels of postoperative inflammatory markers (white blood cell count, C-reactive protein, creatine phosphokinase) were lower with C-VATS and an earlier return to normalization than with A-VATS.Conclusion Various differences exist among the VATS lobectomy techniques, and complete VATS lobectomy as a purely endoscopic surgery may be technically feasible and a satisfactory alternative to the conventional procedure for stage I lung cancer.     

Operative technique for thoracoscopic transmyocardial laser revascularization

We describe herein the operative steps used to perform a transmyocardial laser revascularization by thoracoscopy. A special technique and specific equipment are required for the efficacy and safety of the procedure. Our preliminary results with this novel approach suggest that it could be a valid alternative to the thoracotomic procedure.     

A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax

Background: Recent data suggest that children have a higher incidence of recurrence than adults after nonoperative treatment of primary spontaneous pneumothorax (PSP). Video-assisted thoracoscopic surgery (VATS) allows efficacious therapy with significantly less morbidity. We attempt to define the most cost-effective clinically efficacious strategy using VATS to manage pediatric PSP. Methods: We retrospectively reviewed all admissions to a tertiary care children's hospital for PSP between January 1, 1991 and June 30, 1996. Results: Fifteen children had 29 primary or recurrent PSPs. Mean patient age was 14.8 ± 1.1 years, boy–girl ratio 4:1, median body mass index 18 (normal, 20–25), and 67% of pneumothoraces left sided. All patients were managed initially nonoperatively: 14 with tube thoracostomy drainage and 1 with oxygen alone. Of the children initially managed nonoperatively, 57% had a recurrent pneumothorax, and 50% of these patients eventually developed contralateral pneumothoraces. Nonoperative treatment for recurrence resulted in a 75% second recurrence rate. In contrast, eight children who underwent operative management had a 9% incidence of recurrence. The total for charges accrued in treating 29 pneumothoraces in these 15 patients was approximately $315,000. In the same population, the estimated charges for initial nonoperative therapy followed by bilateral thoracoscopy after a single recurrence would be $230,000. Conclusions: A cost-effective treatment strategy for pediatric primary spontaneous pneumothorax is tube thoracostomy at first presentation, followed by VATS with thoracoscopic bleb resection and pleurodesis for patients who experience recurrent pneumothorax. Received: 15 May 1998/Accepted: 15 January 1999     

Video-assisted thoracoscopic surgery in the management of loculated empyema

Background: Fibropurulent empyema (stage II of Light) does not respond to antibiotic therapy and simple drainage. If the condition is inadequately treated, restrictive pulmonary deficit develops, necessitating thoracotomy and decortication. We report our experience with the videoscopic management of stage II and limited stage III disease. Methods: Ten consecutive patients underwent videoscopic debridement of fibropurulent empyema; three of them required removal of limited visceral and parietal rind. Results: The mean operating time was 42 ± 8.1 min. Postoperative pyrexia and leucocytosis settled within 4.2 ± 2.1 days and 13.1 ± 3.2 days, respectively. Intercostal chest tubes were removed by 4.5 ± 1.0 days. The mean fall in hematocrit following surgery was 4.9%. Parenteral analgesics were required for 1.0 ± 0.5 days and oral analgesics for 3 ± 1.6 days. The mean postoperative stay was 11 ± 8.1 days. No patient required any further intervention. Conclusions: Videoscopic debridement of empyema produces excellent results, with minimal patient morbidity and a short hospital stay. We recommend it as the preferred method for first-line management of fibropurulent (stage II) empyema. Received: 10 December 1998/Accepted: 13 May 1999     

Videothoracoscopic resection of anterior mediastinal teratoma in a child

This report describes a case of anterior mediastinal teratoma in a 10-year-old girl, which was successfully resected thoracoscopically. Received: 4 October 1996/Accepted: 23 January 1997     

Operative technique for thoracoscopic thymectomy

In most cases, myasthenia gravis (MG) and thymoma require complete removal of the thymus gland and resection of the pericardial fatty tissue. There is some debate however, over which surgical approach is best for thymectomy. We have developed a new technique for complete thoracoscopic thymectomy. Between October 1994 and February 1998, we performed a prospective observational study of thoracoscopic thymectomy in 19 patients. The results were analyzed with special reference to perioperative morbidity, short- and intermediate-term improvement of MG, and quality of life. This study showed the feasibility of complete thoracoscopic thymectomy. The procedure was successfully applied in 19 of 20 cases. Thoracoscopic thymectomy was accomplished with zero mortality and a very low perioperative morbidity. While the short-term improvement of MG after this procedure was comparable to that seen with conventional surgery, the short- and intermediate-term quality of life was much better. The preliminary results of thoracoscopic thymectomy appear to be excellent for both patients and neurologists. A prospective randomized trial has been designed to compare thoracoscopic thymectomy with the gold standard of median sternotomy for thymectomy. Received: 9 March 1998/Accepted: 22 June 1998     

Embolization versus surgical resection of pulmonary sequestration: Clinical experiences with a thoracoscopic approach

Purpose

The goal of this study was to compare the safety and efficacy of treatment for pulmonary sequestration (PS) by transcatheter arterial embolization (TAE) versus surgical resection and to consider the role of a thoracoscopic approach.

Methods

A retrospective review involving 73 children (≤ 15 years of age) with PS between 2002 and 2011 was performed.

Results

Forty-two patients were managed with TAE, and 31 underwent surgery alone. Their presenting symptoms were pneumonia (n = 11), pneumothorax (n = 2), pneumomediastinum (n = 1) and respiratory distress (n = 6).Fifty-three (72.6%) were asymptomatic. The average age at treatment was 17.0 ± 44.4 and 31.3 ± 41.7 months for the TAE and surgery groups, respectively. In the TAE group, complete regression was observed in only 3 patients, 4 showed no regression, and 35 (83.3%) had residual lesions. Four patients developed sepsis or other blood vessel complications after TAE. The results of resection via thoracotomy versus a thoracoscopic approach were evaluated in 34 patients, including 3 who underwent the operation after TAE. Twenty-seven patients underwent thoracotomy, and 7 underwent thoracoscopic resection. There were no significant differences between the groups except time to chest tube removal, which was shorter in the thoracoscopic group (p = 0.046). Complications included a wound infection in 1 patient after thoracotomy.

Conclusions

We believe that even in asymptomatic patients, all PSs should be resected because of the risk of infection, the low rate of natural regression, complications after TAE, and to exclude other pathology. Our experience also shows that thoracoscopic resection of PS is feasible, efficacious, and safe in newborns and infants.     

Minimally invasive surgery and clinical decision-making for pediatric malignancy

Background: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. Methods: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. Results: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. Conclusion: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques. Received: 19 March 1999/Accepted: 27 August 1999     

Cost-containing strategies in video-assisted thoracoscopic surgery

Background: Video-assisted thoracoscopic surgery (VATS) is now an established approach in the management of many thoracic conditions. However, the high cost of this new technology has deterred many Asian hospitals from widely applying this technique. Methods: This article describes our strategies to reduce cost in our practice of VATS over the last few years. Results: VATS involves (1) careful patient selection, (2) use of conventional thoracic instruments as much as possible, (3) modification of conventional instruments, (4) limited use of expensive consumables, and (5) development and application of endoscopic suturing technique. Conclusions: VATS is still in evolution. Cost containment, while desirable in the West, is a high priority in Asia if this new surgical approach is to be applicable even in developing countries. More research is greatly needed in this area. Received: 13 February 1996/Accepted: 10 June 1996     

Complications in thoracoscopic spinal surgery

Background: The literature contains few reports on negative outcomes after thoracoscopic spinal surgery. Methods: From November 1995 to February 1998, 90 patients underwent minimally invasive spinal surgery by thoracoscopic assistance as treatment for their anterior spinal lesions. The diagnoses included 41 spinal metastases, 13 cases of scoliosis, 12 burst fractures, 10 cases of tuberculous spondylitis, 8 cases of pyogenic spondylitis, 2 thoracic disc herniations, 2 cases of ankylosing spondylitis with discitis, 1 osteoporotic compression fracture, and 1 case of thoracolumbar kyphosis. The procedures included biopsy only (3 patients); thoracic discectomy (3 patients); multilevel anterior releases, discectomy, and fusion (14 patients); corpectomy for decompression (6 patients); corpectomy and interbody fusion (32) patients; and internal instrumentation (28 patients). Results: A total of 30 complications were noted in 22 patients (24.4%). Two fatal complications occurred, resulting from massive blood transfusion in one case and postoperative pneumonia in another. Other nonfatal complications included four cases of transient intercostal neuralgia, three superficial wound infections, three cases of pharyngeal pain, two cases of lung atelectasis, two cases of residual pneumothorax, two cases of subcutaneous emphysema, one inadvertent pericardial penetration due to adhesion, one chylothorax that resolved after conservative management, one vertebral screw malposition, and one graft dislodgement that needed late revision surgery. Three patients required ventilatory support for longer than 72 hours. Five patients with spinal metastases had an estimated intraoperative blood loss of more than 2,000 ml. No injury to the internal organs or spinal cord was observed. There were four conversions to open procedures due to two cases of severe pleural adhesions and two poorly tolerated one-lung ventilation. At the latest follow-up, nine patients had died as a result of cancer dissemination. Conclusions: (a) Well-selected patients and attention to details are essential to optimizing surgical results. (b) A refined technique for less invasive tumor surgery has been developed. (c) Surgeons had better experience with the standard anterior spinal approach and showed no hesitation in converting to an open procedure when necessary. A procedure failure does not mean a treatment failure. Received: 14 May 1998/Accepted: 25 August 1998     

Anastomosis level and specimen length in surgery for uncomplicated diverticulitis of the sigmoid

Background: Extent of bowel resection and level of anastomosis are unsettled issues of surgery for diverticulitis of the sigmoid. The aim of this study was to compare the adequacy of open colon resection (OCR) with that of laparoscopic colon resection (LCR) for uncomplicated diverticulitis of the sigmoid (UDS), specifically addressing level of anastomosis and length of specimen. Methods: Comparisons were made between 40 selected patients undergoing LCR for UDS between 1992 and 1994 and 35 diagnosis-matched controls who previously underwent OCR by the same surgeons at the same institution. Results: The OCR and LCR patients were well-matched for age, gender, weight, ASA grade, duration of symptoms, and number of previous admissions. There were no significant differences, respectively, between OCR and LCR patients in morbidity rates (2 vs. 5, p= 0.33) and rates of mobilization of the splenic flexure (17:18 vs. 29:11, p < 0.1). Specimen length (18 cm vs. 11 cm, p≪ 0.01), colosigmoid vs. colorectal anastomosis (24:11 vs. 1:39, p≪ 0.01), and presence of inflammatory cells at the proximal resection margin (2 vs. 11, p= 0.02) were significantly different. The OCR patients had statistically longer follow-up than LCR patients (63 months vs. 46 months, p≪ 0.01). Recurrent diverticulitis rates were 9.6% and 2.7% after OCR and LCR, respectively (3 vs. 1, p= 0.73). Conclusions: Inadequate sigmoid resection should prompt diligence to take down the splenic flexure placing the distal anastomotic margin on the rectum to ensure adequate surgery. Received: 12 August 1997/Accepted: 16 November 1997     

Bilateral thoracoscopic stapled volume reduction for bullous vs diffuse emphysema

Background: We compared our results with bullous vs diffuse emphysema by performing a bilateral thoracoscopic stapled volume reduction technique in 15 patients (age 45–80, 10 males, five females). Methods: Eight patients demonstrated bullous emphysema and seven patients diffuse emphysema. Lung reduction was performed with a bilateral thoracoscopic stapled technique utilizing bovine pericardium in the supine position. Results: Comparison of the bullous versus diffuse groups revealed no significant differences in means for the following variables: length of air leak (7.5 vs 3.3 days); length of stay (8.1 vs 6.5 days); pre-op FEV₁ (23% vs 22%); pre-op dyspnea index (3.4 vs 3.6). At 3 months the bullous subset had a highly significant improvement (p < 0.007) in FEV₁ (88%) compared with the diffuse subset FEV₁ (59%). Conclusions: These early results suggest that patients with bullous emphysema are at no greater risk and demonstrate a significantly greater improvement in FEV₁ than patients with diffuse emphysema. Received: 14 May 1997/Accepted: 6 August 1997     

肺部小结节胸腔镜术前CT引导下硬化剂定位的临床应用价值

目的 探讨肺部小结节胸腔镜术前CT引导下注射硬化剂定位的临床应用价值.方法 2010年12月至2012年1月,27例患者,检出29枚孤立性肺结节,胸腔镜术前在CT引导下注射硬化剂(医用胶)定位后成功行胸胸腔镜下肺楔形切除术.结果 CT引导下注射医用胶定位成功率100％.定位时间(6.87±6.75)min,定位后无严重并发症,29枚小结节均成功定位后行胸腔镜下肺楔形切除术,无中转开胸于术,手术后均经病理确诊.结论 CT引导下注射硬化剂(医用胶)定位方法安全、可行,效果可靠.     

Port-access first-rib resection

We have developed a thoracoscopic first rib resection technique for treatment of thoracic outlet syndrome (TOS), employing new instruments designed for endoscopic surgery. A 49-year-old man with Paget-Schroetter syndrome was treated bilaterally, and a 25-year-old woman with neurologic symptoms was treated on the right side by thoracoscopic approach via three ports. Harmonic scalpel, endoscopic elevators, rongeurs, and an endoscopic drill were used. In two patients, approximately 80% of the first rib overlying the subclavian vessels and brachial plexus was successfully removed by this technique. We conclude that port-access first-rib resection is feasible and reproducible using the new instruments described. Received: 9 March 1998/Accepted: 12 November 1998     

McKeown oesophagectomy and pulmonary wedge resection with a prone thoracoscopic and laparoscopic approach: a video report

In the past few years, minimally invasive oesophagectomy has become an increasingly popular approach for oesophagectomy showing advantages in terms of fewer postoperative complications, shorter hospital stay and faster recovery. We present the case of a 60-year-old man with a lesion of the distal third of the oesophagus and solid pulmonary nodule who underwent McKeown subtotal oesophagectomy by laparoscopic and thoracoscopic approach in prone position with concomitant thoracoscopic pulmonary wedge resection. The postoperative course was smooth, and the patient was discharged on postoperative day 10. The procedure is feasible and safe, and combines better respiratory postoperative outcomes even when associated with other diagnostic or therapeutic lung procedures.