Fully thoracoscopic pulmonary lobectomy and specimen extraction through rib segment resection

Background: A technique of fully thoracoscopic pulmonary lobectomy with rib-segment resection for specimen extraction is described, and preliminary results in 18 patients are presented. Methods: Surgery is performed through four 15-mm ports. For all lobes except one, the surgeon operates in front of the patient, where the rib spaces are widest and rib-space trauma is less. When lobar dissection is complete, specimen extraction is performed after resection of a rib segment proportional to tumor size. Muscle section is kept to a minimum. There is no rib retraction. Results: There were no deaths, three conversions to open surgery, and three major complications. Average postoperative stay was 5.4 days for patients without complications and 9.6 days for patients with complications. In total six patients presented with some degree of air leaks, and two had post-thoracotomy pain (>2 month's duration). The literature is reviewed to analyze current techniques and to define parameters of a truly minimally invasive pulmonary lobectomy. Conclusions: This technique is safe and promising; however, thoracoscopic lobectomy still needs refining. Before valid randomized studies comparing thoracoscopic lobectomy and muscle-sparing thoracotomy or posterolateral thoracotomy can be credible, technical issues related to the production of a truly minimally invasive procedure should be resolved. Received: 20 August 1996/Accepted: 19 September 1996     

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 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 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     

Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging

Background: The preoperative staging of lung cancer can be problematical when we attempt to evaluate T factor (T2–T3 versus T4) and N factor (N0 versus N1–N2). In some cases, radiology tests (CT scan, magnetic resonance imaging) cannot entirely dispel the possibility that the mediastinal structures have been infiltrated. N factor is evaluated mainly by dimensional criteria. However, mediastinoscopy and mediastinotomy do not allow the full exploration of all mediastinal mode stations. Method: Starting in 1995, we submitted 10 consecutive patients to videothoracoscopic operative staging with ultrasound color Doppler (VOS-USCD). In five cases, preoperative staging showed possible infiltration of the pulmonary artery (T4). In nine cases, we found involvement of the mediastinal nodes, seven patients were N2, and two were N3. Videothoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. The videothoracoscope and sonographic probe were inserted via three thoracoports placed in the axillary triangle. Results: Following the results of VOS-USCD, the staging and subsequently the therapeutic program were modified in seven of 10 cases (70%). Conclusions: Our preliminary experience indicates that VOS-USCD should be applied to the diagnosis of patients in stage IIIA (N2) and that it is particularly valuable for patients in stage IIIB. Received: 23 May 1997/Accepted: 28 October 1997     

Gasless videoendoscopic implantation of aortobifemoral vascular prostheses via transperitoneal versus extraperitoneal approach in an animal model

Background: The goal of this acute experimental study was to demonstrate the practicability and reproducibility of aortobifemoral bifurcational prosthesis implantations via either a transperitoneal or extraperitoneal approach using gasless videoendoscopic instrumentation. The endoscopically sutured end-to-side aortic anastomoses were also examined for fluid tightness. Methods: Eighteen of the 20 domestic pigs in this experimental study received aortobifemoral vascular prostheses in a gasless videoendoscopic procedure. Bursting pressures and leakage (ml/min) were compared for the endoscopically sutured aortic end-to-side anastomoses versus those sutured in conventional techniques using 6-h-old porcine aortas and 6-mm prostheses. Results: The surgical procedures averaged 4 h for the transperitoneal approach (n= 9) and 4.5 h for the extraperitoneal approach (n= 9). However, these times were significantly reduced with increasing routine. Average aortic occlusion times were 1 h for the transperitoneal approach and 1 h 15 min for the extraperitoneal approach; the average iliacofemoral occlusion time ranged from 1 h 45 min with the transperitoneal approach to 1 h 15 min with the extraperitoneal approach, depending on which side was involved. There were no significant differences in in vitro bursting pressure or leakage amounts between endoscopic and conventionally sutured aortic end-to-side anastomoses. Conclusions: Gasless videoendoscopic implantation of aortobifemoral vascular prostheses in animal subjects is both practicable and reproducible using either a transperitoneal or extraperitoneal approach. The extraperitoneal approach has proven advantages over the transperitoneal approach. The in vitro fluid tightness achieved with endoscopically sutured aortic end-to-side anastomoses is comparable to conventionally sutured anastomoses.     

Hemostasis with the ultrasonically activated scalpel

In patients with implanted pacemaker/cardioverter defibrillator (ICD), the use of electrocautery can lead to serious pacemaker dysfunction. The ultrasonically activated scalpel, however, which has been introduced mainly for the use in laparoscopic surgery, could potentially avoid the outlined problem, since no electrical current flows while in use. This hypothesis was tested in a pacemaker patient undergoing laparoscopic cholecystectomy. During the procedure, no abnormal rhythms or ECG interferences were detected while working in close vicinity to the device. Thus, the ultrasonically activated scalpel provides adequate hemostasis and does not bear the risk of pacemaker dysfunction. Received: 12 January 1999/Accepted: 20 January 1999     

Geometry and reproducibility in 360° fundoplication

Background: In this study, we set out to precisely define two symmetrical points—a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or ``floppy') 360° fundoplication (FP). Methods: For the terms of this study, circumference =c; diameter =d; c/d=π; π= 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n= 5) and intraoperatively (n= 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. Results: The smallest measured value for c was 7.5 cm (d= 2.39 cm); the largest value for c was 10.0 cm (d= 3.18 cm). The mean value was 8.35 cm (d= 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d= 2.66 cm. This technique creates a correctly oriented, symmetrical, ``floppy,' true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible. Conclusions: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a ``floppy' 360° fundoplication. Received: 20 April 1999/Accepted: 15 February 2000/Online publication: 15 May 2000     

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     

The relationship between phalangeal bone density and vertebral deformities

Radiographic absorptiometry (RA) of the phalanges is a convenient and reliable technique for measuring bone mineral density (BMD). It needs only a radiograph of the hand, which can be sent for evaluation to a central facility, whereas other techniques require specialized equipment. We assessed the relationship between RA measurements and the presence of vertebral deformities in a population-based cohort of postmenopausal women, and to compare the results with simultaneously obtained BMD of the hip by dual-energy X-ray absorptiometry (DXA). A total of 389 women aged 55–84 (mean age 67.2 years, SD 8.7) were randomly selected from a large general practice. RA, DXA of the hip, and vertebral deformities in the lateral spine X-rays by vertebral morphometry were assessed. Thirty-eight women (9.8%) had severe (grade II) vertebral deformities, and their BMD at the phalanges and femoral neck was significantly lower than that of women without severe vertebral deformities. Odds ratios for the presence of severe vertebral deformities of 1.5 (95% CI: 1.1–2.1) for RA and 1.3 (95% CI: 0.9–1.9) for DXA, together with similar receiver operating characteristics curves, were found using age-adjusted logistic regression. Phalangeal BMD is related to vertebral deformities at least as closely as BMD of the femoral neck BMD. RA may therefore help to evaluate fracture risk, especially if no DXA equipment is available. Received: 21 July 1998 / Accepted: 1 July 1999     

Laparoscopic hand-assisted surgery for hepatic and pancreatic disease

Herein I describe my initial experience with the use of a novel device, the Omniport, in 15 patients undergoing hand-assisted laparoscopic surgery (HALS) on the liver and pancreas. The device, which essentially consists of a hand cuff with a spiral inflatable valve, enables withdrawal and reinsertion of the hand without loss of pneumoperitoneum during the operation. The cuff's effective sealing pressure is equal to the pneumoperitoneal pressure; hence, hand comfort is maintained during the intervention. The device was effective in maintaining pneumoperitoneum in all cases. All but one operation was completed with the HALS approach. The one conversion was due to bleeding from the superior mesenteric vein during a 90% pancreaticosplenectomy. Immediate effective control of the bleeding by compression between the thumb and index finger was achieved, and the cuff of the Omniport was deflated as the incision was enlarged. There were no postoperative complications. The HALS approach has distinct advantages in terms of exposure and safety over the total laparoscopic technique for major surgery on the liver and pancreas, and it is recommended for these interventions. Received: 4 August 2000/Accepted: 4 August 2000/Online publication: 20 October 2000     

人工起搏器置入352例常见并发症临床分析

目的：分析永久起搏器术后常见并发症的发生原因、处理方法及预防措施。方法：回顾分析解放军总医院第一附属医院1992年8月-2007年12月安装永久起搏器352例患者的临床资料和并发症。结果：男性134例,女性118例,单腔起搏器218例,双腔起搏器122例,三腔起搏器2例。术后常见并发症共17例次,其中感染3例,囊袋积血2例,脂肪液化1例,囊袋破溃2例,电极脱位及微脱位5例,术后心律失常1例,三尖瓣穿孔1例,局部肌肉跳动1例,急性期大面积脑梗塞1例。结论：重视术前预防、规范术中操作、加强术后随访,早期发现、积极处理各种并发症,最大的减少并发症的发生。     

Head and neck cancer implantation at the percutaneous endoscopic gastrostomy exit site

Percutaneous endoscopic gastrostomy is commonly utilized in patients with head and neck cancer. Tumor at the PEG exit site is a rare occurrence, likely due to direct implantation. We present a case report, review of the relevant literature, discussion of the mechanism of spread, and management. Received: 21 November 1997/Accepted: 3 February 1998     

A Triangular Suture to Simplify Reduction Mammaplasty

A technique to facilitate correct preoperative marking for an en bloc resection in superiorly based mammaplasty is presented. A temporary triangular suture is placed to control the estimated resection lines for the removal of the medial and lateral tissue block. The described technique helps to avoid the formation of medial and lateral dog ears and the unpleasant and visible scars that result.     

Complications of surgical endoscopy

Background: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe. Methods: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures. Results: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period. Conclusions: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications. Received 25 March 1996/Accepted: 24 April 1996     

Totally endoscopic Ivor Lewis esophagectomy

Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened. Received: 17 December 1997/Accepted: 18 March 1998     

Porous Polyethylene Implants for Nasal Reconstruction: Clinical and Histologic Studies

This paper describes a technique of using Medpor porous high-density polyethylene implants for nasal reconstruction and chin augmentation. This biocompatible material has been used successfully during the last decade for various applications in the reconstruction of the facial skeleton. Among its most frequent uses are repair of the orbital floor and reconstruction of the burned ear, which became standard methods at many centers. Relatively little experience is, at present, on hand concerning the use of porous polyethylene in reconstruction of the nasal framework. Twenty-three consecutive, difficult nasal reconstructions were performed using this method since 1996. Patients were followed up for from 1 to 3 years (mean, 2 years). The results were durable and stable over the time. Eight patients had saddle nose deformity and 15 had catastrophe noses, mostly referrals, previously operated on from one to four times. My aesthetic goals were correction of the depressed nasal dorsum, creation of an acceptable nasal dorsum in the thick and/or twisted noses, and tip elevation. For nasal applications Medpor is available as a strut or sheet. Its body, once implanted, becomes rapidly vascularized and both soft tissue ingrowth and collagen deposition occur. This was confirmed by the microscopic investigation of biopsies. One patient of Vietnamese origin had an aesthetically pleasing result, but her family refused to accept her westernized nose. This gave me a unique opportunity to study the whole Medpor implant 6 months after implantation. There were two complications, one small implant exposure and one low-virulent infection involving the nasal tip. Following revision and antibiotic treatment, both patients healed without sequel. All reconstructions were successful in restoring nasal aesthetics and function. Four patients underwent chin augmentations with an uneventful clinical course.