The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy.

OBJECTIVE: Whether video-assisted thoracic surgery (VATS) is associated with less shoulder dysfunction when compared with posterolateral thoracotomy (PLT) remains unclear. We therefore conducted this prospective study to assess the shoulder function in patients following major lung resection using either the VATS or PLT approach. METHODS: Twenty-nine consecutive patients were prospectively recruited into the study. Eighteen patients underwent major lung resection through VATS (VATS group) and 11 patients through PLT (open group). Shoulder function was measured preoperatively, and postoperatively at 1 week, 1 month and at 3 months. All assessments were done by two experienced physiotherapists using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. RESULTS: Shoulder strength was significantly better preserved in the VATS group at 1 week after surgery when compared with the PLT group (92 versus 81% of preoperative value; P=0.024). VATS patients also had better range of motion especially with respect to external rotation at 1 week (98 versus 91%; P=0.015) and forward elevation at 1 month (98 versus 93%; P=0.024) and 3 months after surgery (100 versus 96%; P=0.021). Analgesic requirement was significantly less in the VATS group postoperatively at 1 week (P=0.009) and 1 month (P=0.004). CONCLUSIONS: VATS major lung resection is associated with significantly less shoulder dysfunction and pain medication requirement in the early postoperative period when compared to the PLT approach.     

Lobectomy for early-stage lung carcinoma: a cost analysis of full thoracoscopy versus posterolateral thoracotomy

Background  

Major pulmonary resections for early-stage non-small-cell lung cancer (NSCLC) are increasingly being performed by thoracoscopy, but there are economic concerns related to the use of many disposable items and increased operative time. We evaluated and compared the costs of thoracoscopic lobectomy versus open lobectomy.     

Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy

BACKGROUND: Whether video-assisted thoracic surgery (VATS) improves postoperative pulmonary function is still controversial. We compared postoperative pulmonary function after VATS lobectomy and standard lobectomy. METHODS: Eleven patients who had undergone standard lobectomy and 10 patients who had undergone VATS lobectomy were studied. Arterial blood gas analyses were performed on the 4th, 7th, and 14th postoperative days. Pulmonary function, including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1.0), and peak flow rate (PFR) were measured on the 7th and 14th postoperative days (early phase), and approximately 1 year after surgery (late phase). RESULTS: Pulmonary function, as assessed with arterial oxygen partial pressure (PaO2) (p = 0.054), arterial oxygen saturation (O2SAT) (p = 0.063), FVC (p = 0.10), and FEV1.0 (p = 0.08), was better after VATS lobectomy than after thoracotomy on the 7th postoperative day. PFR was significantly better after VATS on both the 7th and 14th postoperative days (p = 0.008 and p = 0.03, respectively). CONCLUSIONS: VATS lobectomy had advantages on early postoperative pulmonary function. We conclude that VATS lobectomy is a beneficial alternative to standard thoracotomy, especially for patients with poor pulmonary reserve.     

改良后外侧小切口在普胸手术中的应用

通过胸腔镜肺切除术的研究和临床应用，作者在３１１例普通外科手术中，采用改良的后外侧小切口。包括肺叶切除加淋巴结清扫１８６例，全肺切除术２３例，食管癌根治术２３例等。手术结果证实采用此切口避免切除或切断肋骨；避免大片胸壁肌肉的切断；明显地减少术后胸痛，肩关节活动障碍；减少出血和减少输血；大大缩短开、关胸时间。作者认为这是可行的切口，可以在开胸手术中广泛应用。     

Muscle-sparing versus posterolateral thoracotomy: a prospective study.

OBJECTIVE: Although the thoracotomy incision is guided in part by the exposure required, both cosmesis and the potential for improved recovery are important factors to be taken into account. We conducted a prospective randomized study in order to compare muscle sparing thoracotomy (MST) and standard posterolateral thoracotomy (PLT) for postoperative pain and physical function during and after hospitalization. MATERIAL AND METHOD: One hundred patients operated from June through December 2004 were recruited in this study. Fifty patients underwent MST of 6-8 cm and 50 had a PLT of more than 8 cm with division of latissimus dorsi and serratus anterior muscles. Operations performed were atypical resections and lobectomies. Pneumonectomies and operations on tumors invading the chest wall or brachial plexus were excluded. Perioperative care was standardized concerning analgetics and physiotherapy. Postoperative pain (quantitated by the visual analogue scale), preoperative and postoperative pulmonary function, shoulder strength, and range of motion were evaluated. RESULTS: There was no difference in demographics, tumor stage, and type of lung resection. Patients were also matched for the number of chest tubes, length of chest tube duration, and length of hospital stay. Pain reported during hospitalization and after hospital discharge within 1 and 2 months did not differ within the two groups (p>0.05). Shoulder function was shown to decrease less in cases of MST, but physical function was not found statistically significant in comparison of the two groups (p>0.05) within 1 month. Rehabilitation was also similar. CONCLUSION: The rates of occurrence of acute or chronic pain and morbidity were equivalent after MST and PLT. It appears that the single advantage of MST over PLT involves the preservation of chest wall musculature in case rotational muscle flaps should be needed along with a better cosmetic result.     

Vocal cord paralysis after surgery to the descending thoracic aorta via left posterolateral thoracotomy

Vocal cord paralysis is one of the frequently encountered complications after aortic surgery. However, reports of vocal cord paralysis after aortic surgery have been limited. In a retrospective cohort study of vocal cord paralysis after aortic surgery at a general hospital, we sought factors related to its development after aortic surgery to the descending thoracic aorta via left posterolateral thoracotomy. We reviewed data for a total of 69 patients who, between 1989 and 1995, underwent aortic surgery to the descending thoracic aorta. We assessed factors associated with the development of vocal cord paralysis and postoperative complications. Postoperative vocal cord paralysis appeared in 19 patients. Multiple logistic regression analysis revealed two risk factors for vocal cord paralysis: chronic dilatation of the aorta at the left subclavian artery (odds ratio = 8.67) and anastomosis proximal to the left subclavian artery (odds ratio = 17.7). The duration of mechanical ventilation was significantly prolonged for patients with vocal cord paralysis. Certain surgical factors associated with left subclavian artery increase the risk of vocal cord paralysis after surgery on the descending thoracic aorta. Vocal cord paralysis after aortic surgery did not increase aspiration pneumonia but was associated with pulmonary complications.     

Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial

Objectives

Post-thoracotomy pain leads to patient discomfort, pulmonary complications, and increased analgesic use. Intercostal nerve injury during thoracotomy or its entrapment during closure can contribute to post-thoracotomy pain. We hypothesized that a modified technique of posterolateral thoracotomy and closure, preserving the intercostal neurovascular bundle, would reduce acute and chronic post-thoracotomy pain.

Muscle-sparing posterolateral thoracotomy

We have developed a technique for posterolateral thoracotomy that allows adequate exposure for most thoracic operations, yet spares both the latissimus dorsi and serratus anterior muscles. Postoperative pain is decreased, functional recovery is improved, and patients can frequently be discharged earlier from the hospital. Although the time for opening is slightly prolonged, closing time is less and the incision can easily be converted to the standard muscle-splitting approach if more room is required.     

Video-assisted thoracic surgery through card-sized utility thoracotomy

The technique of video-assisted thoracic surgery, a minimum invasive surgical procedure is discussed. The characteristics are as follows: through utility thoracotomy, which is smaller than a card of 54 x 85 mm in size, we carry out the procedures using both eyes-vision with right perspective and palpation with fingers. We use conventional tools besides endoscopic tools, such as ultra-long scissors of 30 cm in length, 26 cm long Péan's forceps, which have 2 groove at the tip that allow one to push the knot. We covered a body of a forceps, while tip and the other end are not covered to allow transmission of the electrostream. We have carried out more than 70% of standard lobectomies with modified lymph node dissection for lung cancer according to this technique under the same quality of operation as conventional open thoracotomy. The procedure did not differ from conventional approach in the operation time and amount of bleeding.     

The effect of standard posterolateral versus muscle-sparing thoracotomy on multiple parameters

BACKGROUND: Different alternative approaches to thoracotomy have been developed because of the considerable morbidity associated with the standard posterolateral incision. METHODS: We studied a prospective, randomized, blinded study of 60 consecutive patients to compare surgical approach time, postoperative pain (quantitated by narcotic requirements and the visual analogue scale), pulmonary function, shoulder strength, and range of motion between standard posterolateral (group I) and muscle-sparing (group II) thoracotomy techniques. RESULTS: There were no differences in postoperative surgical time, pulmonary function, shoulder range of motion, mortality, or hospitalization time. There was significantly less postoperative pain in group II. In this group, narcotic requirement was less in the first 24 hours, and visual analogue scale scores were significantly lower (p < 0.05) throughout the first postoperative week. Muscle strength had returned to preoperative levels by 1 month in both groups. Morbidity was identical in the two groups with the exception of postoperative seromas. The prevalence of seroma was 16.6% in the muscle-sparing group. CONCLUSIONS: We conclude that the muscle-sparing incision may be a sensible alternative to a standard posterolateral thoracotomy.