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Thoracic Duct Ligation: Right Video-assisted Thoracoscopic Surgery Approach
Accepted Manuscript Title: Thoracic Duct Ligation: Right Video Assisted Thoracoscopic (VATS) Approach Author: Chris Devulapalli, Jacqueline Anderson, Nathaly Llore, Elizabeth Hechenbleikner, M. Blair Marshall PII: DOI: Reference:
S1522-2942(17)30009-0 http://dx.doi.org/doi: 10.1053/j.optechstcvs.2017.04.001 YOTCT 413
To appear in: Operative Techniques in Thoracic and Cardiovascular Surgery: A Comparative Atlas
Please cite this article as: Chris Devulapalli, Jacqueline Anderson, Nathaly Llore, Elizabeth Hechenbleikner, M. Blair Marshall, Thoracic Duct Ligation: Right Video Assisted Thoracoscopic (VATS) Approach, Operative Techniques in Thoracic and Cardiovascular Surgery: A Comparative Atlas (2017), http://dx.doi.org/doi: 10.1053/j.optechstcvs.2017.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Thoracic Duct Ligation: Right Video Assisted Thoracoscopic (VATS) Approach Chris Devulapalli, MD1; Jacqueline Anderson, BS2; Nathaly Llore, MD1; Elizabeth Hechenbleikner, MD1; M. Blair Marshall, MD1 1
Department of Surgery, Division of Thoracic Surgery, MedStar Georgetown University Hospital, Washington, DC 2 Georgetown University School of Medicine, Washington, DC From: Medstar Georgetown University Hospital, Washington, DC
Corresponding Author: M. Blair Marshall, MD 3800 Reservoir Road NW Pasquerilla Healthcare Center- 4th Floor Department of Surgery, Division of Thoracic Surgery Washington, DC 20007 Phone- (202)- 444- 5045 Fax- (877)- 376-2421 [email protected]
Financial Disclosure: None of the authors had any financial interest in any of the products, devices, or drugs mentioned in the manuscript
Acknowledgements: None
Page 1 of 7
Abstract Thoracic duct injuries can carry significant morbidity and mortality to patients. When medical and percutaneous interventions are unsuccessful at cure, open surgical ligation is often necessary but limited by poor visualization of the thoracic duct and all the morbidities associated with thoracotomy. We describe here a Video Assisted Thoracoscopic (VATS) approach to thoracic duct ligation which offers the benefits of minimally invasive surgery in addition to improved visualization to optimize success rates.
Page 2 of 7
Introduction Thoracic duct (TD) injuries, although uncommon, carry significant morbidity and mortality, documented up to 85% and 24%, respectively1. The duct can be injured in trauma or thoracic operations, and thus cardiothoracic surgeons must employ effective strategies in their armentarium to effectively ligate the duct and resolve the chyle leak in a particularly challenging time and patient population. While the traditional approach has been an open TD ligation via a thoracotomy, the video assisted thoracoscopic (VATS) technique as a safe and effective alternative. The benefit of VATS is two-fold; carbon dioxide insufflation displaces intrathoracic contents creating a clean working field, and the thirty-degree camera facilitates magnified visualization of the TD trajectory. This provides significantly improved visualization over the traditional open surgical approach for two reasons: 1) the magnification is 10-fold; thus, the thoracic duct can be clearly visualized, and 2) the angled camera provides a view under the vertebral body. We often find the duct between the spine and aorta, but it frequently lies on the left side of the spine. With direct overhead vision into the chest, the body of the vertebrae is obstructing the view of the left side of the vertebral body, thus making the course of the thoracic duct challenging for the open surgeon to visualize. The angled camera can reach below the level of the vertebral body, also allowing a view of the left side by changing the angle of the lens. In addition, typically a VATS approach is associated with decreased postoperative pain and morbidity when compared with a thoracotomy2.
Operative Technique
Page 3 of 7
Conclusion In this paper, we describe an alternative to the traditional open approach to thoracic duct ligation with video assisted thoracoscopic surgery (VATS). Regardless of the underlying etiology, chyle leak has previously portended a significant mortality risk from immunosuppression and malnutrition. With the increasing use of modern ultrasonic sealing devices for dissection in thoracic procedures (i.e. esophagectomy), it has been our experience that the incidence of iatrogenic thoracic duct injury has been dramatically reduced in the last decade. Regardless, treatment strategies for the problem, when it does occur, have previously been met with limited success. Peripheral cannulation of the lymphatic system with subsequent embolization of the thoracic duct by interventional radiology has demonstrated success rates at best up to 65%5. The open approach also shares challenges to limit its success mainly due to poor visualization of the duct, with the added morbidities of an open thoracotomy in a patient already deconditioned from a recent surgery or malignancy. We believe that the VATS approach offers a safe and effective alternative to this challenging problem, with the added benefits of improved visualization and a well-tolerated procedure with easier recovery for the patient.
References 1.
Shah RD, Luketich JD, Schuchert MJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg. 2012;93(3):897-903
2.
Förster R, Storck M, Schäfer JR, Hönig E, Lang G, Liewald F. Thoracoscopy versus thoracotomy: a prospective comparison of trauma and quality of life. Langenbecks Arch Surg. 2002;387(1):32-6.
Page 4 of 7
3.
Davis HK. A statistical study of the thoracic duct in man. Wiley Online Library. Available at http://onlinelibrary.wiley.com/doi/10.1002/aja.1000170203/abstract. Accessed: 12/30/2016.
4.
Portillo, J, Kamar N, Melibary, S Quevedo E, and Bergese S. Safety of Liposome extended-release bupivacaine for postoperative pain control. Frontiers in Pharmacology 2014; 90 (5): 1-6.
5.
Cope C. Management of chylothorax via percutaneous embolization. Curr Opin Pulm Med. 2004;10(4):311-4.
Figure 1: Patient positioning during VATS is important to place effective working ports for a posterior mediastinal dissection with laparoscopic instruments. After single-lumen endotracheal tube intubation, the patient is placed in a modified left lateral decubitus position with adequate support of the right arm. Because we use CO2 insufflation, a double lumen tube is not necessary. The position modification involves rotation of the patient slightly anteriorly to place the posterior axillary line at the most superior position, exposing the posterior mediastinal structures, and dropping the ipsilateral arm to move the scapula away from the operative field. Once positioned, flexing of the table by thirty degrees in axis with the patient’s anterior superior iliac spine further expands the intercostal spaces.
Page 5 of 7
Figure 2: Three to four 5 mm ports are inserted for posterior mediastinal exposure. As the most inferior port will be at the level of the diaphragm, it is critical to place the superior ports first, insufflate the chest to press on the diaphragm and then place the additional ports under camera guidance. We typically place two ports along the ninth intercostal space and an additional one or two ports along the sixth intercostal space.
Figure 3: With the trocars in place, the thoracic cavity is then insufflated with CO2 gas to a pressure of 10 mmHg. Insufflation exposes the inferior pulmonary ligament and provides excellent visualization of the posterior mediastinal structures. The right lung is reflected, and the esophagus and thoracic aorta are identified. Although the spine, aorta and thoracic duct can be seen clearly in this image, it is because the angled camera provides the view underneath the vertebral body.
Figure 4 The thoracic duct most commonly travels between the aorta and esophagus along the lateral border of the vertebrae and courses from the right to left chest at T3-T5 dorsal to the esophagus and aorta. Importantly, 35-50% of the population may have aberrant ductal anatomy, often with doubled ducts or a completely unilateral duct3.
Figure 5:
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The TD is identified, isolated and ligated with either clips or a sealing device (LigaSure) at multiple locations along its path. Multiple ligation sites ensures definitive control of a leak. In our experience, the VATS approach is superior in that it optimally identifies the TD for isolated ligation compared to the traditional approach of broadly suture ligating all soft tissue between the aorta and esophagus.
Figure 6: Prior to closing, intercostal nerve blocks are administered under direct visualization with a long acting liposomal-tagged bupivacaine compound (Exparel). We have found this method provides excellent postoperative pain control after VATS procedures and therefore minimizes overall narcotic use4. A 24-French chest tube is placed in the right hemithorax through one of the port sites and is discontinued when the diet is advanced and there is no evidence of a continued leak. Patients are monitored for chest tube output and pain control, which is already minimized by the intercostal nerve blocks. Their diets are advanced and character of the output monitored. The patient is initially placed on a low-fat diet, and fats are reintroduced into their diet after confirming absence of chyle leak. Given the success of this approach in TD ligation, it is rarely necessary to discharge patients with drainage catheters in place.
Operative Video Legend: We also provide a step by step instructional video with voice over at the following link to better visualize the specific technique of surgery performed by the last author (BM): (insert link to video).
Page 7 of 7
S1522-2942(17)30009-0 http://dx.doi.org/doi: 10.1053/j.optechstcvs.2017.04.001 YOTCT 413
To appear in: Operative Techniques in Thoracic and Cardiovascular Surgery: A Comparative Atlas
Please cite this article as: Chris Devulapalli, Jacqueline Anderson, Nathaly Llore, Elizabeth Hechenbleikner, M. Blair Marshall, Thoracic Duct Ligation: Right Video Assisted Thoracoscopic (VATS) Approach, Operative Techniques in Thoracic and Cardiovascular Surgery: A Comparative Atlas (2017), http://dx.doi.org/doi: 10.1053/j.optechstcvs.2017.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Thoracic Duct Ligation: Right Video Assisted Thoracoscopic (VATS) Approach Chris Devulapalli, MD1; Jacqueline Anderson, BS2; Nathaly Llore, MD1; Elizabeth Hechenbleikner, MD1; M. Blair Marshall, MD1 1
Department of Surgery, Division of Thoracic Surgery, MedStar Georgetown University Hospital, Washington, DC 2 Georgetown University School of Medicine, Washington, DC From: Medstar Georgetown University Hospital, Washington, DC
Corresponding Author: M. Blair Marshall, MD 3800 Reservoir Road NW Pasquerilla Healthcare Center- 4th Floor Department of Surgery, Division of Thoracic Surgery Washington, DC 20007 Phone- (202)- 444- 5045 Fax- (877)- 376-2421 [email protected]
Financial Disclosure: None of the authors had any financial interest in any of the products, devices, or drugs mentioned in the manuscript
Acknowledgements: None
Page 1 of 7
Abstract Thoracic duct injuries can carry significant morbidity and mortality to patients. When medical and percutaneous interventions are unsuccessful at cure, open surgical ligation is often necessary but limited by poor visualization of the thoracic duct and all the morbidities associated with thoracotomy. We describe here a Video Assisted Thoracoscopic (VATS) approach to thoracic duct ligation which offers the benefits of minimally invasive surgery in addition to improved visualization to optimize success rates.
Page 2 of 7
Introduction Thoracic duct (TD) injuries, although uncommon, carry significant morbidity and mortality, documented up to 85% and 24%, respectively1. The duct can be injured in trauma or thoracic operations, and thus cardiothoracic surgeons must employ effective strategies in their armentarium to effectively ligate the duct and resolve the chyle leak in a particularly challenging time and patient population. While the traditional approach has been an open TD ligation via a thoracotomy, the video assisted thoracoscopic (VATS) technique as a safe and effective alternative. The benefit of VATS is two-fold; carbon dioxide insufflation displaces intrathoracic contents creating a clean working field, and the thirty-degree camera facilitates magnified visualization of the TD trajectory. This provides significantly improved visualization over the traditional open surgical approach for two reasons: 1) the magnification is 10-fold; thus, the thoracic duct can be clearly visualized, and 2) the angled camera provides a view under the vertebral body. We often find the duct between the spine and aorta, but it frequently lies on the left side of the spine. With direct overhead vision into the chest, the body of the vertebrae is obstructing the view of the left side of the vertebral body, thus making the course of the thoracic duct challenging for the open surgeon to visualize. The angled camera can reach below the level of the vertebral body, also allowing a view of the left side by changing the angle of the lens. In addition, typically a VATS approach is associated with decreased postoperative pain and morbidity when compared with a thoracotomy2.
Operative Technique
Page 3 of 7
Conclusion In this paper, we describe an alternative to the traditional open approach to thoracic duct ligation with video assisted thoracoscopic surgery (VATS). Regardless of the underlying etiology, chyle leak has previously portended a significant mortality risk from immunosuppression and malnutrition. With the increasing use of modern ultrasonic sealing devices for dissection in thoracic procedures (i.e. esophagectomy), it has been our experience that the incidence of iatrogenic thoracic duct injury has been dramatically reduced in the last decade. Regardless, treatment strategies for the problem, when it does occur, have previously been met with limited success. Peripheral cannulation of the lymphatic system with subsequent embolization of the thoracic duct by interventional radiology has demonstrated success rates at best up to 65%5. The open approach also shares challenges to limit its success mainly due to poor visualization of the duct, with the added morbidities of an open thoracotomy in a patient already deconditioned from a recent surgery or malignancy. We believe that the VATS approach offers a safe and effective alternative to this challenging problem, with the added benefits of improved visualization and a well-tolerated procedure with easier recovery for the patient.
References 1.
Shah RD, Luketich JD, Schuchert MJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg. 2012;93(3):897-903
2.
Förster R, Storck M, Schäfer JR, Hönig E, Lang G, Liewald F. Thoracoscopy versus thoracotomy: a prospective comparison of trauma and quality of life. Langenbecks Arch Surg. 2002;387(1):32-6.
Page 4 of 7
3.
Davis HK. A statistical study of the thoracic duct in man. Wiley Online Library. Available at http://onlinelibrary.wiley.com/doi/10.1002/aja.1000170203/abstract. Accessed: 12/30/2016.
4.
Portillo, J, Kamar N, Melibary, S Quevedo E, and Bergese S. Safety of Liposome extended-release bupivacaine for postoperative pain control. Frontiers in Pharmacology 2014; 90 (5): 1-6.
5.
Cope C. Management of chylothorax via percutaneous embolization. Curr Opin Pulm Med. 2004;10(4):311-4.
Figure 1: Patient positioning during VATS is important to place effective working ports for a posterior mediastinal dissection with laparoscopic instruments. After single-lumen endotracheal tube intubation, the patient is placed in a modified left lateral decubitus position with adequate support of the right arm. Because we use CO2 insufflation, a double lumen tube is not necessary. The position modification involves rotation of the patient slightly anteriorly to place the posterior axillary line at the most superior position, exposing the posterior mediastinal structures, and dropping the ipsilateral arm to move the scapula away from the operative field. Once positioned, flexing of the table by thirty degrees in axis with the patient’s anterior superior iliac spine further expands the intercostal spaces.
Page 5 of 7
Figure 2: Three to four 5 mm ports are inserted for posterior mediastinal exposure. As the most inferior port will be at the level of the diaphragm, it is critical to place the superior ports first, insufflate the chest to press on the diaphragm and then place the additional ports under camera guidance. We typically place two ports along the ninth intercostal space and an additional one or two ports along the sixth intercostal space.
Figure 3: With the trocars in place, the thoracic cavity is then insufflated with CO2 gas to a pressure of 10 mmHg. Insufflation exposes the inferior pulmonary ligament and provides excellent visualization of the posterior mediastinal structures. The right lung is reflected, and the esophagus and thoracic aorta are identified. Although the spine, aorta and thoracic duct can be seen clearly in this image, it is because the angled camera provides the view underneath the vertebral body.
Figure 4 The thoracic duct most commonly travels between the aorta and esophagus along the lateral border of the vertebrae and courses from the right to left chest at T3-T5 dorsal to the esophagus and aorta. Importantly, 35-50% of the population may have aberrant ductal anatomy, often with doubled ducts or a completely unilateral duct3.
Figure 5:
Page 6 of 7
The TD is identified, isolated and ligated with either clips or a sealing device (LigaSure) at multiple locations along its path. Multiple ligation sites ensures definitive control of a leak. In our experience, the VATS approach is superior in that it optimally identifies the TD for isolated ligation compared to the traditional approach of broadly suture ligating all soft tissue between the aorta and esophagus.
Figure 6: Prior to closing, intercostal nerve blocks are administered under direct visualization with a long acting liposomal-tagged bupivacaine compound (Exparel). We have found this method provides excellent postoperative pain control after VATS procedures and therefore minimizes overall narcotic use4. A 24-French chest tube is placed in the right hemithorax through one of the port sites and is discontinued when the diet is advanced and there is no evidence of a continued leak. Patients are monitored for chest tube output and pain control, which is already minimized by the intercostal nerve blocks. Their diets are advanced and character of the output monitored. The patient is initially placed on a low-fat diet, and fats are reintroduced into their diet after confirming absence of chyle leak. Given the success of this approach in TD ligation, it is rarely necessary to discharge patients with drainage catheters in place.
Operative Video Legend: We also provide a step by step instructional video with voice over at the following link to better visualize the specific technique of surgery performed by the last author (BM): (insert link to video).
Page 7 of 7