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Expanded applications of diagnostic and therapeutic thoracoscopy
J THoRAc CARDIOVASC SURG 1991;102:721-3
Expanded applications of diagnostic and therapeutic thoracoscopy From 1971 to 1990, 315 thoracoscopies were performed. Recent advances in optic/video systems and endoscopic operating instruments have made thoracoscopy easier and more accurate than 20 years ago. The operative mortatity rate was low (1 %) and the diagnostic accuracy high (99 %). Thoracoscopy has been performed at an increasing frequency in recent years because of its expanded applicatio~ especially in the areas of therapeutic or operative procedures such as carbon dioxide laser pneumothorax or diffuse bullo~ emphysema, neodymium:yttrium-a1uminumtreatment of spontaneo~ garnet laser vaporization of pleural malignant tumors, and thoracoscope/laser-aided pleurectomy, pericardiectomy, or lung resection. Further technologic advancement in thoracoscopy will have a cOiWderable impact on the future of thoracic surgery.
Akio Wakabayashi, MD, Irvine, Calif.
Dagnostic and therapeutic thoracoscopies wereintroduced 80 years ago.I, 2 Despite this early start, thoracoscopy never gained wide acceptance and was used only sporadically in a limited fashion. Recentexplosive popularity of laparoscopic cholecystectomy, however, has stimulated interest in thoracoscopy among thoracic surgeons. The purpose of this report is to review my experienceover the past 20 years. Materials The first five thoracoscopies, in which an original Jacobaeus thoracoscope/ was used, were for the treatment of spontaneous pneumothorax (therapeutic), but all others were for diagnostic purposes until 1987, when the pneumothorax program was reinstated (Table I). During phase I, from 1971 to 1986, 150 thoracoscopies (145 diagnostic and 5 therapeutic) were performed, averaging 9.4 cases per year. During phase 2, from 1987 to 1990, 165 thoracoscopies (60 diagnostic and 105 therapeutic) were done, averaging 41.3 cases per year. A variety of rigid glass rod lens scopes were used until May 1990, after which an Olympus 10 mm rigid thoracoscope (Olympus Corp., Lake Success, N.Y.) was used exclusively. (Food and Drug Administration approval of this thoracoscope is pending.) Fifty-nine diagnostic thoracoscopies were performed without biopsy, either because the diagnosis was obvious or because collected fluid Fromthe Departmentof Surgery,University of California, Irvine, Irvine,Calif. Read at the Seventy-first Annual Meetingof The American Association for ThoracicSurgery, Washington, D.C., May 6-8, 1991. Address forreprints: AkioWakabayashi, MD, Cardiothoracic Surgery, UCI Medical Center, PO Box 14091, Orange, Calif. 92613-1091. 12/6/32830
specimens established the diagnosis. In another 146 cases, biopsy specimens of solid tissues were taken; 98 pleurae, 25 mediastinallymph nodes, 17 lung masses, and 6 others. One hundred ten therapeutic or operative thoracoscopies included spontaneous pneumothorax, 44; bullous emphysema, 32; empyema, 20; malignant pleural effusion, 6; and others, 8 (Table II). Operative thoracoscopy is defined as intrathoracic operative procedures aided by the thoracoscope. Seven patients underwent operative thoracoscopies: excision of mediastinal goiters in 2; partial pericardiectomy in 2 (I malignant, 1 uremic pericarditis); pleurectomy and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser vaporization of malignant mesotheliomas in 2 (I right, I left); and a wedge resection of a metastatic lung cancer in 1.
Technique The operative technique has evolved over the years and only the current technique is described. General anesthesia with double-lumen endotracheal intubation is used in all cases. A 10 mm trocar is inserted into the pleural space at a posterior axillary line and fifth intercostal space, while the ipsilateral lung is collapsed. A rigid 10 mm thoracoscope, 0, 30, or 45 degrees (Olympus Corp., Food and Drug Administration approval pending), depending on the desired viewing angle, is inserted through the trocar. An additional trocar, either a 5 mm or 10 mm, is inserted through a fifth intercostal space at the anterior axillary line, for the passage of an operating probe. Carbon dioxide laser is used for the lung parenchyma and Nd:YAG laser for solid tissues such as tumors. For operative thoracoscopy, a small thoracotomy, 3 em long, is made and an infant rib retractor is occasionally but not always used to spread the intercostal space. After the thoracoscopy, a chest tube is inserted through one of the trocar holes. For spontaneous pneumothorax a 12F chest tube is usually used, and for an extensive operative thoracoscopy a 28F chest tube is used. A small chest tube causes less pain and is preferred.
721
The Journal of Thoracic and Cardiovascular Surgery
Wakabayashi
722
Table I. Thoracoscopy cases Years
Diagnostic
Therapeutic and operative
Total
Cases/year
1971-1986 1987-1990
145 60 205
5 105 110
150 165 310
9.4 41.3
Total
Table II. Therapeutic and operative thoracoscopies No. Spontaneous pneumothorax" Bullous emphysema" Empyema Pleural effusion'[ Others Total
44 32 20 6 8
110
·With carbon dioxide laser or electrocautery. tWith Nd:Y AG laser.
Results
The overalloperativemortality rate was 1% (3/315). The causes of deaths were respiratoryfailure in two and acute myocardialinfarctionin one. Bronchopleural fistulas developed in two patients after carbon dioxide laser contraction of diffuse bullous emphysema and thoracotomy was necessary for surgical closure. One patient requiredthoracotomyto controlbleeding after the extensive lysis of adhesions. Wound infection necessitating a minor incision and drainage developed in one patient. In 203 of 205 diagnosticthoracoscopies, the correct diagnosis was established (99%).Of 44 patients with spontaneous pneumothorax, 20 were treated with electrocautery. It was successful in all 17 patients with blebs but unsuccessful in two of three patients with ruptured apical bullae.The remaining24 patients weretreated with the carbon dioxide laser. The overallsuccess rate of the carbon dioxide laser group was 83% (20/24). The cause of failure in four patients was inappropriate optic/video systems. Twenty patients underwentthoracoscopic debridement ofchronicempyema;the lungsreexpanded in 18,in whom the duration of empyema was lessthan 2 months, and failed to reexpand in two, who had empyema for 4 and 7 months, respectively. Of four patients with malignant pleural effusion who underwent Nd:YAG laser vaporization of pleural implants, three had a successful outcomes. In the other patient, who had chronic malignant pleural effusion for 6 months, the lung failed to reexpand. This patient was treated by decortication and surgicalpleurectomyand isaliveand well16monthsafter the operation. The indications for three thoracic sympathectomieswere causalgia in two and hyperhidrosis in
one. All but one patient tolerated the operative thoracoscopy well. The one patient who died was a 74-year-old man with metastatic thyroid carcinoma of the lingular segmentof the left upper lobe. Respiratoryfailuredeveloped after thoracoscopic resection of the lung tumor. Forty-five days after the operation, he died in a coma. Autopsy revealed a brain metastasisof the thyroid cancer. Two patientsare aliveand receiving chemotherapy 9 and 7 months after pleurectomy and Nd:YAG laser vaporization of malignant mesothelioma. Discussion
The traditional indications for diagnostic or therapeutic3-6 thoracoscopy wereverylimited. I have beensteadilyexpandingits applications. Aortopulmonary window or inferior mediastinallymph nodes were previously accessibleonlyby openthoracotomybut nowbiopsy tissuecan be obtained through the thoracoscope. Lung biopsy has also been extended from interstitial disease? to solid masses. Several new modalities have been introduced, such as thoracoscopic treatment of spontaneous pneumothorax with an electrocautery' or carbon dioxide laser," thoracoscopic carbon dioxide laser ablationof diffuse bullous emphysema,'? and Nd:YAG laservaporization of malignant pleural implants in the treatment of malignant pleural effusion. Thoracoscopic debridement ofchronicempyemahas beenusedeffectively not onlyfor postpneumonectomy empyema' but for all types of chronicempyema. Operativethoracoscopy enabledme to perform aggressive intrathoracic operative procedures through a very small thoracotomy. In conclusion, thoracoscopy carries a verylowmorbidity and mortality rate and attains a very high diagnostic accuracy.Many operativeprocedures that havebeentraditionally performedthrough wideopenthoracotomy can bedone with the thoracoscope. Thoracoscopy will havea considerable impact on the future of thoracic surgery. REFERENCES I. Jacobaeus He. Ueber die Moglichkeit die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Munchen Moo Wochenschr 1910;57:2090-2. 2. Jacobaeus He. Endopleurale Operationen unter der Leitung des Thorakoskops. Beitr Klin Tuberk 1915;35:1-35. 3. Newhouse MT. Thoracoscopy: diagnostic and therapeutic indications. Pneumologie 1989;43:48-52. 4. Dijkman JH, van der Meer JWM, Bakker W, et al. Transpleural lung biopsy by the thoracoscopic route in patients with diffuse interstitial pulmonary disease. Chest 1982; 82:76-83. 5. Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 1981; 124:588-92.
Volume 102 Number 5 November 1991
6. Weissberg D, Kaufman M. Diagnostic and therapeutic pleuroscopy: experience with 137 patients. Chest 1980; 78:732-5. 7. Page RD, Jeffrey RR, Donnelly R J.Thoracoscopy: a review of 121 consecutive surgicalprocedures. Ann Thorac Surg 1989;48:66-8. 8. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of persistent or recurrent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651-3. 9. Wakabayashi A, Brenner M, Wilson AF, et al. Thoracoscopic treatment of spontaneous pneumothorax usingcarbon dioxide laser. Ann Thorac Surg 1990;50:786-90. 10. Wakabayashi A, Brenner M, Kayaleh R, et al. Thoracoscopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991;337:881-3.
Discussion Dr. L. H. Romero (Medford, Mass.). We use a surgically moreversatile technique. The instrumentsfor this were developedbyDr. Geza Jako,a laryngologist and pioneeroflaser surgery. Twothoracoscopes are used: l-inch wideopenlumenwith optional video and a 1Y2-inch widesurgicalthoracoscope. These areinserted through1Y2-inch or 2-inchintercostal incision. They provide directvisualization, normaldepth perception, and tissue coloration. The bivalved surgicalthoracoscope prevents the wide expansion ofribs and minimizes incisional pain and intercostal neuralgia. Superior lighting is provided distally by two large fiberoptic cablesand a high-intensity lightsource. Optionally an operating microscope with 2X to lOX magnification enhances precision in intraoperative detection and surgery. Video is available for demonstration. Specially developed microsurgical instrumentation and the endoscopic use of Nd:YAG or carbon dioxide laser greatly improves surgicalprecision. Collapsing theipsilateral lungduringonelunganesthesia, the surgical thoracoscope provides excellent visualization of the entirethoraciccavity. In addition, there is a three-dimensional view throughthe surgical thoracoscope, in comparison with the two-dimensional view on a video screen. Thoracicsurgeons are trained and experienced at viewing structures in three dimensions during open thoracotomy. Our first case was a bronchogenic carcinoma in whicha diagnosis was made and biopsy tissue was obtained. Our surgical thoracoscopy technique greatly extends the indications over operative thoracoscopy. Additional instrumentation allows performance of excisional biopsies including wedge excisions and segmentectomies through the surgical thoracoscope. If needed, forceps and other instruments can be insertedthrough an auxiliaryopening via a 5 mm trocar.
Thoracoscopy 7 2 3
In surgical thoracoscopies we have performed, there was excellent visualization of the pericardium, which allows pericardial window formation or other cardiac procedures with considerable less invasiveness. We are currently working on a surgical thoracoscopic technique for lobectomy. We have already performed cadaverexperiments in whichwe were able to deliver an entire lobe wrapped in a plastic bag through a 2-inchlong intercostal incision. Dr. Ralph J. Lewis (New Brunswick, N.J.) .We also have beendoingthoracoscopy for many yearsand havefoundit to be very beneficial. Like Dr. Wakabayashi, I believe it is greatly underused by thoracic surgeons. Recently we have upgraded thoracoscopy to what we call video-endoscopic thoracicsurgery. We put a light sourcein the chest with an attached camera and are able to project video imagesonto a screen. Workingthrough smaller ports,we have beenable to do lung biopsies and bullous ablationand to create pericardial windows. We have explored the aortopulmonary window for tumors, have explored the mediastinum, and have recently beenworking on benignsurfacetumorsof the lung.We are amazed at the rapid recovery of our patients. We have dischargedmostofthem within48to 72hours,and I canonlyagree that I think this procedure is goingto havea profoundeffecton the field of general thoracic surgery. I havea commentand a question. We havestarted to use the argon beam coagulator, having foundit to be much superiorto the laser or cautery in doing bullous ablation. We have also found uses for it in sealing air leaks in the lung and bleeding surfacesfrom the lung. Have you any concerns about the buildup of oxygen in the closed thoraciccavitywhile youare working throughthesesmall ports and the possibility of a fire that might develop? We have had no problems so far. Dr. Wakabayashi. I havenot had a chance to use the argon beam coagulator. Do you have enough length of the tip of the argon coagulatorso that it can be passedthrough a small trocar? The tip of the argon beam coagulator I used for sternotomy was not long enough. Dr. Lewis. The devices havean elongatedhandle-like structure with a 45-degree angle that can fit into a 10 or 12 mm opening in the chest, and you can work it with that. Dr. Wakabayashi. If that isthecase,then it isprobablygood. Maybe I'll try it. As I mentioned, I have many patients with bullous emphysema. Those patients' lung function is extremely poor (e.g., a forced expiratory volume in 1second of 12%). When westarted the program we wondered if we could maintain one-lung ventilation and we used 100% oxygen. However, I worried about bursting the lung, so we cut down to 50%or 70% oxygen and so far we have had no accidents.
Expanded applications of diagnostic and therapeutic thoracoscopy From 1971 to 1990, 315 thoracoscopies were performed. Recent advances in optic/video systems and endoscopic operating instruments have made thoracoscopy easier and more accurate than 20 years ago. The operative mortatity rate was low (1 %) and the diagnostic accuracy high (99 %). Thoracoscopy has been performed at an increasing frequency in recent years because of its expanded applicatio~ especially in the areas of therapeutic or operative procedures such as carbon dioxide laser pneumothorax or diffuse bullo~ emphysema, neodymium:yttrium-a1uminumtreatment of spontaneo~ garnet laser vaporization of pleural malignant tumors, and thoracoscope/laser-aided pleurectomy, pericardiectomy, or lung resection. Further technologic advancement in thoracoscopy will have a cOiWderable impact on the future of thoracic surgery.
Akio Wakabayashi, MD, Irvine, Calif.
Dagnostic and therapeutic thoracoscopies wereintroduced 80 years ago.I, 2 Despite this early start, thoracoscopy never gained wide acceptance and was used only sporadically in a limited fashion. Recentexplosive popularity of laparoscopic cholecystectomy, however, has stimulated interest in thoracoscopy among thoracic surgeons. The purpose of this report is to review my experienceover the past 20 years. Materials The first five thoracoscopies, in which an original Jacobaeus thoracoscope/ was used, were for the treatment of spontaneous pneumothorax (therapeutic), but all others were for diagnostic purposes until 1987, when the pneumothorax program was reinstated (Table I). During phase I, from 1971 to 1986, 150 thoracoscopies (145 diagnostic and 5 therapeutic) were performed, averaging 9.4 cases per year. During phase 2, from 1987 to 1990, 165 thoracoscopies (60 diagnostic and 105 therapeutic) were done, averaging 41.3 cases per year. A variety of rigid glass rod lens scopes were used until May 1990, after which an Olympus 10 mm rigid thoracoscope (Olympus Corp., Lake Success, N.Y.) was used exclusively. (Food and Drug Administration approval of this thoracoscope is pending.) Fifty-nine diagnostic thoracoscopies were performed without biopsy, either because the diagnosis was obvious or because collected fluid Fromthe Departmentof Surgery,University of California, Irvine, Irvine,Calif. Read at the Seventy-first Annual Meetingof The American Association for ThoracicSurgery, Washington, D.C., May 6-8, 1991. Address forreprints: AkioWakabayashi, MD, Cardiothoracic Surgery, UCI Medical Center, PO Box 14091, Orange, Calif. 92613-1091. 12/6/32830
specimens established the diagnosis. In another 146 cases, biopsy specimens of solid tissues were taken; 98 pleurae, 25 mediastinallymph nodes, 17 lung masses, and 6 others. One hundred ten therapeutic or operative thoracoscopies included spontaneous pneumothorax, 44; bullous emphysema, 32; empyema, 20; malignant pleural effusion, 6; and others, 8 (Table II). Operative thoracoscopy is defined as intrathoracic operative procedures aided by the thoracoscope. Seven patients underwent operative thoracoscopies: excision of mediastinal goiters in 2; partial pericardiectomy in 2 (I malignant, 1 uremic pericarditis); pleurectomy and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser vaporization of malignant mesotheliomas in 2 (I right, I left); and a wedge resection of a metastatic lung cancer in 1.
Technique The operative technique has evolved over the years and only the current technique is described. General anesthesia with double-lumen endotracheal intubation is used in all cases. A 10 mm trocar is inserted into the pleural space at a posterior axillary line and fifth intercostal space, while the ipsilateral lung is collapsed. A rigid 10 mm thoracoscope, 0, 30, or 45 degrees (Olympus Corp., Food and Drug Administration approval pending), depending on the desired viewing angle, is inserted through the trocar. An additional trocar, either a 5 mm or 10 mm, is inserted through a fifth intercostal space at the anterior axillary line, for the passage of an operating probe. Carbon dioxide laser is used for the lung parenchyma and Nd:YAG laser for solid tissues such as tumors. For operative thoracoscopy, a small thoracotomy, 3 em long, is made and an infant rib retractor is occasionally but not always used to spread the intercostal space. After the thoracoscopy, a chest tube is inserted through one of the trocar holes. For spontaneous pneumothorax a 12F chest tube is usually used, and for an extensive operative thoracoscopy a 28F chest tube is used. A small chest tube causes less pain and is preferred.
721
The Journal of Thoracic and Cardiovascular Surgery
Wakabayashi
722
Table I. Thoracoscopy cases Years
Diagnostic
Therapeutic and operative
Total
Cases/year
1971-1986 1987-1990
145 60 205
5 105 110
150 165 310
9.4 41.3
Total
Table II. Therapeutic and operative thoracoscopies No. Spontaneous pneumothorax" Bullous emphysema" Empyema Pleural effusion'[ Others Total
44 32 20 6 8
110
·With carbon dioxide laser or electrocautery. tWith Nd:Y AG laser.
Results
The overalloperativemortality rate was 1% (3/315). The causes of deaths were respiratoryfailure in two and acute myocardialinfarctionin one. Bronchopleural fistulas developed in two patients after carbon dioxide laser contraction of diffuse bullous emphysema and thoracotomy was necessary for surgical closure. One patient requiredthoracotomyto controlbleeding after the extensive lysis of adhesions. Wound infection necessitating a minor incision and drainage developed in one patient. In 203 of 205 diagnosticthoracoscopies, the correct diagnosis was established (99%).Of 44 patients with spontaneous pneumothorax, 20 were treated with electrocautery. It was successful in all 17 patients with blebs but unsuccessful in two of three patients with ruptured apical bullae.The remaining24 patients weretreated with the carbon dioxide laser. The overallsuccess rate of the carbon dioxide laser group was 83% (20/24). The cause of failure in four patients was inappropriate optic/video systems. Twenty patients underwentthoracoscopic debridement ofchronicempyema;the lungsreexpanded in 18,in whom the duration of empyema was lessthan 2 months, and failed to reexpand in two, who had empyema for 4 and 7 months, respectively. Of four patients with malignant pleural effusion who underwent Nd:YAG laser vaporization of pleural implants, three had a successful outcomes. In the other patient, who had chronic malignant pleural effusion for 6 months, the lung failed to reexpand. This patient was treated by decortication and surgicalpleurectomyand isaliveand well16monthsafter the operation. The indications for three thoracic sympathectomieswere causalgia in two and hyperhidrosis in
one. All but one patient tolerated the operative thoracoscopy well. The one patient who died was a 74-year-old man with metastatic thyroid carcinoma of the lingular segmentof the left upper lobe. Respiratoryfailuredeveloped after thoracoscopic resection of the lung tumor. Forty-five days after the operation, he died in a coma. Autopsy revealed a brain metastasisof the thyroid cancer. Two patientsare aliveand receiving chemotherapy 9 and 7 months after pleurectomy and Nd:YAG laser vaporization of malignant mesothelioma. Discussion
The traditional indications for diagnostic or therapeutic3-6 thoracoscopy wereverylimited. I have beensteadilyexpandingits applications. Aortopulmonary window or inferior mediastinallymph nodes were previously accessibleonlyby openthoracotomybut nowbiopsy tissuecan be obtained through the thoracoscope. Lung biopsy has also been extended from interstitial disease? to solid masses. Several new modalities have been introduced, such as thoracoscopic treatment of spontaneous pneumothorax with an electrocautery' or carbon dioxide laser," thoracoscopic carbon dioxide laser ablationof diffuse bullous emphysema,'? and Nd:YAG laservaporization of malignant pleural implants in the treatment of malignant pleural effusion. Thoracoscopic debridement ofchronicempyemahas beenusedeffectively not onlyfor postpneumonectomy empyema' but for all types of chronicempyema. Operativethoracoscopy enabledme to perform aggressive intrathoracic operative procedures through a very small thoracotomy. In conclusion, thoracoscopy carries a verylowmorbidity and mortality rate and attains a very high diagnostic accuracy.Many operativeprocedures that havebeentraditionally performedthrough wideopenthoracotomy can bedone with the thoracoscope. Thoracoscopy will havea considerable impact on the future of thoracic surgery. REFERENCES I. Jacobaeus He. Ueber die Moglichkeit die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Munchen Moo Wochenschr 1910;57:2090-2. 2. Jacobaeus He. Endopleurale Operationen unter der Leitung des Thorakoskops. Beitr Klin Tuberk 1915;35:1-35. 3. Newhouse MT. Thoracoscopy: diagnostic and therapeutic indications. Pneumologie 1989;43:48-52. 4. Dijkman JH, van der Meer JWM, Bakker W, et al. Transpleural lung biopsy by the thoracoscopic route in patients with diffuse interstitial pulmonary disease. Chest 1982; 82:76-83. 5. Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 1981; 124:588-92.
Volume 102 Number 5 November 1991
6. Weissberg D, Kaufman M. Diagnostic and therapeutic pleuroscopy: experience with 137 patients. Chest 1980; 78:732-5. 7. Page RD, Jeffrey RR, Donnelly R J.Thoracoscopy: a review of 121 consecutive surgicalprocedures. Ann Thorac Surg 1989;48:66-8. 8. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of persistent or recurrent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651-3. 9. Wakabayashi A, Brenner M, Wilson AF, et al. Thoracoscopic treatment of spontaneous pneumothorax usingcarbon dioxide laser. Ann Thorac Surg 1990;50:786-90. 10. Wakabayashi A, Brenner M, Kayaleh R, et al. Thoracoscopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991;337:881-3.
Discussion Dr. L. H. Romero (Medford, Mass.). We use a surgically moreversatile technique. The instrumentsfor this were developedbyDr. Geza Jako,a laryngologist and pioneeroflaser surgery. Twothoracoscopes are used: l-inch wideopenlumenwith optional video and a 1Y2-inch widesurgicalthoracoscope. These areinserted through1Y2-inch or 2-inchintercostal incision. They provide directvisualization, normaldepth perception, and tissue coloration. The bivalved surgicalthoracoscope prevents the wide expansion ofribs and minimizes incisional pain and intercostal neuralgia. Superior lighting is provided distally by two large fiberoptic cablesand a high-intensity lightsource. Optionally an operating microscope with 2X to lOX magnification enhances precision in intraoperative detection and surgery. Video is available for demonstration. Specially developed microsurgical instrumentation and the endoscopic use of Nd:YAG or carbon dioxide laser greatly improves surgicalprecision. Collapsing theipsilateral lungduringonelunganesthesia, the surgical thoracoscope provides excellent visualization of the entirethoraciccavity. In addition, there is a three-dimensional view throughthe surgical thoracoscope, in comparison with the two-dimensional view on a video screen. Thoracicsurgeons are trained and experienced at viewing structures in three dimensions during open thoracotomy. Our first case was a bronchogenic carcinoma in whicha diagnosis was made and biopsy tissue was obtained. Our surgical thoracoscopy technique greatly extends the indications over operative thoracoscopy. Additional instrumentation allows performance of excisional biopsies including wedge excisions and segmentectomies through the surgical thoracoscope. If needed, forceps and other instruments can be insertedthrough an auxiliaryopening via a 5 mm trocar.
Thoracoscopy 7 2 3
In surgical thoracoscopies we have performed, there was excellent visualization of the pericardium, which allows pericardial window formation or other cardiac procedures with considerable less invasiveness. We are currently working on a surgical thoracoscopic technique for lobectomy. We have already performed cadaverexperiments in whichwe were able to deliver an entire lobe wrapped in a plastic bag through a 2-inchlong intercostal incision. Dr. Ralph J. Lewis (New Brunswick, N.J.) .We also have beendoingthoracoscopy for many yearsand havefoundit to be very beneficial. Like Dr. Wakabayashi, I believe it is greatly underused by thoracic surgeons. Recently we have upgraded thoracoscopy to what we call video-endoscopic thoracicsurgery. We put a light sourcein the chest with an attached camera and are able to project video imagesonto a screen. Workingthrough smaller ports,we have beenable to do lung biopsies and bullous ablationand to create pericardial windows. We have explored the aortopulmonary window for tumors, have explored the mediastinum, and have recently beenworking on benignsurfacetumorsof the lung.We are amazed at the rapid recovery of our patients. We have dischargedmostofthem within48to 72hours,and I canonlyagree that I think this procedure is goingto havea profoundeffecton the field of general thoracic surgery. I havea commentand a question. We havestarted to use the argon beam coagulator, having foundit to be much superiorto the laser or cautery in doing bullous ablation. We have also found uses for it in sealing air leaks in the lung and bleeding surfacesfrom the lung. Have you any concerns about the buildup of oxygen in the closed thoraciccavitywhile youare working throughthesesmall ports and the possibility of a fire that might develop? We have had no problems so far. Dr. Wakabayashi. I havenot had a chance to use the argon beam coagulator. Do you have enough length of the tip of the argon coagulatorso that it can be passedthrough a small trocar? The tip of the argon beam coagulator I used for sternotomy was not long enough. Dr. Lewis. The devices havean elongatedhandle-like structure with a 45-degree angle that can fit into a 10 or 12 mm opening in the chest, and you can work it with that. Dr. Wakabayashi. If that isthecase,then it isprobablygood. Maybe I'll try it. As I mentioned, I have many patients with bullous emphysema. Those patients' lung function is extremely poor (e.g., a forced expiratory volume in 1second of 12%). When westarted the program we wondered if we could maintain one-lung ventilation and we used 100% oxygen. However, I worried about bursting the lung, so we cut down to 50%or 70% oxygen and so far we have had no accidents.