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Hand-assisted Thoracoscopic Surgery Causes Less Postoperative Pain than Limited Thoracotomy after Cessation of Epidural Analgesia
ORIGINAL ARTICLE
Original Article
Hand-assisted Thoracoscopic Surgery Causes Less Postoperative Pain than Limited Thoracotomy after Cessation of Epidural Analgesia Joseph M. Paiva, B.Med.Sc.a and Gavin M. Wright, FRACSb,∗ a
The University of Melbourne, Department of Surgery, St. Vincent’s Hospital Melbourne, 55 Victoria Parade, Fitzroy, Vic. 3065, Australia b Cardiothoracic Care Centre, St. Vincent’s Hospital Melbourne, 55 Victoria Parade, Fitzroy, Vic. 3065, Australia
Background: Hand-assisted Thoracoscopic Surgery (HATS) is a novel minimally invasive technique for performing procedures conventionally performed by posterolateral thoracotomy. HATS overcomes a major drawback of thoracoscopic surgery in allowing full manual palpation of the lungs via a subcostal (mini-Kocher’s) incision under videoscopic guidance, avoiding a thoracotomy, when the indication is pulmonary metastasectomy with curative intent or resection of undiagnosed lung nodules. It is postulated HATS may produce improved postoperative quality of life outcomes compared to thoracotomy. Aims: To determine if HATS compared to limited posterolateral thoracotomy causes less postoperative pain after cessation of epidural anaesthesia. Methods: Fifty-two patients were prospectively randomised to receive a limited thoracotomy (n = 26) or HATS (n = 26). Pain scores, measured on a visual analogue scale, were recorded during standard nursing observations and after analgesia demands in the 24 h after epidural removal. Results: Pain scores were significantly lower after HATS compared to limited thoracotomy (3.8 versus 5.2, p = 0.04). There was no difference in postoperative respiratory function. Conclusion: HATS results in lower postoperative pain after cessation of epidural analgesia. This form of analgesia may therefore not be required, reducing the management complexity, complications and hospital stay associated with its use. Short Abstract: Hand-assisted Thoracoscopic Surgery (HATS) is a novel technique allowing full manual lung palpation as an adjunct to Video-assisted Thoracoscopic Surgery (VATS). Fifty-two patients were prospectively randomised to receive limited thoracotomy or HATS. Pain scores were significantly lower after HATS compared to thoracotomy, indicating epidural analgesia may not be required. (Heart Lung and Circulation 2004;13:374–378) © 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Cancer; Lung; Minimally invasive; Quality of life; Randomised; VATS
Introduction
M
inimal access surgery reduces tissue damage by minimising surgical incisions, conferring less pain and disability, and reducing physiological responses to injury that retard recovery.1 These advantages are well demonstrated in comparisons of early postoperative quality of life outcomes for many open versus laparoscopic approaches to intra-abdominal procedures.2–5 Open thoracotomy is currently the gold standard for thoracic access, involving a large muscle-splitting incision and ribspreading. Postoperative pain is significant; a function of incision size and degree of rib-spreading, requiring powerful analgesia postoperatively.6 The resultant poor pulmonary mechanics increases the risk of infection and ∗ Corresponding author. Tel.: +61 3 9419 2477; fax: +61 3 9417 1694. E-mail address: [email protected] (G.M. Wright).
atelectasis.7 These complications are minimized by epidural analgesia. An epidural catheter in itself poses extra risks, including hypotension, bradycardia and urinary retention from autonomic blockade and less commonly, epidural abscess or haematoma. Analogous to laparoscopy in abdominal surgery, Videoassisted Thoracoscopic Surgery (VATS) is well established in the diagnostic and therapeutic armamentarium of the thoracic surgeon. It is superior to thoracotomy by virtue of incision size, early postoperative pain and many quality of life markers including length of hospital stay, convalescence, and pulmonary function.1 However, VATS poses limitations for excision of some lung nodules. Nodules that are not subpleural or large and firm enough to palpate with an instrument are inaccessible by VATS.8 When the indication is curative metastasectomy, VATS is inadequate in localisation and clearance of all nodules, due to inability
© 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2004.08.010
Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
Figure 1. Hand in chest palpating the lung through the subcostal-transdiaphragmatic incision. (Reprinted from Wright et al. [10].)
to palpate the lung.8 This necessitates further surgery for missed lesions, potentially losing control of the disease. The use of the hand as an adjunct for VATS was first described in 1999 by Mineo et al.,9 who used a subxiphoid approach. This solved many of the shortcomings of VATS, allowing the surgeon to introduce the hand into the pleural cavity from below the costal margin, whilst utilising the documented advantages of VATS. In our technique HATS10 (Fig. 1), a modified Kocher’s incision is made for the wrist with the fingers passed behind the costal margin in the extra-peritoneal plane to split the anterior diaphragmatic fibres under videoscopic control and enter the pleural cavity (Fig. 2). Advantages include increased manoeuvrability during resections compared to VATS, with tactile feedback improving depth perception and hand–eye co-ordination.10 The hand-assist incision allows
375
Figure 3. Application of an endoscopic stapler cutter for the excision of a lesion pinched up in hand. (Reprinted from Wright et al. [10].)
unprecedented freedom of movement of the endoscopic stapler used for resection and large specimens can be retrieved easily (Fig. 3). Resection of lesions missed on preoperative imaging, not found on VATS and deep lesions can be achieved with the facility for palpation.10,11 Minimal access techniques today demand critical evaluation in randomised controlled trials against established standards of open surgery.1–6 We studied early postoperative quality of life, including early postoperative pain, for HATS compared to open thoracotomy in a randomised prospective trial.
Methods The study was approved by the Human Research Ethics Committee at St. Vincent’s Hospital, Melbourne (HREC 82/01). The study was conducted as a randomised prospective trial. Patients referred to the Thoracic Care Centre at St. Vincent’s Hospital and St. Vincent’s and Mercy Private Hospital were recruited between October 2001 and August 2004. During this period, 52 patients were randomised to receive a HATS procedure (n = 26) or a limited thoracotomy (n = 26). Randomisation was computer generated and allocation was concealed until after consent was obtained.
Inclusion Criteria
Figure 2. Access into the pleural cavity through a split in the anterior diaphragmatic fibres. (Reprinted from Wright et al. [10].)
Eligible patients were stratified into two groups. The first group were patients with undiagnosed lung nodules less than 2 cm in diameter, at least 1 cm deep to the pleura with a normal bronchoscopy. Patients in the second group had established oligo-metastatic disease involving the lung, suitable for metastasectomy by wedge resection. A well-controlled primary malignancy and no
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Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
extra-pulmonary disease detectable by Positron Emission Tomography (PET) scanning were also required.
Exclusion Criteria Patients with lesions easily resectable by VATS, those with large, central lesions, and those with prior needle biopsy were excluded. The latter criterion was intended to eliminate a possible variable for pleural recurrence.
Anaesthesia All subjects were given epidural anaesthesia to reflect our usual thoracotomy management (unless contraindicated) for a maximum of 5 days post-surgery or 24 h after removal of drainage tubes. Following this, routine ward analgesia including paracetamol, tramadol, oxycodone, nonsteroidal anti-inflammatory drugs and injected narcotics were provided as required.
Limited Posterolateral Thoracotomy An attempt was made to standardise the thoracotomy incision length to 12.5 cm, with extension if necessary. The posterior part of latissmus dorsi was divided; serratus anterior was dissected off the latissmus and spared. A 1-cm segment of the sixth rib was resected sub-periosteally. Intercostal closure was by continuous suture from fifth to sixth intercostal muscles while holding the ribs together by rib-approximator. Latissmus was repaired with a heavy absorbable suture.
Hand-assisted Thoracoscopic Surgery10 The patient was positioned by rotating the affected side between a half-lateral and full lateral position and protecting bony pressure points. Preparation and draping were applied to allow access to the ipsilateral hypochondrial region in addition to standard thoracotomy draping. HAND-ASSIST INCISION. A 7–8 cm incision (cm equal to glove size) was made 2 cm below and parallel to the costal margin and the rectus muscle divided (modified Kocher’s incision). Simultaneously, a port site was established in the seventh intercostal space at the anterior axillary line to allow introduction of a video-telescope as with VATS (Fig. 1).
The fingers were passed behind the costal margin, staying in the extra-peritoneal plane (if possible) deep to the posterior sheath, until the anterior fibres on the underside of the diaphragm are exposed. Under videoscopic control via the anterior port site, long artery forceps were pushed through the diaphragm from below and split in the line of the anterior diaphragmatic fibres radially near its periphery, minimizing the chance of damage to the radial branches of the phrenic nerve (Fig. 2). The hand then broke into the chest through the diaphragmatic split.
ENTRY TO THORACIC CAVITY.
PROCEDURE. With the lung collapsed, the entire lung was palpated. Adhesions were taken down by sweeping with the fingers or with diathermy through another VATS port. Once a target lesion was identified, it was presented to a VATS grasper or linear stapler cutter for excision (Fig. 3). Palpation ensured good margins. The specimen
Heart Lung and Circulation 2004;13:374–378
was placed in an endoscopic specimen bag and retrieved easily through the HATS incision. The diaphragmatic split was subsequently repaired from within the chest by endoscopic suturing or through the subcostal incision by pulling the split inferiorly with tissue forceps. CLOSURE. The anterior port site was used to place an intercostal chest drain. The rectus muscle was re-approximated with a heavy continuous absorbable suture. The skin was closed with a fine subcuticular suture.
Study Design and End-Points The primary end-point was early postoperative pain. Independent nursing staff carried out postoperative pain appraisal in the 24 h after epidural catheter removal using a standard 10-point visual analogue scale (where 0 represented no pain and 10 represented the worst possible pain). Scoring was performed each nursing shift and additionally when a patient requested analgesia. The worst pain score in the 24 h after removal of the epidural was recorded, intending to assess the unmasked pain of the operative incisions. Other markers (as part of a larger study of 60 patients) examined were length of hospital stay and change in pulmonary function, including change in forced expiratory volume in 1 second (FEV1) and diffusing lung capacity, as measured by spirometry done preoperatively and at 42 days postoperatively. Return to preoperative activities of daily living and work was also assessed using the SF12v2® quality of life questionnaire. Diaphragmatic function was assessed at 7 weeks by fluoroscopic screening.
Statistical Methods Data for all patients was analysed on an intention-to-treat basis. After stratification into diagnostic nodule and metastasectomy groups, analysis of differences between the two randomised groups for demographic and operative variables was performed. Continuous normally distributed data was expressed as mean ± standard deviation and non-normally distributed data as the median and range. The Fisher’s exact test for proportional data, the Mann–Whitney Rank Sum test for non-parametric data, and the Student’s two-sample t-test for normally distributed data were used for comparison of pain scores and change in FEV1 between the groups. p < 0.05 was considered statistically significant.
Results Demographic characteristics were similar between the two groups with stratification into undiagnosed nodule biopsies or metastasectomies (Table 1). Clear resection margins were reported in all patients. Extra lesions, undetected on preoperative imaging were found on manual lung palpation in 5 HATS patients and 4 thoracotomy patients. One HATS was converted to open thoracotomy due to pleural symphysis. The mean time of epidural cessation was similar in both groups (Table 2). Three patients did not have an epidural placed due to prior anticoagulation or technical difficulty.
Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
Table 1. Characteristics of Patients Undergoing HATS and Thoracotomy Thoracotomy (n = 26)
HATS (n = 26)
P Value
Gender (M/F) 16/10 17/9 NSa Age 50.0 (±18.4) 56.7 (±20.2) NSb Stratification to undiagnosed nodule (N) or metastasectomy (M) group N 7 9 NSa M 19 17 NSa Clear resection margins 26 26 NSa Extra lesions found on 4 5 NSa manual palpation NS: not significant. a
Fisher’s exact test.
b
Two sample t-test—data presented as mean ± standard deviation.
Early epidural removal or failure occurred in 8 HATS patients and 6 thoracotomy patients. Protocol breaches occurred when pain scores were not recorded for one HATS and one thoracotomy patient, leaving 50 patients for analysis. The worst pain score post-epidural removal was lower (3.8 versus 5.2, VAS, p = 0.04) after HATS compared to thoracotomy, a statistically significant difference (Table 2). Mean reduction in FEV1 postoperatively did not differ significantly between the groups (Table 2). No paradoxical diaphragm movement was seen in the HATS group, although four patients showed less movement than the contralateral hemidiaphragm. One patient in the thoracotomy group had phrenic palsy, due to a subsequent pleurectomy for his mesothelioma at another institution. The intercostal drainage catheter, a potential source of pain independent of the operative incision, was still in situ in 9 patients in the HATS group and 12 patients in the thoracotomy group when VAS scores were taken with no significant differences between groups (Table 2). Postoperative complications relevant to our study included one epidural abscess, 2 prolonged air leaks (>7 days) and 2 cases of persisting neuralgia at 7 weeks in thoracotomy patients. One prolonged air leak occurred in each group and one subcostal wound infection occurred in the HATS group.
377
Discussion HATS has been demonstrated to be safe, practical and efficacious, accomplishing the same objectives as thoracotomy, with both being acceptable options for invasive lung nodule biopsy and pulmonary metastasectomy in our early experience.10–12 All patients in the HATS group underwent the subcostal access technique, except for one (the first HATS patient on trial) who underwent a subxiphoid-retrosternal technique similar to that published by Mineo et al.9 However we found this technique to have the disadvantage of pain from xiphisternectomy. Access for the hand was technically very difficult in those with a narrow costal margin and for posterior lower lobe lesions, causing discomfort for the surgeon, prompting the change to the subcostal trans-diaphragmatic approach.10 Various studies, particularly comparisons of laparoscopic and open procedures and specific to thoracic surgery, VATS and thoracotomy demonstrate reduced early postoperative pain associated with minimally invasive surgery.1–6,13 The significantly less pain recorded for HATS patients compared to thoracotomy patients after epidural removal correlates well with results of previous studies of early postoperative pain comparing open and endoscopic procedures.1–6 Respiratory function is a dependent variable of operative incision pain, splinting the chest and reducing diaphragmatic excursion, deep breathing and coughing, predisposing to infection and lung collapse.7 Change in these parameters, measured by change in FEV1 did not differ between the two groups (Table 2). There was no accessrelated functional diaphragmatic paralysis in any HATS or thoracotomy patients, emphasising the subcostal approach to be well tolerated, as supported by Clarke et al.12 Incomplete movement of the hemidiaphragm of the operated hemithorax in 4 HATS patients can be explained by subsequent organisation and fibrosis in the muscle repair site. We can conclude that, in addition to reduced postoperative pain, respiratory function is equivalent to that for thoracotomy patients. It should be noted that for thoracotomy patients in our study, the 12–13 cm skin and muscle incision made was a relatively limited one, aimed at minimizing morbidity. Given pain is a function of incision size,6 this would theo-
Table 2. Early Postoperative Pain after Epidural Removal and Percentage Change in Respiratory Function Day (after operation) of epidural removal/failure Early removal/failure of epidural (<5 days after operation and prior to intercostal catheter removal) Worst pain score in 24 h after epidural removal Intercostal catheter in situ after epidural removal % change in FEV1 (postoperatively) NS: not significant. a
Mann–Whitney rank sum test.
b
Fisher’s exact test.
c
Two sample t-test—data presented as mean ± standard deviation.
Thoracotomy (n = 26)
HATS (n = 26)
P Value
3 (0–6) 6
3 (0–6) 8
NSa NSb
5.2 (±2.2) 12 18.1 ± 19.0
3.8 (±2.4) 9 18.8 ± 9.9
0.04c NSb NSc
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Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
retically reduce early postoperative pain for thoracotomy patients, further highlighting the benefits associated with HATS. Late postoperative intercostal neuralgia in two thoracotomy patients was evidence of intercostal nerve injury from rib-spreading or closure, manoeuvres avoided in HATS. Early removal or failure of the epidural catheter, which could result in increased pain intensity at time of scoring, occurred in 8 HATS patients and 6 in the thoracotomy group (Table 2). HATS cases where the epidural catheter failed did not subsequently require epidural analgesia, corroborating our hypothesis that this form of analgesia may not be needed after HATS. These limitations do not pertain merely to study conditions, rather reflecting the vagaries of actual clinical practice. Throughout the trial, an epidural catheter was routinely placed to mirror thoracotomy management and standardise trial conditions. However, non-trial HATS cases have not required epidural analgesia, and the authors believe this will not be not be necessary in our routine practice. One quarter of patients had early failure of their epidural by our criteria, despite management in a specialist thoracic unit. Some surgical units do not even use epidural analgesia for thoracotomy. Therefore, our finding of reduced pain in its absence is an important clinical benefit.
Conclusion This randomised study of HATS compared to thoracotomy demonstrated significantly lower postoperative pain for HATS after cessation of epidural analgesia. These results suggest this form of analgesia may not be required, reducing the management complexity, complications and increased hospital stay associated with its use. Whilst we must wait for longer term oncological follow-up in the metastasectomy group, the HATS incision could now be considered the optimal access for diagnosing deep nodules that require excisional biopsy. The authors acknowledge Tyco Healthcare for funding the medical illustrations and The University of Melbourne, Faculty of Medicine for supporting this work. We are grateful to Dr. Dayan Chandrasekara MBBS, surgical registrar from St. Vincent’s Hospital, Melbourne, for his assistance in setting up the Access database used for follow-up during this study.
Heart Lung and Circulation 2004;13:374–378
References 1. Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362–5. 2. Slim K, Bousquet, Kwiatkowski F, Pezet D, Chipponi J. Analysis of randomised controlled trials in laparoscopic surgery. Br J Surg 1997;84:610–4. 3. Nguyen NT, Rosenquist J, Arango A, Cole CJ, Lee SJ, et al. Laparoscopic versus open gastric bypass: a randomised study of outcomes, quality of life and costs. Ann Surg 2001;234: 279–91. 4. Hendolin HI, Paakonen M, Alhava EM, Tarvainen R, Kemppinen T, Lahtinen P. Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function, and stress response. Eur J Surg 2000;166(5):394–9. 5. Landreneau RJ, Wiechman RJ, Hazelrigg SR, Santucci TS, Boley TM, Magee MJ, et al. Success of laparoscopic fundoplication for gastrooesophageal reflux disease. Ann Thorac Surg 1998;66:1886–92. 6. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285–9. 7. Nakata M, Hideyuki S, Yokoyama N, Kurita A, Takiyama W, Shigemistsu T. Pulmonary function after lobectomy: videoassisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2000;70:938–41. 8. McCormack PM, Bains MS, Begg CB, Burt ME. Role of videoassisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg 1996;62:213–6. 9. Mineo TC, Pompeo E, Ambrogi V, Pistolese C. Video-assisted approach for transxiphoid bilateral lung metastasectomy. Ann Thorac Surg 1996;67:1808–10. 10. Wright GM, Clarke CP, Paiva JM. Hand-assisted thoracoscopic surgery. Ann Thorac Surg 2003;75:1665–7. 11. Wright GM, Long H. Hand-assist VATS: minimum invasion, maximum return. Aust NZ J Surg 2001;71(Suppl.):A17. 12. Clarke CP, Ali A, Moshinsky R, Seevanayagam S, Raman J. The effect of hand-assisted thoracoscopic surgery (HATS) for pulmonary secondaries does not compromise diaphragmatic function. Heart Lung Circ 2001;10:39. 13. Sanatmbrogio L, Nosotti M, Bellavati N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59:868–70.
Original Article
Hand-assisted Thoracoscopic Surgery Causes Less Postoperative Pain than Limited Thoracotomy after Cessation of Epidural Analgesia Joseph M. Paiva, B.Med.Sc.a and Gavin M. Wright, FRACSb,∗ a
The University of Melbourne, Department of Surgery, St. Vincent’s Hospital Melbourne, 55 Victoria Parade, Fitzroy, Vic. 3065, Australia b Cardiothoracic Care Centre, St. Vincent’s Hospital Melbourne, 55 Victoria Parade, Fitzroy, Vic. 3065, Australia
Background: Hand-assisted Thoracoscopic Surgery (HATS) is a novel minimally invasive technique for performing procedures conventionally performed by posterolateral thoracotomy. HATS overcomes a major drawback of thoracoscopic surgery in allowing full manual palpation of the lungs via a subcostal (mini-Kocher’s) incision under videoscopic guidance, avoiding a thoracotomy, when the indication is pulmonary metastasectomy with curative intent or resection of undiagnosed lung nodules. It is postulated HATS may produce improved postoperative quality of life outcomes compared to thoracotomy. Aims: To determine if HATS compared to limited posterolateral thoracotomy causes less postoperative pain after cessation of epidural anaesthesia. Methods: Fifty-two patients were prospectively randomised to receive a limited thoracotomy (n = 26) or HATS (n = 26). Pain scores, measured on a visual analogue scale, were recorded during standard nursing observations and after analgesia demands in the 24 h after epidural removal. Results: Pain scores were significantly lower after HATS compared to limited thoracotomy (3.8 versus 5.2, p = 0.04). There was no difference in postoperative respiratory function. Conclusion: HATS results in lower postoperative pain after cessation of epidural analgesia. This form of analgesia may therefore not be required, reducing the management complexity, complications and hospital stay associated with its use. Short Abstract: Hand-assisted Thoracoscopic Surgery (HATS) is a novel technique allowing full manual lung palpation as an adjunct to Video-assisted Thoracoscopic Surgery (VATS). Fifty-two patients were prospectively randomised to receive limited thoracotomy or HATS. Pain scores were significantly lower after HATS compared to thoracotomy, indicating epidural analgesia may not be required. (Heart Lung and Circulation 2004;13:374–378) © 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Cancer; Lung; Minimally invasive; Quality of life; Randomised; VATS
Introduction
M
inimal access surgery reduces tissue damage by minimising surgical incisions, conferring less pain and disability, and reducing physiological responses to injury that retard recovery.1 These advantages are well demonstrated in comparisons of early postoperative quality of life outcomes for many open versus laparoscopic approaches to intra-abdominal procedures.2–5 Open thoracotomy is currently the gold standard for thoracic access, involving a large muscle-splitting incision and ribspreading. Postoperative pain is significant; a function of incision size and degree of rib-spreading, requiring powerful analgesia postoperatively.6 The resultant poor pulmonary mechanics increases the risk of infection and ∗ Corresponding author. Tel.: +61 3 9419 2477; fax: +61 3 9417 1694. E-mail address: [email protected] (G.M. Wright).
atelectasis.7 These complications are minimized by epidural analgesia. An epidural catheter in itself poses extra risks, including hypotension, bradycardia and urinary retention from autonomic blockade and less commonly, epidural abscess or haematoma. Analogous to laparoscopy in abdominal surgery, Videoassisted Thoracoscopic Surgery (VATS) is well established in the diagnostic and therapeutic armamentarium of the thoracic surgeon. It is superior to thoracotomy by virtue of incision size, early postoperative pain and many quality of life markers including length of hospital stay, convalescence, and pulmonary function.1 However, VATS poses limitations for excision of some lung nodules. Nodules that are not subpleural or large and firm enough to palpate with an instrument are inaccessible by VATS.8 When the indication is curative metastasectomy, VATS is inadequate in localisation and clearance of all nodules, due to inability
© 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2004.08.010
Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
Figure 1. Hand in chest palpating the lung through the subcostal-transdiaphragmatic incision. (Reprinted from Wright et al. [10].)
to palpate the lung.8 This necessitates further surgery for missed lesions, potentially losing control of the disease. The use of the hand as an adjunct for VATS was first described in 1999 by Mineo et al.,9 who used a subxiphoid approach. This solved many of the shortcomings of VATS, allowing the surgeon to introduce the hand into the pleural cavity from below the costal margin, whilst utilising the documented advantages of VATS. In our technique HATS10 (Fig. 1), a modified Kocher’s incision is made for the wrist with the fingers passed behind the costal margin in the extra-peritoneal plane to split the anterior diaphragmatic fibres under videoscopic control and enter the pleural cavity (Fig. 2). Advantages include increased manoeuvrability during resections compared to VATS, with tactile feedback improving depth perception and hand–eye co-ordination.10 The hand-assist incision allows
375
Figure 3. Application of an endoscopic stapler cutter for the excision of a lesion pinched up in hand. (Reprinted from Wright et al. [10].)
unprecedented freedom of movement of the endoscopic stapler used for resection and large specimens can be retrieved easily (Fig. 3). Resection of lesions missed on preoperative imaging, not found on VATS and deep lesions can be achieved with the facility for palpation.10,11 Minimal access techniques today demand critical evaluation in randomised controlled trials against established standards of open surgery.1–6 We studied early postoperative quality of life, including early postoperative pain, for HATS compared to open thoracotomy in a randomised prospective trial.
Methods The study was approved by the Human Research Ethics Committee at St. Vincent’s Hospital, Melbourne (HREC 82/01). The study was conducted as a randomised prospective trial. Patients referred to the Thoracic Care Centre at St. Vincent’s Hospital and St. Vincent’s and Mercy Private Hospital were recruited between October 2001 and August 2004. During this period, 52 patients were randomised to receive a HATS procedure (n = 26) or a limited thoracotomy (n = 26). Randomisation was computer generated and allocation was concealed until after consent was obtained.
Inclusion Criteria
Figure 2. Access into the pleural cavity through a split in the anterior diaphragmatic fibres. (Reprinted from Wright et al. [10].)
Eligible patients were stratified into two groups. The first group were patients with undiagnosed lung nodules less than 2 cm in diameter, at least 1 cm deep to the pleura with a normal bronchoscopy. Patients in the second group had established oligo-metastatic disease involving the lung, suitable for metastasectomy by wedge resection. A well-controlled primary malignancy and no
ORIGINAL ARTICLE
Heart Lung and Circulation 2004;13:374–378
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Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
extra-pulmonary disease detectable by Positron Emission Tomography (PET) scanning were also required.
Exclusion Criteria Patients with lesions easily resectable by VATS, those with large, central lesions, and those with prior needle biopsy were excluded. The latter criterion was intended to eliminate a possible variable for pleural recurrence.
Anaesthesia All subjects were given epidural anaesthesia to reflect our usual thoracotomy management (unless contraindicated) for a maximum of 5 days post-surgery or 24 h after removal of drainage tubes. Following this, routine ward analgesia including paracetamol, tramadol, oxycodone, nonsteroidal anti-inflammatory drugs and injected narcotics were provided as required.
Limited Posterolateral Thoracotomy An attempt was made to standardise the thoracotomy incision length to 12.5 cm, with extension if necessary. The posterior part of latissmus dorsi was divided; serratus anterior was dissected off the latissmus and spared. A 1-cm segment of the sixth rib was resected sub-periosteally. Intercostal closure was by continuous suture from fifth to sixth intercostal muscles while holding the ribs together by rib-approximator. Latissmus was repaired with a heavy absorbable suture.
Hand-assisted Thoracoscopic Surgery10 The patient was positioned by rotating the affected side between a half-lateral and full lateral position and protecting bony pressure points. Preparation and draping were applied to allow access to the ipsilateral hypochondrial region in addition to standard thoracotomy draping. HAND-ASSIST INCISION. A 7–8 cm incision (cm equal to glove size) was made 2 cm below and parallel to the costal margin and the rectus muscle divided (modified Kocher’s incision). Simultaneously, a port site was established in the seventh intercostal space at the anterior axillary line to allow introduction of a video-telescope as with VATS (Fig. 1).
The fingers were passed behind the costal margin, staying in the extra-peritoneal plane (if possible) deep to the posterior sheath, until the anterior fibres on the underside of the diaphragm are exposed. Under videoscopic control via the anterior port site, long artery forceps were pushed through the diaphragm from below and split in the line of the anterior diaphragmatic fibres radially near its periphery, minimizing the chance of damage to the radial branches of the phrenic nerve (Fig. 2). The hand then broke into the chest through the diaphragmatic split.
ENTRY TO THORACIC CAVITY.
PROCEDURE. With the lung collapsed, the entire lung was palpated. Adhesions were taken down by sweeping with the fingers or with diathermy through another VATS port. Once a target lesion was identified, it was presented to a VATS grasper or linear stapler cutter for excision (Fig. 3). Palpation ensured good margins. The specimen
Heart Lung and Circulation 2004;13:374–378
was placed in an endoscopic specimen bag and retrieved easily through the HATS incision. The diaphragmatic split was subsequently repaired from within the chest by endoscopic suturing or through the subcostal incision by pulling the split inferiorly with tissue forceps. CLOSURE. The anterior port site was used to place an intercostal chest drain. The rectus muscle was re-approximated with a heavy continuous absorbable suture. The skin was closed with a fine subcuticular suture.
Study Design and End-Points The primary end-point was early postoperative pain. Independent nursing staff carried out postoperative pain appraisal in the 24 h after epidural catheter removal using a standard 10-point visual analogue scale (where 0 represented no pain and 10 represented the worst possible pain). Scoring was performed each nursing shift and additionally when a patient requested analgesia. The worst pain score in the 24 h after removal of the epidural was recorded, intending to assess the unmasked pain of the operative incisions. Other markers (as part of a larger study of 60 patients) examined were length of hospital stay and change in pulmonary function, including change in forced expiratory volume in 1 second (FEV1) and diffusing lung capacity, as measured by spirometry done preoperatively and at 42 days postoperatively. Return to preoperative activities of daily living and work was also assessed using the SF12v2® quality of life questionnaire. Diaphragmatic function was assessed at 7 weeks by fluoroscopic screening.
Statistical Methods Data for all patients was analysed on an intention-to-treat basis. After stratification into diagnostic nodule and metastasectomy groups, analysis of differences between the two randomised groups for demographic and operative variables was performed. Continuous normally distributed data was expressed as mean ± standard deviation and non-normally distributed data as the median and range. The Fisher’s exact test for proportional data, the Mann–Whitney Rank Sum test for non-parametric data, and the Student’s two-sample t-test for normally distributed data were used for comparison of pain scores and change in FEV1 between the groups. p < 0.05 was considered statistically significant.
Results Demographic characteristics were similar between the two groups with stratification into undiagnosed nodule biopsies or metastasectomies (Table 1). Clear resection margins were reported in all patients. Extra lesions, undetected on preoperative imaging were found on manual lung palpation in 5 HATS patients and 4 thoracotomy patients. One HATS was converted to open thoracotomy due to pleural symphysis. The mean time of epidural cessation was similar in both groups (Table 2). Three patients did not have an epidural placed due to prior anticoagulation or technical difficulty.
Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
Table 1. Characteristics of Patients Undergoing HATS and Thoracotomy Thoracotomy (n = 26)
HATS (n = 26)
P Value
Gender (M/F) 16/10 17/9 NSa Age 50.0 (±18.4) 56.7 (±20.2) NSb Stratification to undiagnosed nodule (N) or metastasectomy (M) group N 7 9 NSa M 19 17 NSa Clear resection margins 26 26 NSa Extra lesions found on 4 5 NSa manual palpation NS: not significant. a
Fisher’s exact test.
b
Two sample t-test—data presented as mean ± standard deviation.
Early epidural removal or failure occurred in 8 HATS patients and 6 thoracotomy patients. Protocol breaches occurred when pain scores were not recorded for one HATS and one thoracotomy patient, leaving 50 patients for analysis. The worst pain score post-epidural removal was lower (3.8 versus 5.2, VAS, p = 0.04) after HATS compared to thoracotomy, a statistically significant difference (Table 2). Mean reduction in FEV1 postoperatively did not differ significantly between the groups (Table 2). No paradoxical diaphragm movement was seen in the HATS group, although four patients showed less movement than the contralateral hemidiaphragm. One patient in the thoracotomy group had phrenic palsy, due to a subsequent pleurectomy for his mesothelioma at another institution. The intercostal drainage catheter, a potential source of pain independent of the operative incision, was still in situ in 9 patients in the HATS group and 12 patients in the thoracotomy group when VAS scores were taken with no significant differences between groups (Table 2). Postoperative complications relevant to our study included one epidural abscess, 2 prolonged air leaks (>7 days) and 2 cases of persisting neuralgia at 7 weeks in thoracotomy patients. One prolonged air leak occurred in each group and one subcostal wound infection occurred in the HATS group.
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Discussion HATS has been demonstrated to be safe, practical and efficacious, accomplishing the same objectives as thoracotomy, with both being acceptable options for invasive lung nodule biopsy and pulmonary metastasectomy in our early experience.10–12 All patients in the HATS group underwent the subcostal access technique, except for one (the first HATS patient on trial) who underwent a subxiphoid-retrosternal technique similar to that published by Mineo et al.9 However we found this technique to have the disadvantage of pain from xiphisternectomy. Access for the hand was technically very difficult in those with a narrow costal margin and for posterior lower lobe lesions, causing discomfort for the surgeon, prompting the change to the subcostal trans-diaphragmatic approach.10 Various studies, particularly comparisons of laparoscopic and open procedures and specific to thoracic surgery, VATS and thoracotomy demonstrate reduced early postoperative pain associated with minimally invasive surgery.1–6,13 The significantly less pain recorded for HATS patients compared to thoracotomy patients after epidural removal correlates well with results of previous studies of early postoperative pain comparing open and endoscopic procedures.1–6 Respiratory function is a dependent variable of operative incision pain, splinting the chest and reducing diaphragmatic excursion, deep breathing and coughing, predisposing to infection and lung collapse.7 Change in these parameters, measured by change in FEV1 did not differ between the two groups (Table 2). There was no accessrelated functional diaphragmatic paralysis in any HATS or thoracotomy patients, emphasising the subcostal approach to be well tolerated, as supported by Clarke et al.12 Incomplete movement of the hemidiaphragm of the operated hemithorax in 4 HATS patients can be explained by subsequent organisation and fibrosis in the muscle repair site. We can conclude that, in addition to reduced postoperative pain, respiratory function is equivalent to that for thoracotomy patients. It should be noted that for thoracotomy patients in our study, the 12–13 cm skin and muscle incision made was a relatively limited one, aimed at minimizing morbidity. Given pain is a function of incision size,6 this would theo-
Table 2. Early Postoperative Pain after Epidural Removal and Percentage Change in Respiratory Function Day (after operation) of epidural removal/failure Early removal/failure of epidural (<5 days after operation and prior to intercostal catheter removal) Worst pain score in 24 h after epidural removal Intercostal catheter in situ after epidural removal % change in FEV1 (postoperatively) NS: not significant. a
Mann–Whitney rank sum test.
b
Fisher’s exact test.
c
Two sample t-test—data presented as mean ± standard deviation.
Thoracotomy (n = 26)
HATS (n = 26)
P Value
3 (0–6) 6
3 (0–6) 8
NSa NSb
5.2 (±2.2) 12 18.1 ± 19.0
3.8 (±2.4) 9 18.8 ± 9.9
0.04c NSb NSc
ORIGINAL ARTICLE
Heart Lung and Circulation 2004;13:374–378
ORIGINAL ARTICLE
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Paiva and Wright Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy
retically reduce early postoperative pain for thoracotomy patients, further highlighting the benefits associated with HATS. Late postoperative intercostal neuralgia in two thoracotomy patients was evidence of intercostal nerve injury from rib-spreading or closure, manoeuvres avoided in HATS. Early removal or failure of the epidural catheter, which could result in increased pain intensity at time of scoring, occurred in 8 HATS patients and 6 in the thoracotomy group (Table 2). HATS cases where the epidural catheter failed did not subsequently require epidural analgesia, corroborating our hypothesis that this form of analgesia may not be needed after HATS. These limitations do not pertain merely to study conditions, rather reflecting the vagaries of actual clinical practice. Throughout the trial, an epidural catheter was routinely placed to mirror thoracotomy management and standardise trial conditions. However, non-trial HATS cases have not required epidural analgesia, and the authors believe this will not be not be necessary in our routine practice. One quarter of patients had early failure of their epidural by our criteria, despite management in a specialist thoracic unit. Some surgical units do not even use epidural analgesia for thoracotomy. Therefore, our finding of reduced pain in its absence is an important clinical benefit.
Conclusion This randomised study of HATS compared to thoracotomy demonstrated significantly lower postoperative pain for HATS after cessation of epidural analgesia. These results suggest this form of analgesia may not be required, reducing the management complexity, complications and increased hospital stay associated with its use. Whilst we must wait for longer term oncological follow-up in the metastasectomy group, the HATS incision could now be considered the optimal access for diagnosing deep nodules that require excisional biopsy. The authors acknowledge Tyco Healthcare for funding the medical illustrations and The University of Melbourne, Faculty of Medicine for supporting this work. We are grateful to Dr. Dayan Chandrasekara MBBS, surgical registrar from St. Vincent’s Hospital, Melbourne, for his assistance in setting up the Access database used for follow-up during this study.
Heart Lung and Circulation 2004;13:374–378
References 1. Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362–5. 2. Slim K, Bousquet, Kwiatkowski F, Pezet D, Chipponi J. Analysis of randomised controlled trials in laparoscopic surgery. Br J Surg 1997;84:610–4. 3. Nguyen NT, Rosenquist J, Arango A, Cole CJ, Lee SJ, et al. Laparoscopic versus open gastric bypass: a randomised study of outcomes, quality of life and costs. Ann Surg 2001;234: 279–91. 4. Hendolin HI, Paakonen M, Alhava EM, Tarvainen R, Kemppinen T, Lahtinen P. Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function, and stress response. Eur J Surg 2000;166(5):394–9. 5. Landreneau RJ, Wiechman RJ, Hazelrigg SR, Santucci TS, Boley TM, Magee MJ, et al. Success of laparoscopic fundoplication for gastrooesophageal reflux disease. Ann Thorac Surg 1998;66:1886–92. 6. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285–9. 7. Nakata M, Hideyuki S, Yokoyama N, Kurita A, Takiyama W, Shigemistsu T. Pulmonary function after lobectomy: videoassisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2000;70:938–41. 8. McCormack PM, Bains MS, Begg CB, Burt ME. Role of videoassisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg 1996;62:213–6. 9. Mineo TC, Pompeo E, Ambrogi V, Pistolese C. Video-assisted approach for transxiphoid bilateral lung metastasectomy. Ann Thorac Surg 1996;67:1808–10. 10. Wright GM, Clarke CP, Paiva JM. Hand-assisted thoracoscopic surgery. Ann Thorac Surg 2003;75:1665–7. 11. Wright GM, Long H. Hand-assist VATS: minimum invasion, maximum return. Aust NZ J Surg 2001;71(Suppl.):A17. 12. Clarke CP, Ali A, Moshinsky R, Seevanayagam S, Raman J. The effect of hand-assisted thoracoscopic surgery (HATS) for pulmonary secondaries does not compromise diaphragmatic function. Heart Lung Circ 2001;10:39. 13. Sanatmbrogio L, Nosotti M, Bellavati N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59:868–70.