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One hundred consecutive patients undergoing video-assisted thoracic operations
One Hundred Consecutive Patients Undergoing Video-Assisted Thoracic Operations Ralph J. Lewis, MD, Robert J. Caccavale, MD, Glenn E. Sisler, MD, and James W. Mackenzie, MD Section of General Thoracic Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey
Video-assisted thoracic surgery is a new modality that allows visualization of and access to the intrathoracic organs without making a thoracotomy incision. One hundred consecutive patients underwent 113 thoracic procedures using this technique. Eight wedge resections for metastatic lesions, 6 pericardial windows, 1 bronchogenic cystectomy, 4 explorations of the aortopulmonary window, 1 decortication, 5 pleural scleroses, 8 bullous ablations, 25 lung biopsies, 19 wedge resections for carcinoma, 9 explorations of the thorax, 3 lobectomies, 1 esophageal cystectomy, 14 wedge resections for
benign lesions, 4 pleurectomies, 1 excision of a neurogenic tumor, 3 mediastinal explorations, and 1 imaged axillary dissection were performed. There was no mortality. Ten patients had complications from which they recovered completely. Patients undergoing videoassisted thoracic operations seem to have reduced postoperative pain, shorter hospitalization, and quicker recovery times. currently, this new modality appears to have beneficial value for patients; however, only further experience will determine its true merits. (Ann Thorac Surg 1992;54:421-6)
U
Four patients absolutely refused a formal thoracotomy, but did accept video-assisted thoracic surgery. Every other patient in this series was informed that a conventional thoracotomy might be necessary. In fact, they were given the option of having a thoracotomy directly or having an attempt made to operate using video-assisted thoracic surgery. Each patient elected to try video-assisted thoracic surgery first; nevertheless, they all signed an operative permit granting permission for a formal thoracotomy.
ntil recently, manipulation and resection of intrathoracic structures have been either by thoracoscopy [l] or thoracotomy . Thoracoscopy provides limited access and tunnellike visualization; therefore, only the simplest of diagnostic and therapeutic procedures can be performed [2-51. Although major operations can be done satisfactorily with a thoracotomy, definite morbidity results from the incision, which causes postoperative pain and malfunction of the chest wall. With the development of solid state systems and micro cameras during the early 1980s, projection of anatomical images on a screen became a reality. Recently, this technique has been used in the thoracic cavity with gratifying results [6, 71. Video-assisted thoracic surgery not only permits complex intrathoracic operations to be performed, but avoids making the traditional thoracotomy incision with its inherent morbidity. Postoperative pain is markedly reduced, intensive medical services are minimized, hospitalization is shortened, and recovery time is decreased.
Material and Methods Pa tients One hundred patients underwent a variety of videoassisted thoracic surgical procedures for numerous conditions (Fig 1).There were 49 male and 51 female patients. The average age was 61 years with the youngest being 17 years and the oldest 85 years. Presented at the Twenty-eighth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Feb 3-5, 1992. Address reprint requests to Dr Lewis, 185 Livingston Ave, New Brunswick, NJ 08901.
0 1992 by The Society of Thoracic Surgeons
Technique One-lung ventilation is employed in all patients. A leftsided Mallinckrodt broncho-cath tube (Critical Care, St. Louis, MO) was placed in the majority of patients. In the remainder, a Phycon Univent tube (Vitaid, Lewiston, NY) was used. All endotracheal tubes were accurately and quickly positioned using a flexible pediatric bronchoscope (Fig 2). After the tube is secured, the patient is turned to a lateral decubitus position. A pulse oximeter, rather than an arterial line, is satisfactory in this group of patients. The operative lung is allowed to deflate as the chest is being prepared and draped. In some patients, to maintain a satisfactory 0, saturation, a high concentration of inspired oxygen should be administered, arteriovenous shunting can be avoided by maintaining complete lung deflation, and continuous positive airway pressure should be applied to the collapsed lung. Video optics consist of a 10-mm, 0-degree panoview diagnostic telescope (Richard Wolf Medical Instruments Corporation, Rosemont, IL), a camera and camera head, Dyonics model 7600 Dyonics Auto-Brite Illuminator I1 (Dyonics, Inc, Andover, MA), and a medical grade video monitor. The video monitor is positioned so that the diagnostic tele0003-4975/92/$5.00
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Ann Thorac Surg 1992;54:4214
LEWIS ET AL VIDEO-ASSISTED THORACIC SURGERY
Fig 1. Conditions treated by imaged thoracic surgery in 100 patients.
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Meta- Benign Pneumo Pleural Diffuse Pri- Bullous Peri- Mediasstatic Lung Thorax Effu- Lung mary Dis- cardial tinal Lung Nodule (Recur- sion Disease Pul ease Effusion Mass Nodule rent) Malig
scope is perpendicular to the monitor (Fig 3). The scope is brought to body temperature by immersing it in warm saline sollution, which reduces lens fogging. Depending upon the type of operation, usually three incisions ranging from 15 mm to 35 mm are necessary.
Thor Outlet Syndrome
One incision is made in the sixth or seventh intercostal space in the midaxillary line for insertion of the scope, and the second and third incisions are made in the third to the sixth intercostal space along the anterior and posterior axillary lines (Fig 4). The latter two incisions are used for insertion and manipulation of instruments. At no time is pressure applied to the ribs, nor are they distracted in any way. After digital exploration of the thoracic cavity for adhesions and to verify lung deflation, the scope is inserted. Using conventional thoracic surgical instrumentation, staplers (Ethicon, Inc, Cincinnati, OH), Argon Beam Coagulator (Birtcher Medical Systems, Irvine, CA), and cautery, various procedures can be performed. Upon completion of the procedure, the chest is irrigated with saline solution and the lung is allowed to inflate. Each staple line is carefully observed for bleeding and air leaks. One or two chest tubes are inserted into the thorax. Silastic (Dow Corning, Midland, MI) or rubber tubes seem to be more comfortable than rigid plastic tubes. Patients are usually extubated in the operating room or within a short period of time in the recovery room. Most of these patients can be sent to floor care or to an intermediate care unit. Elderly or debilitated patients are placed in the intensive care unit overnight.
Results
Resectable Primary Pulmonary Malignancies
Fig 2 . Double-lumen endotracheal tube positioned using pediatric flexible bronchscope.
Twenty-two patients had primary lung malignancies. Each patient had a computed tomographic scan of the chest and a bronchoscopy. Cervical mediastinoscopy was performed selectively in 19 patients in whom the computed tomographic scan suggested mediastinal lymphadenopathy greater than 1 cm. Nodes recovered and sent for frozen section in 16 patients were negative for malig-
LEWISETAL VIDEO-ASSISTED THORACIC SURGERY
Ann Thnrac Surg 1992;54:421-6
SURGEON
ANE~THESIA
nancy. All lesions were located in the periphery of the lung and were less than 3 cm in diameter. After wedge resection by video-assisted thoracic surgery and confirmation of malignancy by frozen section, biopsy was performed on any lymph nodes identified in the mediastinum, hilum, or fissure. In this entire group of patients, every node found and subjected to biopsy was negative for malignancy on frozen section. There were 12 patients in whom wedge resection was accepted as a curative procedure. Of these, 4 had squamous cell carcinoma, 1had bronchoalveolar carcinoma, 6 had adenocarcinoma, and 1 had lymphoma. Seven patients went on to thoracotomy and open lobectomy after a video-assisted thoracic surgical wedge resection because the margins were considered to be inade-
423
Fig 3 . Position and location of patient, operating personnel, and equipment during imaged thoracic operation.
quate. In each of these patients, no residual tumor was found either in the lung or lymph nodes. Three patients, 2 with bronchoalveolar carcinoma and 1 with squamous cell carcinoma, underwent lobectomy using videoassisted thoracic surgery.
Benign Lesions Using video-assisted thoracic surgery, 14 patients were found to have benign coin lesions after resection. Seven patients had a mediastinoscopy because of preoperative findings suspicious for malignancy. Obviously, all of these lymph nodes were negative for malignancy. There were 5 hamartomas, 2 granulomas, 1 histoplasmoma, 1 pulmonary cyst, 1 fibroma secondary to radiation, 1 blastomycosis, and 3 caseating granulomas.
Fig 4. Incisions for scope and instruments.
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Ann Thorac Surg 1992;54:421-6
the left chest and one through the right. Four patients had an inflammatory process and 2 had adenocarcinoma. All patients tolerated the procedure, and there has been no recurrence of effusion.
Recurrent Pneumothorax Four patients with recurrent spontaneous pneumothoraces underwent apical bullectomy using a stapler and bullous ablation with the Argon Beam Coagulator. Each patient had an accompanying parietal pleurectomy from the apex of the chest to the fifth rib.
Aortopulmonary Window
Fig 5. Preoperative chest roentgenogram.
MediastI num Three mediastinal lesions were treated. Two middle mediastinal cysts, one bronchogenic and one esophageal, were resected. The cysts were opened, and biopsy specimens from the walls were taken and sent for frozen section. The fluid contents were negative for bacteria on Gram stain, and these results were eventually confirmed by culture. Because no malignancy or infection was found in either case, each cyst was excised down to a 1-cm adherent basilar segment. The residual mucosa was cauterized using the Argon Beam Coagulator. Both patients made an uneventful recovery. A ganglioneuroma of the posterior mediastinum was resected. The Argon Beam Coagulator was effective for hemostasis. The tumor measured 5 cm in diameter and was removed in a sterile plastic bag (Fig 5).
Metastatic Lesions Eight patients with a variety of cancers (1bladder, 3 colon, 3 melanomas, 1 malignant paraganglioneuroma) presented with pulmonary nodules. Resection using videoassisted thoracic surgery confirmed metastatic carcinoma in all patients.
Difftlse Pulmonary Disease Fifteen patients with diffuse pulmonary disease underwent lung biopsy. At operation, the entire lung, mediastinum, and chest wall were surveyed, and two areas, representative of lung pathology, were excised. Interstitial fibrosis was diagnosed in 6 patients, hypersensitivity pneumonia in 4, diffuse necrotizing granulomata in 2, and sarcoid, amyloidosis, and bronchiolitis obliterans in 1 patient each.
Pericardi um Partial yericardiectomy was performed in 6 patients. Indications for operation included impending tamponade, recurrent pericardial effusion, and effusion of unknown cause. Five procedures were performed through
Four patients underwent exploration and biopsy of aortopulmonary window lymph nodes suspected of being malignant. One patient had melanoma, 1 squamous cell carcinoma, and 1 adenocarcinoma. One patient had a computed tomographic scan that suggested a large aortopulmonary window mass; however, no lesion could be found at video-assisted thoracic operation. This patient subsequently underwent a curative pneumonectomy, which confirmed the absence of any metastatic disease.
Pleural Effusions Five patients had recurrent malignant pleural effusions that did not respond to prolonged tube drainage and installation of tetracycline or bleomycin. In each patient, the diffusely invaded parietal pleura was cauterized using the Argon Beam Coagulator. Presently, no effusion has recurred. One patient had an inflammatory process that was decorticated. An empyema was avoided.
Bullous Disease Massive bullae were ablated and coalesced in 4 patients with advanced disease using the Argon Beam Coagulator and surgical staplers.
Exploratory Thoracotomy Ten patients underwent a video-assisted thoracic surgical exploration. Two patients had preoperative chemotherapy before operation because of extensive tumors. Complete evaluation by video-assisted thoracic surgery, in these patients, did not reveal any contraindications to resection, and both had a thoracotomy and a potentially curative operation for adenocarcinoma. One patient had a pneumonectomy and 1 had a lobectomy. After a negative video-assisted thoracic operation, 3 other patients underwent a thoracotomy and lobectomy for primary adenocarcinoma. Four patients were deemed to have unresectable disease because of invasive metastatic carcinoma, and a thoracotomy was avoided in each of these patients. One patient had a diffuse lymphoma.
Esophagus Before and after transhiatal esophagectomy in 3 patients, the mediastinum was visualized. The areas of tumor invasion, adhesions, pleural tears, or bleeding resulting from blunt dissection were evaluated. Because of motion with respiration and a natural tendency for the mediastinal walls to collapse, focusing and visualization can be
LEWIS ET AL VIDEO-ASSISTED THORACIC SURGERY
Ann Thorac Surg 1992;54421-6
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Fig 6 . Complications after imaged thoracic operations. 654-
32-
10Air
Leak
em bolus^
Pulmonary Edema
Operative Bleeding
compromised in this area. Carbon dioxide insufflation can assist with visualization.
First Rib The scope was placed deep in the axilla during first rib resection and used to project the vascular and muscular anatomy onto the monitor. This facilitated visualization of the anatomical dissection by all members of the operating team.
Complications There has been no mortality. There were ten complications (Fig 6). Six patients had air leaks lasting from 7 to 10 days. Three of these patients had ablation of massive bullous disease with the Argon Beam Coagulator and an accompanying lung biopsy. Another patient was currently on maximum chemotherapy and had resection of a metastatic nodule, whereas another had diffuse, advanced pulmonary emphysema with adhesions covering the aortopulmonary window, which was diffusely invaded by carcinoma. The sixth patient was a 32-year-old man who underwent a large wedge resection on the ovoid surface of the lung for a metastatic lesion. At operation, it was determined that an air leak was more acceptable, for this patient, than the loss of a lobe for metastatic disease. A 41-year-old obese woman, who underwent a resection of a histoplasmoma, was preparing to leave the hospital on her third postoperative day when pleuritic chest pain and dyspnea developed. Lung scan was compatible with a pulmonary embolus. Our second patient, in the entire series, required an urgent thoracotomy for bleeding when an Endoloop (Ethicon, Somerville, NJ) slipped from the lung parenchyma. Staplers have been used since that time, with excellent hemostasis. Rapid drainage of a massive malignant pleural effusion in a patient with a double-lumen tube and a deflated lung resulted in reexpansion pulmonary edema. One patient had a superficial wound infection that resolved in 1 week without drainage or antibiotics. All of these patients had a complete and uneventful recovery.
Infection
Contraindications Two situations exist that prevent the use of video-assisted thoracic surgery: the inability to physiologically tolerate one-lung anesthesia determined by unacceptably low oxygen saturations and complete obliteration of the pleural space due to dense adhesions.
Comment Video-assisted thoracic surgery, at this time, appears to have expanding applications in the field of general thoracic surgery [8, 91. It requires a methodical and well thought out approach, as well as extreme patience on the part of the thoracic surgeon. There are times that videoassisted thoracic operations can be more tedious and time consuming than open thoracotomy. Only the considerable patient benefits occurring postoperatively make these annoyances acceptable. In some cases, however, the operation can be accomplished more easily and quickly with video-assisted thoracic surgery than when a thoracotomy is performed. Video-assisted thoracic surgery has also been effective for resecting metastatic nodules, treating recurrent malignant effusions, and creating pericardial windows. Metastatic nodules can be easily localized and resected, confirming the suspected primary lesion. In our small series, the Argon Beam Coagulator has been effective in reducing the recurrence of recalcitrant malignant pleural effusions. Although it is too early to determine its true value, it does seem to have some merit. Approaching the pericardium from the right side has made partial pericardiectomy a much easier procedure. The pericardial fat pad is generally smaller, and the pericardial sac protrudes minimally into the right thorax, even when a large effusion is present, resulting in more working space with improved visibility. Presently, however, video-assisted thoracic surgery should be used only in a prudent and highly selective manner for primary malignant disease of the lung. Wedge
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LEWIS ET AL VIDEO-ASSISTED THORACIC SURGERY
resection for peripheral T1 NO lesions, when generous free margins can be obtained, may be therapeutic in a specific group of patients such as those with compromised pulmonary function, who would not tolerate thoracotomy [10-12]. Lesions on the broad ovoid surfaces, deep in the fissures, or on the diaphragmatic surfaces of the lung can present difficulties in obtaining adequate margins. Circumspection is required when excising from these areas. Ultimately, in all patients with a primary malignancy, it is mandatory that the lesion be resected completely. In many cases, traditional and conventional techniques will be necessary. In this group of patients, when margins were satisfactory, wedge resection was accepted as a curative procedure. If we believed a compromised margin resulted from the wedge, a traditional thoracotomy and lobectomy was performed. To our surprise, none of these patients had residual tumor on microscopic examination. Three patients with malignancy underwent a lobectomy using only the video-assisted thoracic surgical technique. When video-assisted thoracic operations are performed, major muscles are not divided, ribs are not spread, dislocated, or broken, and ligaments, nerves, and blood vessels are not severely damaged. We believe that avoidance of these adverse methods will lead to an accelerated recovery. The number of intercostal incisions or even the length of the incisions do not seem to contribute to postoperative disability or pain so long as the rib cage is not traumatized and remains intact. Attempts to deflate the operative lung by insufflation of CO, through airtight ports creating an iatrogenic pneumothorax in patients with compromised pulmonary reserve could have serious consequences. We avoid this technique and prefer the safety of a double-lumen tube. Video-assisted thoracic surgery has been remarkable in reducing the severity and duration of postoperative pain and allows patients to move and ambulate without difficulty the night of operation. Only small doses of analgesics have been needed, and most patients no longer require admission to the intensive care center. Hospitalization has been shortened for many patients, and most of these patients have returned to preoperative levels of activity after anywhere from 10 to 14 days. Video-assisted thoracic surgery has been supported with fervor by pulmonologists, oncologists, and internists. Patients who were not referred to a thoracic surgeon, when a thoracotomy was the only technique available, are now being referred with enthusiasm. Young, active patients and elderly, debilitated patients, who have been known to refuse a thoracotomy in the past, are now readily accepting video-assisted thoracic surgery. A new patient population, previously unknown to thoracic surgeons, continues to evolve and grow. This is not a new surgical technique, but rather a different approach using standard, basic principles of thoracic surgery. Trained thoracic surgeons have quickly and easily mastered this new modality and have selectively used it as another available option for performing thoracic surgical procedures. When performing video-assisted thoracic operations, the technique should never compromise the intended
Ann Thorac Surg 1992;54:4214
procedure. If there is difficulty in performing the operation, do what you do best, open the thorax. Do not allow the ego to usurp good common sense. There should be no feeling of shame or defeat if the chest has to be opened. This is not minor surgery, but rather major, complex intrathoracic surgery using minimally invasive techniques. For this reason, only trained thoracic surgeons, who have the skill, expertise, and judgment to know when and how to open the chest, should perform this technique. Video-assisted thoracic surgery can be beneficial to patients, and it can bring a new vigor to the entire field of general thoracic surgery. The potential seems unlimited, but if these goals are to be realized, all thoracic surgeons must proceed cautiously, thoughtfully, and with the utmost concern for the well-being of their patients. Although procedures such as lobectomy and pneumonectomy are possible, even at this early date, this should not be the main objective of this technique. At this time, traditional open techniques should be used for most major resections. In the future, as optics, instrumentation, and techniques improve, these major resectional procedures will become safer and more compatible with the technique of video-assisted thoracic surgery. Video-assisted thoracic surgery is still in its embryonic stages of development. Nevertheless, many procedures can be performed presently that would have required a formal thoracotomy in the recent past. Patient comfort and recovery have been gratifying. If appropriately used, video-assisted thoracic surgery can have a significant and beneficial effect for many of our patients. Only time and further experience will determine the true merits of this technique.
References 1. JacobaeusHC. Practical importance of thoracoscopy of chest.
Surg Gynecol Obstet 1921;32:49>500. 2. Lewis RJ, Kunderman PJ, Sisler GE, Mackenzie JW. Direct diagnostic thoracoscopy. Ann Thorac Surg 1976;21:536-9. 3. Lewis RH, Sisler GE, Mackenzie JW. Diffuse, mixed malignant pleural mesothelioma. Ann Thoracic Surg 1981;31: 53-60. 4. Miller JI, Hatcher CR JR. Thoracoscopy: a useful tool in the diagnosis of thoracic disease. Ann Thorac Surg 1978;26: 6&72. 5. Oakes DD, Sherck JP, Brodsky JB, Mark JB. Therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1984;87:269-73. 6. Lewis RH, Caccavale RH, Sisler GE. Special report: videoendoscopic thoracic surgery. N J Med 1991;88:473-5. 7. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651-3. 8. Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102: 721-3. 9. Landreneau RH, Herlan DB, Johnson JA, Boley TM, Nawarawong W, Ferson P. Thoracoscopic neodymium:yttriumaluminum garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991;52:1176-8. 10. Ginsberg RH. Limited resection in the treatment of stage I non-small cell lung cancer: an overview. Chest 1989;96: 50’3-1s. 11. Peters RM. The role of limited resection in carcinoma of the lung. Am J Surg 1982;143:706-10. 12. Pastorino U, Valente M, Bedini V, et al. Limited resection for stage I cancer. Eur J Surg Oncol 1991;1742-6.
Video-assisted thoracic surgery is a new modality that allows visualization of and access to the intrathoracic organs without making a thoracotomy incision. One hundred consecutive patients underwent 113 thoracic procedures using this technique. Eight wedge resections for metastatic lesions, 6 pericardial windows, 1 bronchogenic cystectomy, 4 explorations of the aortopulmonary window, 1 decortication, 5 pleural scleroses, 8 bullous ablations, 25 lung biopsies, 19 wedge resections for carcinoma, 9 explorations of the thorax, 3 lobectomies, 1 esophageal cystectomy, 14 wedge resections for
benign lesions, 4 pleurectomies, 1 excision of a neurogenic tumor, 3 mediastinal explorations, and 1 imaged axillary dissection were performed. There was no mortality. Ten patients had complications from which they recovered completely. Patients undergoing videoassisted thoracic operations seem to have reduced postoperative pain, shorter hospitalization, and quicker recovery times. currently, this new modality appears to have beneficial value for patients; however, only further experience will determine its true merits. (Ann Thorac Surg 1992;54:421-6)
U
Four patients absolutely refused a formal thoracotomy, but did accept video-assisted thoracic surgery. Every other patient in this series was informed that a conventional thoracotomy might be necessary. In fact, they were given the option of having a thoracotomy directly or having an attempt made to operate using video-assisted thoracic surgery. Each patient elected to try video-assisted thoracic surgery first; nevertheless, they all signed an operative permit granting permission for a formal thoracotomy.
ntil recently, manipulation and resection of intrathoracic structures have been either by thoracoscopy [l] or thoracotomy . Thoracoscopy provides limited access and tunnellike visualization; therefore, only the simplest of diagnostic and therapeutic procedures can be performed [2-51. Although major operations can be done satisfactorily with a thoracotomy, definite morbidity results from the incision, which causes postoperative pain and malfunction of the chest wall. With the development of solid state systems and micro cameras during the early 1980s, projection of anatomical images on a screen became a reality. Recently, this technique has been used in the thoracic cavity with gratifying results [6, 71. Video-assisted thoracic surgery not only permits complex intrathoracic operations to be performed, but avoids making the traditional thoracotomy incision with its inherent morbidity. Postoperative pain is markedly reduced, intensive medical services are minimized, hospitalization is shortened, and recovery time is decreased.
Material and Methods Pa tients One hundred patients underwent a variety of videoassisted thoracic surgical procedures for numerous conditions (Fig 1).There were 49 male and 51 female patients. The average age was 61 years with the youngest being 17 years and the oldest 85 years. Presented at the Twenty-eighth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Feb 3-5, 1992. Address reprint requests to Dr Lewis, 185 Livingston Ave, New Brunswick, NJ 08901.
0 1992 by The Society of Thoracic Surgeons
Technique One-lung ventilation is employed in all patients. A leftsided Mallinckrodt broncho-cath tube (Critical Care, St. Louis, MO) was placed in the majority of patients. In the remainder, a Phycon Univent tube (Vitaid, Lewiston, NY) was used. All endotracheal tubes were accurately and quickly positioned using a flexible pediatric bronchoscope (Fig 2). After the tube is secured, the patient is turned to a lateral decubitus position. A pulse oximeter, rather than an arterial line, is satisfactory in this group of patients. The operative lung is allowed to deflate as the chest is being prepared and draped. In some patients, to maintain a satisfactory 0, saturation, a high concentration of inspired oxygen should be administered, arteriovenous shunting can be avoided by maintaining complete lung deflation, and continuous positive airway pressure should be applied to the collapsed lung. Video optics consist of a 10-mm, 0-degree panoview diagnostic telescope (Richard Wolf Medical Instruments Corporation, Rosemont, IL), a camera and camera head, Dyonics model 7600 Dyonics Auto-Brite Illuminator I1 (Dyonics, Inc, Andover, MA), and a medical grade video monitor. The video monitor is positioned so that the diagnostic tele0003-4975/92/$5.00
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LEWIS ET AL VIDEO-ASSISTED THORACIC SURGERY
Fig 1. Conditions treated by imaged thoracic surgery in 100 patients.
35
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I
Meta- Benign Pneumo Pleural Diffuse Pri- Bullous Peri- Mediasstatic Lung Thorax Effu- Lung mary Dis- cardial tinal Lung Nodule (Recur- sion Disease Pul ease Effusion Mass Nodule rent) Malig
scope is perpendicular to the monitor (Fig 3). The scope is brought to body temperature by immersing it in warm saline sollution, which reduces lens fogging. Depending upon the type of operation, usually three incisions ranging from 15 mm to 35 mm are necessary.
Thor Outlet Syndrome
One incision is made in the sixth or seventh intercostal space in the midaxillary line for insertion of the scope, and the second and third incisions are made in the third to the sixth intercostal space along the anterior and posterior axillary lines (Fig 4). The latter two incisions are used for insertion and manipulation of instruments. At no time is pressure applied to the ribs, nor are they distracted in any way. After digital exploration of the thoracic cavity for adhesions and to verify lung deflation, the scope is inserted. Using conventional thoracic surgical instrumentation, staplers (Ethicon, Inc, Cincinnati, OH), Argon Beam Coagulator (Birtcher Medical Systems, Irvine, CA), and cautery, various procedures can be performed. Upon completion of the procedure, the chest is irrigated with saline solution and the lung is allowed to inflate. Each staple line is carefully observed for bleeding and air leaks. One or two chest tubes are inserted into the thorax. Silastic (Dow Corning, Midland, MI) or rubber tubes seem to be more comfortable than rigid plastic tubes. Patients are usually extubated in the operating room or within a short period of time in the recovery room. Most of these patients can be sent to floor care or to an intermediate care unit. Elderly or debilitated patients are placed in the intensive care unit overnight.
Results
Resectable Primary Pulmonary Malignancies
Fig 2 . Double-lumen endotracheal tube positioned using pediatric flexible bronchscope.
Twenty-two patients had primary lung malignancies. Each patient had a computed tomographic scan of the chest and a bronchoscopy. Cervical mediastinoscopy was performed selectively in 19 patients in whom the computed tomographic scan suggested mediastinal lymphadenopathy greater than 1 cm. Nodes recovered and sent for frozen section in 16 patients were negative for malig-
LEWISETAL VIDEO-ASSISTED THORACIC SURGERY
Ann Thnrac Surg 1992;54:421-6
SURGEON
ANE~THESIA
nancy. All lesions were located in the periphery of the lung and were less than 3 cm in diameter. After wedge resection by video-assisted thoracic surgery and confirmation of malignancy by frozen section, biopsy was performed on any lymph nodes identified in the mediastinum, hilum, or fissure. In this entire group of patients, every node found and subjected to biopsy was negative for malignancy on frozen section. There were 12 patients in whom wedge resection was accepted as a curative procedure. Of these, 4 had squamous cell carcinoma, 1had bronchoalveolar carcinoma, 6 had adenocarcinoma, and 1 had lymphoma. Seven patients went on to thoracotomy and open lobectomy after a video-assisted thoracic surgical wedge resection because the margins were considered to be inade-
423
Fig 3 . Position and location of patient, operating personnel, and equipment during imaged thoracic operation.
quate. In each of these patients, no residual tumor was found either in the lung or lymph nodes. Three patients, 2 with bronchoalveolar carcinoma and 1 with squamous cell carcinoma, underwent lobectomy using videoassisted thoracic surgery.
Benign Lesions Using video-assisted thoracic surgery, 14 patients were found to have benign coin lesions after resection. Seven patients had a mediastinoscopy because of preoperative findings suspicious for malignancy. Obviously, all of these lymph nodes were negative for malignancy. There were 5 hamartomas, 2 granulomas, 1 histoplasmoma, 1 pulmonary cyst, 1 fibroma secondary to radiation, 1 blastomycosis, and 3 caseating granulomas.
Fig 4. Incisions for scope and instruments.
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the left chest and one through the right. Four patients had an inflammatory process and 2 had adenocarcinoma. All patients tolerated the procedure, and there has been no recurrence of effusion.
Recurrent Pneumothorax Four patients with recurrent spontaneous pneumothoraces underwent apical bullectomy using a stapler and bullous ablation with the Argon Beam Coagulator. Each patient had an accompanying parietal pleurectomy from the apex of the chest to the fifth rib.
Aortopulmonary Window
Fig 5. Preoperative chest roentgenogram.
MediastI num Three mediastinal lesions were treated. Two middle mediastinal cysts, one bronchogenic and one esophageal, were resected. The cysts were opened, and biopsy specimens from the walls were taken and sent for frozen section. The fluid contents were negative for bacteria on Gram stain, and these results were eventually confirmed by culture. Because no malignancy or infection was found in either case, each cyst was excised down to a 1-cm adherent basilar segment. The residual mucosa was cauterized using the Argon Beam Coagulator. Both patients made an uneventful recovery. A ganglioneuroma of the posterior mediastinum was resected. The Argon Beam Coagulator was effective for hemostasis. The tumor measured 5 cm in diameter and was removed in a sterile plastic bag (Fig 5).
Metastatic Lesions Eight patients with a variety of cancers (1bladder, 3 colon, 3 melanomas, 1 malignant paraganglioneuroma) presented with pulmonary nodules. Resection using videoassisted thoracic surgery confirmed metastatic carcinoma in all patients.
Difftlse Pulmonary Disease Fifteen patients with diffuse pulmonary disease underwent lung biopsy. At operation, the entire lung, mediastinum, and chest wall were surveyed, and two areas, representative of lung pathology, were excised. Interstitial fibrosis was diagnosed in 6 patients, hypersensitivity pneumonia in 4, diffuse necrotizing granulomata in 2, and sarcoid, amyloidosis, and bronchiolitis obliterans in 1 patient each.
Pericardi um Partial yericardiectomy was performed in 6 patients. Indications for operation included impending tamponade, recurrent pericardial effusion, and effusion of unknown cause. Five procedures were performed through
Four patients underwent exploration and biopsy of aortopulmonary window lymph nodes suspected of being malignant. One patient had melanoma, 1 squamous cell carcinoma, and 1 adenocarcinoma. One patient had a computed tomographic scan that suggested a large aortopulmonary window mass; however, no lesion could be found at video-assisted thoracic operation. This patient subsequently underwent a curative pneumonectomy, which confirmed the absence of any metastatic disease.
Pleural Effusions Five patients had recurrent malignant pleural effusions that did not respond to prolonged tube drainage and installation of tetracycline or bleomycin. In each patient, the diffusely invaded parietal pleura was cauterized using the Argon Beam Coagulator. Presently, no effusion has recurred. One patient had an inflammatory process that was decorticated. An empyema was avoided.
Bullous Disease Massive bullae were ablated and coalesced in 4 patients with advanced disease using the Argon Beam Coagulator and surgical staplers.
Exploratory Thoracotomy Ten patients underwent a video-assisted thoracic surgical exploration. Two patients had preoperative chemotherapy before operation because of extensive tumors. Complete evaluation by video-assisted thoracic surgery, in these patients, did not reveal any contraindications to resection, and both had a thoracotomy and a potentially curative operation for adenocarcinoma. One patient had a pneumonectomy and 1 had a lobectomy. After a negative video-assisted thoracic operation, 3 other patients underwent a thoracotomy and lobectomy for primary adenocarcinoma. Four patients were deemed to have unresectable disease because of invasive metastatic carcinoma, and a thoracotomy was avoided in each of these patients. One patient had a diffuse lymphoma.
Esophagus Before and after transhiatal esophagectomy in 3 patients, the mediastinum was visualized. The areas of tumor invasion, adhesions, pleural tears, or bleeding resulting from blunt dissection were evaluated. Because of motion with respiration and a natural tendency for the mediastinal walls to collapse, focusing and visualization can be
LEWIS ET AL VIDEO-ASSISTED THORACIC SURGERY
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425
Fig 6 . Complications after imaged thoracic operations. 654-
32-
10Air
Leak
em bolus^
Pulmonary Edema
Operative Bleeding
compromised in this area. Carbon dioxide insufflation can assist with visualization.
First Rib The scope was placed deep in the axilla during first rib resection and used to project the vascular and muscular anatomy onto the monitor. This facilitated visualization of the anatomical dissection by all members of the operating team.
Complications There has been no mortality. There were ten complications (Fig 6). Six patients had air leaks lasting from 7 to 10 days. Three of these patients had ablation of massive bullous disease with the Argon Beam Coagulator and an accompanying lung biopsy. Another patient was currently on maximum chemotherapy and had resection of a metastatic nodule, whereas another had diffuse, advanced pulmonary emphysema with adhesions covering the aortopulmonary window, which was diffusely invaded by carcinoma. The sixth patient was a 32-year-old man who underwent a large wedge resection on the ovoid surface of the lung for a metastatic lesion. At operation, it was determined that an air leak was more acceptable, for this patient, than the loss of a lobe for metastatic disease. A 41-year-old obese woman, who underwent a resection of a histoplasmoma, was preparing to leave the hospital on her third postoperative day when pleuritic chest pain and dyspnea developed. Lung scan was compatible with a pulmonary embolus. Our second patient, in the entire series, required an urgent thoracotomy for bleeding when an Endoloop (Ethicon, Somerville, NJ) slipped from the lung parenchyma. Staplers have been used since that time, with excellent hemostasis. Rapid drainage of a massive malignant pleural effusion in a patient with a double-lumen tube and a deflated lung resulted in reexpansion pulmonary edema. One patient had a superficial wound infection that resolved in 1 week without drainage or antibiotics. All of these patients had a complete and uneventful recovery.
Infection
Contraindications Two situations exist that prevent the use of video-assisted thoracic surgery: the inability to physiologically tolerate one-lung anesthesia determined by unacceptably low oxygen saturations and complete obliteration of the pleural space due to dense adhesions.
Comment Video-assisted thoracic surgery, at this time, appears to have expanding applications in the field of general thoracic surgery [8, 91. It requires a methodical and well thought out approach, as well as extreme patience on the part of the thoracic surgeon. There are times that videoassisted thoracic operations can be more tedious and time consuming than open thoracotomy. Only the considerable patient benefits occurring postoperatively make these annoyances acceptable. In some cases, however, the operation can be accomplished more easily and quickly with video-assisted thoracic surgery than when a thoracotomy is performed. Video-assisted thoracic surgery has also been effective for resecting metastatic nodules, treating recurrent malignant effusions, and creating pericardial windows. Metastatic nodules can be easily localized and resected, confirming the suspected primary lesion. In our small series, the Argon Beam Coagulator has been effective in reducing the recurrence of recalcitrant malignant pleural effusions. Although it is too early to determine its true value, it does seem to have some merit. Approaching the pericardium from the right side has made partial pericardiectomy a much easier procedure. The pericardial fat pad is generally smaller, and the pericardial sac protrudes minimally into the right thorax, even when a large effusion is present, resulting in more working space with improved visibility. Presently, however, video-assisted thoracic surgery should be used only in a prudent and highly selective manner for primary malignant disease of the lung. Wedge
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resection for peripheral T1 NO lesions, when generous free margins can be obtained, may be therapeutic in a specific group of patients such as those with compromised pulmonary function, who would not tolerate thoracotomy [10-12]. Lesions on the broad ovoid surfaces, deep in the fissures, or on the diaphragmatic surfaces of the lung can present difficulties in obtaining adequate margins. Circumspection is required when excising from these areas. Ultimately, in all patients with a primary malignancy, it is mandatory that the lesion be resected completely. In many cases, traditional and conventional techniques will be necessary. In this group of patients, when margins were satisfactory, wedge resection was accepted as a curative procedure. If we believed a compromised margin resulted from the wedge, a traditional thoracotomy and lobectomy was performed. To our surprise, none of these patients had residual tumor on microscopic examination. Three patients with malignancy underwent a lobectomy using only the video-assisted thoracic surgical technique. When video-assisted thoracic operations are performed, major muscles are not divided, ribs are not spread, dislocated, or broken, and ligaments, nerves, and blood vessels are not severely damaged. We believe that avoidance of these adverse methods will lead to an accelerated recovery. The number of intercostal incisions or even the length of the incisions do not seem to contribute to postoperative disability or pain so long as the rib cage is not traumatized and remains intact. Attempts to deflate the operative lung by insufflation of CO, through airtight ports creating an iatrogenic pneumothorax in patients with compromised pulmonary reserve could have serious consequences. We avoid this technique and prefer the safety of a double-lumen tube. Video-assisted thoracic surgery has been remarkable in reducing the severity and duration of postoperative pain and allows patients to move and ambulate without difficulty the night of operation. Only small doses of analgesics have been needed, and most patients no longer require admission to the intensive care center. Hospitalization has been shortened for many patients, and most of these patients have returned to preoperative levels of activity after anywhere from 10 to 14 days. Video-assisted thoracic surgery has been supported with fervor by pulmonologists, oncologists, and internists. Patients who were not referred to a thoracic surgeon, when a thoracotomy was the only technique available, are now being referred with enthusiasm. Young, active patients and elderly, debilitated patients, who have been known to refuse a thoracotomy in the past, are now readily accepting video-assisted thoracic surgery. A new patient population, previously unknown to thoracic surgeons, continues to evolve and grow. This is not a new surgical technique, but rather a different approach using standard, basic principles of thoracic surgery. Trained thoracic surgeons have quickly and easily mastered this new modality and have selectively used it as another available option for performing thoracic surgical procedures. When performing video-assisted thoracic operations, the technique should never compromise the intended
Ann Thorac Surg 1992;54:4214
procedure. If there is difficulty in performing the operation, do what you do best, open the thorax. Do not allow the ego to usurp good common sense. There should be no feeling of shame or defeat if the chest has to be opened. This is not minor surgery, but rather major, complex intrathoracic surgery using minimally invasive techniques. For this reason, only trained thoracic surgeons, who have the skill, expertise, and judgment to know when and how to open the chest, should perform this technique. Video-assisted thoracic surgery can be beneficial to patients, and it can bring a new vigor to the entire field of general thoracic surgery. The potential seems unlimited, but if these goals are to be realized, all thoracic surgeons must proceed cautiously, thoughtfully, and with the utmost concern for the well-being of their patients. Although procedures such as lobectomy and pneumonectomy are possible, even at this early date, this should not be the main objective of this technique. At this time, traditional open techniques should be used for most major resections. In the future, as optics, instrumentation, and techniques improve, these major resectional procedures will become safer and more compatible with the technique of video-assisted thoracic surgery. Video-assisted thoracic surgery is still in its embryonic stages of development. Nevertheless, many procedures can be performed presently that would have required a formal thoracotomy in the recent past. Patient comfort and recovery have been gratifying. If appropriately used, video-assisted thoracic surgery can have a significant and beneficial effect for many of our patients. Only time and further experience will determine the true merits of this technique.
References 1. JacobaeusHC. Practical importance of thoracoscopy of chest.
Surg Gynecol Obstet 1921;32:49>500. 2. Lewis RJ, Kunderman PJ, Sisler GE, Mackenzie JW. Direct diagnostic thoracoscopy. Ann Thorac Surg 1976;21:536-9. 3. Lewis RH, Sisler GE, Mackenzie JW. Diffuse, mixed malignant pleural mesothelioma. Ann Thoracic Surg 1981;31: 53-60. 4. Miller JI, Hatcher CR JR. Thoracoscopy: a useful tool in the diagnosis of thoracic disease. Ann Thorac Surg 1978;26: 6&72. 5. Oakes DD, Sherck JP, Brodsky JB, Mark JB. Therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1984;87:269-73. 6. Lewis RH, Caccavale RH, Sisler GE. Special report: videoendoscopic thoracic surgery. N J Med 1991;88:473-5. 7. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651-3. 8. Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102: 721-3. 9. Landreneau RH, Herlan DB, Johnson JA, Boley TM, Nawarawong W, Ferson P. Thoracoscopic neodymium:yttriumaluminum garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991;52:1176-8. 10. Ginsberg RH. Limited resection in the treatment of stage I non-small cell lung cancer: an overview. Chest 1989;96: 50’3-1s. 11. Peters RM. The role of limited resection in carcinoma of the lung. Am J Surg 1982;143:706-10. 12. Pastorino U, Valente M, Bedini V, et al. Limited resection for stage I cancer. Eur J Surg Oncol 1991;1742-6.