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The role of thoracoscopy in pediatric surgical practice
The Role of Thoracoscopy in Pediatric Surgical Practice By Bradley M. Rodgers Charlottesville, Virginia Originally described in the early 20th century, the technique of thoracoscopy was first applied to children in the mid 1970s. Since that time, the technique has become adopted widely by pediatric surgeons and is currently considered to be the optimum technique for management of many intrathoracic disorders in children. In most pediatric surgical practices, the most common indications for thoracoscopy include pleural debridement for empyema, mediastinal lymph node biopsy, and pulmonary parenchymal biopsy for inflammatory infiltrates or nodules. With proper adherence to patient seiection and preoperative imaging as weil as appropriate anesthetic techniques, this procedure has proven to be extremely accurate in achieving a diagnosis and very successful in treating most patients. Postoperative recovery is rapid, and complications of the procedure have been relatively infrequent. As pediatric surgeons gain more experience with this technique and as better instrumentation becomes available, thoracoscopy surely will be used for an increasing number of complex intrathoracic disorders.
Copwight 2003, Elsevier Science (USA), A l l rights reserved.
T THE TURN of the 20th century, pulmonary tuberculosis was the number one killer of adults in the United States and Europe. Forlanini 1 had discovered the beneficial effects of pulmonary collapse in some patients with cavitary disease, and this technique was used widely because it represented the only active therapy for the disease at the time. Nonetheless, approximately 50% of patients did not respond to pulmonary collapse therapy because of inflammatory adhesions between the visceral and parietal pleural surfaces. In 1910, a Swedish internist, Hans Jacobaeus, reported the use of Nitze's lighted cystoscope in the pleural space to divide these pleural adhesions. 2 Jacobaeus performed his procedures under local anesthesia and used a heated wire to divide the adhesions. This so-called "intrapleural pneumolysis" was quite successful in achieving pulmonary collapse, with relatively low morbidity and mortality. This technique was adopted quickly in Europe and was accepted slowly in the United States as a useful adjunct to collapse therapy. Jacobaeus was quick to appreciate the other potential uses for thoracoscopy and, in 1921, published a report describing the use of this technique to diagnose benign and malignant lesions of the pleura and pulmoFrom the Department of Surgery, University of Virginia Health System, Charlottesville, VA. Address reprint requests to Bradley M. Rodgers, MD, University of Virginia Health System, Department of Surgery, PO Box 800709, Charlottesville, VA 22908. Copyright 2003, Elsevier Science (USA). All rights reserved. 1055-8586/03/1201-0008535.00/0 doi: 1O.1053/spsu.2003.50005 62
nary parenchyma. 3 Until the introduction of streptomycin and para-aminosalicylic acid (PAS) for the therapy of pulmonary tuberculosis in the mid 1940s, thousands of thoracoscopic intrapleural pneumolysis procedures were performed in the United Stares and Europe. 4 With the advent of successful antibiotic therapy, the technique of thoracoscopy was nearly completely abandoned in the United States. Interestingly, thoracoscopy was still used widely in Europe for the diagnosis of pleural disease, particularly mesothelioma. These procedures in Europe were almost exclusively performed by internists, utilizing local anesthesia, as had been described initially by Jacobaeus. Professors Brandt » and Loddenkemper6 from Germany had reported series of several hundred patients undergoing thoracoscopy and pleural biopsy by 1980. In the early 1970s we were looking for a simple, safe and accurate method for obtaining pulmonary biopsies for the diagnosis of Pneumocystis carinii pneumonia in immunocompromised children. We wanted a procedure that could be performed under local anesthesia to replace open thoracotomy, which required general anesthesia and was associated with significant morbidity and mortality in these patients. We decided to adapt the technique of thoracoscopy, utilizing cup biopsy forceps to obtain pulmonary tissue. We reported our initial experience in 1976, showing that the procedure could be performed rapidly and safely and that the tissue obtained provided a high degree of diagnostic accuracy. 7 The technique, however, was slow to gain widespread utilization, primarily because of the limitations of the minimally invasive surgical instrumentation. The availability of small video cameras shortly thereafter allowed the intrathoracic image to be viewed by the entire operating team and ultimately allowed performance of more complicated intrathoracic procedures in a minimally invasive manner. The introduction of laparoscopic cholecystectomy in 1988 led to an explosive increase in the utilization of minimally invasive surgical techniques of many different types, driving the development of more sophisticated instrumentation. In the last 10 or 15 years the technique of thoracoscopy has enjoyed a true "rebirth," and it is currently accepted and utilized by virtually all practicing pediatric surgeons for a variety of indications. In this article I describe the technique of thoracoscopy in children and review the outcomes reported for the most common indications for the procedure in a pediatric surgical practice. I conclude with a look to the future of this procedure and its ultimate role in a general pediatric surgical practice. Seminars in Pediatric Surgery, Vol 12, No 1 (February), 2003: pp 62-70
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The technique of thoracoscopy in children has undergone a continuous evolution since the first report in 1976. 8 The introduction of more sophisticated and smaller instruments has expanded the indications for the procedure in the pediatric population. Advances in anesthesia care have expanded our use of general anesthesia. Several basic principles remain unchanged, however. It is critical that the availability of these minimally invasive techniques does not change the basic indications for thoracic surgical procedures in children. Although these procedures appear to be associated with less morbidity than a standard thoracotomy, they still carry a risk and should not be applied in an overly aggressive fashion. Likewise, the thoracoscopic procedures should duplicate, in technique, those open procedures refined over years of clinical experience. We should not shortcut the steps in these techniques because of limitations in our instrumentation. Careful patient I selection is essential to minimize the morbidity of these procedures. Although some patients may be able to be treated by minimally invasive techniques, there still are individual patients who are treated more safely with open thoracic surgical procedures. It is this clinical judgment that defines a pediatric surgeon and mandates that when these techniques are used on children, pediatric surgeons should be primarily responsible. All thoracoscopic procedures begin with appropriate patient selection and preoperative imaging. 9 In many cases, this imaging will include computerized axial tomography (CAT) scans to display the intrathoracic abnormality and its relationship to vital intrathoracic structures. This will help to determine the most favorable positioning of the patient and the operating trocars. Proper positioning of these initial trocars is critical, because that will determine the surgeon's approach to the pathology. One then must determine the optimal anesthetic technique for each patient. 1° Usually, this should be done in conjunction with the pediatric anesthesia team. Although many of the more straightforward thoracoscopic procedures, such as lung biopsy or treatment of pneumothorax, may be performed successfully under regional anesthesia, most procedures currently are performed using general anesthetic techniques, often with single lung ventilation. The use of single lung ventilation greatly facilitates many of the more technically demanding procedures, particularly those requiring dissection within the mediastinum. Collapse of the ipsilateral lung and the absence of motion with ventilation allows for the development of a more stable operative field. Ipsilateral lung collapse also may occasionally help highlight isolated pulmonary nodules, which may be difficult to identify in the ventilated lung. However, unilateral ventilation may make identification of a specific air leak in patients with spontaneous pneumothorax far more diffi-
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cult and may make identification of isolated areas of pulmonary infection more difficult to identify for biopsy. Unilateral pulmonary collapse may be obtained in several manners in the pediatric patient. In older and larger children, the double-lumen endotracheal tube may be positioned to allow unilateral or bilateral ventilation. In smaller children, in whom this tube will not fit, unilateral mainstem intubation may be used. In infants and smaller children, mainstem bronchial occlusion of the contralateral lung with a Fogarty catheter may allow unilateral ventilation. Insufflation of CO2 gas under low pressure (4 mm Hg) into the ipsilateral chest may help in further collapsing the lung. The introduction of a broad range of sophisticated endoscopic instruments of various diameters has allowed the expansion of the use of thoracoscopy for smaller and smaller children. We have found the expandable Step (Tyco Health Care, US Surgical) cannula to be very useful for introducing telescopes and instruments into the thorax of children. The initial Step cannula is 3 mm in diameter and is introduced over a Veress needle immediately along the superior surface of the rib. This sheath then is expanded to 5 mm, 10 mm, or 12 mm diameter with radial expanding trocars. We believe that there is less trauma to the intercostal bundle with these trocars, and that this device has reduced the long-term complications of intercostal pain described in adult patients after thoracoscopy. 11 Postprocedural pain relief is facilitated with the use of intrapleural analgesia for most of these procedures. A small epidural catheter is placed through the posterior-most trocar tract, and local anesthetic agents are injected. We have used this techuique for most patients undergoing thoracoscopy, but we have specifically avoided the use of intrapleural analgesia in patients undergoing talc pleurodesis for pneumothorax or pleural debridement for empyema. In the former patients we have concern that injection of local analgesia may wash the talc oft of the visceral pleura and interfere with a uniform pleurodesis. In the latter patients we are concerned that pleural inflammation may alter the absorption of these anesthetic agents and increase the potential for systemic toxicity. We have used 0.7 mL/kg of 0.25% Bupivacaine (AstraZeneca LP, Wilmington, DE) or 0.2% Ropivacaine (AstraZeneca LP) up to a maximum of 15taL, injected every 4 hours. We have experienced no signs of toxicity using this technique in children over a wide range of ages. PULMONARY PARENCHYMAL BIOPSY
Thoracoscopy was first used in children for pulmonary biopsy in patients with diffuse pulmonary infiltrates, and pulmonary biopsy for either diffuse or localized processes continues to be a common indication for thoracoscopy in our practice. 12 In patients with diffuse processes, preoperative imaging with posterior-anterior and
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lateral chest roentgenograms usually is sufficient. Unless there are specific indications not to do so, we have preferred to thoracoscope the right chest because this side presents more pulmonary edges to biopsy. A review of the complications of thoracoscopy in children reported in 1993 indicated that the majority of complications were encountered in patients undergoing lung biopsy for diffuse pulmonary infiltrates. 13 Many of these patients were on high-pressure mechanical ventilation at the time of biopsy, and prolonged air leaks were encountered. Most of the patients in that report had undergone pulmonary biopsy utilizing cup biopsy forceps, with no specific maneuver used for hemostasis or pneumostasis. The technique used for parenchymal biopsy in these patients has changed significantly since that report. Most surgeons currently would utilize the Endo-GIA stapling instrument to obtain this tissue. Nonetheless, many of these patients probably are better served by open lung biopsy, utilizing the GIA stapler through a minithoracotomy. The advantages of less postoperative pain and early ambulation attributed to thoracoscopy are lost on these critically ill patients, and the pneumostasis afforded by the GIA stapler may be superior to that obtained with instruments used for thoracoscopy. The Endo-GIA requires the use of a 12-mm trocar for entry into the chest, and at least 5 cm of the end of the instrument must be in the chest to open the jaws fully. This limits its usefulness in younger patients. We usually use 3 trocars for pulmonary biopsy. The initial 5-mm or 10-mm trocar is used for the thoracoscope. A second 3-mm or 5-mm trocar may be used for dissecting or retracting instruments and a 12-mm trocar for the Endo-GIA. The latter trocar is placed as caudally within the thorax as practical to allow its jaws to open fully. The specimen usually is retrieved through the 12-mm trocar. Rothenberg et a114 have described using pretied ligatures to isolate a tuft of lung tissue for biopsy in very small patients, but this technique may be associated with a higher incidence of air leaks in larger children. Usually, several biopsy specimens are obtained from these patients, often including pieces of different lobes. Patients with localized processes may include children with localized infiltrates or pulmonary nodules. Preoperative imaging with CAT scans in these patients helps to identify the precise location of the pathology (Fig 1). Pulmonary nodules deeper than 1 cm below the visceral pleural surface may be difficult to identify by thoracoscopy because of the absence of the surgeon's tactile sensation. Occasionally, ipsilateral lung collapse will facilitate this identification, and, occasionally, a finger can be placed through one of the enlarged trocar tracts to palpate the surface of the lung and identify the lesion. Waldhausen et al s» have described placing a transthoracic wire into the lesion under CAT guidance immedi-
BRADLEY M. RODGERS
Fig 1. (A) Abdominal CT scan of a 3-year-old girl with abdominal distension. A large left Wilms' tumor is noted in association with a multicystic-dysplastic right kidney. (Iß) A pretherapy chest CT scan on this patient shows 2 small subpleural nodules in the left Iower lobe. This patient underwent thoracoscopy utilizing unilateral ventilation, with right main stem intubation. She was piaced in a full right lateral decubitus position. The 2 nodules in the base of the left Iower lobe were identified readily and resected with the Endo-G[A stapler. These lesions proved to be metastatic Wilms" tumor.
ately before thoracoscopy, and others have utilized image-guided transthoracic tattoo techniques using Methylene blue or lndia ink. 16,I7 Nonetheless, careful patient selection in these instances is important because there will continue to be some deep nodules that cannot be identified and biopsied with thoracoscopic techniques. Wedge biopsy specimens of the areas of infiltrate or the nodules are obtained using the Endo-GIA stapler. These specimens are removed through one of the larger trocars. Occasionally, the trocar tract will need to be enlarged to allow a specimen to be removed. In cases of suspected malignancy, the specimen should be removed from the thoracic cavity in an endosac to avoid tumor implantation in the trocar tract. Thoracoscopic lung biopsy has proven to be a highly accurate technique for pulmonary parenchymal biopsy, providing a generous piece of tissue for pathologic evaluation and culture. Most reports of
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thoracoscopic pulmonary biopsy in children have indicated 100% diagnostic accuracy with diffuse parenchymal processes and greater than 90% accuracy in cases of localized infiltrates or nodules. 12J3,18 Spira et aP 8 reported thoracoscopic biopsy to be highly successful in children with pulmonary nodules suspected to be metastatic, failing to visualize only a single nodule identified radiologically. Rao 19 reviewed the experience with thoracoscopy for intrathoracic malignancy in children at St Jude Children's Research Hospital and found only 3 of 37 patients requiring conversion to open thoracotomy because of inability to visualize or palpate a discrete nodule. Saenz et al 2° reported similar results from Memorial Sloan Kettering with 22 thoracoscopic procedures for lung biopsy. Virtually all of the failures of this technique in this setting relate to poor patient selection and the inability to visualize the lesion to be biopsied, emphasizing the importance of proper preoperative imaging and careful patient selection. 21 MEDIASTINAL DISEASE
As surgeons gained further experience with thoracoscopy in children it became clear that this technique provided a very clear view of virtually all of the mediastinal structures. We reported our initial experience with mediastinal biopsy in children with enlarged mediastinal nodes in 1979 and concluded that this was a highly accurate technique that could be performed under local anesthesia in selected patients. 22 The single false-negative biopsy result obtained from a mediastinal lymph node in this early experience led to an alteration in our surgical technique. Extensive surface biopsy specimens of the large nodes are obtained with cup biopsy forceps. Deeper tissue then is obtained with a transthoracic, visually guided, true-cut needle (Allegiance Healthcare Corp, McGaw Park, IL). We believe this addition has greatly reduced, if not eliminated, the likelihood of falsenegative biopsy results. Preoperative imaging with CAT scans is critical in these patients to help to localize the pathology and show its relationship to surrounding structures. Postioning of the patient and placement of operative trocars in patients with mediastinal pathology must be individualized carefully, based on the location of the lesion relative to surrounding structures. Shifting the patient from a full lateral decubitus position, either anteriorly or posteriorly, often will facilitate exposure using gravity to move the lung out of the line of vision. Most of these procedures may be performed with 3 trocars, a 5-mm or 10-mm trocar for the thoracoscope, and 2 3-mm or 5-mm trocars for dissecting and retracting instruments. The 5-mm fan retractor offen is helpful to push the lung out of the field of vision, and this may be placed through a fourth trocar. Although these procedures occasionally may be performed successfully under local
Fig 2. (A) Posterior-anterior chest roentgenogram on a 15-yearold girl being evaluated for head trauma. On questioning, she had mild dysphagia but no other symptoms. (B) A CT scan showed a iarge mediastinal tumor adjacent to, but not invading, the aortic arch. There was stippled calcification present within the mass. This patient underwent thoracoscopy with uniiateral ventilation. She was placed in a full right lateral decubitus position. A posterior mediastinal ganglioneuroma was resected completely and removed through an enlarged trocar tract.
anesthesia, we currently would prefer general anesthesia with unilateral ventilation. This technique stabilizes the mediastinum and facilitates retraction of the lung. As more sophisticated thoracoscopic instruments have become available, more sophisticated surgical procedures have been possible. Thoracoscopy currently may be the best initial approach for resection of most bronchogenic and enterogenous cysts, benign endothoracic tumors, and the thymus in children with myasthenia gravis (Fig 2). 23.2»Precise dissection of these tissues may be performed under the magnified vision of the thoracoscope, utilizing the Endo-GIA or endoscopic clips for
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vascular control. Initial reports suggest that thoracoscopy may be an acceptable technique for resection of posterior mediastinal neuroblastomas. 23 The magnified view afforded by this technique actually may facilitate resection of the tumors from the intervertebral formen. Isolated case reports indicate that thoracoscopy may be useful for resection of esophageal duplication cysts. The mediastinal lesions, when completely excised, are placed in an endosac and withdrawn from the chest through a somewhat expanded trocar site, without spreading the ribs. Most of the cystic lesions may be decompressed by puncture with a transthoracic needle and withdrawn through a 10-mm or 12-mm trocar. Thoracoscopy was used initially for the minimally invasive surgical esophagomyotomy for treatment of achalasia in children, although most surgeons currently prefer the use of laparoscopy for this procedure. 26-28The laparoscopic approach affords a somewhat better view of the lower esophagus and gastroesophageal junction and allows performance of a standard antireflux procedure, if indicated. Thoracoscopic esophagomyotomy continues to be recommended in selected cases of a failed laparoscopic myotomy. Mehra et a129reported a multicenter review of minimally invasive esophagomyotomy in children and found that thoracoscopy was used for primary therapy in only 4 of 22 patients. With greater experience with thoracoscopy for mediastinal disease, pediatric surgeons have developed several additional indications for the procedures, which have proven successful. Laborde et aP o described, in 1993, successful occlusion of a patent ductus arteriosis in infants. The success of this procedure, even in premature infants, has been substantiated by several investigators since then. 31 Many surgeons now feel that thoracoscopy is the approach of choice for treatment of PDA. The only contraindications to the procedure are calcification of the ductus or a ductus larger than the endoscopic clip (9 mm). Complete occlusion of the ductus usually is confirmed by intraoperative transesophageal echocardiography. Holcomb et al, 32 in 1997, reported the use of thoracoscopy for exposure of the anterior thoracic spine. Working with their orthopedic surgeons they were able to perform thoracic diskectomy and spinal fusion with thoracoscopic exposure. These procedures are performed with unilateral ventilation to facilitate spinal exposure. The patients are placed in a lateral decubitus position. Usually 3 or 4 operative ports are used, placed in the mid to anterior axillary line. 33 Lobe et al, 34 in 1999, reported the first successful thoracoscopic repair of an infant with long-gap esophageal atresia. This procedure was performed with unilateral ventilation, using a contralateral bronchial blocker. Carbon dioxide was insufflated into the ipsilateral chest at low pressure to collapse the lung and facilitate esoph-
BRADLEY M. RODGERS
ageal exposure. An end-to-end esophagoesophagostomy was performed with interrupted sutures, and the anastomosis was sealed with fibrin glue. This remarkable achievement has since been duplicated by others, with most of the patients having a standard Type C esophageal atresia with tracheoesophageal fistulaY ,36 DIAPHRAGM
Thoracoscopy provides an unobstructed view of the entire diaphragm in most patients. Mouroux et aP 7 reported, in 1996, the use of thoracoscopy for plication of the diaphragm in an adult patient with diaphragmatic eventration. Nieto-Zermeno et aP 8 reported successful thoracoscopic diaphragmatic plication in 3 infants in 1998. With follow-up between 6 and 12 months, these patients all had done well with no evidence of recurrent eventration. We and others have used this technique and have found it to be very successful. These procedures are performed with 3 trocars with the patient in a full lateral decubitus position. Unilateral ventilation is used to allow collapse of the ipsilateral lung. We have found, in addition, that using low-pressure (4 mm Hg) CO2 insufftation into the ipsilateral thorax further collapses the lung and allows excellent sustained visualization of the diaphragm. The diaphragm is imbricated with permanent sutures placed in an antero-posterior orientation. Thoracoscopy has been used to identify and repair traumatic diaphragmatic injury in adults. 39,4° These procedures are performed under unilateral ventilation with the patient in a lateral decubitus position. Small penetrating injuries of the diaphragm can be repaired by thoracoscopy, whereas larger more complicated injuries may require conversation to open thoracotomy. To date, no children with traumatic diaphragmatic injury repaired by thoracoscopy have been reported. PLEURAL DISEASE
Thoracoscopy affords direct visualization of the entire pleural surfaces, and the technique provides an excellent method for diagnosis and treatment of most pleural disorders. Pleural biopsy is not a commonly indicated procedure in pediatric surgical practice, although an occasional pleural-based tumor may be approached by thoracoscopy (Fig 3). Spontaneous pneumothorax, however, is a common condition in children and adolescents. Primary spontaneous pneumothorax occurs most commonly in otherwise healthy adolescent boys, whereas secondary spontaneous pneumothorax is seen most frequently in young patients with underlying lung disease, such as cystic fibrosis. All of the surgical procedures performed to treat pneumothorax by open thoracotomy in children may be accomplished with thoracoscopic techniques. 41,42Pleural abrasion or talc pleurodesis have been used most commonly, although apical pleurectomy
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Fig 3, A posterior-anterior chest roentgenogram on a 16-year-old boy who presented with fever and dyspnea. A large, bloody right pleural effusion had been drained by thoracocentesis. This roentgenogram shows a pleural-based mass in the Iower right chest (*) as weil as multiple enlarged right peritracheal lymph nodes. This patient underwent thoracoscopy under unilateral ventilation. He was placed in a full left lateral decubitus position. Biopsies of multiple pleural nodules as weil as mediastinal lymph nodes showed mucoepidermoid adenocarcinoma, presumably from endobronchial origin.
has been used in some patients. Pleural abrasion tends to be somewhat painful to the patient, and is best accomplished under general anesthesia. Talc pleurodesis, however, generally is not painful and may be accomplished with regional anesthetic techniques. 43 Optimal anesthetic management of these patients is a challenge because both double lung ventilation and unilateral ventilation may be desirable at different stages of the procedure. Initial thoracoscopic inspection with the ipsilateral lung actively ventilated will facilitate identification of the area of air leak. Subsequent collapse of the ipsilateral lung facilitates exposure of the entire pleural surface for pleurodesis. In older children this combination of double and single lung ventilation can be achieved with a doublelumen endotracheal tube. In smaller children the use of CO2 insufflation may facilitate ipsilateral lung collapse. Two or 3 trocars are used: a 5-mm or 10-mm trocar for the thoracoscope, a 5-mm trocar for dissecting instruments or the talc insufflator, and a 12-mm trocar for the Endo-GIA, if a bleb is encountered. Any pleural adhesions encountered are divided, and the entire visceral pleural surface is examined for the presence of blebs or air leaks. Isolated pulmonary blebs appear to be somewhat less frequent in children with primary spontaneous
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pneumothorax than in the adult population, occurring in 25% of the patients in our own series. 41 Any blebs encountered are excised with the Endo-GIA stapler or obliterated with a pretied Endoloop. A complete pleurodesis is performed in these patients, either with a pleural abrasion or a talc pleurodesis. For pleural abrasion we have used a piece of Marlex mesh (CR Bard, Inc, Cranston, RI) secured to a 5-mm grasper and passed througb the 10-mm trocar, converting to a 5-mm thoracoscope. For a talc pleurodesis we have used an atomizer passed through 5-mm trocar. Two grams of USP pure talc is aerosolized over the entire visceral pleural surface (Bryan Corp, Woburu, MA). The results of thoracoscopic pleurodesis for treatment of spontaneous pneumothorax appear to be equivalent to those obtained with open procedures, with recurrences occurring in approximately 5% of patients. 41 Thoracoscopy has provided an elegant method for treatment of empyema in children. Hutter et al. 44 first described a technique for thoracoscopic pleural debridement and subsequent pleural irrigation in 1985. A subsequent report indicated that this technique was successful in completely clearing the empyema in 60% of their patients. 45 It was clear from this experience that patients treated earlier in the course of the empyema had a more successful outcome. The stages of empyema were first described by the American Thoracic Society in 1962. 46 This commission divided the clinical course of empyema into 3 distinct phases. Phase I is the initial pleural effusion. This effusion is thin and unilocular and contains white blood cells and only occasional bacteria. In phase II of the empyema fibrin begins to accumulate in the fluid and form multiple locules. The fluid in this stage contains more protein and bacteria. In phase III of the empyema fibroblasts begin to grow into the fibrinous deposition, and there is considerable thickening of the visceral pleura, creating a trapped lung. Patients in phase I usually are treated successfully with simple tube thoracostomy and antibiotics. We reasoned that thoracoscopy would be useful once the pleural fluid became multilocular, in phase II. We reported our initial experience with this technique in 1993, treating 9 children with uniform success. 47 In preparation for thoracoscopy the patients receive either transthoracic ultrasound scan or a CAT scan of the chest to confirm the multilocular nature of the pleural fluid. We prefer ultrasound scan because the radiologist can mark the chest wall over the largest locule of pleural fluid. The technique of thoracoscopy for empyema is best performed under general anesthesia with unilateral ventilation. The ability to collapse the ipsilateral lung facilitates complete debridement of the pleural space. The patient is placed in a full lateral decubitus position and is rolled so that the mark over the largest locule is uppermost. The initial 5-mm or 10-mm
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BRADLEY M. RODGERS
trocar is placed into this locule, and the space is enlarged with blunt dissection with the end of the thoracoscope. A second 5-mm trocar then is placed into this space for the suction cannula. The entire pleural space is opened with blunt dissection or cautery dissection of the pleural adhesions. The fibrinous material within the pleural space is removed by irrigation or with grasping forceps to debride the entire pleural space. If there is considerable fibrinous deposition, a small epidural catheter is left through the posterior trocar tract, while a single chest tube is left through the anterior tract. In the postoperative period, tissue plasminogen activator (t-PA) is used to debride the remaining fibrinous material, injecting 50 to 100 mg mixed in 60 mL of sterile saline through the epidural catheter once daily. This technique of pleural debridement has proven to be uniformly successful and now is our most common indication for thoracoscopy in children. 48 The ease with which the procedure can be performed has stimulated refen'al of these patients very early in the course of the empyema, before they have entered phase III, where a more formal decortication may be required. This experience with treatment of pleural disease has led to the use of thoracoscopy for both congenital and acquired chylothorax.49,5° Extensive preoperative imaging usually is not helpful in these patients. We have not used preoperative lymphangiography. Unilateral ventilation is very helpful to collapse the ipsilateral lung, and additional CO2 insufflation may be helpful. The patient is placed in the lateral decubitus position and rolled forward to open the posterior mediastinum. A 5-mm or 10-mm trocar is placed low in the chest for the thoracoscope. A second 5-mm trocar is placed anteriorly for retraction of the lung. Two 3-mm or 5-mm trocars then are placed for dissecting instruments. In these patients, it usually is possible to identify the site of leak of thoracic duct lymph through the parietal pleura posteriorly. The pleura in this region then is opened longitudinally to identify the thoracic duct proximal and distal to the area of leak. The duct is occluded with metallic clips both proximally and distally, and the region is flooded with fibrin glue. In the occasional case in which a distinct leak is not identifiable, the thoracic duct may be clipped as it enters the chest through the diaphragm, through the aortic hiatus. The duct is a right-sided structure in this region and should be approached through the right chest. PULMONARY RESECTION
As surgeons have gained more experience and confidence with thoracoscopy and as better instruments have been introduced, more complex operative procedures have been undertaken. Several series published from adult thoracic surgical centers have shown the feasibility and safety of thoracoscopic or video-assisted formal pul-
monary lobectomy in adults with early-stage carcinoma of the lung. Rothenberg 51 has adapted these techniques for children and has shown the safety of a formal anatomic lobectomy performed by thoracoscopy in children. In these cases, the vessels and bronchus have been managed individually with the Endo-GIA stapler. The specimen is removed through an expanded trocar site, without spreading the ribs. COMPLICATIONS
Several series have examined the complications of thoracoscopy in children. In 1993, we reported a review of all of the pediatric cases reported to that date in the English-language literature. 13 There was a very low and acceptable complication rate of the procedure for most indications. The single indication that contained the highest frequency of complications and the only reported mortality associated with the procedure was pulmonary biopsy for diffuse interstitial infiltrates. As already mentioned, these patients tended to be rauch sicker than patients with other indications for the procedure, and many were in respiratory failure on mechanical ventilation at the time of biopsy. Chen et a121 have examined the complications from their own thoracoscopic experience and found a similar acceptable rate of complications, principally postoperative pneumothorax and conversion to open thoracotomy. FUTURE APPLICATIONS
The last decade has seen an increasing acceptance of thoracoscopy by pediatric surgeons throughout the world. This technique now is a standard part of the practice of pediatric surgery, and it is one with which practitioners must be familiar. Its role is established firmly in the treatment of many intrathoracic disorders in children. The future will undoubtedly see an expansion of the indications and acceptance of thoracoscopy for more technically demanding procedures, such as formal lobectomy. The reports by Lobe and others of successful repairs of infants with esophageal atresia with or without fistula is an indication of the potential for this technique for other esophageal procedures, such as resection for strictures and division of H-fistulas. Esophagectomy for caustic ingestion may be facilitated by thoracoscopic techniques. The experience with thoracoscopy for occlusion of the ductus arteriosus suggests that the technique may be useful for division of vascular rings and aortic suspension. The successful application of this technique in smaller patients suggests that it may be possible to close congenital diaphragmatic hernias by thoracoscopy. The experience reported from adult trauma centers concerning the utility of thoracoscopy suggests a broader application in pediatric practice. It has been estimated that by the end of the current decade,
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approximately 70% of the intraabdominal procedures currently performed by pediatric surgeons may be performed with minimally invasive techniques. 52 One could speculate that a similar percentage of intrathoracic procedures in children also will be managed with minimally
invasive techniques. In addition to learning the technical skills to safely apply these techniques in children, it will be incumbent on all of us to acquire the judgment to decide which patients may truly benefit by these procedures.
REFERENCES
1. Forlanini C: A contribuziioni della erapia chirurgica della tisiAblazione del polmone: Pneumotorace artificiale: Gazz Osp 68:537539, 585-587,601-602, 009-610, 617-619,625-627,641-643,657-660, 665-667, 689-691,705-707, 1882 2. Jacobaeus HC: Ueber die Moglichkeit die Zystoskopie bei untersuchung seroser hohlungen anzuwenden. Mnnchen Med Wochenschr 57:2090-2092, 1910 3. Jacobaeus HC, Key E: Some experiences of intrathoracic tumors, their diagnosis and their operative treatment Acta Chir Scan 53:573623, 1921 4. Bloomberg AE: Thoracoscopy in perspective. Surg Gynecol Obstet 147:433-443, 1978 5. Brandt HJ: Endoskopie und biopsie in der diagnastik pneumologescher krankheiten. Prax Pneumon 31:384-401, 1977 6. Loddenkemper R: Thoracoscopy: Results in non-cancerous and idiopathic pleural effusions. Poumon 37:261-264, 1981 7. Rodgers BM, Talbert JL: Thoracoscopy for diagnosis of intrathoracic lesions in children. J Pediatr Surg 11:703-708, 1976 8. Rodgers BM: Instrumentation and technique for pediatric thoracoscopy. Pediatr Endosurg Inno Tech 5:93-99, 2001 9. Landreneau RJ, Mack MJ, Keenan RJ, et al: Strategic Planning for video-assisted thoracic surgery. Ann Thorac Surg 56:615-619, 1993 10. McGahren ED, Kern JA, Rodgers BM: Anesthetic techniques for pediatric thoracoscopy. Ann Thorac Surg: 60:927-930, 1995 11. Hutter J, Miller K, Moritz E: Chronic sequels after thoracoscopic procedures for benign diseases. Euro J Cardio-Thorac Surg 17:687-690, 2000 12. Burns RC, McGahren ED, Rodgers BM: Thoracoscopic approach to pulmonary parenchymal lesions. Pediatr Endosurg Inno Tech 5:141-151, 2001 13. Rodgers BM: Pediatric thoracoscopy: Where have we come and what have we learned? Ann Thorac Surg 56:704-707, 1993 14. Rothenberg SS, Wagner JS, Chang JH, et al: The safety and efficacy of thoracoscopic lung biopsy for diagnosis and treatment in infants and children. J Pediatr Surg 31:100-104, 1996 15. Waldhausen JH, Shaw DW, Hall DG, et al: Needle localization for thoracoscopic resection of small pulmonary nodules in children. J Pediatr Surg 32:1624-1625, 1997 16. DeKerviler E, Gossot D, Frija J: Localization techniqnes for the thoracoscopic resection of pulmonary nodules. Int Surg 81:241-244, 1996 17. Partrick DA, Bensard DD, Teitellbaum DH, et al: Snccessfnl thoracoscopic lung biopsy in children utilizing preoperative CT-guided localization. J Pediatr Surg 37:970-973, 2002 18. Spira R, Zamir O, Benarush MW, et al: The role of thoracoscopic biopsy in the diagnosis of pulmonary nodules appearing in children with nonpulmonary cancer. Pediatr Endosurg Inno Tech 2:6568, 1998 19. Rao BN: Present day concepts of thoracoscopy as a modality in pediatric cancer management. Int Surg 82:123-126, 1997 20. Saenz NC, Conlon KCP, Aronson, DC, et al: The application of minimal access procedures in infants, children and young adults with pediatric malignancies. J Laparoendo Advanced Surg Tech 7:289-294, 1997 21. Chen MK, Schropp, Lobe TE: Complications of minimal-access surgery in children. J Pediatr Surg 31:1161-1165, 1996
22. Rodgers BM, Moazam F, Talbert JH: Thoracoscopy in children. Ann Surg 189:176-180, 1979 23. Partrick DA, Rothenberg SS: Thoracoscopic resection of mediastinal masses in infants and children: An evaluation of technique and results. J Pediatr Surg 36:1165-1167, 2001 24. Kolski H, Vajsar J, Kim PCW: Thoracoscopic thymectomy in juvenile myasthenia gravis. J Pediatr Surg 35:768-770, 2000 25. Kogut KA, Bufo, AJ, Rothenberg SS, et al: Thoracoscopic thymectomy for myasthenia gravis in children. J Pediatr Surg 35:15761577, 2000 26. Pelligrini C, Witter LA, Patti M, et al: Thoracoscopic esophagomyotomy: Initial experience with a new approach for the treatment of achalasia. Ann Surg 216:291-299, 1992 27. Swanstrom LL, Pennings J: Laparoscopic esophagomyotomy for achalasia. Surg Endosc 9:286-292, 1995 28. Rothenberg SS, Partrick DA, Bealer JF, et al: Evaluation of minimally invasive approaches to achalasia in children. J Pediatr Surg 36:808-810, 2001 29. Mehra M, Bahar RJ, Ament ME, et al: Laparoscopic and thoracoscopic esophagomyotomy for children with achalasia. J Pediatr Gastroenteral Nutr 33:466-471, 2001 30. Laborde F, Noirhomme P, Kmam J, et al: A new video-assisted thoracoscopic surgical technique for interruption of patient ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 105:278280, 1993 31. Burke RP: Video-assisted endoscopy for congenital heart repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann 4:208-215, 2001 32. Holcomb III GW, Mencio GA, Green NE: Video-assisted thoracoscopic diskectomy and fusion. J Pediatr Surg 32:1120-1122, 1997 33. Dickman CA, Detweiler PW, Porter RW: Endoscopic spine surgery. Clin Neuro 46:520-553, 2000 34. Lobe TE, Rothenberg S, Waldschmidt J, et al: Thoracoscopic repair of esophageaI atresia in an infant: A surgical first. Pediatr Endosurg Innov Tech 3:141-148, 1999 35. Klaas MA, VanderZee DC: Feasibility of thoracoscopic repair of esophageal atresia with distal fistnla. J Pediatr Surg 37:192-196, 2002 36. Rothenberg SS: Thoracoscopic repair of a tracheoesophageal fistula in newborns. J Pediatr Surg 37:869-872, 2002 37. Mouroux J, Padovani B, Pourier NC, et al: Technique for repair of diaphragmatic eventration. Ann Thorac Surg 62:905-907, 1996 38. Nieto-Zermeno J, Ordorica-Flores R, Mntes-Tapia F, et al: Three cases of unilateral congenital diaphragmatic eventration treated by pIication with thoracoscopic surgery. Pediatr Endosurg Innov Tech 2:111-115, 1998 39. Smith RS, Fry WR, Tsoi EKM, et al: Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg 166:690-695, 1993 40. Kern JA, Tribble CG, Spotnitz WD, et al: Thoracoscopy in the subacute management of patients with thoracoabdominal trauma. Chest 104:942-945, 1993 41. Rodgers BM, Burns RC, McGahren ED: Thoracoscopy for treatment of spontaneous pneumothorax in children. Pediatr Endosurg Inno Tech 5:101-107, 2001
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42. Stringel G, Amen NS, Dozor AJ: Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population. J Soc Laparoendo Surg 3:113-116, 1999 43. Tribble CG, Selden RF, Rodgers BM: Talc poudrage in the treatment of spontaneous pneumothoraces in patients with cystic fibrosis. Ann Surg 204:677-680, 1986 44. Hutter JA, Harari D, Braimbridge MV: The management of empyema thoracis by thoracoscopy and irrigation. Ann Thorac Surg 39:517-520, 1985 45. Ridley PD, Braimbridge MV: Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis. Ann Thorac Surg 51:461-464, 1991 46. American Thoracic Society Subcommittee on Surgery-Management of Nontuberculous empyema. Am Rev Respir Dis 85:935-936, 1962
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47. Kern JA, Rodgers BM: Thoracoscopy in the management of empyema in children. J Pediatr Surg 28:1128-1132, 1993 48. McGahren ED: The Use of thoracoscopy for treatment of empyema in children. Pediatr Endosurg Innov Tech 5:117-125, 2001 49. Burns RC, McGahren ED, Rodgers BM: Thoracoscopy in the management of chylothorax. Pediatr Endosurg Innov Tech 5:153-158, 2001 50. Graham DD, McGahren ED, Tribble CG, et al: Use of videoassisted thoracic surgery in the treatment of chylothorax. Ann Thorac Surg 57:1507-1512, 1994 51. Rothenberg SS: Thoracoscopic lung resection in children. J Pediatr Surg 35:271-274, 2000 52. Ure BM, Bax NMA, VanderZee DC: Laparoscopy in infants and children: A prospective study on feasibility and the impact on routine surgery. J Pediatr Surg 36:1170-1173, 2000
Copwight 2003, Elsevier Science (USA), A l l rights reserved.
T THE TURN of the 20th century, pulmonary tuberculosis was the number one killer of adults in the United States and Europe. Forlanini 1 had discovered the beneficial effects of pulmonary collapse in some patients with cavitary disease, and this technique was used widely because it represented the only active therapy for the disease at the time. Nonetheless, approximately 50% of patients did not respond to pulmonary collapse therapy because of inflammatory adhesions between the visceral and parietal pleural surfaces. In 1910, a Swedish internist, Hans Jacobaeus, reported the use of Nitze's lighted cystoscope in the pleural space to divide these pleural adhesions. 2 Jacobaeus performed his procedures under local anesthesia and used a heated wire to divide the adhesions. This so-called "intrapleural pneumolysis" was quite successful in achieving pulmonary collapse, with relatively low morbidity and mortality. This technique was adopted quickly in Europe and was accepted slowly in the United States as a useful adjunct to collapse therapy. Jacobaeus was quick to appreciate the other potential uses for thoracoscopy and, in 1921, published a report describing the use of this technique to diagnose benign and malignant lesions of the pleura and pulmoFrom the Department of Surgery, University of Virginia Health System, Charlottesville, VA. Address reprint requests to Bradley M. Rodgers, MD, University of Virginia Health System, Department of Surgery, PO Box 800709, Charlottesville, VA 22908. Copyright 2003, Elsevier Science (USA). All rights reserved. 1055-8586/03/1201-0008535.00/0 doi: 1O.1053/spsu.2003.50005 62
nary parenchyma. 3 Until the introduction of streptomycin and para-aminosalicylic acid (PAS) for the therapy of pulmonary tuberculosis in the mid 1940s, thousands of thoracoscopic intrapleural pneumolysis procedures were performed in the United Stares and Europe. 4 With the advent of successful antibiotic therapy, the technique of thoracoscopy was nearly completely abandoned in the United States. Interestingly, thoracoscopy was still used widely in Europe for the diagnosis of pleural disease, particularly mesothelioma. These procedures in Europe were almost exclusively performed by internists, utilizing local anesthesia, as had been described initially by Jacobaeus. Professors Brandt » and Loddenkemper6 from Germany had reported series of several hundred patients undergoing thoracoscopy and pleural biopsy by 1980. In the early 1970s we were looking for a simple, safe and accurate method for obtaining pulmonary biopsies for the diagnosis of Pneumocystis carinii pneumonia in immunocompromised children. We wanted a procedure that could be performed under local anesthesia to replace open thoracotomy, which required general anesthesia and was associated with significant morbidity and mortality in these patients. We decided to adapt the technique of thoracoscopy, utilizing cup biopsy forceps to obtain pulmonary tissue. We reported our initial experience in 1976, showing that the procedure could be performed rapidly and safely and that the tissue obtained provided a high degree of diagnostic accuracy. 7 The technique, however, was slow to gain widespread utilization, primarily because of the limitations of the minimally invasive surgical instrumentation. The availability of small video cameras shortly thereafter allowed the intrathoracic image to be viewed by the entire operating team and ultimately allowed performance of more complicated intrathoracic procedures in a minimally invasive manner. The introduction of laparoscopic cholecystectomy in 1988 led to an explosive increase in the utilization of minimally invasive surgical techniques of many different types, driving the development of more sophisticated instrumentation. In the last 10 or 15 years the technique of thoracoscopy has enjoyed a true "rebirth," and it is currently accepted and utilized by virtually all practicing pediatric surgeons for a variety of indications. In this article I describe the technique of thoracoscopy in children and review the outcomes reported for the most common indications for the procedure in a pediatric surgical practice. I conclude with a look to the future of this procedure and its ultimate role in a general pediatric surgical practice. Seminars in Pediatric Surgery, Vol 12, No 1 (February), 2003: pp 62-70
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The technique of thoracoscopy in children has undergone a continuous evolution since the first report in 1976. 8 The introduction of more sophisticated and smaller instruments has expanded the indications for the procedure in the pediatric population. Advances in anesthesia care have expanded our use of general anesthesia. Several basic principles remain unchanged, however. It is critical that the availability of these minimally invasive techniques does not change the basic indications for thoracic surgical procedures in children. Although these procedures appear to be associated with less morbidity than a standard thoracotomy, they still carry a risk and should not be applied in an overly aggressive fashion. Likewise, the thoracoscopic procedures should duplicate, in technique, those open procedures refined over years of clinical experience. We should not shortcut the steps in these techniques because of limitations in our instrumentation. Careful patient I selection is essential to minimize the morbidity of these procedures. Although some patients may be able to be treated by minimally invasive techniques, there still are individual patients who are treated more safely with open thoracic surgical procedures. It is this clinical judgment that defines a pediatric surgeon and mandates that when these techniques are used on children, pediatric surgeons should be primarily responsible. All thoracoscopic procedures begin with appropriate patient selection and preoperative imaging. 9 In many cases, this imaging will include computerized axial tomography (CAT) scans to display the intrathoracic abnormality and its relationship to vital intrathoracic structures. This will help to determine the most favorable positioning of the patient and the operating trocars. Proper positioning of these initial trocars is critical, because that will determine the surgeon's approach to the pathology. One then must determine the optimal anesthetic technique for each patient. 1° Usually, this should be done in conjunction with the pediatric anesthesia team. Although many of the more straightforward thoracoscopic procedures, such as lung biopsy or treatment of pneumothorax, may be performed successfully under regional anesthesia, most procedures currently are performed using general anesthetic techniques, often with single lung ventilation. The use of single lung ventilation greatly facilitates many of the more technically demanding procedures, particularly those requiring dissection within the mediastinum. Collapse of the ipsilateral lung and the absence of motion with ventilation allows for the development of a more stable operative field. Ipsilateral lung collapse also may occasionally help highlight isolated pulmonary nodules, which may be difficult to identify in the ventilated lung. However, unilateral ventilation may make identification of a specific air leak in patients with spontaneous pneumothorax far more diffi-
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cult and may make identification of isolated areas of pulmonary infection more difficult to identify for biopsy. Unilateral pulmonary collapse may be obtained in several manners in the pediatric patient. In older and larger children, the double-lumen endotracheal tube may be positioned to allow unilateral or bilateral ventilation. In smaller children, in whom this tube will not fit, unilateral mainstem intubation may be used. In infants and smaller children, mainstem bronchial occlusion of the contralateral lung with a Fogarty catheter may allow unilateral ventilation. Insufflation of CO2 gas under low pressure (4 mm Hg) into the ipsilateral chest may help in further collapsing the lung. The introduction of a broad range of sophisticated endoscopic instruments of various diameters has allowed the expansion of the use of thoracoscopy for smaller and smaller children. We have found the expandable Step (Tyco Health Care, US Surgical) cannula to be very useful for introducing telescopes and instruments into the thorax of children. The initial Step cannula is 3 mm in diameter and is introduced over a Veress needle immediately along the superior surface of the rib. This sheath then is expanded to 5 mm, 10 mm, or 12 mm diameter with radial expanding trocars. We believe that there is less trauma to the intercostal bundle with these trocars, and that this device has reduced the long-term complications of intercostal pain described in adult patients after thoracoscopy. 11 Postprocedural pain relief is facilitated with the use of intrapleural analgesia for most of these procedures. A small epidural catheter is placed through the posterior-most trocar tract, and local anesthetic agents are injected. We have used this techuique for most patients undergoing thoracoscopy, but we have specifically avoided the use of intrapleural analgesia in patients undergoing talc pleurodesis for pneumothorax or pleural debridement for empyema. In the former patients we have concern that injection of local analgesia may wash the talc oft of the visceral pleura and interfere with a uniform pleurodesis. In the latter patients we are concerned that pleural inflammation may alter the absorption of these anesthetic agents and increase the potential for systemic toxicity. We have used 0.7 mL/kg of 0.25% Bupivacaine (AstraZeneca LP, Wilmington, DE) or 0.2% Ropivacaine (AstraZeneca LP) up to a maximum of 15taL, injected every 4 hours. We have experienced no signs of toxicity using this technique in children over a wide range of ages. PULMONARY PARENCHYMAL BIOPSY
Thoracoscopy was first used in children for pulmonary biopsy in patients with diffuse pulmonary infiltrates, and pulmonary biopsy for either diffuse or localized processes continues to be a common indication for thoracoscopy in our practice. 12 In patients with diffuse processes, preoperative imaging with posterior-anterior and
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lateral chest roentgenograms usually is sufficient. Unless there are specific indications not to do so, we have preferred to thoracoscope the right chest because this side presents more pulmonary edges to biopsy. A review of the complications of thoracoscopy in children reported in 1993 indicated that the majority of complications were encountered in patients undergoing lung biopsy for diffuse pulmonary infiltrates. 13 Many of these patients were on high-pressure mechanical ventilation at the time of biopsy, and prolonged air leaks were encountered. Most of the patients in that report had undergone pulmonary biopsy utilizing cup biopsy forceps, with no specific maneuver used for hemostasis or pneumostasis. The technique used for parenchymal biopsy in these patients has changed significantly since that report. Most surgeons currently would utilize the Endo-GIA stapling instrument to obtain this tissue. Nonetheless, many of these patients probably are better served by open lung biopsy, utilizing the GIA stapler through a minithoracotomy. The advantages of less postoperative pain and early ambulation attributed to thoracoscopy are lost on these critically ill patients, and the pneumostasis afforded by the GIA stapler may be superior to that obtained with instruments used for thoracoscopy. The Endo-GIA requires the use of a 12-mm trocar for entry into the chest, and at least 5 cm of the end of the instrument must be in the chest to open the jaws fully. This limits its usefulness in younger patients. We usually use 3 trocars for pulmonary biopsy. The initial 5-mm or 10-mm trocar is used for the thoracoscope. A second 3-mm or 5-mm trocar may be used for dissecting or retracting instruments and a 12-mm trocar for the Endo-GIA. The latter trocar is placed as caudally within the thorax as practical to allow its jaws to open fully. The specimen usually is retrieved through the 12-mm trocar. Rothenberg et a114 have described using pretied ligatures to isolate a tuft of lung tissue for biopsy in very small patients, but this technique may be associated with a higher incidence of air leaks in larger children. Usually, several biopsy specimens are obtained from these patients, often including pieces of different lobes. Patients with localized processes may include children with localized infiltrates or pulmonary nodules. Preoperative imaging with CAT scans in these patients helps to identify the precise location of the pathology (Fig 1). Pulmonary nodules deeper than 1 cm below the visceral pleural surface may be difficult to identify by thoracoscopy because of the absence of the surgeon's tactile sensation. Occasionally, ipsilateral lung collapse will facilitate this identification, and, occasionally, a finger can be placed through one of the enlarged trocar tracts to palpate the surface of the lung and identify the lesion. Waldhausen et al s» have described placing a transthoracic wire into the lesion under CAT guidance immedi-
BRADLEY M. RODGERS
Fig 1. (A) Abdominal CT scan of a 3-year-old girl with abdominal distension. A large left Wilms' tumor is noted in association with a multicystic-dysplastic right kidney. (Iß) A pretherapy chest CT scan on this patient shows 2 small subpleural nodules in the left Iower lobe. This patient underwent thoracoscopy utilizing unilateral ventilation, with right main stem intubation. She was piaced in a full right lateral decubitus position. The 2 nodules in the base of the left Iower lobe were identified readily and resected with the Endo-G[A stapler. These lesions proved to be metastatic Wilms" tumor.
ately before thoracoscopy, and others have utilized image-guided transthoracic tattoo techniques using Methylene blue or lndia ink. 16,I7 Nonetheless, careful patient selection in these instances is important because there will continue to be some deep nodules that cannot be identified and biopsied with thoracoscopic techniques. Wedge biopsy specimens of the areas of infiltrate or the nodules are obtained using the Endo-GIA stapler. These specimens are removed through one of the larger trocars. Occasionally, the trocar tract will need to be enlarged to allow a specimen to be removed. In cases of suspected malignancy, the specimen should be removed from the thoracic cavity in an endosac to avoid tumor implantation in the trocar tract. Thoracoscopic lung biopsy has proven to be a highly accurate technique for pulmonary parenchymal biopsy, providing a generous piece of tissue for pathologic evaluation and culture. Most reports of
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thoracoscopic pulmonary biopsy in children have indicated 100% diagnostic accuracy with diffuse parenchymal processes and greater than 90% accuracy in cases of localized infiltrates or nodules. 12J3,18 Spira et aP 8 reported thoracoscopic biopsy to be highly successful in children with pulmonary nodules suspected to be metastatic, failing to visualize only a single nodule identified radiologically. Rao 19 reviewed the experience with thoracoscopy for intrathoracic malignancy in children at St Jude Children's Research Hospital and found only 3 of 37 patients requiring conversion to open thoracotomy because of inability to visualize or palpate a discrete nodule. Saenz et al 2° reported similar results from Memorial Sloan Kettering with 22 thoracoscopic procedures for lung biopsy. Virtually all of the failures of this technique in this setting relate to poor patient selection and the inability to visualize the lesion to be biopsied, emphasizing the importance of proper preoperative imaging and careful patient selection. 21 MEDIASTINAL DISEASE
As surgeons gained further experience with thoracoscopy in children it became clear that this technique provided a very clear view of virtually all of the mediastinal structures. We reported our initial experience with mediastinal biopsy in children with enlarged mediastinal nodes in 1979 and concluded that this was a highly accurate technique that could be performed under local anesthesia in selected patients. 22 The single false-negative biopsy result obtained from a mediastinal lymph node in this early experience led to an alteration in our surgical technique. Extensive surface biopsy specimens of the large nodes are obtained with cup biopsy forceps. Deeper tissue then is obtained with a transthoracic, visually guided, true-cut needle (Allegiance Healthcare Corp, McGaw Park, IL). We believe this addition has greatly reduced, if not eliminated, the likelihood of falsenegative biopsy results. Preoperative imaging with CAT scans is critical in these patients to help to localize the pathology and show its relationship to surrounding structures. Postioning of the patient and placement of operative trocars in patients with mediastinal pathology must be individualized carefully, based on the location of the lesion relative to surrounding structures. Shifting the patient from a full lateral decubitus position, either anteriorly or posteriorly, often will facilitate exposure using gravity to move the lung out of the line of vision. Most of these procedures may be performed with 3 trocars, a 5-mm or 10-mm trocar for the thoracoscope, and 2 3-mm or 5-mm trocars for dissecting and retracting instruments. The 5-mm fan retractor offen is helpful to push the lung out of the field of vision, and this may be placed through a fourth trocar. Although these procedures occasionally may be performed successfully under local
Fig 2. (A) Posterior-anterior chest roentgenogram on a 15-yearold girl being evaluated for head trauma. On questioning, she had mild dysphagia but no other symptoms. (B) A CT scan showed a iarge mediastinal tumor adjacent to, but not invading, the aortic arch. There was stippled calcification present within the mass. This patient underwent thoracoscopy with uniiateral ventilation. She was placed in a full right lateral decubitus position. A posterior mediastinal ganglioneuroma was resected completely and removed through an enlarged trocar tract.
anesthesia, we currently would prefer general anesthesia with unilateral ventilation. This technique stabilizes the mediastinum and facilitates retraction of the lung. As more sophisticated thoracoscopic instruments have become available, more sophisticated surgical procedures have been possible. Thoracoscopy currently may be the best initial approach for resection of most bronchogenic and enterogenous cysts, benign endothoracic tumors, and the thymus in children with myasthenia gravis (Fig 2). 23.2»Precise dissection of these tissues may be performed under the magnified vision of the thoracoscope, utilizing the Endo-GIA or endoscopic clips for
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vascular control. Initial reports suggest that thoracoscopy may be an acceptable technique for resection of posterior mediastinal neuroblastomas. 23 The magnified view afforded by this technique actually may facilitate resection of the tumors from the intervertebral formen. Isolated case reports indicate that thoracoscopy may be useful for resection of esophageal duplication cysts. The mediastinal lesions, when completely excised, are placed in an endosac and withdrawn from the chest through a somewhat expanded trocar site, without spreading the ribs. Most of the cystic lesions may be decompressed by puncture with a transthoracic needle and withdrawn through a 10-mm or 12-mm trocar. Thoracoscopy was used initially for the minimally invasive surgical esophagomyotomy for treatment of achalasia in children, although most surgeons currently prefer the use of laparoscopy for this procedure. 26-28The laparoscopic approach affords a somewhat better view of the lower esophagus and gastroesophageal junction and allows performance of a standard antireflux procedure, if indicated. Thoracoscopic esophagomyotomy continues to be recommended in selected cases of a failed laparoscopic myotomy. Mehra et a129reported a multicenter review of minimally invasive esophagomyotomy in children and found that thoracoscopy was used for primary therapy in only 4 of 22 patients. With greater experience with thoracoscopy for mediastinal disease, pediatric surgeons have developed several additional indications for the procedures, which have proven successful. Laborde et aP o described, in 1993, successful occlusion of a patent ductus arteriosis in infants. The success of this procedure, even in premature infants, has been substantiated by several investigators since then. 31 Many surgeons now feel that thoracoscopy is the approach of choice for treatment of PDA. The only contraindications to the procedure are calcification of the ductus or a ductus larger than the endoscopic clip (9 mm). Complete occlusion of the ductus usually is confirmed by intraoperative transesophageal echocardiography. Holcomb et al, 32 in 1997, reported the use of thoracoscopy for exposure of the anterior thoracic spine. Working with their orthopedic surgeons they were able to perform thoracic diskectomy and spinal fusion with thoracoscopic exposure. These procedures are performed with unilateral ventilation to facilitate spinal exposure. The patients are placed in a lateral decubitus position. Usually 3 or 4 operative ports are used, placed in the mid to anterior axillary line. 33 Lobe et al, 34 in 1999, reported the first successful thoracoscopic repair of an infant with long-gap esophageal atresia. This procedure was performed with unilateral ventilation, using a contralateral bronchial blocker. Carbon dioxide was insufflated into the ipsilateral chest at low pressure to collapse the lung and facilitate esoph-
BRADLEY M. RODGERS
ageal exposure. An end-to-end esophagoesophagostomy was performed with interrupted sutures, and the anastomosis was sealed with fibrin glue. This remarkable achievement has since been duplicated by others, with most of the patients having a standard Type C esophageal atresia with tracheoesophageal fistulaY ,36 DIAPHRAGM
Thoracoscopy provides an unobstructed view of the entire diaphragm in most patients. Mouroux et aP 7 reported, in 1996, the use of thoracoscopy for plication of the diaphragm in an adult patient with diaphragmatic eventration. Nieto-Zermeno et aP 8 reported successful thoracoscopic diaphragmatic plication in 3 infants in 1998. With follow-up between 6 and 12 months, these patients all had done well with no evidence of recurrent eventration. We and others have used this technique and have found it to be very successful. These procedures are performed with 3 trocars with the patient in a full lateral decubitus position. Unilateral ventilation is used to allow collapse of the ipsilateral lung. We have found, in addition, that using low-pressure (4 mm Hg) CO2 insufftation into the ipsilateral thorax further collapses the lung and allows excellent sustained visualization of the diaphragm. The diaphragm is imbricated with permanent sutures placed in an antero-posterior orientation. Thoracoscopy has been used to identify and repair traumatic diaphragmatic injury in adults. 39,4° These procedures are performed under unilateral ventilation with the patient in a lateral decubitus position. Small penetrating injuries of the diaphragm can be repaired by thoracoscopy, whereas larger more complicated injuries may require conversation to open thoracotomy. To date, no children with traumatic diaphragmatic injury repaired by thoracoscopy have been reported. PLEURAL DISEASE
Thoracoscopy affords direct visualization of the entire pleural surfaces, and the technique provides an excellent method for diagnosis and treatment of most pleural disorders. Pleural biopsy is not a commonly indicated procedure in pediatric surgical practice, although an occasional pleural-based tumor may be approached by thoracoscopy (Fig 3). Spontaneous pneumothorax, however, is a common condition in children and adolescents. Primary spontaneous pneumothorax occurs most commonly in otherwise healthy adolescent boys, whereas secondary spontaneous pneumothorax is seen most frequently in young patients with underlying lung disease, such as cystic fibrosis. All of the surgical procedures performed to treat pneumothorax by open thoracotomy in children may be accomplished with thoracoscopic techniques. 41,42Pleural abrasion or talc pleurodesis have been used most commonly, although apical pleurectomy
THORACOSCOPY
Fig 3, A posterior-anterior chest roentgenogram on a 16-year-old boy who presented with fever and dyspnea. A large, bloody right pleural effusion had been drained by thoracocentesis. This roentgenogram shows a pleural-based mass in the Iower right chest (*) as weil as multiple enlarged right peritracheal lymph nodes. This patient underwent thoracoscopy under unilateral ventilation. He was placed in a full left lateral decubitus position. Biopsies of multiple pleural nodules as weil as mediastinal lymph nodes showed mucoepidermoid adenocarcinoma, presumably from endobronchial origin.
has been used in some patients. Pleural abrasion tends to be somewhat painful to the patient, and is best accomplished under general anesthesia. Talc pleurodesis, however, generally is not painful and may be accomplished with regional anesthetic techniques. 43 Optimal anesthetic management of these patients is a challenge because both double lung ventilation and unilateral ventilation may be desirable at different stages of the procedure. Initial thoracoscopic inspection with the ipsilateral lung actively ventilated will facilitate identification of the area of air leak. Subsequent collapse of the ipsilateral lung facilitates exposure of the entire pleural surface for pleurodesis. In older children this combination of double and single lung ventilation can be achieved with a doublelumen endotracheal tube. In smaller children the use of CO2 insufflation may facilitate ipsilateral lung collapse. Two or 3 trocars are used: a 5-mm or 10-mm trocar for the thoracoscope, a 5-mm trocar for dissecting instruments or the talc insufflator, and a 12-mm trocar for the Endo-GIA, if a bleb is encountered. Any pleural adhesions encountered are divided, and the entire visceral pleural surface is examined for the presence of blebs or air leaks. Isolated pulmonary blebs appear to be somewhat less frequent in children with primary spontaneous
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pneumothorax than in the adult population, occurring in 25% of the patients in our own series. 41 Any blebs encountered are excised with the Endo-GIA stapler or obliterated with a pretied Endoloop. A complete pleurodesis is performed in these patients, either with a pleural abrasion or a talc pleurodesis. For pleural abrasion we have used a piece of Marlex mesh (CR Bard, Inc, Cranston, RI) secured to a 5-mm grasper and passed througb the 10-mm trocar, converting to a 5-mm thoracoscope. For a talc pleurodesis we have used an atomizer passed through 5-mm trocar. Two grams of USP pure talc is aerosolized over the entire visceral pleural surface (Bryan Corp, Woburu, MA). The results of thoracoscopic pleurodesis for treatment of spontaneous pneumothorax appear to be equivalent to those obtained with open procedures, with recurrences occurring in approximately 5% of patients. 41 Thoracoscopy has provided an elegant method for treatment of empyema in children. Hutter et al. 44 first described a technique for thoracoscopic pleural debridement and subsequent pleural irrigation in 1985. A subsequent report indicated that this technique was successful in completely clearing the empyema in 60% of their patients. 45 It was clear from this experience that patients treated earlier in the course of the empyema had a more successful outcome. The stages of empyema were first described by the American Thoracic Society in 1962. 46 This commission divided the clinical course of empyema into 3 distinct phases. Phase I is the initial pleural effusion. This effusion is thin and unilocular and contains white blood cells and only occasional bacteria. In phase II of the empyema fibrin begins to accumulate in the fluid and form multiple locules. The fluid in this stage contains more protein and bacteria. In phase III of the empyema fibroblasts begin to grow into the fibrinous deposition, and there is considerable thickening of the visceral pleura, creating a trapped lung. Patients in phase I usually are treated successfully with simple tube thoracostomy and antibiotics. We reasoned that thoracoscopy would be useful once the pleural fluid became multilocular, in phase II. We reported our initial experience with this technique in 1993, treating 9 children with uniform success. 47 In preparation for thoracoscopy the patients receive either transthoracic ultrasound scan or a CAT scan of the chest to confirm the multilocular nature of the pleural fluid. We prefer ultrasound scan because the radiologist can mark the chest wall over the largest locule of pleural fluid. The technique of thoracoscopy for empyema is best performed under general anesthesia with unilateral ventilation. The ability to collapse the ipsilateral lung facilitates complete debridement of the pleural space. The patient is placed in a full lateral decubitus position and is rolled so that the mark over the largest locule is uppermost. The initial 5-mm or 10-mm
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BRADLEY M. RODGERS
trocar is placed into this locule, and the space is enlarged with blunt dissection with the end of the thoracoscope. A second 5-mm trocar then is placed into this space for the suction cannula. The entire pleural space is opened with blunt dissection or cautery dissection of the pleural adhesions. The fibrinous material within the pleural space is removed by irrigation or with grasping forceps to debride the entire pleural space. If there is considerable fibrinous deposition, a small epidural catheter is left through the posterior trocar tract, while a single chest tube is left through the anterior tract. In the postoperative period, tissue plasminogen activator (t-PA) is used to debride the remaining fibrinous material, injecting 50 to 100 mg mixed in 60 mL of sterile saline through the epidural catheter once daily. This technique of pleural debridement has proven to be uniformly successful and now is our most common indication for thoracoscopy in children. 48 The ease with which the procedure can be performed has stimulated refen'al of these patients very early in the course of the empyema, before they have entered phase III, where a more formal decortication may be required. This experience with treatment of pleural disease has led to the use of thoracoscopy for both congenital and acquired chylothorax.49,5° Extensive preoperative imaging usually is not helpful in these patients. We have not used preoperative lymphangiography. Unilateral ventilation is very helpful to collapse the ipsilateral lung, and additional CO2 insufflation may be helpful. The patient is placed in the lateral decubitus position and rolled forward to open the posterior mediastinum. A 5-mm or 10-mm trocar is placed low in the chest for the thoracoscope. A second 5-mm trocar is placed anteriorly for retraction of the lung. Two 3-mm or 5-mm trocars then are placed for dissecting instruments. In these patients, it usually is possible to identify the site of leak of thoracic duct lymph through the parietal pleura posteriorly. The pleura in this region then is opened longitudinally to identify the thoracic duct proximal and distal to the area of leak. The duct is occluded with metallic clips both proximally and distally, and the region is flooded with fibrin glue. In the occasional case in which a distinct leak is not identifiable, the thoracic duct may be clipped as it enters the chest through the diaphragm, through the aortic hiatus. The duct is a right-sided structure in this region and should be approached through the right chest. PULMONARY RESECTION
As surgeons have gained more experience and confidence with thoracoscopy and as better instruments have been introduced, more complex operative procedures have been undertaken. Several series published from adult thoracic surgical centers have shown the feasibility and safety of thoracoscopic or video-assisted formal pul-
monary lobectomy in adults with early-stage carcinoma of the lung. Rothenberg 51 has adapted these techniques for children and has shown the safety of a formal anatomic lobectomy performed by thoracoscopy in children. In these cases, the vessels and bronchus have been managed individually with the Endo-GIA stapler. The specimen is removed through an expanded trocar site, without spreading the ribs. COMPLICATIONS
Several series have examined the complications of thoracoscopy in children. In 1993, we reported a review of all of the pediatric cases reported to that date in the English-language literature. 13 There was a very low and acceptable complication rate of the procedure for most indications. The single indication that contained the highest frequency of complications and the only reported mortality associated with the procedure was pulmonary biopsy for diffuse interstitial infiltrates. As already mentioned, these patients tended to be rauch sicker than patients with other indications for the procedure, and many were in respiratory failure on mechanical ventilation at the time of biopsy. Chen et a121 have examined the complications from their own thoracoscopic experience and found a similar acceptable rate of complications, principally postoperative pneumothorax and conversion to open thoracotomy. FUTURE APPLICATIONS
The last decade has seen an increasing acceptance of thoracoscopy by pediatric surgeons throughout the world. This technique now is a standard part of the practice of pediatric surgery, and it is one with which practitioners must be familiar. Its role is established firmly in the treatment of many intrathoracic disorders in children. The future will undoubtedly see an expansion of the indications and acceptance of thoracoscopy for more technically demanding procedures, such as formal lobectomy. The reports by Lobe and others of successful repairs of infants with esophageal atresia with or without fistula is an indication of the potential for this technique for other esophageal procedures, such as resection for strictures and division of H-fistulas. Esophagectomy for caustic ingestion may be facilitated by thoracoscopic techniques. The experience with thoracoscopy for occlusion of the ductus arteriosus suggests that the technique may be useful for division of vascular rings and aortic suspension. The successful application of this technique in smaller patients suggests that it may be possible to close congenital diaphragmatic hernias by thoracoscopy. The experience reported from adult trauma centers concerning the utility of thoracoscopy suggests a broader application in pediatric practice. It has been estimated that by the end of the current decade,
THORACOSCOPY
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approximately 70% of the intraabdominal procedures currently performed by pediatric surgeons may be performed with minimally invasive techniques. 52 One could speculate that a similar percentage of intrathoracic procedures in children also will be managed with minimally
invasive techniques. In addition to learning the technical skills to safely apply these techniques in children, it will be incumbent on all of us to acquire the judgment to decide which patients may truly benefit by these procedures.
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47. Kern JA, Rodgers BM: Thoracoscopy in the management of empyema in children. J Pediatr Surg 28:1128-1132, 1993 48. McGahren ED: The Use of thoracoscopy for treatment of empyema in children. Pediatr Endosurg Innov Tech 5:117-125, 2001 49. Burns RC, McGahren ED, Rodgers BM: Thoracoscopy in the management of chylothorax. Pediatr Endosurg Innov Tech 5:153-158, 2001 50. Graham DD, McGahren ED, Tribble CG, et al: Use of videoassisted thoracic surgery in the treatment of chylothorax. Ann Thorac Surg 57:1507-1512, 1994 51. Rothenberg SS: Thoracoscopic lung resection in children. J Pediatr Surg 35:271-274, 2000 52. Ure BM, Bax NMA, VanderZee DC: Laparoscopy in infants and children: A prospective study on feasibility and the impact on routine surgery. J Pediatr Surg 36:1170-1173, 2000