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Use of thoracoscopy in clinical practice
Use of Thoracoscopy in Clinical Practice Martin B. Durtschi, MD, Seattle, Washington
Endoscopic surgery and, in particular, thoraeoscopy, have become useful clinical tools as both technique and instrumentation have evolved. Our experience with a series of 20 patients undergoing thoracoscopy, including the indications, results, and outcome, is presented. Indications for thoracoscopy and biopsy or resection include the diagnosis and, in some cases, treatment of idiopathic pulmonary infiltrates, mycetomas, lung masses, spontaneous pneumothorax, and empyema. Morbidity is limited, and there has been no mortality due to the procedure.
From the Departmentof Surgery,SwedishHospitalMedicalCenter, Universityof WashingtonSchoolof Medicine,Seattle,Washington. Requests for reprints shouldbe addressedto Martin B. Durtschi, MD, Suite210, 515 Minor,Seattle,Washington98104. Presentedat the 79th AnnualMeetingof the North PacificSurgical Association,Tacoma,Washington,November13-14, 1992.
592
' n 1910, J a c o b a e u s i n t r o d u c e d t h e r a p e u t i c thoracoscopy, primarily for the treatment of pulmonary tuberculosis. The decline of the incidence of tuberculosis and an increasing understanding of the physiology of the pleural space caused thoracoscopy to be used more diagnostically and less therapeutically. Recently, enormous advances in instrumentation have sparked a resurgence in the use of thoracoscopy, for both the investigation and treatment of diseases of the mediastinum, lung, and pleural space. Thoracoscopy, also known as video-assisted thoracic surgery (VATS), has been used in adults [1,2] and children [3,4]. Indications have included idiopathic pleural effusions [5], diffuse pulmonary infiltrates [6], spontaneous pneumothorax [7-9], hyperhidrosis [10], Raynaud's phenomenon [11], thoracic empyema [12], mediastinal cysts and masses [3,13], pulmonary nodules [14], and pericardial disease [15]. Recently, both esophagectomy [16] and pulmonary lobectomy [17] have been reported. Presented here is our initial clinical experience with thoracoscopy in clinical practice. PATIENTS AND METHODS Twenty patients underwent VATS at the Swedish Hospital Medical Center in Seattle, Washington. The indications in 12 males and 8 females, aged 11 to 71 years, were lung mass in 9 patients, infiltrate in 6 patients, hilar mass in 2 patients, pneumothorax in 1 patient, idiopathic effusion in 1 patient, and causalgia in 1 patient. Fifteen of the 20 patients had concomitant disease, including acquired immunodefiency syndrome, lymphoma, myelodysplasia, or leukemia. Five patients had no underlying severe disease. All patients underwent thoracoscopy in the operating room receiving general endotracheal anesthesia while in the lateral decubitus position. Our preference is for the use of a double-lumen endotracheal tube to allow total collapse of the ipsilateral lung. Two patients, however, underwent successful thoracoscopy with only a singlelumen endotracheal tube, either because positive-pressure ventilation had been instituted preoperatively and could not be discontinued for an endotracheal tube change (one patient) or because the small tracheal size prevented the insertion of a double-lumen tube (one patient). To improve exposure in the pleural space, a tension pneumothorax was created with the judicious insufflation of carbon dioxide in two patients. The chest was entered, and a thoracoscope was inserted under direct vision. Blind placement of trocars was not done to avoid damaging either the lung or other pleural or mediastinal structures. Adhesions of lung to parietal pleura were lysed by gentle finger dissection or sharply lysed with clear visualization of the operative field.
THE AMERICANJOURNAL OF SURGERY VOLUME165 MAY 1993
THORACOSCOPY
Ports for placement of the thoracoscope and operating instruments ranged from 5 to 12 mm in diameter. Video endoscopic systems included rigid thoracoscopes with both 0 ~ and 30 ~ lenses, cameras, and monitors, a high-flow carbon dioxide insufflator, and a video printer. Endoscopic staplers with both tissue (3.5 mm) and vascular (3.0 V) staple lengths (U.S. Surgical Corporation, Norwalk, CT) were passed into the pleural space through a 12-ram port and were used to divide tissue. Initial entry into the pleural space was through the sixth or seventh intercostal space in the mid-axillary line, with the subsequent introduction of retracting and stapling instruments chosen after a thorough inspection of the pleural space and definition of the area of interest. No patient required placement of more than three entry ports in total, and the total incision length in almost all patients was less than 3.5 cm. Specimens were usually easily removed through a 12-mm entry site, with larger specimens removed through slightly enlarged incisions when necessary. At the completion of the procedure, chest tubes were placed, if needed, and the lung was re-expanded. Finally, instruments to facilitate urgent thoracotomy were kept in the operating room during thoracostomy. RESULTS In 17 of 20 patients, the preoperative goal (diagnosis or diagnosis and treatment) was successfully achieved by thoracoscopy (85%). One patient with mediastinal and aortopulmonary window adenopathy confirmed by computerized axial tomographic scan proved to have no pathologic findings at the aortopulmonary window at thoracoscopy, and cervical mediastinoscopy was used to document active tuberculosis. One patient with a pulmonary mass had previously had a pleural effusion and tube thoracostomy, resulting in extensive pleural adhesions, and adequate exposure required conversion to thoracotomy. Finally, one patient early in the series had inadequate deflation of her lung, and thoracoscopy could not safely be performed. Her surgery was also converted to thoracotomy. This procedure was diagnostic in 17 of 18 patients (94%). It was both diagnostic and therapeutic in 7 of 18 patients (39%). Diagnoses included invasive aspergillosis in five patients, diffuse interstitial or alveolar damage in four patients, organized pneumonia or scar in two patients, Hodgkin's disease in one patient, empyema in one patient, pulmonary bleb disease in one patient, sarcoidosis in one patient, benign carcinoid in one patient, and normal nerve and ganglion in one patient undergoing sympathectomy. There were no significant complications due to the procedure in any patient. One patient had an accumulation of a small amount of noninfected serous fluid in a thoracoscopy incision, which was easily drained. There were no wound infections. There was no postoperative hemorrhage, and no patient required transfusion. No patient required postoperative intubation and ventilation solely due to performance of the procedure. No patient died as a result of thoracoscopy.
Of 18 patients undergoing thoracoscopy, only 1 required enlargement of an incision to facilitate removal of a large segment of the right middle lobe containing a small benign carcinoid. All other patients had a maximum of three trocar sites, equivalent to a total incision length of 1.5 inches. Only three patients complained of moderate or severe pain, with all of the other patients complaining only of minimal pain or slight discomfort. Blood loss was not measured or estimated at greater than 50 mL in any patient. Chest tubes remained in place for between 0 and 11 days postoperatively (mean: 3.1 days). The single patient requiring prolonged tube thoracostomy was intubated because of severe bilateral adult respiratory distress syndrome and had high peak airway pressures. Her functioning chest tube was not removed because of concern about barotrauma. The last three patients in the series had their chest tubes removed either in the operating room or the recovery room after the lung was expanded and they had been extubated. Finally, although thoracoscopy has been performed with both general and local anesthetics, this experience was limited to patients undergoing surgery with general endotracheal anesthesia only. Visualization of the interpleural anatomy is excellent after the induction of a total unilateral pneumothorax, which allows, in particular, close inspection of the superior pleural surfaces and apex of the lung. COMMENTS The European literature has documented the extensive and successful use of VATS for multiple indications. Morbidity and mortality have been remarkably limited. Recently, institutions in the United States have also begun to publish their clinical experience supporting the use of thoracoscopy. Schaberg et al [6] performed thoracoscopy in 419 patients with greater than 85% accuracy (diagnosis or clarification of diagnosis) in diseases other than histiocytosis X. Only one complication, an air embolus, was documented. Page et al [14] used thoracoscopy in 121 patients resulting in 1 death (myocardial infarction) and 11 complications (9.1%), primarily respiratory in nature. Sensitivity was 99%, and specificity was 94%. Inderbitzi and Molnar [18] noted a complication rate of 5.6%, with 2 of 52 patients requiring surgical reintervention for intrathoracic hemorrhage. Thoracoscopy has been reported to be most effective in establishing a cause of pleural effusion [5], treating spontaneous pneumothorax [19], and diagnosing diffuse interstitial lung disease [6]. Early results of thoracoscopically performed thoracic sympathectomy for upper extremity arteriopathy, hyperhidrosis, causalgia, or Raynaud's phenomenon are mixed [10]. Fifty-three percent of patients treated by Guerin et al [11] had favorable results, but an unacceptable failure rate was noted early in that series, which led to modification of technique and improved results. Other reports have been largely anecdotal but do demonstrate that sympathectomy can be satisfactorily performed thoracoscopicaUy.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 165
MAY 1993
593
DURTSCHI
Treatment of empyema by thoracoscopic d6bridement and irrigation led to complete resolution in 60% of patients reported by Ridley and Braimbridge [12]. Recently, five cases of subtotal endoscopic esophagectomy for malignant (four patients) and benign (one patient) disease were reported, with essentially no blood loss measured in four of those patients [16]. Lewis et al [17] have described three patients with lung carcinoma who underwent thoracoscopic lobectomy with good results. The patients reported here represented most of the commonly accepted indications for thoracoscopic exploration. Thoracoscopy was successful in 18 of 20 patients in whom it was attempted, and the preoperative goals of the procedure were satisfied in all but 1. In every case, diagnostic information was obtained and was used in clinical decision-making. Therapy, such as bleb resection, d6bridement of empyema, resection of mycetoma, or curative resection of a solitary pulmonary nodule, was immediately added to patient management and prevented subsequent thoracotomy. There were no significant complications of thoracoscopy. Air leak from stapled lung tissue, with resulting tube thoracostomy, was limited, and there were no prolonged bronchopleural fistulas, even when patients required high-pressure ventilation for diffuse interstitial lung disease. As confidence with this procedure has increased, routine postoperative tube thoracostomy has been eliminated and is reserved for drainage of blood or air documented at the time of surgery. Pain was remarkably decreased. Although accurate quantitation of pain is impossible to determine in retrospect, nearly all patients reported either no pain or minimal discomfort on the first postoperative day. Blood loss was noted as minimal and was usually measured as less than 50 mL. The total length of the incision was less than 4 cm in all but one patient who required enlargement of a single incision to facilitate excision and removal of a large segment of the right middle lobe. The indications for thoracoscopy are not different than those for thoracotomy. The improvements in technology, which allow the surgeon to perform less invasive surgery, should not lead to a change in the reasons to perform the surgery. Rather, it may allow an easier postoperative course for the patient and eventually lead to a decrease in complications such as atelectasis, bleeding, and pain. Thoracoscopy will not substitute for thoracotomy in all cases. Proper patient selection and a clear definition of the goals of the relative procedures are important for maintaining patient safety and maximizing outcome. Recently, the Councils of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons formed a joint committee on thoracoscopy and VATS. Their guidelines suggest that thoracoscopy or VATS should be performed only by surgeons qualified to perform open thoracic surgical procedures and to manage
594
their potential complications. Guidelines for learning VATS techniques resemble those for other endoscopically performed procedures, including hands-on laboratory experience and proctoring by previously qualified surgeons. REFERENCES 1. EngelerA, Frey JG, TschoppJM. Thoracoscopy:diagnosticand therapeutic use. Journal Suisse de Medecine 1992; 122: 27-32. 2. Coltharp WH, Arnold JH, Alford WC Jr, et al. Videothoracoscopy: improvedtechnique and expanded indications. Ann Thorac Surg 1992; 53: 776-8. 3. Rogers DA, Philippe PG, Lobe TE, et al. Thoracoscopyin children: an initial experiencewith an evolvingtechnique. J Laparoendosc Surg 1992; 2: 7-14. 4. Landreneau RJ, Mack MJ, Hezelrig Sr, et al. Video-assisted thoracic surgery: basic technicalconceptsand intercostalapproach strategies. Ann Thorac Surg 1992; 54: 800-7. 5. Boutin C, Astoul P, Seitz B. The role of thoracoscopyin the evaluation and management of pleural effusions. Lung 1990; 168(Suppl): 1113-21. 6. Schaberg T, Suttmann-BayerlA, LoddenkemperR. Thoracoscopy in diffuse lung diseases. Pneumologie 1989; 43:112-5. 7. InderbitziR, Furrer M, Striffeler H. Surgicalthoracoscopy--indieations and technique. Early results in spontaneous pneumothorax. Chirurg 1992; 63: 334-41. 8. Nathanson LK, ShimiSM, Wood RA, CuschieriA. Videothoracoscopicligationof bulls and pleurectomyfor spontaneouspneumothorax. Ann Thorac Surg 1991; 52: 316-9. 9. TsukamotoT, Nakamura H, Satch T, et aL Comparativestudies using a rigid thoracoscopeand fiberoptic bronchoscopeto treat spontaneous pneumothorax. Chest 1991; 100: 953-8. 10. ToomesH, Linder A. Thoracoscopicsympathectomyin hyperhidrosis. Pneumologie 1989; 43: 107-8. 11. Guerin JC, DemolombeS, Brudon JR. Thoracic sympathectomy by thoracoseopy.Aproposof 15 cases. Rev Mal Respir 1990;7: 327-30. 12. Ridley PD, BraimbridgeMV. Thoracoscopicdebridementand pleural irrigation in the management of empyema thoracis. Ann Thorac Surg 1991; 53: 461-4. 13. Lewis RJ, Caccavale RJ, Sisler GE. Imaged thoracoscopic surgery:a new thoracictechniquefor resectionof mediastinalcysts. Ann Thorac Surg 1992; 53: 318-20. 14. Page RD, Jeffrey RR, DonnellyRJ. Thoracoscopy:a reviewof 121 consecutivesurgical procedures. Ann Thorac Surg 1989; 48: 66-8. 15. Vogel B, Mall W. Thoracoscopic pericardial fenestration-diagnostic and therapeutic aspects. Pneumologie 1990; 44(Suppl 1): 184-5. 16. Cuschieri A, Shimi S, Banting S. Endoscopicoesophagectomy through a right thoracoscopicapproach.J R Coil Surg Edinb 1992; 37: 7-11. 17. Lewis RJ, Sisler GE, Caccavale ILl. Imaged thoracic lobectomy. Ann Thorac Surg 1992; 54: 80-3. 18. Inderbitzi R, Molnar J. Experiences in the diagnostic and surgical video-endoscopyof the thoracic cavity.SchweizMed Wochenschr 1990; 120: 1965-70. 19. Inderbitzi R, Furrer M, Striffeler H. Surgical thoracoscopy--indications and technique. Early results in spontaneous pneumothorax. Chirurg 1992; 63: 334-41.
THE AMERICAN JOURNAL OF SURGERY VOLUME165 MAY 1993
Endoscopic surgery and, in particular, thoraeoscopy, have become useful clinical tools as both technique and instrumentation have evolved. Our experience with a series of 20 patients undergoing thoracoscopy, including the indications, results, and outcome, is presented. Indications for thoracoscopy and biopsy or resection include the diagnosis and, in some cases, treatment of idiopathic pulmonary infiltrates, mycetomas, lung masses, spontaneous pneumothorax, and empyema. Morbidity is limited, and there has been no mortality due to the procedure.
From the Departmentof Surgery,SwedishHospitalMedicalCenter, Universityof WashingtonSchoolof Medicine,Seattle,Washington. Requests for reprints shouldbe addressedto Martin B. Durtschi, MD, Suite210, 515 Minor,Seattle,Washington98104. Presentedat the 79th AnnualMeetingof the North PacificSurgical Association,Tacoma,Washington,November13-14, 1992.
592
' n 1910, J a c o b a e u s i n t r o d u c e d t h e r a p e u t i c thoracoscopy, primarily for the treatment of pulmonary tuberculosis. The decline of the incidence of tuberculosis and an increasing understanding of the physiology of the pleural space caused thoracoscopy to be used more diagnostically and less therapeutically. Recently, enormous advances in instrumentation have sparked a resurgence in the use of thoracoscopy, for both the investigation and treatment of diseases of the mediastinum, lung, and pleural space. Thoracoscopy, also known as video-assisted thoracic surgery (VATS), has been used in adults [1,2] and children [3,4]. Indications have included idiopathic pleural effusions [5], diffuse pulmonary infiltrates [6], spontaneous pneumothorax [7-9], hyperhidrosis [10], Raynaud's phenomenon [11], thoracic empyema [12], mediastinal cysts and masses [3,13], pulmonary nodules [14], and pericardial disease [15]. Recently, both esophagectomy [16] and pulmonary lobectomy [17] have been reported. Presented here is our initial clinical experience with thoracoscopy in clinical practice. PATIENTS AND METHODS Twenty patients underwent VATS at the Swedish Hospital Medical Center in Seattle, Washington. The indications in 12 males and 8 females, aged 11 to 71 years, were lung mass in 9 patients, infiltrate in 6 patients, hilar mass in 2 patients, pneumothorax in 1 patient, idiopathic effusion in 1 patient, and causalgia in 1 patient. Fifteen of the 20 patients had concomitant disease, including acquired immunodefiency syndrome, lymphoma, myelodysplasia, or leukemia. Five patients had no underlying severe disease. All patients underwent thoracoscopy in the operating room receiving general endotracheal anesthesia while in the lateral decubitus position. Our preference is for the use of a double-lumen endotracheal tube to allow total collapse of the ipsilateral lung. Two patients, however, underwent successful thoracoscopy with only a singlelumen endotracheal tube, either because positive-pressure ventilation had been instituted preoperatively and could not be discontinued for an endotracheal tube change (one patient) or because the small tracheal size prevented the insertion of a double-lumen tube (one patient). To improve exposure in the pleural space, a tension pneumothorax was created with the judicious insufflation of carbon dioxide in two patients. The chest was entered, and a thoracoscope was inserted under direct vision. Blind placement of trocars was not done to avoid damaging either the lung or other pleural or mediastinal structures. Adhesions of lung to parietal pleura were lysed by gentle finger dissection or sharply lysed with clear visualization of the operative field.
THE AMERICANJOURNAL OF SURGERY VOLUME165 MAY 1993
THORACOSCOPY
Ports for placement of the thoracoscope and operating instruments ranged from 5 to 12 mm in diameter. Video endoscopic systems included rigid thoracoscopes with both 0 ~ and 30 ~ lenses, cameras, and monitors, a high-flow carbon dioxide insufflator, and a video printer. Endoscopic staplers with both tissue (3.5 mm) and vascular (3.0 V) staple lengths (U.S. Surgical Corporation, Norwalk, CT) were passed into the pleural space through a 12-ram port and were used to divide tissue. Initial entry into the pleural space was through the sixth or seventh intercostal space in the mid-axillary line, with the subsequent introduction of retracting and stapling instruments chosen after a thorough inspection of the pleural space and definition of the area of interest. No patient required placement of more than three entry ports in total, and the total incision length in almost all patients was less than 3.5 cm. Specimens were usually easily removed through a 12-mm entry site, with larger specimens removed through slightly enlarged incisions when necessary. At the completion of the procedure, chest tubes were placed, if needed, and the lung was re-expanded. Finally, instruments to facilitate urgent thoracotomy were kept in the operating room during thoracostomy. RESULTS In 17 of 20 patients, the preoperative goal (diagnosis or diagnosis and treatment) was successfully achieved by thoracoscopy (85%). One patient with mediastinal and aortopulmonary window adenopathy confirmed by computerized axial tomographic scan proved to have no pathologic findings at the aortopulmonary window at thoracoscopy, and cervical mediastinoscopy was used to document active tuberculosis. One patient with a pulmonary mass had previously had a pleural effusion and tube thoracostomy, resulting in extensive pleural adhesions, and adequate exposure required conversion to thoracotomy. Finally, one patient early in the series had inadequate deflation of her lung, and thoracoscopy could not safely be performed. Her surgery was also converted to thoracotomy. This procedure was diagnostic in 17 of 18 patients (94%). It was both diagnostic and therapeutic in 7 of 18 patients (39%). Diagnoses included invasive aspergillosis in five patients, diffuse interstitial or alveolar damage in four patients, organized pneumonia or scar in two patients, Hodgkin's disease in one patient, empyema in one patient, pulmonary bleb disease in one patient, sarcoidosis in one patient, benign carcinoid in one patient, and normal nerve and ganglion in one patient undergoing sympathectomy. There were no significant complications due to the procedure in any patient. One patient had an accumulation of a small amount of noninfected serous fluid in a thoracoscopy incision, which was easily drained. There were no wound infections. There was no postoperative hemorrhage, and no patient required transfusion. No patient required postoperative intubation and ventilation solely due to performance of the procedure. No patient died as a result of thoracoscopy.
Of 18 patients undergoing thoracoscopy, only 1 required enlargement of an incision to facilitate removal of a large segment of the right middle lobe containing a small benign carcinoid. All other patients had a maximum of three trocar sites, equivalent to a total incision length of 1.5 inches. Only three patients complained of moderate or severe pain, with all of the other patients complaining only of minimal pain or slight discomfort. Blood loss was not measured or estimated at greater than 50 mL in any patient. Chest tubes remained in place for between 0 and 11 days postoperatively (mean: 3.1 days). The single patient requiring prolonged tube thoracostomy was intubated because of severe bilateral adult respiratory distress syndrome and had high peak airway pressures. Her functioning chest tube was not removed because of concern about barotrauma. The last three patients in the series had their chest tubes removed either in the operating room or the recovery room after the lung was expanded and they had been extubated. Finally, although thoracoscopy has been performed with both general and local anesthetics, this experience was limited to patients undergoing surgery with general endotracheal anesthesia only. Visualization of the interpleural anatomy is excellent after the induction of a total unilateral pneumothorax, which allows, in particular, close inspection of the superior pleural surfaces and apex of the lung. COMMENTS The European literature has documented the extensive and successful use of VATS for multiple indications. Morbidity and mortality have been remarkably limited. Recently, institutions in the United States have also begun to publish their clinical experience supporting the use of thoracoscopy. Schaberg et al [6] performed thoracoscopy in 419 patients with greater than 85% accuracy (diagnosis or clarification of diagnosis) in diseases other than histiocytosis X. Only one complication, an air embolus, was documented. Page et al [14] used thoracoscopy in 121 patients resulting in 1 death (myocardial infarction) and 11 complications (9.1%), primarily respiratory in nature. Sensitivity was 99%, and specificity was 94%. Inderbitzi and Molnar [18] noted a complication rate of 5.6%, with 2 of 52 patients requiring surgical reintervention for intrathoracic hemorrhage. Thoracoscopy has been reported to be most effective in establishing a cause of pleural effusion [5], treating spontaneous pneumothorax [19], and diagnosing diffuse interstitial lung disease [6]. Early results of thoracoscopically performed thoracic sympathectomy for upper extremity arteriopathy, hyperhidrosis, causalgia, or Raynaud's phenomenon are mixed [10]. Fifty-three percent of patients treated by Guerin et al [11] had favorable results, but an unacceptable failure rate was noted early in that series, which led to modification of technique and improved results. Other reports have been largely anecdotal but do demonstrate that sympathectomy can be satisfactorily performed thoracoscopicaUy.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 165
MAY 1993
593
DURTSCHI
Treatment of empyema by thoracoscopic d6bridement and irrigation led to complete resolution in 60% of patients reported by Ridley and Braimbridge [12]. Recently, five cases of subtotal endoscopic esophagectomy for malignant (four patients) and benign (one patient) disease were reported, with essentially no blood loss measured in four of those patients [16]. Lewis et al [17] have described three patients with lung carcinoma who underwent thoracoscopic lobectomy with good results. The patients reported here represented most of the commonly accepted indications for thoracoscopic exploration. Thoracoscopy was successful in 18 of 20 patients in whom it was attempted, and the preoperative goals of the procedure were satisfied in all but 1. In every case, diagnostic information was obtained and was used in clinical decision-making. Therapy, such as bleb resection, d6bridement of empyema, resection of mycetoma, or curative resection of a solitary pulmonary nodule, was immediately added to patient management and prevented subsequent thoracotomy. There were no significant complications of thoracoscopy. Air leak from stapled lung tissue, with resulting tube thoracostomy, was limited, and there were no prolonged bronchopleural fistulas, even when patients required high-pressure ventilation for diffuse interstitial lung disease. As confidence with this procedure has increased, routine postoperative tube thoracostomy has been eliminated and is reserved for drainage of blood or air documented at the time of surgery. Pain was remarkably decreased. Although accurate quantitation of pain is impossible to determine in retrospect, nearly all patients reported either no pain or minimal discomfort on the first postoperative day. Blood loss was noted as minimal and was usually measured as less than 50 mL. The total length of the incision was less than 4 cm in all but one patient who required enlargement of a single incision to facilitate excision and removal of a large segment of the right middle lobe. The indications for thoracoscopy are not different than those for thoracotomy. The improvements in technology, which allow the surgeon to perform less invasive surgery, should not lead to a change in the reasons to perform the surgery. Rather, it may allow an easier postoperative course for the patient and eventually lead to a decrease in complications such as atelectasis, bleeding, and pain. Thoracoscopy will not substitute for thoracotomy in all cases. Proper patient selection and a clear definition of the goals of the relative procedures are important for maintaining patient safety and maximizing outcome. Recently, the Councils of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons formed a joint committee on thoracoscopy and VATS. Their guidelines suggest that thoracoscopy or VATS should be performed only by surgeons qualified to perform open thoracic surgical procedures and to manage
594
their potential complications. Guidelines for learning VATS techniques resemble those for other endoscopically performed procedures, including hands-on laboratory experience and proctoring by previously qualified surgeons. REFERENCES 1. EngelerA, Frey JG, TschoppJM. Thoracoscopy:diagnosticand therapeutic use. Journal Suisse de Medecine 1992; 122: 27-32. 2. Coltharp WH, Arnold JH, Alford WC Jr, et al. Videothoracoscopy: improvedtechnique and expanded indications. Ann Thorac Surg 1992; 53: 776-8. 3. Rogers DA, Philippe PG, Lobe TE, et al. Thoracoscopyin children: an initial experiencewith an evolvingtechnique. J Laparoendosc Surg 1992; 2: 7-14. 4. Landreneau RJ, Mack MJ, Hezelrig Sr, et al. Video-assisted thoracic surgery: basic technicalconceptsand intercostalapproach strategies. Ann Thorac Surg 1992; 54: 800-7. 5. Boutin C, Astoul P, Seitz B. The role of thoracoscopyin the evaluation and management of pleural effusions. Lung 1990; 168(Suppl): 1113-21. 6. Schaberg T, Suttmann-BayerlA, LoddenkemperR. Thoracoscopy in diffuse lung diseases. Pneumologie 1989; 43:112-5. 7. InderbitziR, Furrer M, Striffeler H. Surgicalthoracoscopy--indieations and technique. Early results in spontaneous pneumothorax. Chirurg 1992; 63: 334-41. 8. Nathanson LK, ShimiSM, Wood RA, CuschieriA. Videothoracoscopicligationof bulls and pleurectomyfor spontaneouspneumothorax. Ann Thorac Surg 1991; 52: 316-9. 9. TsukamotoT, Nakamura H, Satch T, et aL Comparativestudies using a rigid thoracoscopeand fiberoptic bronchoscopeto treat spontaneous pneumothorax. Chest 1991; 100: 953-8. 10. ToomesH, Linder A. Thoracoscopicsympathectomyin hyperhidrosis. Pneumologie 1989; 43: 107-8. 11. Guerin JC, DemolombeS, Brudon JR. Thoracic sympathectomy by thoracoseopy.Aproposof 15 cases. Rev Mal Respir 1990;7: 327-30. 12. Ridley PD, BraimbridgeMV. Thoracoscopicdebridementand pleural irrigation in the management of empyema thoracis. Ann Thorac Surg 1991; 53: 461-4. 13. Lewis RJ, Caccavale RJ, Sisler GE. Imaged thoracoscopic surgery:a new thoracictechniquefor resectionof mediastinalcysts. Ann Thorac Surg 1992; 53: 318-20. 14. Page RD, Jeffrey RR, DonnellyRJ. Thoracoscopy:a reviewof 121 consecutivesurgical procedures. Ann Thorac Surg 1989; 48: 66-8. 15. Vogel B, Mall W. Thoracoscopic pericardial fenestration-diagnostic and therapeutic aspects. Pneumologie 1990; 44(Suppl 1): 184-5. 16. Cuschieri A, Shimi S, Banting S. Endoscopicoesophagectomy through a right thoracoscopicapproach.J R Coil Surg Edinb 1992; 37: 7-11. 17. Lewis RJ, Sisler GE, Caccavale ILl. Imaged thoracic lobectomy. Ann Thorac Surg 1992; 54: 80-3. 18. Inderbitzi R, Molnar J. Experiences in the diagnostic and surgical video-endoscopyof the thoracic cavity.SchweizMed Wochenschr 1990; 120: 1965-70. 19. Inderbitzi R, Furrer M, Striffeler H. Surgical thoracoscopy--indications and technique. Early results in spontaneous pneumothorax. Chirurg 1992; 63: 334-41.
THE AMERICAN JOURNAL OF SURGERY VOLUME165 MAY 1993