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Video-assisted thoracic surgery
Video-assisted thoracic surgery The Chang Gung experience Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as foUows: (1) Video-assisted thoracic surgery can be as effective therapeuticaUy as many formal thoracotomy. (2) ExceUent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an exceUent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visuaUy guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also aUows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest. (J THORAC CARDIOVASC SURG 1994;108:834-40)
Hui-Ping Liu, MD, Chau-Hsiung Chang, MD, Pyng Jing Lin, MD, Hung-Chang Hsieh, MD, Jen-Ping Chang, MD, and Ming-Jang Hsieh, MD, Taipei, Taiwan, Republic of China
DesPite the wide application of video-assisted techniques in "thoracoscopic" or "thoracic" surgery, the majority of surgeons have limited experience with these techniques. Data from recent literatures showed that video-assisted thoracic surgery (VATS) addresses a variety of more complex thoracic problems.l- 2 The applications of it have resulted in a number of controversial aspects.
From Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China. Received for publication Feb. 25, 1994. Accepted for publication July II, 1994. Address for reprints: Hui-Ping Liu, MD, Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199, Tun-Hwa North Rd., Taipei, Taiwan, Republic of China. Copyright @ 1994 by Mosby-Year Book, Inc. 0022-5223/94 $3.00
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Because the use of a new technology needs to incorporate wide experiences from worldwide centers, we present here our own experiences with the use of VATS in the past 22 months at Chang Gung Memorial Hospital in Taipei. We hope that we can make some contribution to this rapidly evolving field. Patients and methods Patients. VATS was first carried out in this hospital in March 1992. The first patient was a 21-year-old woman who had a recurrent spontaneous pneumothorax. Since then, 299 other patients have had video-assisted procedures by means of the technique described as follows. In total, there were 172 men and 128 women with ages ranging from 1 to 83 years (average 57 years). Forty-one patients had preexisting chronic cardiac or respiratory disabilities. Four had a severely limited respiratory reserve with a forced expiratory volume in 1 second of 0.5 L. All the patients were informed that an open thoracotomy might be necessary and all signed the operative consent form. Basic technique. All the procedures were performed with the
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patient under general anesthesia with double-lumen endotracheal intubation. Patients were positioned and draped as for a standard open procedure. After the chest was prepared and the lung for use in the procedure was collapsed, a 2 em incision was made over the seventh intercostal space at the midaxillary line. The chest was entered carefully through a stab incision. Digital palpation determined the presence of adhesions and the bleeders from the wounds (usually muscle) were checked meticulously.1fnone were present, an 11 mm nondisposable trocar was inserted through which the thoracoscope was inserted. The entire thoracic cavity was then carefully explored by means of projected images on the video monitor. Depending on the site of the lesionand the type of the operation, another one or two stab incisions (2 em) were made to allow the introduction of conventional instruments into the chest. No trocars or thoracoports (Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.) were used in those incisions. The procedures were usually carried out with three incisions in a triangular configuration on the chest. Various procedures can be performed with conventional thoracic surgical instruments. Specific details of the technique for different procedures are described as follows. Bullectomy jblebectomy and pleurodesis. The apex was investigated first for an actively leaking bleb/bulla. If the site of the leak was not found in the collapsed lung, the anesthesiologist was asked to inflate the lung slowly with a small tidal volume. Warm saline solution was introduced into the chest until the actively leaking area became visible. Once the leak or bleb/ bulla was found, an Endo-GIA 30 stapler (Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.) was placed through one of the incisions and fired across the base of the bleb/bulla. The stapler line was carefully examined for a possible air leak and pleurodesis was later performed. In patients with secondary spontaneous pneumothorax (usually elderly patients with preexisting lung diseases) and an emphysematous change of lung parenchyma, the bulla was often so broad that resection with staplers across its base was not possible. The active leaks were usually ligated with Endoloop ligatures (Ethicon, Inc., Somerville, N.J.). In each ofthe bullae, at least two to three Endoloop ligatures were applied to shrink and obliterate the leaks. The shrunk bulla was resected after ligation.Sometimes, the exact site of the leak could not be identified and then talc insufflation was performed directly to the leaking area under video guidance. This was performed only when the lung was totally and fully reexpanded with the aid of the ventilator. On completion of the procedure, a chest tube (32F) was placed through one of the incisions. All the wounds were closed with interrupted 3-0 silk sutures. Wedge resection oflung nodule. After insertion of the thoracoscope, the nodule was identified by means of inspection, instrumental palpation, and digital confirmation of its size and margin. It was then grasped with a conventional ring forceps that was inserted through a second incision. Through the third incision, one or two applications of the Endo-GIA 30 stapler werefired to achieve a wedge resection of the lung parenchyma containing the nodule. The lung was then slowly reexpanded under image visualization to assure the staple line for hemostasis and air leaks. Pulmonary, pleural, and mediastinal (including lymph nodes) biopsies. On thoracoscopic exploration, the entire thoracic cavity was inspected for evidence of a mass or metastasis. Lung biopsies were accomplished with endoscopic stapled
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wedge resections of the specimen. A cup biopsy forceps was usually used for resection of the pleural or mediastinal lesions. Sometimes, electrocautery was used to penetrate the capsule of the mass so that an accurate sample of the tissue could be obtained. All of the bleeders were controlled with the electrocautery. Mediastinal tumor resection. Under video vision, the entire mediastinum was thoroughly investigated. Conventional ring forceps, Satinsky clamps, and electrocautery were used for traction and dissection of the tumor. The dissection was simple and usually straightforward. The tumor can be extracted easily through an extended manipulation incision. A chest tube was placed within the pleura and the incisions were closed with interrupted sutures. Decortication and enucleation ofempyema. The exploration often reveals loculi of pus and fibrinous adhesions within the chest cavity. Conventional instruments with a long-handled clamp, ring forceps, and a large-bore wall suction tube were frequently used to break down the empyema cavity. All the debris and necrotic tissue can be repeatedly removed and washed out with warm saline solution. The fibrous pleural "peel" can be grasped and decorticated to a maximal extent by interchanging the position of conventional instruments through different manipulation incisions. Changing the position of the scope also improved visual orientation and allowed better access to certain areas for further debridement. Two chest tubes (32F) were usually placed for suction drainage after completion of the procedure. Evacuation ofblood clot (chest trauma). The blood clots can be evacuated efficiently with the aforementioned large-bore conventional wall suction tube. Warm saline solution was always introduced through one of the incisions to wash out the blood clots, and at the same time it aids in identifying the bleeders. The active bleeders were usually cauterized or clipped, under video vision. Pericardial window/pericardiectomy. After the thoracoscope was introduced, the phrenic nerve was routinely identified and kept in view throughout the procedure. A stab incision was usually created on the surface of the distended pericardium by electrocautery. A conventional sharp Kelly clamp was then used carefully to penetrate the stabbed hole to allow pericardial fluid to drain into the pleural space. The hole was then dilated and grasped with a forceps. This opening was further enlarged by electrocautery to create an adequate pericardiopleural window (usually 3 by 4 em). The fluid was sent for cytologic evaluation and the specimen was sent for pathologic analysis. A 32F chest tube was placed through the inferior incision, which had already been made. If a bilateral pericardiectomy was indicated, the left and right sides of the pericardium were resected sequentially to a maximal extent as in an open procedure. This resection was accomplished in the aforementioned manner. VATS lobectomy. As soon as the monitors and thoracoscope were functional, one of the incisions (usually one close to the lesion) was extended (4 to 6 em in length). This incision, which we called an extended manipulation channel, was usually created earlier to accommodate the standard conventional instruments passing into it for manipulation and eventually for specimen retrieval at the end ofthe operation. The procedure usually started with the dissection of the interlobar fissure and the pleural adhesions with electrocautery. The lung parenchyma was retracted with conventional ring forceps. The interlobar arteries were identified and dissected carefully with a conventional
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Table I. VATS procedures at Chang Gung Memorial Hospital (Taipei) from March 1992 to December 1993 Spontaneous pneumothorax (bullectomyjpleurodesis) Mediastinal tumor resection Mediastinal lymph nodebiopsies Infiltrating lungdiseases (wedge biopsy) Lung nodule (wedge resection) Pulmonary lobectomy PericardiaI window/pericardiectomy Pleurallesions (biopsies) Empyema (decortication) Lung abscess (pneumonotomy) Chest trauma (hemothorax) Esophageal diseases VATS esophagectomy VATS esophagomyomectomy VATS esophagectomy and reconstruction
75 24 9 II
76 16
26 15 7
3 9 29 6 3 20
right-angled hemostat and diathermy. Blunt dissection with the tip of the wall suction tube aided in the exposure of the interlobar vessels. The vessels were usually encircled with 3-0 silk sutures and the ligation was performed as in open thoracotomy. Either the suture was tied directly through the extended manipulation channel or the externally tied knot was cinched down inside the thoracic cavity with a right-angled hemostat. The arteries were then cut and hemostasis was checked meticulously. The pulmonary vein was managed in the same way as the interlobar artery. The interlobar bronchus was finally divided by means of the Endo-GIA stapler with a 3.5 mm staple cartridge. When the specimen was completely freed, it was retrieved through the extended manipulation channel. The lung was reexpanded under video vision to verify that the bronchial seal was adequate. Two chest tubes were placed through the incisions already made. The wounds were then closed with interrupted sutures. Esophageal procedures. Esophageal procedures include VATS esophagomyomectomy, esophagectomy, and thoracic esophageal reconstruction. VATS ESOPHAGOMYOMECTOMY. VATS esophagomyomectomy was performed through the left side of the chest on the distal part of the esophagus. After insertion of the thoracoscope, the inferior ligament was divided first with electrocautery. The myotomy began with dissection through the outer longitudinal muscle layer with a ring forceps and electrocautery. When the inner circular muscle layer was reached, the fibers were lifted away from the mucosa and were carefully divided with diathermy. A small rounded "pusher" may aid in the separation of the muscle from the mucosa. The myotomy was then continued from the level of the inferior pulmonary ligament to approximately I cm past the gastroesophageal junction. Lateral myomectomy was performed to prevent possible healing of the muscle edges. Finally, a diluted methylene blue solution was introduced through a nasogastric tube into the esophagus to ensure the integrity of the mucosa. Oral feedings started the following day and the patient was discharged when able to tolerate food intake. • VATS ESOPHAGECTOMY. For VATS esophagectomy, after completion of the esophageal reconstruction through a laparotomy and cervicotomy, the patient was placed in a left lateral
position. The first incision (2 em) was created in the seventh intercostal space in the posterior axillary line for introduction of the scope. Two incisions (both 2 ern) were created in the third and seventh intercostal spaces in the anterior axillary line for lung traction. The other two incisions (3 to 4 ern), so-called manipulation channels, were created in the fourth and seventh intercostal spaces in the midaxillary lines. The mobilization of the esophagus was initially carried out in an area that was not involvedby the tumor. After the mediastinal pleura was opened, the lateral sides of the esophagus were loosened with the tip of the conventional wall suction tube. Once partly freed, the esophagus was grasped and elevated. It was then separated from the surrounding tissue by electrocautery. Any lymph nodes visible in the region were removed. The esophageal tumor was resected to a maximal extent under image visualization. All the vesselswere divided between metal clips or electrocautery. Earlyon, the upper and lower portions of the esophagus had been resected and ligated with an umbilical tape during laparotomy and cervicotomy. By traction on these tapes, the esophagus was further dissected and mobilized. When the esophagus was completely freed, it was placed in a protective bag (usually glove) and retrieved through one of the extended manipulation channels. A 32F chest tube was placed in the esophageal bed. All of the wounds were closed with interrupted sutures. VATS ESOPHAGECTOMY AND RECONSTRUCTION. The abdominal procedure in preparation of the gastric tube was the same for VATS esophagectomy and reconstruction as for an open procedure. The patient was turned to the left lateral position and the incisions were performed as described earlier. By interchange of conventional instruments through different manipulation incisions, the esophagus was dissected to an adequate margin (usually close to the thoracic inlet) and the gastric tube was delivered into the chest. The cardioesophageal junction was divided. (This was initially stapled during laparotomy.) A site was chosen (usually posterior aspect of the stomach) for esophagogastric anastomosis. Traction sutures were placed on the distal end after transection of the esophagus. A hand-sewn 1-0 Prolene pursestring suture (Ethicon) was placed on the distal edge of the esophagus under video guidance. (Sometimes, direct visualization through the extended manipulation channels aided in the execution of the conventional suturing technique.) A curved intraluminal stapler (Ethicon) without an anvil was introduced through the extended manipulation channel (seventh intercostal space) and into a gastrotomy incision. Under image visualization, the anvil was then placed on the center rod and inserted into the esophagus with traction on the sutures. The pursestring knot was tied and the stapler was closed and fired. Stapler lines were carefully examined. A nasogastric tube (16F) was placed within the stomach for decompression. The gastrotomy wound was then closed and the pleural cavity was irrigated with a warm saline solution. The chest tube was placed in the esophageal bed and all of the incisions were closed with interrupted 3-0 silk. A routine esophagogram was performed 2 weeks after the operation.
Results Table I summarizes the characteristics of all patients in the series. A total of 300 patients were reviewed. Seventy-five patients underwent a VATS procedure to treat their air leaks. Thirty-five young patients (ages ranging from 13 to 36 years) with primary spontaneous pneu-
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mothorax were treated by apical blebectomy/bullectomy with the Endo-GIA 30 stapler, Each patient had a subsequent pleural abrasion from the apex to the fifth rib. In 29 patients (52 to 80 years of age) secondary spontaneous pneumothorax was managed through ligation of the bullae with Endoloop ligatures. Subsequent talc insufflation was performed before ending the procedure. In these two groups of patients, the chest tube drainage required ranged from 2 to 5 days and the average hospital stay was 5 days (range 3 to 7 days). One patient required a second operation for an air leak when an Endoloop ligature (only one catgut Endoloop ligature used) slipped from the lung parenchyma after a forceful sneeze 2 days after the operation. The patient's air leak was resolved 3 days after a second VATS operation by means of the conventional suturing technique. Since then, at least two to three slow absorbable Endoloop ligatures made of PDS II suture (Ethicon) were used without any complication. In another 11 patients (ages ranging from 55 to 71 years) with diffuse bullous lung diseases, the exact leaking bullae were not clearly identified. Ligation of the bullae by the Endoloop ligature technique in this group of patients seemed impossible, and thus only thoracoscopic talc insufflation was performed directly to the air leak area. Two patients had prolonged air leaks lasting from 10 to 14 days after the procedure. In the remaining nine patients air leaks ended quickly within 1 week. All of the patients had an uneventful postoperative course. No recurrence of pneumothorax has been seen during a mean follow-up of 16 months. Thoracoscopic wedge resections for peripherally located nodules were performed in 76 patients. Twenty-nine patients were found to have benign lesions (hamartoma, n = 6; caseating granuloma, n = 10; cryptococcosis, n = 2; interstitial fibrosis, n = 8; and sclerosing hemangioma, n = 3) and 47 had metastatic pulmonary lesions from a variety of primary cancers (limb sarcoma, n = 19; renal, n = 3; colon, n = 6; uterus, n = 2; pharynx, n = 3; salivary gland, n = 2; liver, n = 1; thymus, n = 3; esophagus, n = 3; thyroid, n = 3; and metastatic spindle cell tumor of unknown primary, n = 2). The mean diameter of the resected nodule was 1.2 em with a range of 0.5 to 3.5 em. All of the nodules detected by chest computed tomographic scan were successfully identified and resected thoracoscopieally with a mean postoperative hospital stay of 4.5 days (range 3 to 9 days). Prolonged pleural effusionwas noted in two patients. Their chest tubes were removed on days 7 and 8, respectively. No morbidity or mortality was attributable to the procedure. Twenty-four mediastinal tumors were resected by means of VATS. These include six teratomas, five neurofibromas, two ganglioneuromas, six neurilemomas,
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one paraganglioma, one cystic lymphangioma, and three granulomas. Fifteen lesions were located in the posterior mediastinum, three were in the superior mediastinum, and six were found in the anterior mediastinum. The average tumor size was 3.5 ern (range 1.5 to 6 em). All of the patients have had an uneventful postoperative course with an average hospital stay of 5 days. Lung biopsies (wedge resection) of infiltrating lung diseases were performed uneventfully with the Endo-GIA stapler in 11 patients. Successful confirmation of malignancy by frozen section was also accomplished in 15 patients through thoracoscopic pleural biopsies. Nine patients with enlarged mediastinal lymph nodes were subjected to VATS biopsies. Seven of the specimens were found to be positive for malignancy and two showed benign inflammatory changes. Thoracoscopic drainage of empyema was accomplished in seven patients. Five of them were in an early transitional phase (fibrinopurulent stage). Two had loculated collections of pus and debris. Decortication with release of the trapped lung was uneventfully performed through thoracoscopic intervention. Despite prolonged hospital stays of 2 weeks while waiting for the chest tubes to be shortened for open drainage, all of the patients had complete reexpansion of the lung after the operation. Thoracoscopy-assisted evacuation of blood clots was achieved in nine patients with acute chest trauma. Three had penetrating chest wounds with progressive bloody discharge from the chest tube. The active intercostal bleeding vessels were cauterized with electrocautery under video guidance. The other six patients had blunt chest trauma with an accumulation of blood clots. Complete evacuation was successfully performed with full expansion of the lung after the operation. A pericardial window was created in 24 patients by the VATS technique. Two of the patients with early effusive constrictive pericarditis (as a result of tuberculosis) received bilateral thoracoscopic pericardiectomy. Indications for the operation included impending pericardial tamponade after cardiac procedures in two patients, recurrent/loculated pericardial effusion in six, massive pericardial effusion with simultaneous presence of pleural effusions in seven, and massive pericardial effusion combined with abnormal lung disease in nine. Thirteen of them had a chronic inflammatory process and eleven patients had metastatic carcinoma. All of the patients tolerated the procedure well except two patients with impending pericardial tamponade, who received subxiphoid decompression first because of low arterial blood pressure after the induction. No intraoperative or postoperative complications were related to the procedures. Twelve patients with centrally located pulmonary
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metastasis underwent VATS lobectomy. The other benign lesions subjected to VATS lobectomy were bronchiectasis in two cases, endobronchial hamartoma in one, and atypical carcinoid in one (TI NO MO). The lobes excised by VATS included eight right lower lobes, one middle lobe, two right upper lobes, four left lower lobes, and one left upper lobe. The mean operative time was 3 hours (range 2.5 hours to 4 hours). Average blood losswas 100 ml and mean hospital stay was 6 days (range 4 to 8 days). VATS esophagectomies were performed in six patients, who had uneventful postoperative courses. Average time for thoracoscopic dissection and removal of the esophagus was 130 minutes (range 80 to 210 minutes). The average blood loss was 150 m!. As for VATS esophagomyomectomy, the mean operative time was 3 hours (range 2.5 to 4.2 hours). Blood loss was minimal «50 ml). Postoperatively, the patients (VATS esophagomyomectomy) were able to tolerate oral feeding within 24 hours, and swallowing was excellent in a mean follow-up period of 8 months. VATS esophagectomies and reconstructions were achieved thoracoscopically in 20 patients (17 men and 3 women), ages ranging from 56 to 70 years. The reason for this approach was advanced-stage esophageal cancer (mid to lower third), for which most of the patients request only palliation. All patients were offered a less invasive method of accomplishing the same palliative surgical treatment performed through open thoracotomy. The procedures consisted of complete resection of tumors in 16 cases and nearly total resection' in four. The incomplete resection was due to the dense and fixed adhesion of the tumor to the aorta, for which only a palliative resection can be achieved thoracoscopically. Digestive continuity was uneventfully restored by gastric pullup to the thoracic inlet under video vision. Average operative time (VATS esophagectomy and reconstruction only) was 5 hours (range 4.5 to 7 hours). The average blood loss was 250 m!. All patients had a smooth passage of contrast medium at studies performed 2 weeks after the operation. Two patients complained of dysphagia 3 weeks after postoperative radiotherapy. The symptoms improved after an endoscopic bouginage to the anastomotic region. All of the patients were free of symptoms within 12.5 months of follow-up.
Discussion With every new technologic innovation comes an accompanying rush to embrace it. The 1990s has witnessed a worldwide resurgence of interest in thoracoscopy with the rediscovery of the technique by surgeons. Since the first reports in 1991 by Dr. Ralph Lewis and his associates.' of New Brunswick, New Jersey, a vital tech-
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nical branch of our surgical specialty, VATS, has developed rapidly. With the advancement of endoscopicequipment and surgical skills, VATS has been expanded to now serve as a useful modality for the management of many intrathoracic diseases. The technique has been increasingly developed and used.v '? Problems in terms of applications and manipulation also became progressivelyobvious." Our experience indicates that, when the use of disposable endoscopic instruments was compared with the use of nondisposable conventional instruments, there were no substantial difference in terms of VATS procedures. However, concerning the cost and effectiveness of the two instruments, reusable conventional instruments were superior to disposable endoscopic instruments. Not only were they easier to manipulate, but they also allowed active bleeders to be securely grasped and controlled. Long conventional clamps (Satinsky or curved vascular clamps) thus seem to be the safest and easiest devices to manipulate in controlling active hemorrhage. In addition, performance of VATS procedures through the trocar channels seems unnecessary because an airtight system was not needed in the chest. In the VATS procedures conventional instruments could be manipulated easily through a 2 cm incision without application of the expensive trocars or thoracoports. Surgeons should take advantage of every opportunity to use the familiar, already available, and more economical instruments to perform an operation. On the basis of these ideas, we performed the VATS procedures routinely using conventional thoracic instruments except for Endo-GIA staplers when a thoracoscopic wedge resection of the lung was indicated. By incorporating conventional instruments, VATS allows the surgeon to perform procedures similar to those used in open thoracotomy and to use more natural hand manipulations. With the combined use of conventional' instruments, dissection, grasping, suturing, biopsies, excisions, and control of the hemorrhage will become much easier and faster. Those who relied excessively on disposable endoscopic instruments will find themselves in trouble when facing an active hemorrhage. In our series, we encountered one patient with an active hemorrhage during VATS lobectomy. A conventional vascular clamp was introduced immediately. The bleeders was suture ligated effectively through the already extended manipulation incision. From these experiences, we recommended early creation of an extended manipulation channel instead of "wasting" it for only retrieval of the specimen. This was especially useful when performing major VATS procedures. Classically, standard thoracic surgery required long and painful incisions, often to perform relatively simple
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procedures. VATS resection of mediastinal tumors ( <5 em) with conventional instruments avoids these incisions without compromising the treatment. The role of thoracoscopy in the management of spontaneous pneumothorax was especially noteworthy. VATS drainage and evacuation of empyema cavities also was effective. Thus, with the availability of VATS techniques, earlier intervention in patients with spontaneous pneumothorax, empyema (fibrinopurulent stage), and hemothorax should be the rule. Enucleation of solitary, indeterminate, or metastatic lung nodules in high-risk patients seems to be an ideal indication for VATS in avoiding large mcrsions.
VATS pericardial decompression was a technically simple procedure that can both determine the lung/pleural disease and effectively create the pericardial window. However, patients considered for a VATS pericardial window should' be able to tolerate general anesthesia. In the presence of unstable hemodynamics, one should perform the drainage immediately instead of wasting time to prepare the thoracoscope. Clearly, a subxiphoid route was the simplest approach for pericardial decompression. We advocate this approach for relieving the effusion if no concomitant lung/pleural disease or previous procedure existed that might preclude the approach. Generally, if effusion was noted in either pleural space, the approach should be on that side of the thoracic cavity so that both the pleural and pericardial effusions can be drained. The VATS approach for lobectomy has been proved effective.P: 19 In our experience, lower lobe lobectomies were technically relatively easier to perform. However, until now we have been very selective to the indications for VATS lobectomy. Only in those patients with favorable anatomy and complete fissures will VATS lobectomy be uneventful and comfortable. As for the surgical treatment of primary lung cancer, the approach was too time consuming to accomplish a complete lymph node dissection. Therefore, at the present stage of development, we recommend open thoracotomy for patients with primary lung cancer to achieve a noncom promising, adequate, and complete surgical therapy. The VATS approaches for the treatment of esophageal diseases are now still considered investigational and under clinical evaluation.v 16,20,21 We had obtained a limited range of experience in VATS esophagectomy and reconstruction. In our impression, this was a relatively painstaking procedure because of the time needed to mobilize and reconstruct the esophagus through small incisions. However, persistence was rewarded with promising results. The esophageal dissection should be started only when a clear view of the mediastinum has been obtained. In one case we had mistaken the trachea for the
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esophagus during the dissection. The dissecting plane was known to be wrong only when the encircled tape was visible through video vision. From our experience, it was clear that VATS esophagectomy was not minor surgery; it was a minimally invasive, complex intrathoracic operation. To date, VATS performed at our hospital has been successful. Our techniques did not differ greatly from those reported in the literatures. However, we have not used expensive disposable endoscopic instruments in performing the VATS. We strongly recommend the routine use of conventional nondisposable instruments to achieve a truly cost-effective and minimally invasive video-assisted procedure. Currently, we are now using this technique almost exclusively to treat the majority of patients with surgical diseases of the chest. We believe that when used appropriately, VATS will be an excellent technique and will replace thoracotomy in the near future. We expressour gratitude to Miss K. H. Chen for her preparation of the manuscript. REFERENCES 1. Landreneau RJ, Mack MJ, Mazelhjg SR, et aI. Video-assisted thoracic surgery: basic technical conceptsand intercostalapproach strategies.Ann Thorac Surg 1992;54:8007.
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18. Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy: Should it be done? Ann Thorac Surg 1992; 54:80-3. 19. Roviaro GC, Rebuffat C, Aroli V, et al. Videoendoscopic pulmonary lobectomy for cancer. Surg Laparosc Endosc 1992;2:244-7. 20. Cushieri A, Shimi S, Banting S. Endoscopic esophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 1992;37:7-11. 21. Buess GF, Becker HD, Naruhn MB, et al. Endoscopic esophagectomy without thoracotomy. Probl Gen Surg 1991;8:478-86. 22. Liu HP, Lin PJ, Chang CH, Chang JP. Video-assisted thoracic surgery: manipulation without trocar in 112 consecutive procedure. Chest 1993;104:1452-4. 23. Mack MJ, Hazelrigg SR, Landreneau RJ. Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1993;56:825-32.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OFTHORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1994 issues from the Publisher, at a cost of $82.50 for domestic, $106.28 for Canadian, and $100.50 for international subscribers for Vol. 107 (January-June) and Vol. 108 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., SUbscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone 1(800) 4534351 or (314) 453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
Hui-Ping Liu, MD, Chau-Hsiung Chang, MD, Pyng Jing Lin, MD, Hung-Chang Hsieh, MD, Jen-Ping Chang, MD, and Ming-Jang Hsieh, MD, Taipei, Taiwan, Republic of China
DesPite the wide application of video-assisted techniques in "thoracoscopic" or "thoracic" surgery, the majority of surgeons have limited experience with these techniques. Data from recent literatures showed that video-assisted thoracic surgery (VATS) addresses a variety of more complex thoracic problems.l- 2 The applications of it have resulted in a number of controversial aspects.
From Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China. Received for publication Feb. 25, 1994. Accepted for publication July II, 1994. Address for reprints: Hui-Ping Liu, MD, Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199, Tun-Hwa North Rd., Taipei, Taiwan, Republic of China. Copyright @ 1994 by Mosby-Year Book, Inc. 0022-5223/94 $3.00
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Because the use of a new technology needs to incorporate wide experiences from worldwide centers, we present here our own experiences with the use of VATS in the past 22 months at Chang Gung Memorial Hospital in Taipei. We hope that we can make some contribution to this rapidly evolving field. Patients and methods Patients. VATS was first carried out in this hospital in March 1992. The first patient was a 21-year-old woman who had a recurrent spontaneous pneumothorax. Since then, 299 other patients have had video-assisted procedures by means of the technique described as follows. In total, there were 172 men and 128 women with ages ranging from 1 to 83 years (average 57 years). Forty-one patients had preexisting chronic cardiac or respiratory disabilities. Four had a severely limited respiratory reserve with a forced expiratory volume in 1 second of 0.5 L. All the patients were informed that an open thoracotomy might be necessary and all signed the operative consent form. Basic technique. All the procedures were performed with the
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patient under general anesthesia with double-lumen endotracheal intubation. Patients were positioned and draped as for a standard open procedure. After the chest was prepared and the lung for use in the procedure was collapsed, a 2 em incision was made over the seventh intercostal space at the midaxillary line. The chest was entered carefully through a stab incision. Digital palpation determined the presence of adhesions and the bleeders from the wounds (usually muscle) were checked meticulously.1fnone were present, an 11 mm nondisposable trocar was inserted through which the thoracoscope was inserted. The entire thoracic cavity was then carefully explored by means of projected images on the video monitor. Depending on the site of the lesionand the type of the operation, another one or two stab incisions (2 em) were made to allow the introduction of conventional instruments into the chest. No trocars or thoracoports (Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.) were used in those incisions. The procedures were usually carried out with three incisions in a triangular configuration on the chest. Various procedures can be performed with conventional thoracic surgical instruments. Specific details of the technique for different procedures are described as follows. Bullectomy jblebectomy and pleurodesis. The apex was investigated first for an actively leaking bleb/bulla. If the site of the leak was not found in the collapsed lung, the anesthesiologist was asked to inflate the lung slowly with a small tidal volume. Warm saline solution was introduced into the chest until the actively leaking area became visible. Once the leak or bleb/ bulla was found, an Endo-GIA 30 stapler (Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.) was placed through one of the incisions and fired across the base of the bleb/bulla. The stapler line was carefully examined for a possible air leak and pleurodesis was later performed. In patients with secondary spontaneous pneumothorax (usually elderly patients with preexisting lung diseases) and an emphysematous change of lung parenchyma, the bulla was often so broad that resection with staplers across its base was not possible. The active leaks were usually ligated with Endoloop ligatures (Ethicon, Inc., Somerville, N.J.). In each ofthe bullae, at least two to three Endoloop ligatures were applied to shrink and obliterate the leaks. The shrunk bulla was resected after ligation.Sometimes, the exact site of the leak could not be identified and then talc insufflation was performed directly to the leaking area under video guidance. This was performed only when the lung was totally and fully reexpanded with the aid of the ventilator. On completion of the procedure, a chest tube (32F) was placed through one of the incisions. All the wounds were closed with interrupted 3-0 silk sutures. Wedge resection oflung nodule. After insertion of the thoracoscope, the nodule was identified by means of inspection, instrumental palpation, and digital confirmation of its size and margin. It was then grasped with a conventional ring forceps that was inserted through a second incision. Through the third incision, one or two applications of the Endo-GIA 30 stapler werefired to achieve a wedge resection of the lung parenchyma containing the nodule. The lung was then slowly reexpanded under image visualization to assure the staple line for hemostasis and air leaks. Pulmonary, pleural, and mediastinal (including lymph nodes) biopsies. On thoracoscopic exploration, the entire thoracic cavity was inspected for evidence of a mass or metastasis. Lung biopsies were accomplished with endoscopic stapled
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wedge resections of the specimen. A cup biopsy forceps was usually used for resection of the pleural or mediastinal lesions. Sometimes, electrocautery was used to penetrate the capsule of the mass so that an accurate sample of the tissue could be obtained. All of the bleeders were controlled with the electrocautery. Mediastinal tumor resection. Under video vision, the entire mediastinum was thoroughly investigated. Conventional ring forceps, Satinsky clamps, and electrocautery were used for traction and dissection of the tumor. The dissection was simple and usually straightforward. The tumor can be extracted easily through an extended manipulation incision. A chest tube was placed within the pleura and the incisions were closed with interrupted sutures. Decortication and enucleation ofempyema. The exploration often reveals loculi of pus and fibrinous adhesions within the chest cavity. Conventional instruments with a long-handled clamp, ring forceps, and a large-bore wall suction tube were frequently used to break down the empyema cavity. All the debris and necrotic tissue can be repeatedly removed and washed out with warm saline solution. The fibrous pleural "peel" can be grasped and decorticated to a maximal extent by interchanging the position of conventional instruments through different manipulation incisions. Changing the position of the scope also improved visual orientation and allowed better access to certain areas for further debridement. Two chest tubes (32F) were usually placed for suction drainage after completion of the procedure. Evacuation ofblood clot (chest trauma). The blood clots can be evacuated efficiently with the aforementioned large-bore conventional wall suction tube. Warm saline solution was always introduced through one of the incisions to wash out the blood clots, and at the same time it aids in identifying the bleeders. The active bleeders were usually cauterized or clipped, under video vision. Pericardial window/pericardiectomy. After the thoracoscope was introduced, the phrenic nerve was routinely identified and kept in view throughout the procedure. A stab incision was usually created on the surface of the distended pericardium by electrocautery. A conventional sharp Kelly clamp was then used carefully to penetrate the stabbed hole to allow pericardial fluid to drain into the pleural space. The hole was then dilated and grasped with a forceps. This opening was further enlarged by electrocautery to create an adequate pericardiopleural window (usually 3 by 4 em). The fluid was sent for cytologic evaluation and the specimen was sent for pathologic analysis. A 32F chest tube was placed through the inferior incision, which had already been made. If a bilateral pericardiectomy was indicated, the left and right sides of the pericardium were resected sequentially to a maximal extent as in an open procedure. This resection was accomplished in the aforementioned manner. VATS lobectomy. As soon as the monitors and thoracoscope were functional, one of the incisions (usually one close to the lesion) was extended (4 to 6 em in length). This incision, which we called an extended manipulation channel, was usually created earlier to accommodate the standard conventional instruments passing into it for manipulation and eventually for specimen retrieval at the end ofthe operation. The procedure usually started with the dissection of the interlobar fissure and the pleural adhesions with electrocautery. The lung parenchyma was retracted with conventional ring forceps. The interlobar arteries were identified and dissected carefully with a conventional
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Table I. VATS procedures at Chang Gung Memorial Hospital (Taipei) from March 1992 to December 1993 Spontaneous pneumothorax (bullectomyjpleurodesis) Mediastinal tumor resection Mediastinal lymph nodebiopsies Infiltrating lungdiseases (wedge biopsy) Lung nodule (wedge resection) Pulmonary lobectomy PericardiaI window/pericardiectomy Pleurallesions (biopsies) Empyema (decortication) Lung abscess (pneumonotomy) Chest trauma (hemothorax) Esophageal diseases VATS esophagectomy VATS esophagomyomectomy VATS esophagectomy and reconstruction
75 24 9 II
76 16
26 15 7
3 9 29 6 3 20
right-angled hemostat and diathermy. Blunt dissection with the tip of the wall suction tube aided in the exposure of the interlobar vessels. The vessels were usually encircled with 3-0 silk sutures and the ligation was performed as in open thoracotomy. Either the suture was tied directly through the extended manipulation channel or the externally tied knot was cinched down inside the thoracic cavity with a right-angled hemostat. The arteries were then cut and hemostasis was checked meticulously. The pulmonary vein was managed in the same way as the interlobar artery. The interlobar bronchus was finally divided by means of the Endo-GIA stapler with a 3.5 mm staple cartridge. When the specimen was completely freed, it was retrieved through the extended manipulation channel. The lung was reexpanded under video vision to verify that the bronchial seal was adequate. Two chest tubes were placed through the incisions already made. The wounds were then closed with interrupted sutures. Esophageal procedures. Esophageal procedures include VATS esophagomyomectomy, esophagectomy, and thoracic esophageal reconstruction. VATS ESOPHAGOMYOMECTOMY. VATS esophagomyomectomy was performed through the left side of the chest on the distal part of the esophagus. After insertion of the thoracoscope, the inferior ligament was divided first with electrocautery. The myotomy began with dissection through the outer longitudinal muscle layer with a ring forceps and electrocautery. When the inner circular muscle layer was reached, the fibers were lifted away from the mucosa and were carefully divided with diathermy. A small rounded "pusher" may aid in the separation of the muscle from the mucosa. The myotomy was then continued from the level of the inferior pulmonary ligament to approximately I cm past the gastroesophageal junction. Lateral myomectomy was performed to prevent possible healing of the muscle edges. Finally, a diluted methylene blue solution was introduced through a nasogastric tube into the esophagus to ensure the integrity of the mucosa. Oral feedings started the following day and the patient was discharged when able to tolerate food intake. • VATS ESOPHAGECTOMY. For VATS esophagectomy, after completion of the esophageal reconstruction through a laparotomy and cervicotomy, the patient was placed in a left lateral
position. The first incision (2 em) was created in the seventh intercostal space in the posterior axillary line for introduction of the scope. Two incisions (both 2 ern) were created in the third and seventh intercostal spaces in the anterior axillary line for lung traction. The other two incisions (3 to 4 ern), so-called manipulation channels, were created in the fourth and seventh intercostal spaces in the midaxillary lines. The mobilization of the esophagus was initially carried out in an area that was not involvedby the tumor. After the mediastinal pleura was opened, the lateral sides of the esophagus were loosened with the tip of the conventional wall suction tube. Once partly freed, the esophagus was grasped and elevated. It was then separated from the surrounding tissue by electrocautery. Any lymph nodes visible in the region were removed. The esophageal tumor was resected to a maximal extent under image visualization. All the vesselswere divided between metal clips or electrocautery. Earlyon, the upper and lower portions of the esophagus had been resected and ligated with an umbilical tape during laparotomy and cervicotomy. By traction on these tapes, the esophagus was further dissected and mobilized. When the esophagus was completely freed, it was placed in a protective bag (usually glove) and retrieved through one of the extended manipulation channels. A 32F chest tube was placed in the esophageal bed. All of the wounds were closed with interrupted sutures. VATS ESOPHAGECTOMY AND RECONSTRUCTION. The abdominal procedure in preparation of the gastric tube was the same for VATS esophagectomy and reconstruction as for an open procedure. The patient was turned to the left lateral position and the incisions were performed as described earlier. By interchange of conventional instruments through different manipulation incisions, the esophagus was dissected to an adequate margin (usually close to the thoracic inlet) and the gastric tube was delivered into the chest. The cardioesophageal junction was divided. (This was initially stapled during laparotomy.) A site was chosen (usually posterior aspect of the stomach) for esophagogastric anastomosis. Traction sutures were placed on the distal end after transection of the esophagus. A hand-sewn 1-0 Prolene pursestring suture (Ethicon) was placed on the distal edge of the esophagus under video guidance. (Sometimes, direct visualization through the extended manipulation channels aided in the execution of the conventional suturing technique.) A curved intraluminal stapler (Ethicon) without an anvil was introduced through the extended manipulation channel (seventh intercostal space) and into a gastrotomy incision. Under image visualization, the anvil was then placed on the center rod and inserted into the esophagus with traction on the sutures. The pursestring knot was tied and the stapler was closed and fired. Stapler lines were carefully examined. A nasogastric tube (16F) was placed within the stomach for decompression. The gastrotomy wound was then closed and the pleural cavity was irrigated with a warm saline solution. The chest tube was placed in the esophageal bed and all of the incisions were closed with interrupted 3-0 silk. A routine esophagogram was performed 2 weeks after the operation.
Results Table I summarizes the characteristics of all patients in the series. A total of 300 patients were reviewed. Seventy-five patients underwent a VATS procedure to treat their air leaks. Thirty-five young patients (ages ranging from 13 to 36 years) with primary spontaneous pneu-
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mothorax were treated by apical blebectomy/bullectomy with the Endo-GIA 30 stapler, Each patient had a subsequent pleural abrasion from the apex to the fifth rib. In 29 patients (52 to 80 years of age) secondary spontaneous pneumothorax was managed through ligation of the bullae with Endoloop ligatures. Subsequent talc insufflation was performed before ending the procedure. In these two groups of patients, the chest tube drainage required ranged from 2 to 5 days and the average hospital stay was 5 days (range 3 to 7 days). One patient required a second operation for an air leak when an Endoloop ligature (only one catgut Endoloop ligature used) slipped from the lung parenchyma after a forceful sneeze 2 days after the operation. The patient's air leak was resolved 3 days after a second VATS operation by means of the conventional suturing technique. Since then, at least two to three slow absorbable Endoloop ligatures made of PDS II suture (Ethicon) were used without any complication. In another 11 patients (ages ranging from 55 to 71 years) with diffuse bullous lung diseases, the exact leaking bullae were not clearly identified. Ligation of the bullae by the Endoloop ligature technique in this group of patients seemed impossible, and thus only thoracoscopic talc insufflation was performed directly to the air leak area. Two patients had prolonged air leaks lasting from 10 to 14 days after the procedure. In the remaining nine patients air leaks ended quickly within 1 week. All of the patients had an uneventful postoperative course. No recurrence of pneumothorax has been seen during a mean follow-up of 16 months. Thoracoscopic wedge resections for peripherally located nodules were performed in 76 patients. Twenty-nine patients were found to have benign lesions (hamartoma, n = 6; caseating granuloma, n = 10; cryptococcosis, n = 2; interstitial fibrosis, n = 8; and sclerosing hemangioma, n = 3) and 47 had metastatic pulmonary lesions from a variety of primary cancers (limb sarcoma, n = 19; renal, n = 3; colon, n = 6; uterus, n = 2; pharynx, n = 3; salivary gland, n = 2; liver, n = 1; thymus, n = 3; esophagus, n = 3; thyroid, n = 3; and metastatic spindle cell tumor of unknown primary, n = 2). The mean diameter of the resected nodule was 1.2 em with a range of 0.5 to 3.5 em. All of the nodules detected by chest computed tomographic scan were successfully identified and resected thoracoscopieally with a mean postoperative hospital stay of 4.5 days (range 3 to 9 days). Prolonged pleural effusionwas noted in two patients. Their chest tubes were removed on days 7 and 8, respectively. No morbidity or mortality was attributable to the procedure. Twenty-four mediastinal tumors were resected by means of VATS. These include six teratomas, five neurofibromas, two ganglioneuromas, six neurilemomas,
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one paraganglioma, one cystic lymphangioma, and three granulomas. Fifteen lesions were located in the posterior mediastinum, three were in the superior mediastinum, and six were found in the anterior mediastinum. The average tumor size was 3.5 ern (range 1.5 to 6 em). All of the patients have had an uneventful postoperative course with an average hospital stay of 5 days. Lung biopsies (wedge resection) of infiltrating lung diseases were performed uneventfully with the Endo-GIA stapler in 11 patients. Successful confirmation of malignancy by frozen section was also accomplished in 15 patients through thoracoscopic pleural biopsies. Nine patients with enlarged mediastinal lymph nodes were subjected to VATS biopsies. Seven of the specimens were found to be positive for malignancy and two showed benign inflammatory changes. Thoracoscopic drainage of empyema was accomplished in seven patients. Five of them were in an early transitional phase (fibrinopurulent stage). Two had loculated collections of pus and debris. Decortication with release of the trapped lung was uneventfully performed through thoracoscopic intervention. Despite prolonged hospital stays of 2 weeks while waiting for the chest tubes to be shortened for open drainage, all of the patients had complete reexpansion of the lung after the operation. Thoracoscopy-assisted evacuation of blood clots was achieved in nine patients with acute chest trauma. Three had penetrating chest wounds with progressive bloody discharge from the chest tube. The active intercostal bleeding vessels were cauterized with electrocautery under video guidance. The other six patients had blunt chest trauma with an accumulation of blood clots. Complete evacuation was successfully performed with full expansion of the lung after the operation. A pericardial window was created in 24 patients by the VATS technique. Two of the patients with early effusive constrictive pericarditis (as a result of tuberculosis) received bilateral thoracoscopic pericardiectomy. Indications for the operation included impending pericardial tamponade after cardiac procedures in two patients, recurrent/loculated pericardial effusion in six, massive pericardial effusion with simultaneous presence of pleural effusions in seven, and massive pericardial effusion combined with abnormal lung disease in nine. Thirteen of them had a chronic inflammatory process and eleven patients had metastatic carcinoma. All of the patients tolerated the procedure well except two patients with impending pericardial tamponade, who received subxiphoid decompression first because of low arterial blood pressure after the induction. No intraoperative or postoperative complications were related to the procedures. Twelve patients with centrally located pulmonary
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metastasis underwent VATS lobectomy. The other benign lesions subjected to VATS lobectomy were bronchiectasis in two cases, endobronchial hamartoma in one, and atypical carcinoid in one (TI NO MO). The lobes excised by VATS included eight right lower lobes, one middle lobe, two right upper lobes, four left lower lobes, and one left upper lobe. The mean operative time was 3 hours (range 2.5 hours to 4 hours). Average blood losswas 100 ml and mean hospital stay was 6 days (range 4 to 8 days). VATS esophagectomies were performed in six patients, who had uneventful postoperative courses. Average time for thoracoscopic dissection and removal of the esophagus was 130 minutes (range 80 to 210 minutes). The average blood loss was 150 m!. As for VATS esophagomyomectomy, the mean operative time was 3 hours (range 2.5 to 4.2 hours). Blood loss was minimal «50 ml). Postoperatively, the patients (VATS esophagomyomectomy) were able to tolerate oral feeding within 24 hours, and swallowing was excellent in a mean follow-up period of 8 months. VATS esophagectomies and reconstructions were achieved thoracoscopically in 20 patients (17 men and 3 women), ages ranging from 56 to 70 years. The reason for this approach was advanced-stage esophageal cancer (mid to lower third), for which most of the patients request only palliation. All patients were offered a less invasive method of accomplishing the same palliative surgical treatment performed through open thoracotomy. The procedures consisted of complete resection of tumors in 16 cases and nearly total resection' in four. The incomplete resection was due to the dense and fixed adhesion of the tumor to the aorta, for which only a palliative resection can be achieved thoracoscopically. Digestive continuity was uneventfully restored by gastric pullup to the thoracic inlet under video vision. Average operative time (VATS esophagectomy and reconstruction only) was 5 hours (range 4.5 to 7 hours). The average blood loss was 250 m!. All patients had a smooth passage of contrast medium at studies performed 2 weeks after the operation. Two patients complained of dysphagia 3 weeks after postoperative radiotherapy. The symptoms improved after an endoscopic bouginage to the anastomotic region. All of the patients were free of symptoms within 12.5 months of follow-up.
Discussion With every new technologic innovation comes an accompanying rush to embrace it. The 1990s has witnessed a worldwide resurgence of interest in thoracoscopy with the rediscovery of the technique by surgeons. Since the first reports in 1991 by Dr. Ralph Lewis and his associates.' of New Brunswick, New Jersey, a vital tech-
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nical branch of our surgical specialty, VATS, has developed rapidly. With the advancement of endoscopicequipment and surgical skills, VATS has been expanded to now serve as a useful modality for the management of many intrathoracic diseases. The technique has been increasingly developed and used.v '? Problems in terms of applications and manipulation also became progressivelyobvious." Our experience indicates that, when the use of disposable endoscopic instruments was compared with the use of nondisposable conventional instruments, there were no substantial difference in terms of VATS procedures. However, concerning the cost and effectiveness of the two instruments, reusable conventional instruments were superior to disposable endoscopic instruments. Not only were they easier to manipulate, but they also allowed active bleeders to be securely grasped and controlled. Long conventional clamps (Satinsky or curved vascular clamps) thus seem to be the safest and easiest devices to manipulate in controlling active hemorrhage. In addition, performance of VATS procedures through the trocar channels seems unnecessary because an airtight system was not needed in the chest. In the VATS procedures conventional instruments could be manipulated easily through a 2 cm incision without application of the expensive trocars or thoracoports. Surgeons should take advantage of every opportunity to use the familiar, already available, and more economical instruments to perform an operation. On the basis of these ideas, we performed the VATS procedures routinely using conventional thoracic instruments except for Endo-GIA staplers when a thoracoscopic wedge resection of the lung was indicated. By incorporating conventional instruments, VATS allows the surgeon to perform procedures similar to those used in open thoracotomy and to use more natural hand manipulations. With the combined use of conventional' instruments, dissection, grasping, suturing, biopsies, excisions, and control of the hemorrhage will become much easier and faster. Those who relied excessively on disposable endoscopic instruments will find themselves in trouble when facing an active hemorrhage. In our series, we encountered one patient with an active hemorrhage during VATS lobectomy. A conventional vascular clamp was introduced immediately. The bleeders was suture ligated effectively through the already extended manipulation incision. From these experiences, we recommended early creation of an extended manipulation channel instead of "wasting" it for only retrieval of the specimen. This was especially useful when performing major VATS procedures. Classically, standard thoracic surgery required long and painful incisions, often to perform relatively simple
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procedures. VATS resection of mediastinal tumors ( <5 em) with conventional instruments avoids these incisions without compromising the treatment. The role of thoracoscopy in the management of spontaneous pneumothorax was especially noteworthy. VATS drainage and evacuation of empyema cavities also was effective. Thus, with the availability of VATS techniques, earlier intervention in patients with spontaneous pneumothorax, empyema (fibrinopurulent stage), and hemothorax should be the rule. Enucleation of solitary, indeterminate, or metastatic lung nodules in high-risk patients seems to be an ideal indication for VATS in avoiding large mcrsions.
VATS pericardial decompression was a technically simple procedure that can both determine the lung/pleural disease and effectively create the pericardial window. However, patients considered for a VATS pericardial window should' be able to tolerate general anesthesia. In the presence of unstable hemodynamics, one should perform the drainage immediately instead of wasting time to prepare the thoracoscope. Clearly, a subxiphoid route was the simplest approach for pericardial decompression. We advocate this approach for relieving the effusion if no concomitant lung/pleural disease or previous procedure existed that might preclude the approach. Generally, if effusion was noted in either pleural space, the approach should be on that side of the thoracic cavity so that both the pleural and pericardial effusions can be drained. The VATS approach for lobectomy has been proved effective.P: 19 In our experience, lower lobe lobectomies were technically relatively easier to perform. However, until now we have been very selective to the indications for VATS lobectomy. Only in those patients with favorable anatomy and complete fissures will VATS lobectomy be uneventful and comfortable. As for the surgical treatment of primary lung cancer, the approach was too time consuming to accomplish a complete lymph node dissection. Therefore, at the present stage of development, we recommend open thoracotomy for patients with primary lung cancer to achieve a noncom promising, adequate, and complete surgical therapy. The VATS approaches for the treatment of esophageal diseases are now still considered investigational and under clinical evaluation.v 16,20,21 We had obtained a limited range of experience in VATS esophagectomy and reconstruction. In our impression, this was a relatively painstaking procedure because of the time needed to mobilize and reconstruct the esophagus through small incisions. However, persistence was rewarded with promising results. The esophageal dissection should be started only when a clear view of the mediastinum has been obtained. In one case we had mistaken the trachea for the
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esophagus during the dissection. The dissecting plane was known to be wrong only when the encircled tape was visible through video vision. From our experience, it was clear that VATS esophagectomy was not minor surgery; it was a minimally invasive, complex intrathoracic operation. To date, VATS performed at our hospital has been successful. Our techniques did not differ greatly from those reported in the literatures. However, we have not used expensive disposable endoscopic instruments in performing the VATS. We strongly recommend the routine use of conventional nondisposable instruments to achieve a truly cost-effective and minimally invasive video-assisted procedure. Currently, we are now using this technique almost exclusively to treat the majority of patients with surgical diseases of the chest. We believe that when used appropriately, VATS will be an excellent technique and will replace thoracotomy in the near future. We expressour gratitude to Miss K. H. Chen for her preparation of the manuscript. REFERENCES 1. Landreneau RJ, Mack MJ, Mazelhjg SR, et aI. Video-assisted thoracic surgery: basic technical conceptsand intercostalapproach strategies.Ann Thorac Surg 1992;54:8007.
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The Journal of Thoracic and Cardiovascular Surgery November 1994
18. Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy: Should it be done? Ann Thorac Surg 1992; 54:80-3. 19. Roviaro GC, Rebuffat C, Aroli V, et al. Videoendoscopic pulmonary lobectomy for cancer. Surg Laparosc Endosc 1992;2:244-7. 20. Cushieri A, Shimi S, Banting S. Endoscopic esophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 1992;37:7-11. 21. Buess GF, Becker HD, Naruhn MB, et al. Endoscopic esophagectomy without thoracotomy. Probl Gen Surg 1991;8:478-86. 22. Liu HP, Lin PJ, Chang CH, Chang JP. Video-assisted thoracic surgery: manipulation without trocar in 112 consecutive procedure. Chest 1993;104:1452-4. 23. Mack MJ, Hazelrigg SR, Landreneau RJ. Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1993;56:825-32.
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