State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

Evaluation of long-term outcome after lung lobectomy for canine non-neoplastic pulmonary consolidation via thoracoscopic or thoracoscopic-assisted surgery in 12 dogs

OBJECTIVE

To report outcomes of thoracoscopic (TL) and thoracoscopic-assisted lung lobectomy (TAL) for treatment of non-neoplastic pulmonary consolidation (PC) in dogs.

STUDY DESIGN

Retrospective case series.

ANIMALS

Twelve client-owned dogs.

METHODS

The medical records of 12 dogs that underwent TL or TAL for PC at 3 veterinary institutions between 2011 and 2020 were reviewed. Signalment, history, physical examination, diagnostics, days in hospital, anesthetic and procedure times, intraoperative/postoperative complications, conversion rates, duration of indwelling thoracic drain, and long-term outcomes were recorded.

RESULTS

Nine patients underwent a TL approach and 3 underwent TAL. In those that underwent TL, conversion to an intercostal thoracotomy was performed in 4 out of 9 dogs. Conversion was performed due to adhesions (n = 3) or poor visualization (1). Histopathologic examination was consistent with pneumonia due to an infectious process (n = 10), bronchioalveolar malformation with abnormal cilia (1), and left-sided cardiac insufficiency vs. pulmonary alveolar proteinosis (1). The mean duration of hospital stay was 4 days (range, 1-6 days). Complications occurred postoperatively in 7 dogs and included self-limiting hemorrhage (n = 3), self-resolving pneumothorax (2), incisional dehiscence (1), and severe dyspnea in a brachycephalic breed leading to euthanasia (1). For the 11 dogs that survived the perioperative period, there was no evidence of recurrence with a median follow up of 24 months (range, 5-120 months).

CONCLUSION

Thoracoscopic (TL) and thoracoscopic-assisted lung lobectomy (TAL) is a reasonable surgical approach in select dogs with PC.

CLINICIAL RELEVANCE

Conversion rates were higher than those historically reported for dogs undergoing thoracoscopic lung lobectomy for primary lung tumors.

Video-assisted thoracoscopic surgery simulation and training: a comprehensive literature review

BACKGROUND

Video-assisted thoracic surgery (VATS) has become the standard for lung cancer diagnosis and treatment. However, this surgical technique requires specific and dedicated training. In the past 20 years, several simulator systems have been developed to promote VATS training. Advances in virtual reality may facilitate its integration into the VATS training curriculum. The present review aims to first provide a comprehensive overview of the simulators for thoracoscopic surgery, focused especially on simulators for lung lobectomy; second, it explores the role and highlights the possible efficacy of these simulators in the surgical trainee curriculum.

METHODS

A literature search was conducted in the PubMed, EMBASE, Science Direct, Scopus and Web of Science databases using the following keywords combined with Boolean operators "AND" and "OR": virtual reality, VR, augmented reality, virtual simulation, mixed reality, extended reality, thoracic surgery, thoracoscopy, VATS, video-assisted thoracoscopic surgery, simulation, simulator, simulators, training, and education. Reference lists of the identified articles were hand-searched for additional relevant articles to be included in this review.

RESULTS

Different types of simulators have been used for VATS training: synthetic lung models (dry simulators); live animals or animal tissues (wet simulators); and simulators based on virtual or augmented reality. Their role in surgical training has been generally defined as useful. However, not enough data are available to ascertain which type is the most appropriate.

CONCLUSIONS

Simulator application in the field of medical education could revolutionize the regular surgical training curriculum. Further studies are required to better define their impact on surgeons' training programs and, finally, on patients' quality of care.

The introduction of wide-angle 270° laparoscopy through a novel laparoscopic camera system

BACKGROUND

Laparoscopy has enjoyed improvements over the last three decades primarily in achieving high definition, but the 70° field of view (FOV) remains unchanged. Complications related to events that take place out of the FOV continue to be reported. Additional problems leading to poor visualization are fogging and smoke accumulation. A novel laparoscopic system (SurroundScope, 270Surgical) was developed and dramatically expands the FOV from the 70° to 270° by adding side cameras at the distal tip of the laparoscope, while LED illumination eliminates fogging and improves smoke effects. This study describes the initial clinical experience with SurroundScope and its potential advantages over traditional laparoscopy.

METHODS

SurroundScope was studied at Bnai Zion Medical Center in Israel and the Minnesota Institute for Minimally Invasive Surgery in America. 27 laparoscopic surgeries were performed, and at the end of each procedure, evaluations were completed by all surgeons and camera holders.

RESULTS

All 27 cases were completed successfully without adverse events. No injuries occurred as a result of surgical tool manipulation outside of the central frame while 133 potentially adverse events were identified on side frames. There was no fogging across the 27 cases. The impact of smoke was negligible in all cases, as laparoscope removal or venting was never necessary. Surgeon respondents indicated that tools could be followed from the port to the site of surgery without camera manipulation. Most surgeons strongly agreed that the potential to identify bleeding was improved. Camera holders strongly agreed that the ergonomics were improved and that they moved the camera less than with a standard laparoscope.

CONCLUSIONS

Initial results demonstrate numerous advantages for SurroundScope as compared to traditional laparoscopy. The important benefits of expanded FOV, complete lack of fogging, and negligible smoke may improve patient safety, reduce adverse events and the duration of surgery. Further investigation to quantify these benefits is recommended.

Clinical and economic benefits associated with the use of powered and tissue-specific endoscopic staplers among the patients undergoing thoracoscopic lobectomy for lung cancer

Background: Thoracoscopic lobectomy for lung cancer is a complex procedure where endoscopic staplers play a critical role in transecting the lung parenchyme, vasculature, and bronchus. This retrospective study was performed to investigate the economic benefits of powered and tissue-specific endoscopic staplers such as gripping surface technology (GST) and powered vascular stapler (PVS) compared to standard staplers.Methods: Two hundred and seventy-five patients who received a thoracoscopic lobectomy between 2008 and 2016 were included. Group 1 (n = 117) consisted of patients who received the operation with manual endoscopic staplers, whereas Group 2 (n = 158) consisted of patients who received the operation with GST and PVS.Results: Patient demographics and clinical characteristics were comparable, except smoking history, pulmonary function, and pleural adhesion. All patients received the operation successfully without mortalities and broncho-pleural fistula. Operation time and blood loss were higher in Group 1. Pleurodesis was performed less in Group 2 than in Group 1 (18.0% vs 3.8%, p < 0.0001). Group 2 had statistically significant lower adjusted hospital costs (Korean Won, 14,610,162 ± 4,386,628 vs 12,876,111 ± 5,010,878, p < 0.0001), lower adjusted hemostasis related costs (198,996 ± 110,253 vs 175,291 ± 191,003, p = 0.0101); lower cartridge related adjusted costs (1,105,091 ± 489,838 vs 839,011 ± 307,894, p < 0.0001) compared to Group 1. As well, Group 2 showed ∼12% lower adjusted total hospital costs compared to Group 1. Multivariable analysis revealed that Group 1 was related to increased hospital costs.Conclusions: This study showed that thoracoscopic lobectomy with powered and tissue-specific endoscopic staplers were associated with better clinical outcomes and reduced adjusted hospital costs when compared in Korean real-world settings.

Postoperative complications and management after lung volume reduction surgery

The aim of lung volume reduction surgery (LVRS) for patients suffering from severe emphysema is to improve lung function and palliate dyspnea. Careful patient selection in a multidisciplinary approach in a high-volume center is mandatory for a successful outcome. Pulmonary complications including air leak and pneumonia as well as cardiac complications are the most common complications after LVRS. The following article will focus on most common complications observed after LVRS and review the management strategies to improve surgical outcome.

Continuous 389 cases of Da Vinci robot-assisted thoracoscopic lobectomy in treatment of non-small cell lung cancer: experience in Shanghai Chest Hospital

Background

To analyze the perioperative indexes of 389 patients with non-small cell lung cancer in single center after robot-assisted thoracoscopic (RATS) lobectomy, and to summarize the surgical key points in robotic lobectomy.

Methods

The clinical data of 389 stage I non-small cell lung cancer patients who underwent RATS lobectomy from May 2013 to December 2016 were retrospectively analyzed. Among them, there were 261 females (67.1%) and 128 males (32.9%); aged from 20-76 years old, with a mean age of 55.01 years; with ASA I in 106 cases, ASA II in 267 cases and ASA III in 16 cases; with BMI from 16.87-34.05, averaged at 23.09±2.79. The largest tumor in preoperative chest CT measurement was 0.3-3.0 cm, ranging from 1.29±0.59 cm; with stage Ia in 153 cases, stage Ib in 148 cases, stage Ic in 32 cases, stage IIb in 26 cases and stage IIIa in 30 cases; including 380 adenocarcinomas and 9 squamous carcinomas.

Results

The operating time was 46-300 min, averaged at 91.51±30.80 min; with a blood loss of 0-100 mL in 371 cases (95.80%), 101-400 mL in 12 cases (3.60%) and >400 mL in 2 cases (0.60%); there were 4 (1.2%) conversions to thoracotomy, in which 2 patients had massive hemorrhage and 2 patients had extensive dense adhesion; there was no mortality during operation and perioperatively. The drainage on the first day after operation was 0-960 mL, averaged at 231.39±141.87 mL; the postoperative chest tube was placed for 2-12 d, averaged at 3.96±1.52 d; the postoperative hospital stay was 2-12 d, averaged at 4.96±1.51 d, with postoperative hospital stay >7 d in 12 cases (3.60%). The postoperative air leakage was the main reason (35 cases, 9%) for prolonged hospital stay, and there was no re-admitted case within 30 days. All the patients underwent systemic lymph node dissection. The total cost of hospitalization was 60,389.66-134,401.65 CNY, averaged at 93,809.23±13,371.26 CNY.

Conclusions

The application of Da Vinci robot surgery system in resectable non-small cell lung cancer is safe and effective, and could make up for the deficiencies of traditional thoracoscopic surgery. The number and level of robot surgery in our center have reached international advanced level, but the relatively expensive cost has become a major limitation in limiting its widespread use. With continuous improvements in robotic technology, its scope of application will be wider, which will inevitably bring new insights in lung surgical technology.

Impact of Powered and Tissue-Specific Endoscopic Stapling Technology on Clinical and Economic Outcomes of Video-Assisted Thoracic Surgery Lobectomy Procedures: A Retrospective, Observational Study

Introduction

Video-assisted thoracic surgery (VATS) lung resections are complex procedures with a critical role played by endoscopic staplers in the transection of vessels, bronchi, and lung tissue. This retrospective, observational study compared hospital resource use, costs, and complications of VATS lobectomy procedures for whom powered versus manual endoscopic surgical staplers were used.

Methods

Patients ≥ 18 years of age undergoing elective VATS lobectomy during an inpatient admission from January 1, 2012 to September 30, 2016 were identified from the Premier Healthcare Database (first admission = index admission). Use of either powered or manual endoscopic staplers during the index admission was identified from hospital administrative records. Multivariable regression analyses adjusting for patient, hospital, and provider characteristics and hospital-level clustering were carried out to compare the following outcomes between the powered and manual stapler groups: hospital length of stay (LOS), operating room time (ORT), hospital costs, complications (bleeding and/or transfusions, air leak complications, pneumonia, and infection), discharge status, and 30-, 60-, and 90-day all-cause readmissions.

Results

The powered and manual stapler groups comprised 659 patients (mean age 66.1 years; 53.6% female) and 3100 patients (mean age 66.7 years; 54.8% female), respectively. In the multivariable analyses, the powered stapler group had shorter LOS (4.9 vs. 5.9 days, P < 0.001), lower total hospital costs ($23,841 vs. $26,052, P = 0.009), and lower rates of combined hemostasis complications (bleeding and/or transfusions; 8.5% vs. 16.0%, P < 0.001) and transfusions (5.4% vs. 10.9%, P = 0.002), compared with the manual stapler group. Other outcomes did not differ significantly between the study groups. Similar trends were observed in subanalyses comparing devices across predominant manufacturers in each group, and in subanalyses of patients with comorbid chronic obstructive pulmonary disease.

Conclusion

In this analysis of VATS lobectomy procedures, powered staplers were associated with significant benefits with respect to selected types of hospital resource use, costs, and clinical outcomes when compared with manual staplers.

Funding

Johnson & Johnson.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0679-z) contains supplementary material, which is available to authorized users.

Initial experience of robot-assisted thoracoscopic surgery in China

Background

The objective of this study was to evaluate the safety and feasibility of robot-assisted thoracoscopic surgery (RATS).

Methods

From May 2009 to May 2013, 48 patients with intrathoracic lesions underwent RATS with the da Vinci® Surgical System was reported (11 lobectomies, 37 mediastinal tumour resections).

Results

RATS was successfully and safely completed in all 48 patients. Conversion of the operation to open surgery was not needed in any patient. The average operation time was 85.9 min, average blood loss 33 ml, and average hospital stay 3.9 days. No patient required blood transfusion. The only recognized adverse event was the development of a bronchopleural fistula in one patient.

Conclusions

RATS appears feasible and safe in thoracic surgery. More investigation will be needed in order to determine its possible long-term benefits and cost effectiveness. Copyright © 2014 John Wiley & Sons, Ltd.

Video-assisted radical thoracoscopic and laparoscopic surgery for esophageal carcinoma

Esophageal cancer is a common malignancy, for which surgery is the most effective treatment. Compared with traditional surgery, video-assisted thoracoscopic and laparoscopy minimally invasive surgery enables less trauma, better visibility, reduced bleeding and postoperative pain, and lower incidence of surgical complications through a minimally invasive, safe, and highly cost-effective approach in favor of early rehabilitation after surgery. Therefore, the promotion and application of this surgical approach will undoubtedly benefit the majority of patients with esophageal cancer. We have performed video-assisted thoracoscopic and laparoscopy minimally invasive surgery for more than 150 patients in our hospital to date, and have carried out a series of studies in this regard. As the video shows, this approach is safe and reliable with minimal injury and bleeding.

Lung volume reduction surgery after lung transplantation for emphysema-chronic obstructive pulmonary disease

Lung Volume Reduction Surgery (LVRS) has become a palliative treatment for patients with advanced emphysema and disabling dyspnea. After single lung transplantation in chronic obstructive pulmonary disease, LVRS may be indicated to improve graft dysfunction caused by native lung hyperinflation compressing the grafted lung. This common complication is the subject of our study, which showed LVRS to be helpful to manage this situation. We performed an observational retrospective and descriptive study using the data of 293 patients transplanted in our center between January 1996 and October 2011. Some of the patients who underwent a single lung transplantation developed native lung hyperinflation years after the transplantation, interfering with respiratory function due to graft compression.

American Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer

BACKGROUND/PURPOSE

Although the use of minimally invasive surgical (MIS) techniques for children with cancer is being practiced by some, its role remains unclearly defined. The purpose of this review was to describe the current literature on MIS for thoracic and mediastinal lesions in children.

METHODS

We performed a literature search for English studies that evaluated MIS techniques for biopsy or resection in children with suspected or established cancer. Only studies with greater than 20 patients were included in the review.

RESULTS

Ten studies were included for review. Each represented institutional retrospective reviews of experience. Seven were single-institution studies, and 3 were multi-institutional. There were no prospective nor randomized identified.

CONCLUSIONS

Based on primarily retrospective and observational data, the use of MIS for children with cancer who have pulmonary and mediastinal lesions seems to be effective and safe. Ideally, prospective studies are needed to evaluate this further.

Video-assisted surgery for lung cancer. State of the art and personal experience

This paper reviews the role of videothoracoscopy in lung cancer, highlighting its utility in definitive staging, diagnosis, and treatment. We show exploratory videothoracoscopy to be the perfect technique for last-minute staging, looking for tumor invasion, especially parietal T3 and vascular T4 (due to videopericardioscopy), management of solitary pulmonary nodules, and the possibility of radical treatment with video-assisted thoracoscopic lobectomy. We perform an overview of the literature and analyze our experience of 1,381 patients with lung cancer. In 1,277 of them, the final decision on resectability was made by exploratory videothoracoscopy, including 91 by videopericardioscopy (only 30 were considered non-resectable on videopericardioscopy). Solitary pulmonary nodules were diagnosed in 382 cases (190 were cancer), and we performed 260 major lung resections by video-assisted thoracoscopic surgery (22 pneumonectomies, 238 lobectomies/bilobectomies).

Natural orifice transluminal endoscopic surgery (N.O.T.E.S.) for neoplasia of the chest and mediastinum

Indications for Natural Orifice Transluminal Endoscopic Surgery or NOTES have so far mainly concerned intra-abdominal surgery. The next question to be addressed was whether this access can be extended into other body cavities and, in particular, whether there is a significant role for NOTES above the diaphragm? Using the esophagus, one of the mediastinal organs, as a direct carrier to access the mediastinum and the pleural cavity would eliminate the dissection of the pretracheal fascia required by mediastinoscopy and would give access to the inner part of lung parenchyma. Alternatively, transgastric (or even transvaginal) transhiatal approaches could supplement standard operative techniques in order to minimize abdominal wall ingression. Furthermore, conventional techniques seem disproportionate measures for relatively simple procedures such as evaluating the outcome of chemotherapy and restaging of medically treated mediastinal lesions. As a truly minimal access technique, NOTES could therefore find new indications for intervention. The obvious limiting factor in all of this is assurance of 'leak proof' mural closure. However, if safety of access-site sealing can be established in clinical studies, we could have found an easier, reproducible alternative to the access to mediastinum. This review examines the rationale and evidence for proposing such a venture and deliberates its likely clinical applicability and thereby its potential to become a reality.

The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review

BACKGROUND

Upper dorsal sympathectomy achieves excellent long-term results in the treatment of primary palmar hyperhidrosis. Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions. It has been claimed that lowering the level of sympathectomy (from T2 to T3 and even T4), substituting resection by other means of ablation, and limiting its extend reduce the occurrence of this sequel. This review was designed to evaluate the validity of these claims.

METHODS

A MEDLINE search was performed for the years 1990--2006 and all publications about thoracoscopic upper dorsal sympathectomy for hyperhidrosis were retrieved.

RESULTS

The search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions.

CONCLUSIONS

The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.

Video-assisted thoracic surgery (VATS) of the lung: analysis of intraoperative and postoperative complications over 15 years and review of the literature

BACKGROUND

Video-assisted thoracic surgery (VATS) in the diagnosis and treatment of pulmonary diseases has been used since the early 1990s, yet its impact on intraoperative and postoperative morbidity has not yet been fully evaluated. This report aims to provide a retrospective analysis of the literature and the authors' clinical experience with VATS in pulmonary surgery, with the goal of ascertaining rational criteria that explain operative complications and thus improve outcomes.

METHODS

Over a period of 15 years 1,615 VATS procedures were performed in our department, 743 of which involved only the lung. The accesses employed were based on the use of three ports through which a thoracoscope, endoscopic instruments, and an endostapler were inserted; for major pulmonary resections, a utility thoracotomy without rib spreader was added. Resections less than segmentectomy were performed using the endostapler directly on the parenchyma, whereas in the anatomic resections all the hilar structures were isolated and separately sectioned.

RESULTS

The procedures performed were as follows: surgical biopsy, 98; wedge resection, 412; segmentectomy, 15; lobectomy, 217; pneumonectomy, 1. Besides the cases in which there were intraoperative complications that could be resolved thoracoscopically, it was necessary to convert to open surgery in 80 patients (10.8%): in 24 (3.3%), for general reasons linked to the technique of VATS itself; in 56 (7.5%), for specific causes correlated to the type of exeresis. The overall postoperative morbidity rate was 8.3% with no deaths.

CONCLUSIONS

The analysis of the literature and our experience show that VATS is a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. To further reduce intraoperative and postoperative morbidity, however, it is necessary to select the patients carefully, to adhere strictly to oncological surgical principles, and to adopt a meticulous technique. Although conversion to open surgery represents failure of VATS, it is mandatory when the procedure is not completely safe.

Video-assisted thoracic surgery (VATS) lobectomy: 13 years' experience

BACKGROUND

Major lung resection by video-assisted thoracic surgery (VATS) has been proven to be both safe and technically feasible, but is not routinely performed in most hospitals. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained.

METHODS

We have performed a retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit, Virgen Macarena University Hospital, Seville (Spain) since 1992. The clinical records of all patients were drawn from the hospital archive and data for the following variables were recorded for analysis: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications, postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. We also describe our surgical technique for each lobectomy.

RESULTS

A total of 237 major pulmonary resections were performed, on 203 males and 34 males, with a mean age of 61.43 years (non-small-cell bronchogenic carcinoma: 204, benign processes: 24, carcinoid tumors: 4, and lobectomy due to metastases: 5). The overall conversion rate was 14.01%. Mean duration of lobectomy was 153 min, with a median of 98 min, and mean postoperative stay was 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications. Perioperative mortality was 3.7%. The actuarial 5-year survival rate was 77.7%.

CONCLUSIONS

VATS lobectomy is a viable safe procedure that meets oncological criteria for lung cancer surgery. In our experience, VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas.

Combined thoracoscopic and endoscopic management of mid-esophageal benign lesions: use of the prone patient position

BACKGROUND

Both benign tumors and mid-esophageal diverticula are rare conditions; underlying disorders may be present in case of diverticula. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions.

PATIENTS AND METHODS

A total of 12 patients with symptomatic mid-esophageal lesions were studied, benign tumors were seven cases and five cases of diverticula. We present our experiences with thoracoscopic enucleation of benign tumors and diverticulectomy aided by peroperative endoscopy. All the patients were placed in the prone position and approached via a right thoracotomy.

RESULTS

Two patients had minor complications of pneumonitis and dysphagia, which were treated conservatively. One patient had a leak from the staple line that needed a second-look thoracoscopy and evacuation of abscess.

DISCUSSION

In this study, we highlight the use of the prone patient position, the advantages of a right thoracoscopic approach and the value of peroperative endoscopy. The prone position was first described in 1994, but has not been popular. Peroperative endoscopy accurately localizes diverticula and determines level of stapler application.

CONCLUSION

Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in diverticulectomy. Based on our experience, we believe the prone patient position is the ideal position for esophageal surgery.

Transvesical thoracoscopy: a natural orifice translumenal endoscopic approach for thoracic surgery

BACKGROUND

Recently there has been an increasing enthusiasm for using natural orifices translumenal endoscopic surgery (NOTES) to perform scarless abdominal procedures. We have previously reported the feasibility and safety of the transvesical endoscopic peritoneoscopy in a long-term survival porcine model as useful for those purposes. Herein, we report our successful experience performing transvesical and transdiaphragmatic endoscopic approach to the thoracic cavity in a long-term survival study in a porcine model.

METHODS

Transvesical and transdiaphragmatic endoscopic thoracoscopy was performed in six anesthetized female pigs. A 5 mm transvesical port was created on the bladder wall and an ureteroscope was advanced into the peritoneal cavity. After diaphragm inspection, we introduced through the left diaphragmatic dome a ureteroscope into the left thoracic cavity. In all animals, we performed thoracoscopy as well as peripheral lung biopsy. Animals were sacrificed by day 15 postoperatively.

RESULTS

We easily introduced a 9.8 Fr ureteroscope into the thoracic cavity that allowed us to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. Postmortem examination revealed complete healing of vesical and diaphragmatic holes, whereas no signs of infection or adhesions were observed in the peritoneal or thoracic cavities.

CONCLUSION

This study demonstrates the feasibility of transvesical thoracoscopy in porcine model. However, although this study extends the potential applications of NOTES to the thoracic cavity, new instruments and further work are needed to provide evidence that this could be translated to humans and with advantages for patients.

Thoracoscopic management of benign tumors of the mid-esophagus: a retrospective study

Benign esophageal tumors are rare conditions. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, increasingly more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions. We present our experiences from a specialised minimally invasive surgery unit. We have managed 12 patients with benign tumors of the mid-esophagus from 1995 to 2007 in our institute. The enucleation was achieved with the patient placed in the prone position and approached via a right thoracoscopy in all cases. Hospital stay was 3-5 days and there were minor postoperative complications in 2 patients. Mortality was nil. There were 10 patients with leiomyoma and 2 with GISTs, as proved by immunohistochemistry. Short and long-term follow up was satisfactory, with none of the patients having recurrences or other problems. Leiomyomas and GISTs, respectively, are the commonest benign tumors of the esophagus. Tumors more than 5 cm have to be enucleated, and thoracotomy has been the traditional approach to these lesions. Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in locating the lesion as well as confirming its complete removal. Based on our experience, a right thorax approach and the prone patient position is the ideal for thoracoscopic procedures.

Decreased invasiveness via two methods of thoracoscopic lobectomy for lung cancer, compared with open thoracotomy

BACKGROUND AND OBJECTIVE

Video-assisted thoracic surgery (VATS) lobectomy for primary lung cancer is considered minimally invasive. However, different procedures may be used for the VATS lobectomy, from complete videoscopic (CV) surgery to a technique similar to the muscle-sparing thoracotomy. We divided patients into two groups based on the surgical approach and analysed the outcomes.

METHODS

Two hundred and thirty-one patients were treated using one of two VATS procedures: the video-supported method (VS, n = 63) and the CV method (n = 168). Patients treated by posterolateral thoracotomy (PL, n = 61) were also evaluated for certain postoperative parameters and pulmonary function. The CV method is the standard VATS lobectomy procedure in our institution, but the VS method is used when the CV method becomes difficult because of severe adhesion around the pulmonary artery, or for other reasons.

RESULTS

Creatinine phosphokinase and CRP levels, and blood loss were lower in the VS and CV groups than in the PL group. Blood loss during CV was lower than that during VS. Postoperative VC after CV was higher than that after PL. Analgesic requirements in both VATS groups were lower than that in the PL group. The visual analogue scale pain score was lower in both VATS groups than in the PL group.

CONCLUSIONS

Two methods of VATS cause less surgical damage than PL. CV, in particular, causes less damage to pulmonary function than PL, and achieves good postoperative quality of life.

Thoracoscopy: Origins Revisited

The ways in which thoracoscopy has evolved wonderfully illustrate how a diagnostic and therapeutic technique can transcend a particular medical or surgical subspecialty. In this review, an in-depth history is provided to enable readers to better understand the nature of minimally invasive endoscopic pleural imaging techniques.

Video-assisted thoracoscopic dissection of the brachial plexus: cadaveric study and illustrative case

OBJECTIVE

Standard surgical approaches to the brachial plexus require an open operative technique with extensive soft tissue dissection. A transthoracic endoscopic approach using video-assisted thoracoscopic surgery (VATS) was studied as an alternative direct operative corridor to the proximal inferior brachial plexus.

METHODS

VATS was used in cadaveric dissections to study the anatomic details of the brachial plexus at the thoracic apex. After placement of standard thoracoscopic ports, the thoracic apex was systematically dissected. The limitations of the VATS approach were defined before and after removal of the first rib. The technique was applied in a 22-year-old man with neurofibromatosis who presented with a large neurofibroma of the left T1 nerve root.

RESULTS

The cadaveric study demonstrated that VATS allowed for a direct cephalad approach to the inferior brachial plexus. The C8 and T1 nerve roots as well as the lower trunk of the brachial plexus were safely identified and dissected. Removal of the first rib provided exposure of the entire lower trunk and proximal divisions. After the fundamental steps to the dissection were identified, the patient underwent a successful gross total resection of a left T1 neurofibroma with VATS.

CONCLUSION

VATS provided an alternative surgical corridor to the proximal inferior brachial plexus and obviated the need for the extensive soft tissue dissection associated with the anterior supraclavicular and posterior subscapular approaches.

Problems in pathologic staging of lung cancer

CONTEXT

Tumor stage is the most important prognostic and predictive factor for patients with lung cancer, the most lethal neoplasm in the United States. It is used by thoracic surgeons, radiation therapists, and oncologists to determine whether patients with these neoplasms will be treated surgically with curative intent or with palliative radiation therapy and/or chemotherapy.

OBJECTIVE

To review the variety of practical problems that can arise during the assessment of the pathologic stage and other prognostic/predictive factors included in the College of American Pathologist checklist for evaluation of resected lung neoplasms.

DATA SOURCES

Potential practical difficulties that can arise during the pathologic staging of lung cancer patients include the distinction between pT1, pT2, and pT3 lesions based on their location and the presence of visceral pleura and/or parietal pleura invasion; the differential diagnosis between multiple synchronous or metachronous primary lung neoplasms (pT1m) and intrapulmonary metastasis of non-small cell carcinoma of the lung (pT4 or pM1 according to their location); and the role of the recent American Joint Committee on Cancer terminology for the classification of lymph nodes (isolated tumor cells, micrometastases, and metastases).

CONCLUSIONS

The variety of practical problems that can arise during the assessment of important prognostic and predictive features such as resection margin status and evaluation of lymphovascular invasion are reviewed. A brief discussion of the assessment of the effects of neoadjuvant therapy on resected lung neoplasms is also included.

Thoracoscopic Lung Lobectomy for Treatment of Lung Tumors in Dogs

OBJECTIVE

To report use of thoracoscopic lung lobectomy (TLL) for treatment of lung tumors (LT) in dogs.

STUDY DESIGN

Retrospective study.

ANIMALS

Nine dogs.

METHODS

Dogs that had TLL for tumor removal were included. Using general anesthesia and 1-lung ventilation, TLL was performed using a 30-60 mm endoscopic gastrointestinal anastomosis stapler. If the visual field was obscured, lobe resection was completed via thoracotomy.

RESULTS

Metastatic and primary LT were resected by thoracoscopic lobectomy in 9 dogs (6 male, 3 female; mean (+/-SD) weight, 29+/-7 kg; mean age, 10.7+/-1.9 years). Six dogs had a solitary mass and 3 dogs had 2 masses within a single lobe. The left caudal lobe was removed in 3 dogs. In 5 dogs, TLL was used alone whereas conversion to thoracotomy was required in 4 dogs because of poor visibility. There were 7 metastatic LT and 2 primary LT. Mean duration of thoracoscopic surgery was 108.8+/-30.3 minutes compared with 150.75+/-55.4 minutes in dogs requiring conversion to thoracotomy. Mean hospitalization was 3.1+/-1.3 days.

CONCLUSION

Provided the visual field is not obscured, TLL can be performed effectively in dogs.

CLINICAL RELEVANCE

Dogs with metastatic or primary LTs should be considered for TLL, particularly for small masses positioned away from the hilus in the left caudal lung lobe.

Rounded atelectasis of the lung

Rounded atelectasis of the lung (RA) is a lesion well described in the medical literature, yet often very difficult to diagnose. In recent years, the widespread use of high-resolution imaging modalities employed in the struggle against cancer, coinciding with the peak of the asbestos epidemic, have boosted the detection frequency of RA. However, its differential diagnosis still poses a challenge to the pulmonary specialist and the radiologist, as little is known about its pathogenesis. Furthermore, the multifactorial etiology of RA and its occasional coexistence with lung cancer make the task of confidently ruling out malignancy sometimes daunting. This article attempts to provide an update on RA's etiology, radiological evaluation, clinical management, and prognosis based on recent advances in broadly available diagnostic modalities and minimally invasive interventional procedures. An exemplary case of post-tuberculous RA is illustrated, as RA often presents as an unusual finding of a fairly common disease.

Minithoracotomy combined with mechanically stapled bronchial and vascular ligation for anatomical lung resection

BACKGROUND

The most appropriate approach to anatomic pulmonary resection has been debated with the advance of minimally invasive techniques and especially the common use of mechanical staplers. Video assisted surgery and muscle-sparing thoracotomy are established options of surgical approach for lung resection. We utilize a combined technique of vertical muscle sparing minithoracotomy and mechanical closure of the hilum structures to accomplish lung resection.

METHODS

From December 1995 through January 2002, 713 patients (mean age, 65 +/- 11, 44.6% male) underwent anatomic pulmonary resection including 64 pneumonectomies, 514 lobectomies, and 135 formal segmental resections. Pulmonary resection was approached though a direct access, vertical, minithoracotomy (< 10 cm), and vascular ligation was performed with port-access endostapling instrumentation. Full mediastinal lymph node sampling was performed for primary lung cancer.

RESULTS

The average operative time was 55 minutes for lobectomy-formal segmentectomy and 62 minutes for pneumonectomy. An average of 3.6 staple applications were utilized to ligate the pulmonary vasculature (n = 2548 for 713 patients). Operative vascular complications included 5 minor intimal fractures, 1 posterior segmental arterial avulsion, and 1 staple misfiring for an adverse event rate during stapler application of 0.27%. Only one conversion to standard thoracotomy was necessary to control bleeding from the pulmonary vein. There were no intraoperative deaths.

CONCLUSIONS

Vertical minithoracotomy is a safe and expedited approach for anatomic lung resection. Direct visualization for dissection and effective pulmonary hilum mechanical closure with staplers were demonstrated. This approach is a reasonable option when a complete video-assisted surgery seems to be hazardous and a full open thoracotomy could represent an additional morbidity.

Traitement actuel du pneumothorax primaire et secondaire

INTRODUCTION

The treatment of a primary or secondary spontaneous pneumothorax remains controversial and many therapeutic options exist. In the event of a first episode of pneumothorax, should the patient be treated by observation, aspiration or thoracic drainage? For patients undergoing a thoracoscopic intervention for a spontaneous pneumothorax which is the best technique to treat the lung and parietal pleura? What are the results of thoracoscopy compared to thoracotomy and are the costs comparable?

PERSPECTIVES

The optimal treatment for a first episode of pneumothorax remains to be determined. As there are only a limited number of patients in the published randomised controlled studies only grade B or C recommendations can be given. This is also true for the treatment of the lung and parietal pleura during a thoracoscopic intervention. Most authors advise that an apical pleurectomy is performed. With regard to results and cost of thoracoscopy compared to thoracotomy, conflicting results have been published and definite conclusions cannot be drawn.

CONCLUSION

As large randomised prospective studies are not available regarding the treatment of pneumothorax only grade B or C recommendations can be given.

Video-assisted thoracoscopic surgery is a promising treatment for solitary fibrous tumor of the pleura

STUDY OBJECTIVES

Solitary fibrous tumors of the pleura (SFTPs) are slow-growing neoplasms. Approximately 800 cases have been reported in the literature to date. The aim of this study was to address our experience with the management of SFTPs and to evaluate the advantage of video-assisted thoracoscopic surgery (VATS) in SFTP treatment.

DESIGN

Retrospective analysis of our experience.

SETTING

Department of Thoracic and Cardiovascular Surgery, Nara Medical University.

PATIENTS

From January 1992 to August 2002, 13 patients with a SFTP were referred to us for surgical resection after VATS was adopted in our hospital. The study group consisted of seven men and six women with a mean age of 49.8 years (age range, 37 to 72 years).

RESULTS

Surgical excision was performed with VATS only in nine patients, with VATS plus a small thoracotomy in three patients, and by a posterolateral thoracotomy without VATS in one patient. The mean chest-drain duration was 1.3 days (range, 1 to 3 days), and the mean duration of hospital stay was 8.6 days (range, 3 to 30 days). Eleven tumors, originating from the visceral pleura, were pedunculate, and 2 tumors from the parietal pleura were not pedunculate. Two cases were focally characterized by a mitotic count in excess of four mitoses per 10 high-power fields and by cellular pleomorphism. Follow-up periods ranged from 6 to 120 months, with a mean of 49.7 months and a median of 42 months. All patients have remained well with no recurrence or metastasis.

CONCLUSIONS

Complete surgical resection is the treatment of choice for SFTPs. For the pedunculate tumors, therefore, VATS is a powerful and useful approach. Even when it is necessary to perform a small thoracotomy in addition to VATS for the removal of a large tumor, VATS may play an important role in reducing the size of the thoracotomy incision, which results in less invasive surgery. To minimize postoperative morbidity, VATS may be the most promising surgical approach for the resection of SFTPs.

Clinical trials of peripheral stage I (T1N0M0) non-small cell lung cancer

Debate continues regarding the choice of resection for peripheral stage I (T1N0M0) non-small cell lung cancer (NSCLC). Anatomic lobectomy has been considered the standard of care for resectable NSCLC; however, intriguing results of clinical trials have been reported with the use of sublobar resection as primary therapy of selected small peripheral lung cancers. Most modern clinical studies comparing lobectomy to sublobar resection of stage I NSCLC demonstrate equivalent survival, but local recurrence following sublobar resection appears to be greater. Low energy computed tomography screening programs for lung cancer have increasingly identified small peripheral lesions potentially amenable to effective therapeutic management with sublobar resection. We discuss the possible management scenarios for stage I NSCLC in this age of early computed tomography detection of lung cancer, more precise molecular biologic staging of the disease, optimized peri-operative management of the marginally resectable patient, and improved adjunctive treatment measures for local control following lung cancer resection.

Management of primary spontaneous pneumothorax

The optimal management of primary spontaneous pneumothorax remains the subject of considerable controversy. During the last few years, however, interesting new data on pathogenesis and various treatment techniques have been published, which have led to the publication of some interesting and thought-provoking opinion articles. The author reviews the latest developments in pneumothorax pathophysiology and management.