SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
An undiagnosed pulmonary sequestration showed abnormal vessels at video-assisted thoracoscopy. Mediastinal or lung masses which are situated at the base of the thorax must be dissected with great caution because of the possible existence of vascular malformations.
OBJECTIVE: One of the indications for the rapidly expanding use of thoracoscopic surgery as an alternative to thoracotomy is the excision of peripheral lung nodules. Nodules judged too small or too far from the pleural surface to be seen or palpated during thoracoscopy must be localized beforehand. The purpose of this study was to evaluate the feasibility and effectiveness of percutaneous placement of spring hookwires to localize such nodules before video-assisted thoracoscopy. SUBJECTS AND METHODS: Under CT guidance, 17 nodules in 14 patients were preoperatively localized with the Kopans breast lesion localization system. Three patients who had solitary nodules had thoracoscopic resections for diagnosis because a previous transthoracic needle or transbronchial biopsy had been unsuccessful. Four patients who had lesions less than 8 mm in diameter had thoracoscopic biopsies because transthoracic fine-needle aspiration biopsy was not likely to be diagnostic. Seven patients, who had a total of 10 nodules, had therapeutic wedge resections of either limited metastases or a second bronchogenic carcinoma. Mean nodule diameter was 10 mm (range, 3-20 mm). The mean distance from nodule to costal pleura was 9 mm (range, 0-25 mm). At the end of the procedure, wire placement was confirmed by CT scanning. After thoracoscopy, the surgeons were questioned about the stability and utility of each hookwire localization. RESULTS: In all 17 procedures, a hookwire was placed successfully. In one case, the wire dislodged before thoracoscopy (after a 6-hr preoperative delay and severe bending of the wire during induction of anesthesia). In 16 of the 17 resections, the surgeon thought that thoracoscopic identification of the lesion would not have been possible without hookwire localization. Only one localization, across a major fissure, required placement of a second wire to localize a nodule. Wire-related complications included two instances of serious pain, five cases of clinically insignificant pneumothorax, and one large pneumothorax requiring drainage before a second nodule in the same lung was localized. CT scanning showed presumed local pulmonary hemorrhage in six cases without hemoptysis or hemothorax. CONCLUSION: CT-guided hookwire localization is easily and safely performed and permits thoracoscopic resection of lung nodules, which might otherwise be impossible.
In addition to qualitative establishment of diagnosis the aim of modern investigational procedures is quantitative analysis of disease extension and of functional impairment. The most important endoscopic-bioptical techniques for establishment of diagnosis are bronchoscopy and thoracoscopy. In bronchology flexible bronchoscopy with a relative share of about 90% clearly holds now a dominant position versus the rigid technique. Suspected cancer is the most prominent indication (ca. 60%). Visible intrabronchial lesions can be diagnosed in more than 90%. In extrabronchial and peripheral bronchopulmonary disease technical aids like transbronchial needle aspiration (TBNA), bronchoalveolar lavage (BAL) or transbronchial biopsy (TBB) are required, resulting in a diagnostic yield, that may range between 30 and 90% depending on the particular disease entity. Thoracoscopy is the second most important endoscopic procedure and accounts for about 1/10 of the investigational frequency of bronchoscopy. Pleural - generally exsudative - effusion provides by far the most frequent indication with a relative incidence of 75%. Etiological diagnosis can be established in about 90% of pleural effusions. The maximum yield of 100% may be achieved in tuberculous effusions, in malignant effusion sensitivity comes close to 100%. Non-endoscopic bioptical techniques include guided perthoracic needle aspiration and "blind" pleural biopsy. Diagnostic escalation or tumor staging may require surgical procedures, which can be performed by conventional techniques (mediastinoscopy, minithoracotomy) or video-assisted thorascopy. Explorative thoracotomy is the most extensive investigation. For functional evaluation of number of "classical" techniques are available (spirometry, gas transfer analysis, spiroergometry) more recently expanded by radionuclide perfusion and ventilation studies. Besides grading of functional impairment they allow clinical diagnosis of diseases characterized by specific functional patterns (asthma, bronchitis, emphysema, sleep associated disorders) and serve preoperative assessment in surgery. Increasingly important modern imaging techniques like computed tomography (CT), nuclear magnetic resonance (NMR) or ultrasonic investigation are not featured in this clinically focused article.
The main problem with clinical introduction of laparoscopic techniques in urology is that despite experience with endoscopy no significant endoscopic training is given. Laparoscopic nephrectomy, in particular, is a rather complicated procedure and needs an adequate training concept: The beginner should have the possibility of practising in vitro in a closed "pelvi-trainer" to learn video-optical coordination and orientation; then it is necessary to get used to handling the instruments and practise the different steps of the procedure (i.e. clipping of vessels, sacking of the kidney) either in phantom models or in explanted animal organs. On this basis, we performed laparoscopic nephrectomy in an animal model (n = 18 porcine kidneys). We were able to standardize the technique of creating a pneumoperitoneum, the positioning of the animal, the site and size of the trocars, and preparation and clipping techniques (i.e. Endo-GIA) and entrapment of the kidney (testing different organ bags). A step-by-step approach was used for the introduction to clinical application. For simulation and training of video-assisted preparation techniques in patients and step-wise introduction to laparoscopy (instruments, endocoagulation, trocars), we created a "lap-tent", which was placed over the wound after exposition of Gerota's fascia. Further preparation was performed under laparoscopic conditions (without pneumoperitoneum) with a limited time allowed (1 h). Thereafter, we started with time-limited laparoscopy and laparoscopic lymphadenectomy prior to pelvic surgery (prostatectomy, cystectomy) to introduce the staff to the technique of pneumoperitoneum and placement of the trocars and to the use of the instruments in general. Based on this step-by-step training concept, after a 6-months period we were successful in introducing transperitoneal laparoscopic nephrectomy (TLN) to our clinical routine. So far, we have performed 20 laparoscopic nephrectomies, 1 nephro-ureterectomy, 4 tumour nephrectomies (inducing adrenalectomy), 2 adrenalectomies, and 6 modified retroperitoneal lymphadenectomies. In the lesser pelvis we have experience with 20 laparoscopic varicocelectomies, 23 pelvic lymphadenectomies, and 5 diagnostic laparoscopies for cryptorchidism (February 1993).
Video-assisted thoracoscopy (VAT) provides an opportunity for evaluation and biopsy within the pleural space and at the pulmonary hilum. The application of a standardized approach for VAT in patients with primary lung cancers was evaluated. Of 49 patients, 6 patients could not be evaluated due to intrapleural adhesions. Of the remaining 43 patients, an unsuspected parietal pleural metastasis was identified in 2, obviating further surgery. The other 41 patients underwent anatomic resection after VAT staging, which was carried out during the same operative procedure. Pathologic staging of the specimens revealed 20 T1 N0, 10 T2 N0, 5 T1 N1, and 6 T2 N1 lesions. Among the T2 lesions, 10 of 16 (63%) involved visceral pleural invasion, all of which were identified at VAT staging. Among the N1 lesions, 6 of 11 (55%) were identified at VAT staging; in the remainder, N1 nodes were not accessible to biopsy. No morbidity or mortality was noted. Routine VAT staging in patients with lung cancer is a safe technique, reduces the need for an exploratory thoracotomy, and may identify patients with localized lung cancers who are at high risk for postoperative recurrence.
Thoracoscopy is increasingly being used for diagnosis and treatment of pleuropulmonary disease. The recent revival was made possible by the tremendous advances in endoscopic technology. The main requirements for diagnostic purposes are rigid telescopes and forceps, and for interventional thoracoscopy scissors, staplers and a video recorder. The procedure can be performed either under local or general anaesthesia, with or without double lumen intubation, after inducing an artificial pneumothorax. At the end of the procedure, a chest tube should always be inserted, even if only for a few minutes until the lung re-expands. Main diagnostic indications are pleural effusions, pneumothorax and diffuse lung disease. Main therapeutic indications are pleurodesis by talcage in effusion and pneumothorax and a variety of diseases of the lung, the pleura and the mediastinum, where thoracotomy may be replaced by video-assisted thoracoscopy. The well-known indications of the past remain a domain of pneumologists, whereas minimal invasive thoracotomy is the task of thoracic surgeons. For some indications no sharp line has to be drawn, provided the facilities and skills are present, including those for the management of complications.
The vast majority of patients suffering with emphysema cannot be helped by surgery. A fortunate minority, consisting of specific subsets of patients, can benefit, but to do so the surgeon must have a flexible approach and select the optimal procedure for each patient. There is no one operation that is ideal in all circumstances. A major exploratory thoracotomy remains the approach of choice in specific situations (1) when dealing with the rare patient who has a congenital air cyst in the context of otherwise normal lungs. Local excision usually is possible but lobectomy may be necessary; (2) when dealing with an infected bulla in which the situation can only be ascertained at operation, where adhesions may cause difficulty and drainage may prove inappropriate, and lung resection is necessitated; and (3) when operating for a pneumothorax in which the situation can only be assessed at operation, and control of air leak is mandatory by ligation, bullectomy, or intracavitary drainage. The future role of video-assisted operations in this context must await the longer follow-up of larger series. In the elective management of patients with emphysema, those with a dominant bulla we continue to treat by intracavitary drainage. The Brompton technique offers a simple, safe, and effective therapeutic option in carefully selected patients. We believe the advantages to be threefold. Firstly, the use of CT scanning, important in patient selection, allows one to plan the incision so that a minithoracotomy can be performed, reducing the morbidity and mortality formerly associated with thoracotomy in patients with poor respiratory reserve. Secondly, the approach obviates the need to resect adjacent lung tissue, which in a generalized and progressive disease may be physiologically of disproportionate importance. Finally, pleurodesis allows any future recurrent bullae to be intubated and drained percutaneously under local anesthetic with minimal risk of pneumothorax. In those patients who have generalized emphysema without significant bullae, the role of volume-reduction surgery is being investigated. We await longer-term follow-up but fear that with wider application this major operation will accumulate significant mortality. Transplantation remains an option that must be limited to the youngest patients and those who are close to the terminal phase of their illness.
For anterior approaches to the thoracic spine, a posterolateral thoracotomy has been the standard approach. Recent expanded experience with video-assisted thoracic surgical techniques has allowed us to perform many thoracic spine procedures that previously required open approaches. These procedures include drainage of spinal abscesses, biopsy of vertebral bodies, discectomy for a herniated nucleus pulposus, and anterior releases for kyphoscoliosis. All procedures were successful, but experience is limited and follow-up still short. It is hoped that further experience will prove that this less invasive approach can be widely applied in the practice of thoracic spinal surgery.
During the period March 3, 1992 to September 30, 1993 36 video-assisted thoracoscopic operations were performed at the Surgical Department of the University of Cologne. In 12 cases wedge resection of peripheral pulmonary nodules were carried out. Two of the patients underwent video-assisted thoracoscopic lobectomy of the left lower lobe due to peripheral primary bronchogenic carcinoma. In 6 cases biopsy of the lung or pleura was undertaken. Further indications were partial pleurectomy and resection of blebs (n = 12). Pleural effusion was drained under thoracoscopic vision twice. No intraoperative complications occurred. Two patients proceeded to thoracotomy after persistence of pneumothorax following thoracoscopic pleurectomy. The postoperative course of the remaining patients was uneventful and was especially characterized by the reduction in pain and disability. In accordance to the experience of other authors we believe that thoracoscopic surgery is a method with a promising future. Further investigations have to evaluate indications, different techniques, and long term results.
After an extensive favorable experience with the Lapides-Ball open retropubic bladder neck suspension, we chose to perform this operation laparoscopically. We describe video-assisted extraperitoneal laparoscopic bladder neck suspension (VELBNS), in which we employ a single laparoscopic cannula and a laparoscopic bladder suspension set for suturing and simultaneously use video-assisted cystoscopy and laparoscopy for precise suture placement. Over 16 months, we operated on 70 patients with stress urinary incontinence secondary to hypermobility of the urethra. We describe the patient evaluation and selection and the surgical principles and techniques. Five procedures were converted to open operations because of bladder lacerations (two cases) or inability to dissect the space of Retzius because of scar tissue (three cases). At 3 months, 4 patients had unresponsive de novo urgency incontinence, and 61 patients were dry and without protection. One patient had a recurrence at 6 months that was corrected by open surgery. All 12 patients seen at 1 year were dry. We intend to survey our patients annually to obtain long-term results.
A video-assisted thoracoscopic microsurgical approach was performed to treat a myelopathic patient with a severe kyphotic deformity caused by chronic nonunion of compression fractures of the T7-9 vertebrae. The kyphotic deformity was treated by combined operative procedures. First, an anterior release was performed using a thoracoscopic technique, sectioning the anterior longitudinal ligament and performing multilevel thoracic discectomies. Next, a posterior reduction and internal fixation of the deformity was achieved using hook-rod instrumentation. Finally, bone graft harvested during the posterior approach was used for interbody fusion via a thoracoscopic approach. Microsurgical thoracoscopic techniques potentially can be used in a variety of spinal surgeries. Compared to transthoracic and posterolateral approaches, this technique presents distinct advantages to treatment of anterior spinal pathology. The small incisions made into the intercostal spaces without retracting the ribs may reduce postoperative pain, shorten the length of hospitalization, and allow early return to activity. The operative techniques used in this case are described in detail. This report demonstrates that thoracoscopic discectomies and interbody fusion are technically feasible and can be effectively performed with acceptable results.
The few reports in the literature on thoracoscopic anatomic lung resections were almost exclusively for early primary lung cancers. We report our combined experience on video-assisted thoracoscopic (VAT) lobectomy for benign diseases from two major hospitals in Hong Kong over a 20-month period. From August 1993 to March 1995, 66 VAT lobectomies were performed; of this number, 10 cases (15%) were for benign diseases (5 tuberculosis, 2 organized pneumonia, 1 bronchiectasis, 1 sclerosing hemangioma, 1 infected bronchogenic cyst). There was no mortality or incidence of intraoperative complications. Postoperative complications occurred in one patient with tuberculosis and consisted of persistent air leak and subsequent wound infection. There were no long-term complications after a mean follow-up of 11 months. The mean duration of chest tube drainage was 6.7 days and that of hospital stay was 9.8 days. These results were not statistically different from those achieved in VAT lobectomies performed for malignant tumors (5.0 days for drainage and 6.8 days for hospital stay) despite the fact that hilar dissection was sometimes more difficult in the former because of inflammatory changes. We conclude that VAT lobectomy for benign diseases is technically feasible even though its role in thoracic surgery remains to be defined.
Video-assisted thoracoscopy (VAT) offers a new approach to the diagnosis and treatment of many thoracic conditions. From September 1992 to August 1993, a total of 163 VAT procedures were successfully performed on 108 patients (87 male, 21 female; age range from 12 to 77) which consisted of 42 bleb eliminations and 64 mechanical pleurodesis for spontaneous pneumothorax, 11 wedge resections for pulmonary nodules, three wedge biopsies for diffuse pulmonary infiltrate, four thoracic sympathectomies, resections of two mediastinal masses, three pericardial windows, 10 guided pleural biopsies for undiagnosed effusions, six guided drainage of empyema and haemothorax, 16 staging of intrathoracic tumours and two explorations for penetrating thoracic trauma. There was no procedure-related mortality. Complications included one recurrence for spontaneous pneumothorax, one re-exploration for bleeding (also by VAT approach), one wound infection, and six persistent air leaks for more than 10 days. The median duration of postoperative chest tube drainage was 2 days and the median hospital stay was 4 days. It was concluded that VAT is a safe and effective approach in thoracic surgery and with further refinement in instrumentation even more procedures will be technically feasible. The long-term results of VAT are being awaited in order to define its true merits in thoracic surgery.
A variety of video-assisted thoracic operations are being reported with increasing frequency. Problems encountered during the development of this technology have received less attention. During the course of 27 months, 69 consecutive patients underwent minimally invasive procedures at our institution. Conversion to thoracotomy was required in 16 of 49 (33%) patients undergoing diagnostic procedures and 1 of 20 (5%) patients undergoing therapeutic interventions. Fewer complications occurred in those patients with diagnostic procedures (10 of 49, 20%) versus therapeutic interventions (10 of 20, 50%; p = 0.01). Logistic regression analysis showed chronic obstructive pulmonary disease to be an independent risk factor for complications. The mean postoperative stay was 7.9 +/- 6.8 days for diagnostic and 12.8 +/- 9.7 days for therapeutic interventions (p = 0.02). As new technologic improvements were introduced, the mean hospital stay decreased (first 10 months: 14.6 +/- 10.0 days, 10 to 20 months: 9.8 +/- 9.6 days, more than 20 months: 5.2 +/- 3.0 days, p < 0.004). The surgeon's thoracoscopic experience was not as strongly predictive (5 or fewer cases: 8.9 +/- 5.9 days, 6 to 15 cases: 13.1 +/- 12.6 days, more than 15 cases: 5.0 +/- 2.0 days). Although thoracoscopic surgery is promising, the potential for problems requires careful surgical judgment and expertise in dealing with thoracic complications.
Dorsal sympathectomy and the management of the thoracic outlet syndrome have been considerably improved with the use of video assistance because it affords both magnification and an improved light system. Two techniques of video assistance were employed in the group of patients described here. One involved the sympathectomy done through three ports using standard video-assisted thoracic surgical methods. The second technique involved a transaxillary incision with removal of the first rib using video-assistance magnification and light, operating either directly or secondarily while visualizing the image on the television set. (The vast majority of cases have been performed using this latter technique.) Major indications for performing dorsal sympathectomy include (1) hyperhidrosis, (2) Raynaud's phenomenon, (3) Raynaud's disease, (4) causalgia, (5) reflex sympathetic dystrophy, and (6) vascular insufficiency of the upper extremity. Except for hyperhidrosis, all of the other indications require the usual diagnostic techniques, including cervical sympathetic blockade to assess whether the symptoms are relieved by temporary blockade of the sympathetic ganglia. In 326 patients, sympathectomy, performed either alone or in conjunction with first-rib removal for relief of the thoracic outlet syndrome, has been successful. In only 6 patients has sympathetic activity recurred in less than 6 months. Initially all of them were treated conservatively. Three of the 6 required a repeat sympathectomy. Postsympathectomy neuralgia occurred in only 2 of more than 326 patients. Both cases were managed successfully in a conservative fashion. Among the patients in whom a Horner's syndrome was not deliberately induced, the syndrome developed in 2. In both, the syndrome resolved spontaneously within several months.
Between June 1991 and July 1992, 118 patients (57 men and 61 women) underwent video-assisted thoracoscopy for indeterminate pulmonary nodules. Median age was 64 years (range 30 to 85 years). Thoracotomy was performed in 33 patients (28.0%) after thoracoscopy only because the nodule could not be located in 17 patients, was too large to safely resect in 5, appeared malignant in 4, and for technical reasons in 7. Eighty-five patients underwent thoracoscopic wedge excision. Twenty-one (24.7%) of these 85 patients also had thoracotomy--15 to perform formal lung resection for bronchogenic carcinoma, 3 for nondiagnostic abnormalities, 2 to locate a second nodule, and 1 for stapler malfunction. The remaining 64 patients (54.2%) had only video-assisted thoracoscopic wedge excision. A single wedge excision was performed in 56 patients, two in 6, and three in 2. Pathologic examination of these 74 nodules revealed a granuloma in 30, metastatic cancer in 25, hamartoma in 7, lymphoma in 1, and other benign lesions in 11. There were no deaths and only 4 (6.3%) complications in these 64 patients. The 64 patients treated by thoracoscopy only were compared with a similar group of 64 patients who had wedge excision via thoracotomy without prior thoracoscopy. Postoperative analgesic requirements were less in the patients treated by thoracoscopy. Median hospitalization in the thoracoscopy group was 3 days compared with 6 days in the thoracotomy group (p < 0.05). Median total charge for the thoracoscopy-only group was $12,898 as compared with $12,502 for patients undergoing wedge excision via thoracotomy. We conclude that thoracoscopic wedge excision is a safe and effective procedure in selected patients with an indeterminate pulmonary nodule. A significant number of patients (45.8%), however, required a thoracotomy to accomplish a safe operation or to ensure adequate staging and resection for malignancy. Although thoracoscopy reduces postoperative analgesia requirements and shortens hospital stay, total hospital charges were similar to charges for a wedge excision via thoracotomy.
BACKGROUND: Thoracic surgeons have historically played a significant role in surgical treatment of benign esophageal disorders. With the advent of video-assisted thoracic surgical techniques, chest surgeons have also become adept at minimally invasive procedures. Thus, it seems appropriate that thoracic surgeons participate in minimally invasive antireflux operations, such as laparoscopic Nissen fundoplication. METHODS: From February 1993 to May 1995, 66 patients (32 male, 34 female) with a mean age of 45.5 years (range, 15 to 82 years) underwent a laparoscopic fundoplication. Gastroesophageal reflux disease was diagnosed on the basis of history and endoscopically documented esophagitis or abnormal esophageal pH testing or both. There were 45 type I, 3 type II, and 7 type III hiatal hernias. Eleven patients had gastroesophageal reflux disease with no hernia. RESULTS: Conversion to laparotomy occurred in 6 patients (9%) due to bleeding in 2 patients, inability to expose the gastroesophageal junction in 3, and gastric laceration in 1 patient. All but 1 patient underwent a Nissen fundoplication performed over a 50F to 60F dilator. The remaining patient (type II hernia without gastroesophageal reflux disease) underwent a reduction, closure, and anterior gastropexy. There was no operative mortality. Immediate postoperative morbidity included moderate dysphagia in 7 patients (11%), ileus in 2 patients (3%), and deep venous thrombosis and atrial arrhythmia in 1 each (1.5%). Excluding 1 patient hospitalized for 42 days due to severe psychosis, the mean postoperative stay was 4.0 +/- 2.5 days (median, 3 days). Three patients (5%) required dilation for dysphagia, and 1 (1.5%) has noted recurrent reflux during follow-up (mean, 14.4 months; range, 6 to 30 months). A single patient has undergone reoperation for persistent dysphagia (1.5%). CONCLUSIONS: A laparoscopic Nissen procedure is safe, effective treatment for refractory gastroesophageal reflux disease when performed by thoracic surgeons experienced in minimally invasive surgical procedures.
Sympathetic nerve disorders of the upper extremities can be treated by neurosurgeons using upper thoracic sympathectomy via a posterior approach. Descriptions have been published of alternative endoscopic procedures involving thermocoagulation, laser coagulation, or nonvideo-assisted ganglionectomy using equipment not widely available, with low morbidity and excellent results. The authors describe the use of an endoscopic approach to the thoracic sympathetic ganglia with systems designed for laparoscopic cholecystectomy. Thoracic ganglionectomy is reported in 22 patients with primary palmar hyperhidrosis and eight patients with reflex sympathetic dystrophy. The patients underwent double-lumen endotracheal intubation, after which 11- and 5.5-mm trocars were introduced into the chest cavity. Pneumothorax was produced with CO2 insufflation. Fiberoptic closed-circuit television was used to visualize the structures to be dissected. The parietal pleura over the heads of the first and second ribs was excised using 5-mm blunt and sharp insulated coagulating microscissors. The stellate and upper thoracic ganglia were clearly identified and dissected. The T-2 and T-3 ganglia were grasped with forceps and excised. A No. 16 French chest tube was introduced through a trocar, placed under water seal after the lungs were reinflated, and removed in the recovery room. The average hospital stay was 15.4 hours. There were no intraoperative complications. The average operating time was 30 minutes per side. Five patients had mild pleuritic pain which resolved within 2 weeks after surgery. Six (75%) of the eight patients with reflex sympathetic dystrophy had complete or partial relief of their symptoms (average follow-up period 5 months), and all patients had complete relief of hyperhidrosis (average follow-up period 8 months). Endoscopic ganglionectomy requires readily available and easily used instrumentation and provides a well-tolerated, cost-effective alternative to posterior thoracic sympathectomy for primary palmar hyperhidrosis and reflex sympathetic dystrophy.