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The video shows six different established thoracoscopic interventions besides the treatment of spontaneous pneumothorax. Adhesiolysis (1) is demonstrated in a patient with malignant pleural effusion, followed by palliative pleurodesis by talkage (2). Resections of benign extra- (3) and intrapulmonary (4) tumors are shown as well as endoscopic pericardial fenestration (5) and thoracic sympathectomy (6).
Report on four patients with achalasia of the oesophagus. Longitudinal myotomy was performed by thoracoscopy as minimally invasive procedure. The advantages of the transthoracic, thoracoscopic versus the transabdominal operation are discussed.
From September '92 to November '93, 15 lobectomies were performed under thoracoscopic guidance. After a thoracoport was inserted through the seventh intercostal space to conduct the operation utilizing a monitor, a six to ten cm incision was made in the fifth intercostal space. The pulmonary arteries and veins were divided after stapling with an Endo GIA or Roticulator 30-VIII. The lobar bronchus was stapled with a Roticulator 30-3.5, 30-4.8 or an Endo TA and affected lobes were resected. In cases of lung cancer, lymph node dissection has become possible as well due to the improvement of endoscopic instrumentation.
His extensive developmental and clinical work made Raimund Wittmoser a major trailblazer in endoscopic surgery from the 1950s on. His single-puncture technique for operative thoracoscopy permitted surgical interventions of peerless quality on the sympathetic and vagal nerves. His basic surgical principle was to achieve the greatest possible selectivity by a segmental approach to the sympathetic rami communicantes or the individual branches of the vagus nerve. Besides his extraordinary surgical skills, his particular achievement was the development of new instrumental and ancillary technologies for endoscopic surgery. In addition to the development of new endoscopes and imaging systems, his pressure-regulated CO2 insufflation system and low frequency cautery technique had major impact on the further development of endoscopic surgery. Finally, Wittmoser's surgical interventions in the autonomic nervous system were of outstanding quality and set standards still observed by thoracoscopic surgeons today.
The technique of video-assisted thoracic surgery (VATS) offers a new approach for management of effusive diseases of the pericardium. By the thoracoscopic approach, which can be performed through either the right or left chest cavity, an extensive pericardiectomy equivalent to one performed through a thoracotomy can be performed. Patients with benign effusive pericarditis, malignant pericardial effusions with a good prognosis, post-radiation pericarditis, purulent pericarditis, and delayed tamponade after open cardiac procedures can be optimally managed by video-assisted techniques.
Thoracoscopic excision of an oesophageal leiomyoma was successfully performed in 4 patients. The tumours were enucleated easily without intraoperative complication. A patient in whom the muscular layer was not sutured after removal of the myoma presented with a pseudo-diverticulum one year after the operation and required a thoracotomy for resection. This new procedure which reduces the operative trauma and postoperative pain and allows quick recovery, is described.
Thoracoscopic instruments of today are rooted in surgical innovations which began over 100 years ago. The advent of modern video-optical equipment and endoscopic techniques has given birth to a wide array of new instruments and surgical uses. This process is still in full swing. An overview of the most important developments is given, and future lines of development are explored.
A technique for endoscopic-assisted oesophagectomy is described using either a lateral or prone position for the oesophageal dissection. In a consecutive series of 34 patients, two were found to have hepatic deposits at preliminary laparoscopy, and four were inoperable at thoracoscopic staging. A further two had fibrous obliteration of the pleural cavity. Of the 26 procedures, 20 were performed in the lateral position and six in the prone position. There was one conversion to open thoracotomy due to massive aortic bleeding. There were no deaths. Postoperative complications included pneumonia (n = 3), recurrent laryngeal nerve palsy (n = 2) and one anastomotic leak. The median postoperative stay was 12 days (range 9-30 days). It is suggested that the prone position has technical advantages and reduces the postoperative respiratory complications.
Techniques for intrathoracal stapler anastomosis under thoracoscopic control were studied and developed in an experimental program. Since this procedure is possible from two directions, both directions were evaluated. Two different techniques, a transoral and a transhiatal, resulted. For the transoral technique the stapler is inserted from above. The anvil, which is connected to a wire, is drawn into the abdomen together with the distal oesophagus. Retracting the wire pulls both the anvil and the stomach tube up into the thorax after the insertion of the anvil. The second technique requires a special attachment to introduce the anvil transhiatally into the thorax and into the oesophageal stump. The gastric tube is pushed into the thorax by the stapler gun, which is inserted into the stomach through an antrostomy. The insertion of the anvil into the oesophageal stump can also be achieved with the support of a flexible endoscope including a polyp snare.
Experiences based on 75 minimal invasive intrathoracic procedures performed during a one and half--year--period are reported. The standard video thoracoscopic and mini-thoracotomy methods are compared. The possible indications are discussed, and the authors' opinion about the role of these methods in pulmonary resections is presented. They call attention to the consideration of the limits and possibilities of this new technique.
Schwannomas are most often benign tumors originating from the sheath of peripheral nerves. Most are asymptomatic and detected incidentally on a routine chest X-ray. Resection is generally recommended to confirm the diagnosis. In a 35-year-old patient we resected and removed an intrathoracic schwannoma of the 6th intercostal nerve thoracoscopically. The technique of resection and protected removal is described.
We present the initial results fo thoracoscopic resection of pulmonary nodules, based on a report of 23 patients. The resection was performed through a sole thoracoscopy in 12 cases, but was associated with a mini-incision in 11 cases. In 4 cases, the procedure had to be converted to thoractomy. We discuss the problems encountered and the indications of the technique.
This report describes a thoracoscopic approach for performing parietal pleurectomy. We have developed and used this technique successfully in 12 patients for treatment of recurrent spontaneous pneumothorax with extended bullous lung alterations (stage 4 according to the classification of Vanderschueren). For this purpose we need videoendoscopy and specially designed equipment, including pliable silicone trocars and angled instruments. The mean age of the patients was 38 years; no deaths and no complications occurred. The average period of postoperative hospitalization was 3.3 days. During the follow-up period ranging between 5 and 10 months (mean 7.5), no relapsing pneumothorax was observed.
Although video-assisted thoracoscopic surgery (VATS) is now accepted by many as the approach of choice in the management of primary spontaneous pneumothorax (PSP), the optimal procedure and timing of surgical intervention remain as areas of contention. The author reviewed his personal experience with 224 consecutive VATS procedures for PSP. Mechanical pleurodesis was performed in every case and was the only procedure in 20 patients. We had experienced with several means of eliminating subpleural bullae once identified: stapled bullectomy (151), endoloop (12), argon beam coagulation (6) and endoscopic suturing (35). There were no mortality or intraoperative complications. The median postoperative hospital stay was 3 days. So far, we have had 4 recurrences (1.8%) after a mean follow-up of 20 months (range 1 to 36 months). Complications consisted of 10 persistent air leaks, 1 wound complication, and 1 chest wall bleeding. We conclude that 1) VATS is a safe and effective approach in the treatment of PSP; 2) Stapled-bullectomy is quick and reliable but costly; 3) Endoloop and suturing are viable alternative techniques that may prove to be more cost effective; and 4) we do not recommend the use of argon beam coagulation as the primary treatment modality.
Thoracoscopy was used in the diagnosis and treatment of three patients with diaphragmatic disorders, including traumatic injury of the diaphragm, partial eventration of the diaphragm, and catamenial pneumothorax (endometriosis of the diaphragm). An excellent view of the diaphragm was obtained by using thoracoscopy. The diaphragmatic injury was repaired primarily, the eventration plicated, and the focal endometriosis resected. Recovery was rapid and uneventful in all three patients. Thoracoscopic surgery, although relatively new, may be an acceptable alternative to the conventional operative management of diaphragmatic disorders and may actually reduce the morbidity and mortality associated with thoracotomy.
The recent progress made in endoscopic surgery has increased the number of thoracoscopic procedures, especially in the field of pulmonary nodules resection. The main problem related to these newly developed surgical procedures is the difficulty in locating the target nodule. We describe the techniques we currently use to facilitate the localization of pulmonary nodules. These techniques include preoperative methylene blue injection and insertion of a hookwire into the lung nodule, but also intraoperative palpation (digital and instrumental) and ultrasonography.
Between April 1992 and March 1995, 83 patients underwent video-assisted (VATS) thoracoscopic major pulmonary resection (lobectomy: 72, bilobectomy: 4, or pneumonectomy: 7). Conversion to open thoracotomy was required in a further 21 cases (rate=20.2%). There was no in unit mortality; 2 patients died within 30 days (1.9% overall). Analysis (median values) of the VATS lobectomy cases demonstrated; operation time - 135 minutes; blood loss - 80 mls; High Dependency stay - 38 hours; total postoperative stay - 7 days. Comparison between 70 VATS lobectomies and a simultaneous group of 110 open thoracotomy cases confirmed reduced postoperative morphine consumption (83 mg open vs 57 mg VATS; p<0.001). One pneumonectomy patient exhibited a transient sympathetic dysaesthesia and one lobectomy patient developed a mild post thoracotomy pain syndrome. Long-term follow-up of VATS lobectomy for patients with primary bronchogenic carcinoma (49) revealed 1 bronchogenic cancer related death during an overall mean follow-up of 16.5 months.
Although Video-Assisted Thoracoscopic Surgery (VATS) is now accepted by many as the approach of choice in the management of primary spontaneous pneumothorax (PSP), the optimal procedure and the timing of surgical intervention remain areas of contention. The authors reviewed their combined experience with 518 consecutive VATS procedures for PSP in 483 patients. Mechanical pleurodesis was performed in every case and was the only procedure in 20 patients. We had experience with several means of eliminating subpleural bullae once identified: stapled bullectomy (196), endoloop (261), argon beam coagulation (6) and endoscopic suturing (35). There were no mortality or intraoperative complications. Median postoperative hospital stay was 3 days. So far, we have had 9 recurrences (1.74%), after a mean follow up of 20 months (range one to 36 months). Complications consisted of 18 persistent air leaks, 14 would infections and 1 chest wall bleeding. We conclude that (1) VATS is a safe and effective approach in the treatment of PSP; (2) Stapled-bullectomy is quick and reliable but costly; (3) Endoloop and suturing are viable alternative techniques that may prove to be more cost effective; (4) we do not recommend to use argon beam coagulation as the primary treatment modality.