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PubMed1999

Thoracoscopic surgery for pulmonary tuberculosis.

Tuberculosis historically was a major impetus for the development of thoracic surgery, and it remains a serious health problem of global proportion. Thoracoscopy was first introduced at the turn of this century for closed chest adhesiolysis as an adjunct to collapse therapy for treatment of tuberculosis. This indication became obsolete with the discovery of streptomycin during the 1940s; and for a long time since then thoracoscopy was used only sporadically for the diagnosis of pleural disease. However, over the last few years, modern video-assisted thoracoscopic surgery (VATS) has provided a new approach to the management of pulmonary tuberculosis. Over the last 5 years we have used VATS for diagnosis or treatment (or both) of 62 patients with pulmonary tuberculosis, including 20 pleural biopsies, 8 decortications, 17 wedge lung resections, 8 drainages of empyema, and 9 lobectomies. There was no surgical mortality, and complications were few. We conclude that VATS provides a safe, effective diagnostic modality (pleural biopsy, wedge resections) and therapeutic modality (decortications, drainage of empyema) for selected patients with pulmonary tuberculosis.

Adolescent↗
PubMed2002

Diverticulum of the midthoracic esophagus: pathogenesis and surgical treatment.

Midthoracic esophageal diverticula represent 15% of all esophageal diverticula. Gastrointestinal endoscopy, barium swallow, esophageal manometry (indispensable for detecting any motor alterations often at the root of the pathogenesis of the diverticulum and for selecting the best surgical option), and 24-h pHmetry are the correct examinations to perform. Simple diverticulectomy performed via thoracoscopy can be sufficient for small diverticula without associated motor alterations. In other cases, it is best to combine diverticulectomy with a longitudinal extramucous myotomy extending at least 3 or 4 cm above and below the neck of the diverticulum or to the entire esophageal body for diffuse esophageal spasm. We report the case of a 67-year-old male patient with a sacciform diverticulum at the mid-third on the anterior wall of the thoracic esophagus. Manometric examination showed peristaltic waves with an amplitude and duration that were above normal at the inferior third of the esophagus. Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) were essentially normal. The diagnosis was pulsion-type midthoracic esophageal diverticulum. We performed a diverticulectomy with endoGIA via right thoracoscopy and extramucous myotomy extended from the upper margin of the diverticulum to the esophageal inlet in the hiatus, corresponding to the area showing motor alteration. After 3 months, the patient reported complete remission of symptoms and had gained 4 kg. Radiography of the digestive tube showed a normal transit at the distal esophagus. Manometric follow-up revealed the presence of peristaltic waves with a normal amplitude and duration along the entire esophagus.

Aged↗
PubMed2005

Multimedia article. Entirely thoracoscopic pneumonectomy using the prone position: a new technique.

BACKGROUND: Reports on video-assisted pneumonectomy have remained scarce, despite early demonstration of its technical feasibility. A totally videothoracoscopic pneumonectomy was first reported by Conlan and Sandor. The patient in this report was positioned in the full lateral position. In this video, we report a totally videothoracoscopic left-side pneumonectomy with the patient in prone position. METHODS: A 49-year-old man was admitted to our hospital for a bifocal cancer of the left lower lung lobe (LLL) and the cervical esophagus. The preoperative workup included a chest computed tomography (CT) scan showing a 3-cm mass of the laterobasal segment of the LLL, with retrotumoral atelectasis, lymph nodes smaller than 1 cm in diameter at the aortopulmonary window and under the carena, and finally posterolateral adherences between the parietal and the visceral pleura. Flexible bronchoscopy confirmed the presence of a bronchial tumor at the offspring of the apical bronchus of the LLL. Biopsy showed invasive adenocarcinoma, and a CT scan of the neck and head was significant for tumoral infiltration of the cervical esophagus and retropharyngeal space. Gastroscopy showed a stenosis of the cervical esophagus and hypopharynx. Biopsy showed spinocellular epithelioma, but CT scan of the abdomen and bone scintigraphy did not show metastatic disease. A position emission tomography (PET) scan confirmed the findings of the CT scan. Pneumonectomy and esophagectomy by thoracoscopy, laparoscopy, and cervicotomy were proposed. The purpose of this video is to show the details of the thoracoscopic technique with the patient in the prone position. RESULTS: After induction of general anesthesia, a double-lumen endotracheal tube was placed. The patient was subsequently placed and strapped in a prone position. The surgical team was placed to the left of the patient. A 10-mm trocar was placed in the seventh intercostal space on the posterior axillary line, and a 30 degrees angled videoscope was introduced. Three additional 5-mm trocars were placed at the same level in the 5th, 9th, and 11th intercostal spaces on the posterior axillary line. The mediastinal pleura was opened just ventral to the aorta. The first structure identified was the left main bronchus, which was dissected free and transected with a linear stapler (blue load). The aortopulmonary window became immediately visible. Clearance of this window's lymphoglandular tissue showed, bottom to top, the inferior pulmonary vein, the superior pulmonary vein, and the pulmonary artery. These vascular structures were carefully dissected free with the cautery hook and transected with a vascular linear stapler (white load). The lung was freed entirely tend placed in a retrieval bag for later transhiatal extraction during the laparoscopic phase of the esophagectomy. The intraoperative time for the pneumonectomy was 146 min, and intraoperative blood loss was 30 ml. The pathology report confirmed the presence of invasive, poorly differentiated adenocarcinoma. The bronchial section was free of tumor. One intrapulmonary lymphnode (N1) was positive, whereas all 10 N2 and N3 nodes harvested were free of disease. The tumor was thus staged as IIB (pT2N1Mx). The esophagetomy specimen showed fairly wide differentiated keratinizing of the spinocellular epithelioma with invasion of both pyriform sinuses and both sides of the glottis. CONCLUSIONS: First described by Cuschieri et al. in 1992, the prone position for thoracoscopy allows for a more direct approach to the aortopulmonary window under excellent visual and ergonomic circumstances. Dissection of the hilar larger vessels and performance of lymphnode sampling appear more straightforward because with this technique, the lung is kept out of harm's way, thanks to gravity.

Humans↗
PubMed2006

Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy.

BACKGROUND: Oesophagectomy with extended lymphadenectomy carries considerable morbidity due to parietal trauma. It is also technically extremely demanding because the difficult access even through a large thoracotomy requires the use of long instruments to reach the deepest recess in the chest cavity. Since the first thoracoscopic oesophagectomy reported by Cuschieri et al. [1] in 1992, different minimally invasive approaches have been proposed [2-12]. The aim of this video is to show the accurate and relative ease of an entirely thoracoscopic and laparoscopic oesophagectomy with an extended lymph node dissection of mediastinum in prone position (thoracoscopically) and celiac trunk (laparoscopically). METHODS: Oesophagectomy by thoracoscopy, laparoscopy and cervicotomy was proposed in a 63-year-old man with a lower third oesophageal cancer. General anaesthesia was performed with a double-lumen endotracheal tube and the patient was placed in prone position. Surgeons were positioned at the right side of the patient. Only three trocars were needed. A 10 mm 30-degree angled scope was inserted in the 7th intercostal space on the posterior axillary line and the remaining two 5 mm trocars were inserted in the 5th and 9th intercostal spaces on the posterior axillary line. Prone position allows an excellent visibility of the operative field even in an only partially deflated lung. In order to achieve a good exposure, transitory pneumothorax with CO2 (14 mmHg) was performed. The mediastinal pleura overlying the oesophagus was incised and the arch of azygos vein was isolated, ligated and divided. The oesophagus was circumferentially mobilized from the thoracic inlet down to oesophageal hiatus. Para oesophageal and subcarinal lymph nodes were dissected so as to remain in block with the surgical specimen. A 28 F chest tube was inserted in the 8th intercostal space on the anterior axillary line. In the second stage the patient was placed in supine position and pneumoperitoneum was established. Five trocars were placed along an ideal semicircular line, with the concavity facing the subcostal margin and a 30-degree angled laparoscope was used. The lesser omentum was widely opened up the right pillar of the hiatus. Mobilization of the greater curvature of the stomach was performed preserving the right gastroepiploic artery. A wide Kocher maneuver was performed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. This artery and the left gastric vein were dissected, clipped and sectioned. All fatty tissue and lymph nodes along hepatic artery, left gastric artery and celiac trunk were resected in block with the surgical specimen. Multiple applications of a linear endoscopic stapler were used to create the gastric tube. Finally the distal oesophagus was dissected, until the thoracoscopic dissection field was joined. In the third stage a left lateral cervicotomy was performed and the cervical oesophagus was dissected down to the thoracoscopic dissection plane. Oesophagus and stomach were delivered through the cervical incision and an oesophagogastric anastomosis was created by a linear stapler technique. Cervical and abdominal drainages were installed. RESULTS: The total operative time was 271 minutes (thoracoscopy: 106 minutes, laparoscopy 120 minutes and cervicotomy 45 minutes) and blood loss was about 100 ml. Histological examination demonstrated a squamous cell carcinoma. Both margins of resection were free of tumour and 29 lymph nodes were retrieved. The final stage was IIA (pT3N0Mx). CONCLUSIONS: Thoracoscopic and laparoscopic oesophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopic oesophagectomy in prone position improves the quality of dissection because: The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harm's way. For the same reason small to moderate bleeding will not obscure the operative field. Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon. This article contains a supplementary video.

Blood Loss, Surgical↗
PubMed1999

Video-assisted thoracoscopic surgery to the upper thoracic spine.

BACKGROUND: The standard open technique for exposure of the upper thoracic spine, T1-T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically. METHODS: A new approach, the so-called "extended manipulating channel method," was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients' ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy. RESULTS: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients. CONCLUSIONS: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5-3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities.

Adult↗
PubMed1992

Thoracoscopic lung biopsy.

Progress in instrumentation and techniques developed for laparoscopic surgery have paved the way for a resurgent interest in thoracoscopic procedures. Traditional thoracoscopy was limited by access, restricted visualization, and surgical devices. Recent cases provided an opportunity to successfully perform thoracoscopic pulmonary wedge excisions using state-of-the-art technology and instruments adapted from laparoscopy. These preliminary cases provided an opportunity to modify and adapt these techniques to thoracic procedures. Video thoracoscopy is rapidly evolving in both methods and instrumentation.

Adult↗
PubMed1993

Thoracoscopic transdiaphragmatic approach for adrenal biopsy.

The role of thoracoscopy for the management of intrathoracic diseases has expanded with advancement in endoscopic instrumentation and technology. We report a case of thoracoscopic transdiaphragmatic biopsy of an adrenal gland for metastatic carcinoma. The procedure was uncomplicated and the patient was discharged on the second postoperative day. The morbidity of traditional approaches for adrenal operation was avoided. Thoracoscopy may be a useful approach in selected patients for adrenal operation.

Adrenal Gland Neoplasms↗
PubMed1993

Thoracoscopic resection of mediastinal cysts.

Thoracoscopy would seem to have several potential advantages over open techniques in terms of the attendant postoperative pain and pulmonary complications. Although many questions exist pertaining to the use of thoracoscopy in the therapeutic management of malignancies of the mediastinum, its use for benign disorders appears desirable. Since December 1990, we have removed 9 mediastinal cysts using a thoracoscopic procedure. These included 7 bronchogenic or enteric cysts, 1 pericardial cyst, and 1 thymic cyst. The average cyst size was 4.2 cm, with 11 cm the largest diameter. Complete removal of the cysts was possible in all but 1 case, in which the cyst adhered to vital structures. A portion of the cyst wall was therefore left intact and the mucosa cauterized. The average hospital stay in these patients was 2.1 days, and there were no intraoperative or postoperative complications. All cysts were benign. The resection of mediastinal cyst using thoracoscopic procedures and based on standard surgical indications would seem to be appropriate. Thoracoscopic removal should be considered as an alternative method to resection of mediastinal cysts.

Bronchogenic Cyst↗
PubMed1993

Role of mechanical stapling devices in thoracoscopic pulmonary resection.

For its first 80 years, thoracoscopy was primarily reserved for the evaluation and treatment of pleural disease. Extension of thoracoscopic techniques to management of parenchymal lung disease remained limited until the availability of endostaplers and adaption of video-assisted techniques through minimal access incisions. The widespread acceptance of mechanical staplers in open lung resections during the previous two decades has facilitated conversion to closed methods in the past 2 years. A variety of techniques for mechanical stapling in thoracoscopy are discussed. The impact of mechanical stapling in 300 consecutive thoracoscopic pulmonary resections is presented.

Humans↗
PubMed1994

A thoracoscopic peek: what did Jacobaeus see?

More than 80 years ago, Jacobaeus inserted a cystoscope into the pleural space of patients with pleural diseases to visually examine the pathology. Subsequently, he courageously inserted a galvanocautery instrument into the pleural space through a separate entry site to divide adhesions between the lung and chest wall under direct vision. This was done to establish therapeutic pneumothorax for patients with pulmonary tuberculosis. The discovery of effective antituberculosis chemotherapy eliminated the need for lung collapse therapy, and thoracoscopy was discarded as no longer useful. Today, the enthusiasm for thoracoscopic surgical intervention, both diagnostic and therapeutic, is a result of applied technologic innovations. Rediscovery of thoracoscopy is exciting and expands the vision for both diagnostic and therapeutic applications predicted by Jacobaeus.

History, 19th Century↗
PubMed1996

Colored collagen is a long-lasting point marker for small pulmonary nodules in thoracoscopic operations.

BACKGROUND: To locate small deep pulmonary nodules under thoracoscopy, we developed a long-lasting point marker termed "colored collagen." METHODS: Colored collagen is composed of 0.8% atelocollagen, 5% methylene blue, and 32% contrast medium. The affinity between atelocollagen and methylene blue was examined in a washing test using 2 mol/L of NaCl. For clinical application, a computed tomography-guided colored collagen injection was performed in 11 patients to localize 11 deep pulmonary nodules, which were less than 20 mm in diameter. RESULTS: The washing test showed that atelocollagen and methylene blue combined with each other firmly. An experimental study using rabbit lung showed that the colored collagen stayed at the injected site for 10 days without toxicity. In clinical application, the colored collagen could be seen as a clear spot using the thoracoscopy 1 to 4 days after the injection in all of the 11 pulmonary nodules. There was no complication except for a slight pneumothorax in 2 patients. CONCLUSIONS: The colored collagen, because it stays in the injected site for a long time, solves the problem of the single dye injection method, which requires both a computed tomographic scan and an operating room simultaneously, and also the colored collagen, because of its point dyeing, can mark the nodule more accurately than a single dye.

Adult↗
PubMed1995

Video-assisted thoracoscopic resection of intercostal neurofibroma.

BACKGROUND Video-assisted thoracoscopy (VAT) is being increasingly utilized by thoracic surgeons as an alternative to thoracotomy for several thoracic disorders. Neuroendoscopy is an exciting addition to the neurosurgical armamentarium. These procedures are attractive alternatives in the era of minimally invasive surgery and cost containment, while providing the highest quality medical care to patients. METHODS We report the application of this technology in a patient presenting with intractable thoracic radicular pain secondary to an intercostal neurofibroma. Complete excision of the intercostal neurofibroma was performed utilizing VAT. RESULTS The patient reported good relief of her preoperative thoracic radicular pain. She was ready for discharge from the hospital within 72 hours of surgery. CONCLUSIONS With the advent of improved instrumentation, video-assisted thoracoscopy offers a safe alternative to thoracotomy and the potential benefits of less postoperative discomfort and shorter hospital stays. The potential neurosurgical applications of VAT should not be overlooked.

Adult↗
PubMed2005

VATS thoracic-duct division for aortic surgery-related chylous leakage.

Traumatic chylothorax is a serious morbidity due to aortic surgery. We treated this complication successfully by supradiaphragmatic thoracic-duct division in five adults (three men, two women, aged 61.5+/-19.5 years) and a 3-year-old male infant after an average interval of 4.1+/-1.8 days following initial aortic surgery: graft-replacement of subclavian or descending aortic aneurysm in the adults, and correction of aortic coarctation in the infant. A right thoracoscopic approach was used in the adults and the left thoracotomy was re-used in the infant. Individual exposure and division of the thoracic duct was accomplished using an ultrasonic coagulator. The operating time was 22+/-5.5 min for the thoracoscopy cases, and 70 min for the infant. There was no mortality and no procedure-related morbidity, and chylous leakage ceased immediately in all patients. There was no recurrence of chylothorax during a mean follow-up period of 17+/-9.7 months. Despite our limited experience, we conclude that the present supradiaphragmatic thoracic duct division technique (right thoracoscopy in adults) is safe and perfectly effective, and therefore prompt application of this method is recommendable for treatment of aortic surgery-related traumatic chylo-leakage, particularly in vulnerable elderly or infant patients.

Aortic Aneurysm↗
PubMed2005

Thoracoscopic resection of intra- and extralobar pulmonary sequestration in the first 3 months of life.

BACKGROUND: Thoracoscopic techniques have gained increasing acceptance in pediatric surgery, but experience with newborns and small children is limited. To our knowledge, a series of minimally invasive resection of pulmonary sequestration in newborns has not yet been reported in the literature. We report on 5 patients with pulmonary sequestration thoracoscopically. METHODS: From November 2000 to November 2002, 5 patients underwent thoracoscopic resection of pulmonary sequestration. Ages ranged from 4 to 91 days. Two patients had postnatal pulmonary symptoms. Preoperative diagnosis was dubious in 4 children. There were 4 extralobar and 1 intralobar pulmonary sequestrations. RESULTS: Thoracoscopy was performed with 3-mm instruments and 3 to 5 ports. All procedures were completed successfully. The median duration of the operation was 95 minutes (range, 63-117 minutes), and visualization was excellent. Anomalous blood vessels were clipped and/or ligated. Four patients were extubated immediately after the operation, 1, the day after. The postoperative course was uneventful in all children. At follow-up after 14 months (mean; range, 10-19 months), all patients were free of symptoms and had normal chest x-rays. CONCLUSION: Thoracoscopy is feasible for resection of intra- and extralobar pulmonary sequestrations during the first 3 months of life.

Bronchopulmonary Sequestration↗
PubMed2005

Thoracoscopic diaphragmatic eventration repair in children: about 10 cases.

BACKGROUND AND AIM: Recent reports in literature have emphasized the clinical perception of reduced pain, postoperative morbidity, and dysfunction associated with thoracoscopic approach compared with standard thoracotomy. The authors describe a thoracoscopic approach and technical details for diaphragmatic eventration repair in children. PATIENTS AND METHODS: Ten patients, 4 girls and 6 boys, 1 teenager (14 years old) and 9 children (age range, 6-41 months; average, 17 months), were operated for a diaphragmatic eventration in 3 different pediatric surgery teams, according to the same technique. Symptoms were recurrent infection (7 cases), dyspnea on exertion (2 cases), and a rib deformity (1 case). An elective thoracoscopy was performed, patient in a lateral decubitus. A low carbon dioxide insufflation allowed a lung collapse. Reduction of the eventration was made progressively when folding and plicating the diaphragm. Plication of the diaphragm was done with an interrupted suture (6 cases) or a running suture (4 cases). The procedure finished either with an exsufflation (4 cases) or a drain (6 cases). RESULTS: A conversion was necessary in 2 cases: 1 insufflation was not tolerated and 1 diaphragm, higher than the fifth space, reduced too much the operative field. Patients recovered between 2 and 4 days. Dyspnea disappeared immediately. Mean follow-up of 16 months could assess the clinical improvement in every patient. DISCUSSION: Thoracoscopic conditions are quite different between a diaphragmatic hernia repair previously reported and an eventration. Concerning diaphragmatic hernias, reduction is easy, giving a large operative space for suturing the diaphragm. Concerning diaphragmatic eventrations, the lack of space remains important at the beginning of the procedure despite the insufflation into the pleural cavity. The operative ports must be high enough in the chest to allow a good mobility of the instruments. Chest drainage seems to be unnecessary. CONCLUSION: Diaphragmatic eventration repair by thoracoscopy is feasible, safe, and efficient in children. Above all, it avoids a thoracotomy. It improves the immediate postoperative results with a good respiratory function.

Adolescent↗
PubMed2006

Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: experience with 174 nodules.

OBJECTIVE: Several techniques have been reported for the localization of small pulmonary nodules in thoracoscopic resection. In the present study we examined the usefulness and complications of computed tomography-guided lipiodol marking for thoracoscopic resection in our experience of 174 nodules. METHODS: Computed tomography-guided lipiodol marking was performed on 174 nodules less than 30 mm in size. Of these nodules, 45 showed ground-glass opacity images and 129 showed solid images on computed tomography. The mean size of the nodules was 10 +/- 6 mm (range, 2-30 mm), and their mean depth from the pleural surface was 10 +/- 7 mm (range, 0-30 mm). One to 7 days before thoracoscopy, all of the nodules were marked with 0.4 to 0.5 mL of lipiodol by using computed tomography. The marked nodules were grasped with a ring-shaped forceps during fluoroscopy and resected by means of thoracoscopy. RESULTS: All the nodules could be marked and localized by means of fluoroscopy as a clear spot during thoracoscopic surgery. Complications of the marking were chest pain requiring analgesia in 16 (11%) patients, hemosputum in 11 (6%) patients, pneumothorax in 30 (17%) patients, and hemopneumothorax in 1 (0.6%) patient. Eleven (6%) patients with pneumothorax required drainage, and the patient with hemopneumothorax required an emergency operation. No other complications were observed. CONCLUSION: Lipiodol marking is a useful, safe, and inexpensive procedure for localizing ground-glass opacity lesions, small pulmonary nodules, or both for thoracoscopic resection.

Adult↗
PubMed2006

Reconstruction of upper digestive tract: reducing morbidity by laparoscopic pull-up.

BACKGROUND: Gastric pull-up is a useful method for reconstruction of the upper digestive tract, with considerable morbidity/mortality, especially in esophageal cancers (EC). OBJECTIVE: To analyze the experience of a multidisciplinary team with a laparoscopic gastric pull-up (LGPU) method, with or without thoracoscopy, in a series of 120 patients with EC. STUDY DESIGN: Retrospective. PATIENTS AND METHODS: From 1992 to 2004, 120 EC [cervical/cervicothoracic (3.0%), middle third (15.0%), and inferior third (82.0%)]. Most were squamous cell carcinomas (47.0%) and adenocarcinomas (34.0%). Stomach was dissected and mobilized exclusively by laparoscopy. Occasionally, laparoscopic approach was extended cranially, until connecting with cervical dissection. In other cases, dissection of thoracic esophagus was accomplished through a thoracoscopic approach. RESULTS: Eighty-one patients (68.0%) had LGPU; 39 (32.0%) needed thoracoscopy. Mortality was 5.9%. Complications were fistula (10.0%) and pneumonia (10.0%). All fistulae closed spontaneously; 89.2% of patients could swallow a normal oral diet. CONCLUSION: Low morbidity/mortality of LGPU for EC compared favorably with conventional techniques.

Adenocarcinoma↗
PubMed1993

Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury.

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.

Adolescent↗