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There are many ways to gain access to the chest. In recent years, there has been a rediscovery of the clamshell incision, an evolving concept of the utility incision for video-assisted thoracic surgery (VATS), and a continued emphasis on the importance and usefulness of the muscle-sparing axillary thoracotomy, which continues to be the author's most frequently used incision.
Video-assisted thoracic surgical procedures continue to be performed with increased frequency; the role of this new technique in the treatment of pulmonary malignancies or metastatic mediastinal adenopathies is not yet defined. Out of a series of 100 consecutive video-assisted thoracic operations, 22 patients resulted affected by a malignancy in the lung or in the subcarinal lymphnodes: six patients had a primary lung cancer and were operated with a video-assisted small thoracotomy of 5 cm (three lobectomy and three segmentectomy) because of a very poor respiratory reserve. Nine patients received a video-assisted wedge resection of a nodule resulted at the frozen section a metastasis of a carcinoma: a small thoracotomy of 8 cm was made and a hand entered the thoracic cage to obtain a careful palpation of the entire lung; five patients had enlarged lymphnodes only in posterior and inferior mediastinum, inaccessible by cervical mediastinoscopy or anterior mediastinotomy: thoracoscopic exploration obtained a useful mediastinal nodal sampling for these adenopathies. In selected cases video-assisted thoracic surgery can be used for resection or assessment of thoracic malignancies.
OBJECTIVE: To evaluate the analgesic efficacy of thoracic paravertebral block (TPVB) with different doses of liposomal bupivacaine (LB) or ropivacaine in patients undergoing single-port thoracoscopic lung surgery. METHODS: A total of 105 patients scheduled for video-assisted single-port thoracoscopic lung surgery were randomized in a 1:1:1 ratio into three groups: low-dose LB group (group LL), high-dose LB group (group HL), or ropivacaine group (group R). All received ultrasound-guided TPVB at the T5/6 level preoperatively. The primary outcome was the area under the curve (AUC) of NRS of pain at activity (AUC-aNRS) from 1 to 72 h postoperatively. Secondary outcomes included the AUC of NRS of pain at rest (AUC-rNRS) from 1 to 72 h postoperatively, NRS of pain at rest and at activity at 1, 6, 24, 48, and 72 h postoperatively, and the cumulative opioid consumption at 24, 48, and 72 h postoperatively. Additionally, postoperative recovery and adverse events were assessed. RESULTS: AUC-aNRS differed significantly among groups (p = 0.0092), with high-dose LB lower than low-dose LB (p = 0.0071), but not versus ropivacaine. No significant difference was found in AUC-rNRS (p > 0.05). The group-by-time interactions for NRS of pain at rest and at activity were not significant (p > 0.05). Cumulative opioid consumption at 24, 48, and 72 h was lower in group HL versus group LL (all p < 0.017), but not versus ropivacaine. Postoperative recovery and adverse events showed no differences (p > 0.05). CONCLUSION: LB combined with TPVB is not superior to ropivacaine for postoperative analgesia in single-port thoracoscopic lung resection.
We describe herein the successful utilization of a video-assisted thoracic surgical approach to repair Morgagni's hernia. The patient was a 62-year-old woman in whom a routine chest X-ray had revealed an asymptomatic mass, which was presumed to be a pericardial lipoma or Morgagni's hernia. The video-assisted thoracic surgical approach was combined with a right submammary minithoracotomy to successfully repair the hernia without performing a laparotomy. The patient's postoperative course was uneventful and she was discharged 14 days after surgery. Thus, we believe that video-assisted thoracic surgery may be a useful and effective method for repairing Morgagni's hernia.
Advances in video-assisted thoracoscopic (VAT) surgery allow it to assume an increasingly important therapeutic role. Two successful VAT lobectomies (left upper lobe and right lower lobe) were performed in patients with stage I adenocarcinoma. An 8 cm access minithoracotomy for hilar dissection and subsequent specimen delivery was used. Routine mediastinal node sampling was performed thoracoscopically as would be done conventionally. Video-assisted thoracoscopic lobectomy of the right upper lobe was attempted in another patient but he required emergency conversion to open thoracotomy because of bleeding from mechanical failure of the vascular staple-cutter. Although VAT lobectomy is feasible technically, attention to detail is important when mechanical devices are used to minimize the chance of malfunctioning. Once disaster occurs the surgeon should be capable of dealing with the consequences.
We studied the use of video-assisted thoracoscopic (VAT) surgery in the management of metastatic osteosarcoma. From September 1993 to March 1994, we performed a total of 11 VAT wedge resections of pulmonary metastatic osteosarcoma in seven patients (six males, one female, age 12 to 46 years). Three patients had bilateral procedures performed either under the same anaesthesia or in stages. One patient had two operations on the same side. The average number of nodules excised was three. Two patients subsequently required formal lobectomies when the metastatic tumours were either too big or too close to the hilum for safe wedge resections. There was one death on postoperative day 3 due to dysrhythmia. One patient died 5 months later from a progression of his underlying disease. Two patients remained disease free up to 8 and 12 months, respectively, from their first operations. The average postoperative chest drain duration was 1.4 +/- 0.7 days and hospital stay 2.3 +/- 1.1 days. The procedure was well tolerated and postoperative morbidity was minimal. We conclude that although VAT wedge resection of pulmonary metastatic osteosarcoma is feasible technically and is associated with a short hospital stay and minimal morbidity, this approach cannot be recommended when complete resection of all metastases is the goal as the technique relies heavily on computed tomographic scans to detect nodules. Recurrence of metastasis from 4 to 6 months in three of seven patients argues against VAT surgery being an adequate procedure. The high cost of the staplers, in addition, is a secondary consideration.
Video-assisted of thoracoscopic surgery (VATS) is the minimally invasive surgery. It has characteristic of mini-incision, less pain, less bleeding, less transfusing, less affecting cardio pulmonary function. So it is one of the development directions of thoracic surgery. The authors had finished 41 cases VATS. Operative indication was expatiated. The requirement of anesthesia is lower. The patients whose pulmonary function were too severe destructive to walk could be treated by VATS. The authors discussed some questions of VATS.
The use of endoscopic video-assisted technique in facial rejuvenation is one of the most recent advances in aesthetic plastic surgery of the face. It replaces the bicoronal incision without the necessity of skin resection. The idea is to detach the muscles from the periorbital attachment, forcing the occipital muscle to pull the forehead tissue back and thus elevating the eyebrows. Therefore, we developed a flexible fiber endoscope that allows the surgeon to guide flexible instruments through its working channel. The endoscope is introduced through a 1-cm midscalp incision so that it can be used to expose and treat soft tissue regions in the forehead, the midface, and the neck.
Since 1959, when mediastinoscopy was introduced by Carlens, the practice has been technically unchanged. The authors suggest how the new video technologies could be very helpful to this procedure leading to an ergonomic position for the operator and a faster performance. Initial experience is reported.
STUDY DESIGN: A prospective multicenter study on 100 consecutive surgical procedures. OBJECTIVES: A prospective multicenter study was performed to evaluate the early perioperative complications in 100 endoscopic spinal procedures--78 video-assisted thoracic surgical procedures and 22 laparoscopic lumbar instrumentation and fusion procedures. SUMMARY OF BACKGROUND DATA: Endoscopic procedures have been widely applied in general surgery for appendectomy, cholecystectomy, liver resection, Nissen fundoplication, colon resection, and hernia repairs. Video-assisted thoracic surgery is widely used for pleural biopsy, lung resection, and sympathectomy. This is the first large series to date investigating the safety and potential complications using endoscopic surgery for anterior decompression or fusion of the thoracolumbar spine. METHODS: Video-assisted thoracic surgical procedures included multilevel anterior thoracic releases for deformity, 27 patients; anterior thoracic discectomies with spinal canal decompression, 41 patients; pyogenic vertebral osteomyelitis decompression, 2 patients; and vertebral corpectomy for neurologic decompression, 8 patients. Mean operative time was 2 hours, 34 minutes (range, 45 minutes to 6 hours), and mean length of stay was 4.97 days (range, 2-21 days). Anterior laparoscopic interbody stabilization and fusion at L4-5 or L5-S1 was performed in 22 patients. The mean operative time was 4 hours, 17 minutes (range, 2 hours, 40 minutes to 9 hours), and the mean length of stay was 5.6 days (range, 1-23 days). RESULTS: The most common video-assisted thoracic surgical complications were transient intercostal neuralgia (six patients) and atelectasis (five patients). The most common laparoscopic complication was bone graft donor site infection (two patients). There were two endoscopic cases that were converted to open procedures, one for extensive pleural adhesions and one for a common iliac vein laceration. CONCLUSIONS: The endoscopic spinal approaches proved to be safe operative procedures in 100 consecutive cases. There were no permanent iatrogenic neurologic injuries and no deep spinal infections.
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.
BACKGROUND: The application of video-endoscopy to general thoracic surgery is radically changing the approach to many benign and malignant diseases of the chest. Since July 1991, we have performed 794 purely thoracoscopic and 101 video-assisted thoracic surgical (VATS) procedures on 860 patients. STUDY DESIGN: Comprehensive, prospectively acquired data examining the specific indications for and outcomes of this new technique were prospectively entered into a thoracic surgical database. Preoperative, intraoperative, postoperative, and outcome variables were studied for the entire group as well as three high-risk cohorts: age over 70 years (n = 198), forced expiratory volume in one second (FEV1) of less than 1 L (n = 46), and Karnofsky performance index of less than 8 (n = 61). RESULTS: The 895 cases involved 449 men and 446 women of ages 15 to 89 years (mean 56 +/- 16 years standard deviation). The indications for surgery were diagnostic in 501 cases (56 percent), therapeutic in 244 cases (27 percent), and both diagnostic and therapeutic in an additional 150 cases (17 percent). The specific procedures performed were operations on the lung (569 cases), pleura (196 cases), esophagus (42 cases), mediastinum (51 cases), and pericardium (37 cases). Fifty-seven percent of the procedures were for a malignant process and 43 percent were for benign or infectious pathology. There were nine deaths for a series operative mortality rate of 1.0 percent. Thirteen patients (1.4 percent) required conversion to a limited thoracotomy for technical reasons. There were 127 complications in 121 patients yielding a morbidity rate in all patients of 14 percent. Mortality rates in the elderly, poor lung function, and depressed performance index cohorts were 1.5, 2.1, and 9.8 percent, respectively. Morbidity rates in these high-risk populations were 19, 30, and 18 percent, respectively. The median postoperative length of stay was three days after closed thoracoscopy and five days after VATS resection. CONCLUSIONS: These data underscore the flexibility, safety, efficacy, and potential for cost savings of videoscopic surgery in patients with thoracic diseases. The ability to perform excisional biopsy improves diagnostic specificity and sensitivity to nearly 100 percent. Video-assisted thoracic surgical techniques also offer a minimally invasive procedure with acceptable risk to patients heretofore inoperable by standard thoracotomy.
PURPOSE OF THE STUDY: The aim of this study is to describe a new operative technique for anterior lumbar and lumbosacral fusion using a video assisted anterior extra peritoneal approach. MATERIAL: Ten patients were operated on. There were 3 men and 7 females. Age at operation ranged from 18 to 55. There were 8 degenerative and 2 iatrogenic discopathias. Fused level was L4-L5 (5 patients) and L5-S1 (5 patients). Average hospital stay was 6 days. METHODS: A small vertical 4-5 cm incision is made on the mid line, centered on the umbilicus for the approach to L4-L5, and between the umbilicus and pubis for the L5-S1 approach. The peritoneum is cleaved from the abdominal wall on the left side, and the anterior aspect of the spine is progressively freed. The endoscope is laterally introduced. It gives an excellent view of the prevertebral area. A specially designed retractor is used for retraction of the iliac vessels. Following removal of the intervertebral disc, a special spreader allows obtention of a normal intervertebral space height and insertion of an autogenous iliac graft. DISCUSSION: Anterior approach of the lumber intervertebral discs allows disc resection and grafting in a strict middle position. The extra peritoneal simplifies the postoperative course and avoids digestive and septic complications of the transperitoneal approach. The video assistance gives excellent exposure by a small incision with direct visual control; it should be differentiated form the true endoscopic lumbar surgery which is performed under C02 insufflation, with exclusive endoscopic vision and with instruments introduced through trocards. CONCLUSION: Video-assistance allows an approach to the lumbar and lumbosacral spine by an anterior non invasive extra peritoneal approach, with low morbidity, increasing the possibilities of anterior fusion in the treatment of lumbar discopathias and instability without radicular compromise.
Surgical treatment of emphysema and chronic obstructive pulmonary disease (COPD) has received renewed attention because of advances in instrumentation and techniques. Our approach includes video-assisted thoracotomy, neodymium-Yag and KTP laser plication of emphysematous bullae, pulmonary resection using reinforced stapling, and pleurodesis: reduction pneumonoplasty. In a 9-month period, 28 patients (age 52 to 78, 23 men and 5 women) with end-stage disease underwent reduction pneumonoplasty. Oxygen therapy was required in 82 per cent, steroid therapy was used in 86 per cent, and the preoperative FEV1 averaged 0.68 +/- 0.05. The most severely diseased lung was determined by physical, chest film, and CT scan, and this lung had reduction pneumonoplasty. There were no hospital mortalities. Prolonged postoperative air leaks occurred in 42 per cent of patients. Postoperatively FEV1 was 0.91 +/- 0.35. Lung size (chest film) showed 21.6 per cent reduction in volume. Subjective improvement was noted in 78.6 per cent (22/28) of patients, and no patient reported worse symptoms. Half of the steroid-using patients required a reduced steroid dose or no steroid therapy, and 5/23 (21.7%) patients had reduced oxygen requirements. Reduction pneumonoplasty can improve the symptoms of severe emphysema and COPD. Our results with treatment of one lung suggest that further improvement may be anticipated by proceeding with surgery for the contralateral lung.
A total of 82 consecutive patients with recurrent or persistent spontaneous pneumothorax were considered for thoracoscopic blebectomy or bullectomy and pleurodesis. The median age was 47 years, and 70% were men. All the patients were successfully treated using a video-assisted thoracoscopic technique. There were no deaths attributable to the procedure. Complications occurred in 6 patients (7.3%). Three patients (4%) with diffuse bullous lung disease had prolonged intubation (9, 11, and 12 days, respectively). Persistent air leaks lasting from 10 to 14 days occurred in 2 patients (3%). One patient had an endoloop slip from the lung parenchyma after a forceful sneeze 2 days after the operation. Air leak subsided after the second operation using a conventional suturing technique. Blebs or bullae were present in 69 patients (83%). These were ablated by endoscopic stapling (37 patients) and through thoracoscopic ligation using an endoloop technique (32 patients). In this group of patients, the median postoperative hospital stay was 5 days. Thirteen patients with air leaks and diffuse bullous lung disease received only talc insufflation thoracoscopically. All of them showed good lung expansion after the operation. There are no recurrences, with a mean follow-up of 22 months. These results suggest that thoracoscopic ablation of blebs or bullae and pleurodesis may be applicable to patients with spontaneous pneumothorax who require surgical intervention.
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.
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.