Page 52 - World Association of Laparoscopic Surgeons - Journal

WJOLS

The Role of Thoracoscopy in Diagnosis and Treatment of Pleural Disease

controlled studies are certainly necessary before thoracos- complications occurred in the thoracotomy group.
copic ablation can be advocated for the large number of Insufficient time has elapsed to report on the long-term local
high-risk patients with emphysematous bullous disease. control and survival in each group. This study underscores
Lobectomy for localized lung carcimoma is possible the importance of not supplanting accepted open procedures
using current VATS technology. Kirby et al 6 described with a VATS operation because of purported advantages
successful VATS lobectomy with lymph node staging in and limited evidence of equivalence.
35 of 41 (85%) study patients. Patients were placed in the
Other Operative Applications
lateral position for possible posterolateral thoracotomy.
Initially, a thoracoscopy port was placed in the seventh or Thoracoscopic esophagomyotomy is a new approach for
eighth intercostal space in the anterior axillary line. A zero- treating achalasia. Thoracotomy or laparotomy can
4
degree thoracoscope with a video camera was introduced necessitate significant hospital stays. Medical management
into the pleural space. A second thoracoscopy port was then by esophageal dilation is occasionally complicated by
4
placed in the eighth or ninth intercostal space in the posterior perforation. Peuegrini et al successfully completed 17 of
axillary line. Next, a 6 cm access minithoracotomy incision 19 (89%) cases for achalasia by either a VATS (15) or a
was placed just below the tip of the scalpula through which laparoscopic (2) Heller myotomy. Two (11%) cases
larger thoracic instruments could be introduced into the necessitated open procedures. The mean hospital stay was
chest. Whenever possible, a muscle-sparing incision was 3 days, the mean lower esophageal pressure was lowered
used. This nonrib spreading access incision allowed for from 32 to 10 mm Hg postoperatively, and no deaths or
better inspection and palpation of the lung, both of which major complications were reported. In the successful cases,
are limitations of the VATS approach. To ensure proper short-term results with regard to dysphagia were excellent
staging of the lung cancer, multiple biopsy specimens of or good in 14 (82%), fair in 2 (12%) and poor in 1 (6%).
hilar and mediastinal lymph nodes were obtained, in Three (21%) of the 14 patients with initial excellent or good
particular in those few patients who had not undergone a results required a second procedure. Long-term outcome
staging mediastinoscopy. This VATS technique also data are not reported.
allowed for biopsy specimens of lymph node stations that Pericardial effusions, malignant or benign, can be
are not readily accessible by mediastinoscopy. These stations addressed by the less invasive thoracoscopic pericardiec-
include the posterior subcarinal, paraesophageal hilar and tomy. Under single-lung ventilation using a double-lumen
inferior pulmonary ligament nodes. This nonrib spreading endotracheal tube, thoracic surgeons can obtain an excellent
access incision also allowed for the safe removal of the view of the mediastinum. To relieve tamponade, a
resected specimen. The special technical considerations for pericardial window of suitable size is cut. Pericardial fluid
6
each lobe resection are available in more detail. Of the 41 is then aspirated from the thorax and an intercostal drain is
patients, no major intraoperative complications occurred. left for further decompression. 5,64 Hazelrigg et al 65 used
Six (14%) patients required conversion to open thoracotomy VATS to perform pericardiectomy in 35 patients after failed
because VATS lobectomy proved technically impossible. medical management and pericardiocentesis. There were
The 35 patients who underwent VATS had an uneventful no intraoperative and only four postoperative complications
recovery with a mean hospital stay of 5.7 days. This study (two dysrhythmias, two pneumonias). Although palliative
indicates that VATS lobectomy is technically to terminal patients, thoracoscopy may decrease the number
accomplishable, but subsequent analysis of cancer of thoracotomies and limit hospitalizations for malignant
recurrence rate and survival data is forthcoming. The VATS pericardial disease. 65,66 Its superiority to the subxiphoid
approach has not yet been proved superior to standard pericardial window for both benign and malignant
thoracotomy for lung cancer resection. pericardial disease, however, has not been shown. 76
In a subsequent prospective, randomized trial, 72
Mediastinal Tumors
involving 61 patients with presumed clinical stage I non-
small cell lung cancer, VATS lobectomy was directly A thoracoscopic approach has been advocated for patients
compared with muscle-sparing thoracotomy with with posterior and middle mediastinal tumors. Access can
lobectomy. Six patients were excluded because of be difficult, however, and it may be necessary to convert to
nonmalignant disease (three) or because an attempted VATS open thoracotomy in (is greater than) 10% of instances. 29
lobectomy was converted to thoracotomy (three). There Postoperative hospitalization is often less than after
were no significant differences in the operating time, thoracotomy, but conversion should not be delayed if there
intraoperative blood loss, duration of chest tube drainage, is bleeding, the lesion cannot be appropriately exposed, or
length of hospital stay, or disabling postsurgical pain. More tumors are large.

World Journal of Laparoscopic Surgery, January-April 2012;5(1):4-15 11