Page 53 - World Association of Laparoscopic Surgeons - Journal

Atul Soni et al

Vasospastic Disease seeding at the entry site and death. 7,11-14 It is difficult to
summarize the overall complication rate because it depends
Thoracoscopic sympathectomies are performed using either
on the indication, type of anesthesia, equipment, patient
electrocautery, dissection, or excision in patients with
Raynaud’s syndrome, causalgia or essential hyperhydrosis. 30 population and experience of the operator.
The incidence of subcutaneous emphysema with
Exposure is usually through the anterior chest wall, and 28-30
procedures can be performed bilaterally at a single setting. 31 thoracoscopy ranges from 0.5 to 7%. The risk of
infection appears to be low, with only 5 (0.5%) infections
Bullectomy and Lung Volume Reduction Surgery recorded in a collected series of 1,145 patients. 10
Postoperative fevers were reported in 16% and persistent
Thoracoscopy is an accepted modality for lung volume
air leak in only 2% of 817 simple rigid thoracoscopies. 14
reduction surgery, with results that appear similar to those
obtained after median sternotomy. 34 Endoscopic stapling In a retrospective series of 121 diagnostic thoracoscopies
9
performed under general anesthesia, Page et al reported a
can be performed with or without buttressing staple lines.
total complication rate of 9.1% (predominantly respiratory).
Results of bilateral procedures appear better than unilateral
In a prospective study of 102 diagnostic thoracoscopies
procedures, and costs are often less than with median
sternotomy. 35 Although improvements in pulmonary performed under local anesthesia, Menzies and
Charbonneau 2 reported 5.5% minor and 1.9% major
function, exercise performance, and quality of life have been 68
noted, 36 FEV often deteriorates toward baseline prelung complication rates. Kaiser and Bavaria reported and
1
resection values within 2 years. The role of thoracoscopy overall 10% incidence of complications in their series of
266 various thoracoscopies.
vs median sternotomy for bilateral lung volume reduction
surgery is currently being evaluated in various trials. Morbidity from thoracoscopic talc poudrage is minimal.
Lange et al 69 studied patients 22 to 35 years after tale
Chest Trauma poudrage for spontaneous pneumothorax and found only a
minimal restrictive pulmonary impairment. Fever (16%) and
Thoracoscopy provides an effective and safe modality by
55
pain (9%) are other minor side effects from talc. Additional
which to initially evaluate and often manage stable patients
with blunt or penetrating chest trauma. 37 Diaphragmatic complications, such as ARDS or acute pneumonitis (after
high-dose intrapleural talc suspension rather than talc
injury, hemothorax, and lung parenchymal lacerations can
insufflation) have been reported, but are extremely rare. 70,71
be treated, although difficulties associated with active
Caution must be exercised in performing talc poudrage in
bleeding, suboptimal single-lung ventilation, or intense
the young patient, especially in potential lung transplant
pleural inflammation should prompt conversion to an open
candidates, because the obliterative pleuritis and resultant
thoracotomy.
fibrosis will complicate future thoracotomy.
Cardiovascular Disease
Mortality
Thoracoscopy can be used for ligation of a patient ductus
72
38
arteriosus, as well as to harvest internal thoracic artery in Boutin et al reviewed 4,300 simple rigid thoracoscopies
patients undergoing coronary bypass grafting. 39 (mostly diagnostic) and reported a mortality rate of less than
9
A significant reduction in postoperative pain has been 1%. Page et al reported 1 (0.7%) perioperative death among
10
described, attributed to the absence of rigorous chest their 121 patients. Ohri et al had 5 of 100 (5%) patients
retractions. It is likely that many other applications for die postoperatively (mean age, 68 years). The VATS study
thoracoscopy-assisted cardiovascular surgery will emerge. group reported 38 (2.5%) deaths among their various 1,820
interventional cases performed at more than 40 institutions.
LIMITATIONS/ COMPLICATIONS AND No patient died intraoperatively in this collected series.
FUTURE DIRECTIONS Overall, perioperative mortality rates for thoracoscopy range
The thoracoscopic approach to a variety of diagnostic and from 0 to 9%. 2,7,1-11,14,73-75,82
therapeutic problems has few limitations other than a need
CONTROVERSIES IN THORACOSCOPY
to demonstrate safety and cost-effectiveness compared with
more conventional approaches. Who should perform thoracoscopy, pulmonologists or
thoracic surgeons—is a primary topic of debate.
Morbidity
Thoracoscopy can be performed by a pulmonologist under
Known complications of thoracoscopy include bleeding, local/regional anesthesia (medical thoracoscopy) or by a
empyema, wound infection, prolonged air leak, tumor thoracic surgeon under general anesthesia (video-assisted

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