Biarned &iPhartnacother( 1992) 46,139-141 0 Elsevier, Paris
139
Dossier
Surgical endosccrpy in thoracic surgery .J Mouroux,
H Richelme
Service de Chirurgie Abdominale et Thoracique. HGpital Pasteur BP 69. 06002 Nice Cedex, France (Received 6 May 1992; accepted 20 May 1992)
- From November 1990 to April 1992, 32 patients were operated on by video tboracoscoEic surgery (VTS). Included were 22 males and 10 females, mean age 47.6 years. VTS has been used therapeutically on 25 occasions: 20 spontaneous pneumothoraxes; two recurrent pleuritis; two cysts; one mediastinal; one pulmonary; and one thoracic sympathectomy. VTS was also used diagnostically seven times: five lung biopsies and two mediastinal lymph node biopsies. It was necessary to perform a mini-thoracotomy in one patient and proceed to immediate thoracotomy in three patients. There were no deaths in this series, the morbidity was two patients with collapsed iungs, one of which required drainage. VTS must be performed under standard thoracic surgical conditions: selective intubation, and fully equipped to make an immediate thoracotomy. The advantages of VTS are aesthetic and functional, the post-operative pain is reduced in intensity and duration. At present, VTS is indicated for the treatment of spontaneous pneumothorax, the assessment and biopsy of mediastinal lymph node and the excision of some lung lesions. Improvements in the apparatus should lead to a broadening of these indications in the future. Summary
surgical endoscopy I thoracic surgery
Rdsumi - Yidbthoracoscopie cn chirurgie thoracique. De novembre 1990 *i ovril 1992, 32 patients ogt kte’ appe’r&s par vidt%-thoracoscopie. I1 s’agissair de 22 hommes et de 10 femmes d’cige moyen 47.6 ans. La chirurgie par vidt?o-thorgcoscopie (CVT) a Ai utilisPe ic vis& the’rapeutique 25 fois: 20 pneumothorax spontan& 2 pleurdsies rkidivantes, 2 kystes l’un mkdiastinal lhutre pulmonaire, I sympathectomie thoracique. La CVT a &k utiliske ti vise’e diagnostique 7 fois: 5 biopsies pulmonaires et 2 biopsies d’ade’nopathies mGdiastinales. En per-opkatoire il a t%rEnkessaire d’associer une mini-thoracotomie et de rialiser 3 thoraco-conversions. La mortalite’ de cette se’rie a t?tte’nulle, la morbidite’ Ptait due d 2 dkkollements dent un a nkcessite’ un drainage. A distance une rkcidive d’un pneumothorax a e’te’observk. La CVT doit e’tre rialise’e dans les conditions de la chirurgie traditionnelle: intubation se’lective, possibilitf ir tout moment de rialiser une thoracotomie. Les avantages de la CVT sent esthe’tiques et fonctionnels, les douleurs post .opPratoir:s sent diminuies en durke et en intensite’. Actuellement la CVT peut &re propost?e pour le traitement du pneumothorax spcntane, la sympathectomie thoracique, l’expertise et la biopsie d’ade’nopathies mkdiastinales et l’exe’rt?se de certaines l&ions pulmonaires. L’amNioration du mate’riel devrait dans l’avenir permettre d’ilargir ses indications. video-thoracoscopie
I chirurgie thoracique
Introduction Thoracoscopy is an old technique. In the main, it is used for diagnostic investigations. The developments in video technology and surgical instrument design have given this procedure a new dimension. Today it is possible to undertake real thoracic surgery operations using a video-thoracoscope avoiding the resort to thoracotomy. The aim of this study, carried out on 32 patients operated on using video-thoracoscopic surgery (VTS), was
to define the conditions under which the procedure was used, to indentify its advantages, and to discuss some of its indications.
Patients Thirty-two patients were operated on by VTS. during the period November 1990 to April 1992. They were 22 males and 10 females, with a mean age of 47.6 years (range 14-92 years). During the same period, 340
140 patients were operated on using standard procedures. VTS was used as a curative procedure 25 times: in 20 cases of s~ntaneous pneumothorax, two cases of recurrent pleuritis, in two patients to excise cysts (one mediastinal and one pulmonary) and to perform a thoracic sympathectomy in one patient. VTS was used as a diagnostic procedure in seven patients, in five to take a lung biopsy and in two to biopsy enlarged mediastinal lymph nodes, in one case situated in the aortin-pulmon~y window causing a recurrent laryngeal nerve paralysis, the other in the anterior mediastinum in contact with the left phrenic nerve.
Technique The operation was performed under standard conditions for thoracic surgery using genera1 anaesthesia and selective intubation. In the majority of indications, the patient was placed in the lateral decubitus position. Blocking thb ventilation of the lung and the introduction of 500 ml of CO2 into the pleural cavity assured the c*:.l-?l I....~....‘...
mtywdnn ."*._i_ii.=
off
&
Upon completion of the operation, one or two drains can be placed in the thoracic cavity through the trocar orifices.
Results A mini-~oracotomy (6 cm) was required in a patient to enable the extraction of a cyst from the right lower lobe that had been dissected by VTS. Three thoraco-conversions were made. In one patient with a lung biopsy, the absence cf the lesion on the surface of the lung made its location and biopsy impossible. In two cases of pneumothorax, thoracotomy was required, in one as it was not possible to block the airway, in the other the extent and the adhesion of bullous lesions caused the attempt to be abandoned. Post-operative
:df,g
Position of the trocars The first IO mm trocar was placed for the introduction
of the optical system linked to the video camera. The position of this trocar varied _rWv.ull15 ~-n*,-u~- Lo - ihc operation to be performed. For the treatment of a pneuhnothorax, plet;itis or lung biopsy, the trocar was situated in the 6th intercostal space behind the point of the scapula. For sympathectomy and mediastinal lymph node biopsies the trocar was placed at the level of the 2nd or 3rd intercostal space in the media-~avicular line, ai‘d the patient was placed in the dorsal decubitus position. Two other trocars were required, their diameters varied from 5 to 12 mm. The various instruments were introduced through these trocars: grasping forceps, coagulation hook, scissors, auto-suture forceps (Endo GIA type). l
Technical possibiiities The instruments currently available allow the following procedures: a) freeing of pulmonary-pleural adhesions using scissors and the coagulation hook, b) dissection and excision of mediastinal structures (para-oesophageal cyst, sympathetic ganglia); c) excision of peripheral parenchymatous lesions using the auto-stitors forceps which produced a section-suture of tissues between two triple rows of staples; d) creation of a pleurodesis: by abrasion of the pleura with an irritant solution; (16 cases) by pleurectomy (two cases) by elec~ocoagulation of the par&al pleura (two eases); we have abandoned this last technique.
There were no deaths following VTS. The morbidity was due to partial collapse of the lung in two patients, requiring a new drainage in one of them. All the patients complained of pain at the drainage sites, but the quantity of analgesics was reduced by haif compared to a thoracotomy for the same indication. The mean duration of hospitalization varied according to the indications for VTS, for the treatment of pneumothorax it was 9.2 days (range 6-20 days) and for the other indications 5.7 days (range 4-7 days). Late resutts One patient had a recurrent pneumothorax. This was among one the first patients in this series; pleurodesis had been achieved by elec?rocoagulation. At a subsequent open thorac~~tomy we observed a total lack of pleural adhesion. Comments VTS combines the efficiency of traditional surgery and the advantages of thoracoscopy. While VTS should be considered as a specific s;=crative technique, it should only be undertaken by thoracic surgeons and anaesthetists experienced in thoracic surgery. In practice, VTS requires selective tracheobronchial intubation of patients with abnormal ventilatory volumes and the occlusion of one lung. Furthermore it can be difficult before the exploration of some lesions to
141 decide upon the best method of treatment, hence an initial VTS procedure may have to be immediately converted into a thoracotomy. The results of this series have shown that: VTS is feasible in the majority of indications proposed. There is a considerable reduction of post-operative pain. In practice, with the exception of the first post-operative day, the intensity and duration of pain is clearly diminished [3]. There is an aesthsetic advantage. Functional recovery is faster in thi: absence of having to cut muscle. To date there are four main indications for VTS: i) treatment of spontaneous pneumothorax. VTS enables the parenchymatous lesions to be treated (excision of bullous lesions) and creation of pleurodesis by pleural abrasion or pleurectomy. common spontaneous In the forms of pneumothorax (young subjects, recurrencies, and isolated bullous dystrophy) the treatment can be carried out with VTS. In other forms of pneumothorax or in certain patients (diffuse bullous emphysema, respiratory insufficiency) the operation can be started as a VTS procedure. The current limitations of the technique may require the operation to be converted to an open thoracotomy if it is judged dangerous to continue. ii) Thoracic sympathectomy. Standard thoracoscopy has been used to produce a chemical or thermal destruction of thoracic sympathetic ganglia in cases of palmar hyperhidrosis or distal arteritis in the upper limbs [ 1, 21. VST in these cases allows the sympathetic ganglia to be surgically excised producing a better result [7]. iii) Assessment and biopsy of enlarged mediastinal lymph nodes. VTS allows nodes that are not accessible by mediastinoscopy to be inspected: nodes in the aorto-pulmonary window, below the carina or the phrenic nodes VTS can avoid the need for thoracotomy and enables biopsies to be taken. This technique may be useful in the assessment of some lung cancers. iv) The excision of peripheral parenchymatous lung lesions. The excision of parenchymatous lesions raises the problem of their accessibility. They should be “well placed” and in a periphery of the lung parenchyma for operation by VTS (one of our cases required thoraco-conversion).
The excision of parenchymatous lesions by VTS is especially indicated in small round lesions. These excisions often have a double aim; diagnosis and cure. Solitary or very few peripheral metastatic lesions, in certain well-selected patients, can be excised by VTS, but at the expense of not being able to make a manual exploration of the lung.
Conclusion Other indications have been suggested (excision of mediastinal or parietai lesions) [4, 51. The results still need to be evaluated. It is likely that in the near future advances in the instrumentation and operator experience will enable this technique to be further developed and new indications defined for this procedure.
References Byrne J, Walsh TN, Hederman WP (1990) Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis. Br J Surg 77, 1046 Guerin JC, Demolombe S, Brudon JR (1990) Symphatholyse thoracique par thoracoscopie. A propos de I5 cas. Ann Chir 44, 236 Kl&mann P, Levi SF, Debesse B (1991) La pleurectomie parietale percutanee par vidio,endoscopie. Le traitement moderne du pneumothorax spontane recidivant. Rev Ma1 Resp 8, 459 Lewis RJ, Caccavale RJ, Sisler GE (1992) Imaged thoracoscopic surgery: a new thoracic technique for resection of mediastinal cysts. Ann Thorac Surg 53, 318
Mouroux J, Benchimol D, Bernard JL, Tran A, Padovani B, Rampal P, Bourgeon A, Richelme H (1991) Exe&e d’un kyste bronchoginique par video-thoracoscopie. Presse Mid 320, 1768 O’Riordan BG, Daniel FJ, Fletcher DB (1992) Open lung biopsy without thoracotomy: technique and possible indications. Ausr N 2 Surg 62, 79 Peilion C, Testart J (1991) La thoracoscopie chirurgicale. Presse M&d 20, 1215
139
Dossier
Surgical endosccrpy in thoracic surgery .J Mouroux,
H Richelme
Service de Chirurgie Abdominale et Thoracique. HGpital Pasteur BP 69. 06002 Nice Cedex, France (Received 6 May 1992; accepted 20 May 1992)
- From November 1990 to April 1992, 32 patients were operated on by video tboracoscoEic surgery (VTS). Included were 22 males and 10 females, mean age 47.6 years. VTS has been used therapeutically on 25 occasions: 20 spontaneous pneumothoraxes; two recurrent pleuritis; two cysts; one mediastinal; one pulmonary; and one thoracic sympathectomy. VTS was also used diagnostically seven times: five lung biopsies and two mediastinal lymph node biopsies. It was necessary to perform a mini-thoracotomy in one patient and proceed to immediate thoracotomy in three patients. There were no deaths in this series, the morbidity was two patients with collapsed iungs, one of which required drainage. VTS must be performed under standard thoracic surgical conditions: selective intubation, and fully equipped to make an immediate thoracotomy. The advantages of VTS are aesthetic and functional, the post-operative pain is reduced in intensity and duration. At present, VTS is indicated for the treatment of spontaneous pneumothorax, the assessment and biopsy of mediastinal lymph node and the excision of some lung lesions. Improvements in the apparatus should lead to a broadening of these indications in the future. Summary
surgical endoscopy I thoracic surgery
Rdsumi - Yidbthoracoscopie cn chirurgie thoracique. De novembre 1990 *i ovril 1992, 32 patients ogt kte’ appe’r&s par vidt%-thoracoscopie. I1 s’agissair de 22 hommes et de 10 femmes d’cige moyen 47.6 ans. La chirurgie par vidt?o-thorgcoscopie (CVT) a Ai utilisPe ic vis& the’rapeutique 25 fois: 20 pneumothorax spontan& 2 pleurdsies rkidivantes, 2 kystes l’un mkdiastinal lhutre pulmonaire, I sympathectomie thoracique. La CVT a &k utiliske ti vise’e diagnostique 7 fois: 5 biopsies pulmonaires et 2 biopsies d’ade’nopathies mGdiastinales. En per-opkatoire il a t%rEnkessaire d’associer une mini-thoracotomie et de rialiser 3 thoraco-conversions. La mortalite’ de cette se’rie a t?tte’nulle, la morbidite’ Ptait due d 2 dkkollements dent un a nkcessite’ un drainage. A distance une rkcidive d’un pneumothorax a e’te’observk. La CVT doit e’tre rialise’e dans les conditions de la chirurgie traditionnelle: intubation se’lective, possibilitf ir tout moment de rialiser une thoracotomie. Les avantages de la CVT sent esthe’tiques et fonctionnels, les douleurs post .opPratoir:s sent diminuies en durke et en intensite’. Actuellement la CVT peut &re propost?e pour le traitement du pneumothorax spcntane, la sympathectomie thoracique, l’expertise et la biopsie d’ade’nopathies mkdiastinales et l’exe’rt?se de certaines l&ions pulmonaires. L’amNioration du mate’riel devrait dans l’avenir permettre d’ilargir ses indications. video-thoracoscopie
I chirurgie thoracique
Introduction Thoracoscopy is an old technique. In the main, it is used for diagnostic investigations. The developments in video technology and surgical instrument design have given this procedure a new dimension. Today it is possible to undertake real thoracic surgery operations using a video-thoracoscope avoiding the resort to thoracotomy. The aim of this study, carried out on 32 patients operated on using video-thoracoscopic surgery (VTS), was
to define the conditions under which the procedure was used, to indentify its advantages, and to discuss some of its indications.
Patients Thirty-two patients were operated on by VTS. during the period November 1990 to April 1992. They were 22 males and 10 females, with a mean age of 47.6 years (range 14-92 years). During the same period, 340
140 patients were operated on using standard procedures. VTS was used as a curative procedure 25 times: in 20 cases of s~ntaneous pneumothorax, two cases of recurrent pleuritis, in two patients to excise cysts (one mediastinal and one pulmonary) and to perform a thoracic sympathectomy in one patient. VTS was used as a diagnostic procedure in seven patients, in five to take a lung biopsy and in two to biopsy enlarged mediastinal lymph nodes, in one case situated in the aortin-pulmon~y window causing a recurrent laryngeal nerve paralysis, the other in the anterior mediastinum in contact with the left phrenic nerve.
Technique The operation was performed under standard conditions for thoracic surgery using genera1 anaesthesia and selective intubation. In the majority of indications, the patient was placed in the lateral decubitus position. Blocking thb ventilation of the lung and the introduction of 500 ml of CO2 into the pleural cavity assured the c*:.l-?l I....~....‘...
mtywdnn ."*._i_ii.=
off
&
Upon completion of the operation, one or two drains can be placed in the thoracic cavity through the trocar orifices.
Results A mini-~oracotomy (6 cm) was required in a patient to enable the extraction of a cyst from the right lower lobe that had been dissected by VTS. Three thoraco-conversions were made. In one patient with a lung biopsy, the absence cf the lesion on the surface of the lung made its location and biopsy impossible. In two cases of pneumothorax, thoracotomy was required, in one as it was not possible to block the airway, in the other the extent and the adhesion of bullous lesions caused the attempt to be abandoned. Post-operative
:df,g
Position of the trocars The first IO mm trocar was placed for the introduction
of the optical system linked to the video camera. The position of this trocar varied _rWv.ull15 ~-n*,-u~- Lo - ihc operation to be performed. For the treatment of a pneuhnothorax, plet;itis or lung biopsy, the trocar was situated in the 6th intercostal space behind the point of the scapula. For sympathectomy and mediastinal lymph node biopsies the trocar was placed at the level of the 2nd or 3rd intercostal space in the media-~avicular line, ai‘d the patient was placed in the dorsal decubitus position. Two other trocars were required, their diameters varied from 5 to 12 mm. The various instruments were introduced through these trocars: grasping forceps, coagulation hook, scissors, auto-suture forceps (Endo GIA type). l
Technical possibiiities The instruments currently available allow the following procedures: a) freeing of pulmonary-pleural adhesions using scissors and the coagulation hook, b) dissection and excision of mediastinal structures (para-oesophageal cyst, sympathetic ganglia); c) excision of peripheral parenchymatous lesions using the auto-stitors forceps which produced a section-suture of tissues between two triple rows of staples; d) creation of a pleurodesis: by abrasion of the pleura with an irritant solution; (16 cases) by pleurectomy (two cases) by elec~ocoagulation of the par&al pleura (two eases); we have abandoned this last technique.
There were no deaths following VTS. The morbidity was due to partial collapse of the lung in two patients, requiring a new drainage in one of them. All the patients complained of pain at the drainage sites, but the quantity of analgesics was reduced by haif compared to a thoracotomy for the same indication. The mean duration of hospitalization varied according to the indications for VTS, for the treatment of pneumothorax it was 9.2 days (range 6-20 days) and for the other indications 5.7 days (range 4-7 days). Late resutts One patient had a recurrent pneumothorax. This was among one the first patients in this series; pleurodesis had been achieved by elec?rocoagulation. At a subsequent open thorac~~tomy we observed a total lack of pleural adhesion. Comments VTS combines the efficiency of traditional surgery and the advantages of thoracoscopy. While VTS should be considered as a specific s;=crative technique, it should only be undertaken by thoracic surgeons and anaesthetists experienced in thoracic surgery. In practice, VTS requires selective tracheobronchial intubation of patients with abnormal ventilatory volumes and the occlusion of one lung. Furthermore it can be difficult before the exploration of some lesions to
141 decide upon the best method of treatment, hence an initial VTS procedure may have to be immediately converted into a thoracotomy. The results of this series have shown that: VTS is feasible in the majority of indications proposed. There is a considerable reduction of post-operative pain. In practice, with the exception of the first post-operative day, the intensity and duration of pain is clearly diminished [3]. There is an aesthsetic advantage. Functional recovery is faster in thi: absence of having to cut muscle. To date there are four main indications for VTS: i) treatment of spontaneous pneumothorax. VTS enables the parenchymatous lesions to be treated (excision of bullous lesions) and creation of pleurodesis by pleural abrasion or pleurectomy. common spontaneous In the forms of pneumothorax (young subjects, recurrencies, and isolated bullous dystrophy) the treatment can be carried out with VTS. In other forms of pneumothorax or in certain patients (diffuse bullous emphysema, respiratory insufficiency) the operation can be started as a VTS procedure. The current limitations of the technique may require the operation to be converted to an open thoracotomy if it is judged dangerous to continue. ii) Thoracic sympathectomy. Standard thoracoscopy has been used to produce a chemical or thermal destruction of thoracic sympathetic ganglia in cases of palmar hyperhidrosis or distal arteritis in the upper limbs [ 1, 21. VST in these cases allows the sympathetic ganglia to be surgically excised producing a better result [7]. iii) Assessment and biopsy of enlarged mediastinal lymph nodes. VTS allows nodes that are not accessible by mediastinoscopy to be inspected: nodes in the aorto-pulmonary window, below the carina or the phrenic nodes VTS can avoid the need for thoracotomy and enables biopsies to be taken. This technique may be useful in the assessment of some lung cancers. iv) The excision of peripheral parenchymatous lung lesions. The excision of parenchymatous lesions raises the problem of their accessibility. They should be “well placed” and in a periphery of the lung parenchyma for operation by VTS (one of our cases required thoraco-conversion).
The excision of parenchymatous lesions by VTS is especially indicated in small round lesions. These excisions often have a double aim; diagnosis and cure. Solitary or very few peripheral metastatic lesions, in certain well-selected patients, can be excised by VTS, but at the expense of not being able to make a manual exploration of the lung.
Conclusion Other indications have been suggested (excision of mediastinal or parietai lesions) [4, 51. The results still need to be evaluated. It is likely that in the near future advances in the instrumentation and operator experience will enable this technique to be further developed and new indications defined for this procedure.
References Byrne J, Walsh TN, Hederman WP (1990) Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis. Br J Surg 77, 1046 Guerin JC, Demolombe S, Brudon JR (1990) Symphatholyse thoracique par thoracoscopie. A propos de I5 cas. Ann Chir 44, 236 Kl&mann P, Levi SF, Debesse B (1991) La pleurectomie parietale percutanee par vidio,endoscopie. Le traitement moderne du pneumothorax spontane recidivant. Rev Ma1 Resp 8, 459 Lewis RJ, Caccavale RJ, Sisler GE (1992) Imaged thoracoscopic surgery: a new thoracic technique for resection of mediastinal cysts. Ann Thorac Surg 53, 318
Mouroux J, Benchimol D, Bernard JL, Tran A, Padovani B, Rampal P, Bourgeon A, Richelme H (1991) Exe&e d’un kyste bronchoginique par video-thoracoscopie. Presse Mid 320, 1768 O’Riordan BG, Daniel FJ, Fletcher DB (1992) Open lung biopsy without thoracotomy: technique and possible indications. Ausr N 2 Surg 62, 79 Peilion C, Testart J (1991) La thoracoscopie chirurgicale. Presse M&d 20, 1215
