Thoracoscopy, Thoracoscopic Wedge Resection
Kemp H. Kernstine Sr.
Athoracotomy incision is traumatic and painful and frequently leaves the patient with a cosmetically unappealing scar. Two percent of thoracotomy patients have incapacitating pain that lasts for more than a year, 4% have upper extremity disability, and 40% have persistent mild-to-moderate discomfort. Reducing the incision size and avoiding the use of a rib retractor appears to reduce the trauma, pain, and disability. Endoscopic thoracic surgery appears to accomplish these goals. This chapter discusses the basic principles of thoracoscopy as applied to two common problems.
SCORE™, the Surgical Council on Resident Education, classified thoracoscopy with or without biopsy and thoracoscopic pleurodesis as “COMPLEX” procedures.
STEPS IN PROCEDURE
Single lung ventilation is preferred, if feasible
Most procedures are performed in lateral decubitus position; some procedures require prone or supine position to access lesions
Have radiographs available in OR
Initial port placement is generally in anterior axillary line at fifth to seventh intercostal space
Place additional ports as required
To achieve the highest pathological yield in a lung biopsy, identify region of interest by radiographic studies, fluoroscopy, palpation, hook wire, or other method
The lung biopsy should be performed in the most cephalad region and near an edge to minimize the risk of prolonged air leak and
Check for air leaks
Close incisions with small chest tube or fluted drain to bulb suction in place
For spontaneous pneumothorax:
Resect blebs with stapler
Abrade pleural surfaces or remove parietal pleura from fourth rib to apex
Place chest tube into apical region and leave in place for 2 to 3 days
HALLMARK ANATOMIC COMPLICATIONS
Inability to localize target lesion
Air leak
Three types of thoracic endoscopic procedures can be performed:
Pleuroscopy usually involves a single puncture wound and portal for visualization, biopsy, and dissection. Visualization is either directly through an open scope, such as a Pilling or Storz mediastinoscope, or indirectly with a digital scope. The direct scope gives a limited view, but is very efficient in that it allows visualization and manipulation through the same port. Pleuroscopy is ideally suited to evaluate and treat pleural effusions or pleural masses. It may also assist in placement of pleural drains. Although pleuroscopy is done most frequently under general anesthesia, it may also be performed using fairly mild sedation with local anesthesia, if the planned procedure is brief with minimal manipulation.
Thoracoscopy involves two or more portals through which the visualization, dissection, and resection are performed.
Video-assisted thoracoscopic surgery (VATS) employs multiple ports or ports plus a small access incision. All the dissection that would be performed through an open thoracotomy is performed by endoscopic visualization. A nonrib-spreading incision may be necessary to dissect and extract the surgical specimen. To minimize pain, retractors
are not used. Thoracoscopy and VATS are used for a wider variety of procedures: Lung biopsies; wedge resections; resections of thoracic masses; intrapleural, extrapleural, hilar, and mediastinal masses; and resection of lesions within the esophageal wall, portions of the esophagus, and myotomies.
It is essential to obtain a chest computed tomography (CT) scan before performing any form of endoscopic thoracic surgery. This allows three-dimensional operative planning and appropriate positioning of the surgical ports. The most appropriate patients for the thoracoscopic or video-assisted procedure are those who have had no prior thoracotomy, have a large thoracic cavity, are not ventilator dependent, and are not obese. Lesions most suitable for access through this approach are smaller than 3 cm and are peripherally located, although with more advanced techniques selected cases involving larger lesions and those more centrally located can be resected. Preoperative pulmonary function testing is very helpful in assisting intraoperative and postoperative management.
Anesthetic intubation management is dependent on the procedure planned. All three procedures may be performed using (a) single-lumen intubation with apnea or CO2 insufflation, (b) double-lumen intubation, or (c) bronchial blocker. For brief, pleurally based procedures, apnea may be appropriate. Ventilator-dependent patients may require CO2 insufflation taking care to avoid excess intrapleural pressure and hypotension. Single-lung ventilation by either double-lumen tube technique or bronchial blocker is desirable because it improves intrathoracic visibility, minimizes respiratory motion, reduces pulmonary parenchymal bleeding, and decreases the damage to the lung and the pulmonary vasculature. The greater the complexity of the intended endoscopic procedure, the greater these factors must be realized.
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