139 - Congenital Anomalies of the Esophagus
Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume II > The Mediastinum > Section XXVII - Invasive Diagnostic Investigations and Surgical Approaches > Chapter 164 - Video-Assisted Thoracic Surgery for Mediastinal Tumors and Cysts and Other Diseases Within the Mediastinum
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Chapter 164
Video-Assisted Thoracic Surgery for Mediastinal Tumors and Cysts and Other Diseases Within the Mediastinum
Alberto de Hoyos
Amit Patel
Ricardo S. Santos
Rodney J. Landreneau
The development of advanced video-assisted thoracic surgery (VATS) instrumentation and surgical techniques has allowed for increasing VATS applications to disease processes of the mediastinum for diagnostic evaluation and definitive surgical treatment, as noted by Allen (2002), Kelemen and Naunheim (2000), and Roviaro (2000, 2002), Linn (2000), Soliani (1998), Hurley (1994), and Hazelrigg (1993a) and their co-workers since the earlier report by one of us (RJL) and associates (1992a).
VATS techniques have yielded decreased patient pain and morbidity while increasing patient and referring physician acceptance. VATS techniques and thoracic surgeon's skills have advanced to the level that most mediastinal pathology can now be approached with VATS. The thoracic surgery community is now recognizing VATS techniques as an effective approach for the diagnosis and treatment of many common mediastinal diseases.
In this chapter, the role of VATS in the diagnosis and therapy of mediastinal diseases will be reviewed, along with the indications and results of VATS procedures for the mediastinum (Table 164-1). VATS instrumentation, equipment, and basic techniques and operative strategies previously described by one of us (RJL) and colleagues (1992c, 1993a, and 1993b) are reviewed separately in Chapter 32.
VIDEO-ASSISTED THORACIC SURGICAL MANAGEMENT OF MEDIASTINAL LYMPHADENOPATHY
The thoracic surgeon continues to maintain an important role in establishing the diagnosis of indeterminate mediastinal masses and lymphadenopathy. Improvements in the resolution of modern diagnostic radiographic modalities, specifically magnetic resonance (MR) imaging and helical computed tomography (CT) have allowed for more accurate clinical (radiographic) evaluation of the mediastinum, as emphasized by MacDonald and Hansell (2003). They are, however, neither sufficiently sensitive nor specific in identifying lymph node metastasis before surgical exploration. Both methods are limited by the fact that they supply morphologic information (i.e., lymph node size) that does not differentiate between benign and malignant changes.
By contrast, positron emission tomography (PET) with the metabolic tracer fluorodeoxyglucose allows for functional characterization of tissues. Because malignant tissue, particularly non small cell lung cancer (NSCLC), is characterized by increased glucose metabolism, PET permits the visualization not only of the primary tumor but also of metastatic spread. Measuring the amount of accumulated radioactivity in suspected lesions using standardized uptake values has helped improve the results further, as reported by MacDonald and Hansell (2003). The sensitivity (94.1%) and specificity (70%) of PET compare favorably with those of CT scan, as described by Graeter (2003) and Fritscher-Ravens (2003) and their coinvestigators. False-positive findings in PET (positive predictive value of 49.3%) may be seen in inflammatory conditions, and histologic verification appears necessary for exact lymph node staging. On the other hand, in view of the high negative predictive value of PET (98.4%), mediastinoscopy may be omitted in patients whose PET scan results are negative, although this issue is being investigated further. False-negative PET studies may be seen in three specific settings: tumors with relatively low metabolic activity (bronchioalveolar carcinoma and carcinoid tumors), tumors less than 1.5 cm in size, and hyperglycemia. Detterbeck and associates (2003) have summarized the guidelines for invasive staging of lung cancer. Transbronchial and CT-guided percutaneous needle biopsy can be effective in selected cases to confirm malignant
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cytology metastatic to mediastinal lymph nodes. However, a surgical biopsy is still required in many instances to establish a histologic diagnosis. Ribet and Cardot (1993) reported that indeterminate mediastinal lymphadenopathy without evidence of disease elsewhere may require surgical biopsy to establish the histologic diagnosis in more than 40% of patients. Fritscher-Ravens and co-workers (2003) compared CT, PET, and endoscopic ultrasonography with and without fine-needle aspiration (FNA) for the staging of mediastinal lymph nodes in patients with lung cancer. They concluded that the results of PET could be improved when combined with CT and that the specificity of endoscopic ultrasound was improved by routine use of fine-needle cytology.
Table 164-1. Potential Indications of Mediastinal Pathology for Video-Assisted Thoracic Surgery (VATS) Intervention | |
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The senior author (RJL) and associates (1993b) continue to advocate cervical mediastinoscopy as the preferred minimally invasive surgical diagnostic approach to most peritracheal and subcarinal mediastinal lymphadenopathy identified by preoperative CT scanning of the chest. The technique of cervical mediastinoscopy, as described by Harken and associates (1954) and popularized by Carlens (1959), is relatively simple, safe, and effective (Fig. 164-1). Recently, Gossot and associates (1996) demonstrated that the diagnostic yield of cervical mediastinoscopy was comparable to that of VATS. They also pointed out that the potential morbidity and instrumentation needs inherent with VATS could be avoided when the lymphadenopathy was in reach of the cervical mediastinoscopic approach.
Limitations of the cervical mediastinoscopic approach for accessing the lymph nodes in the anterior mediastinum and aortopulmonary window stations led to parasternal or anterior mediastinotomy approaches, as described by Stemmer and associates (1965) and popularized by McNeill and Chamberlain (1966). Familiar to most thoracic surgeons, Chamberlain's anterior mediastinotomy approach has become an effective adjunct to cervical mediastinoscopy in the evaluation of mediastinal lymphadenopathy. Although the introduction of anterior mediastinotomy was a welcome alternative to a standard thoracotomy to access the mediastinum, other investigators developed techniques of extended cervical mediastinoscopy to avoid the anterior mediastinotomy. Kirschner (1971) described the technique of passing the mediastinoscope anterior to the great vessels (Fig. 164-2), whereas Ginsberg and colleagues (1987) reported their method of passing the mediastinoscope between the innominate and the left carotid arteries to access the aortopulmonary window. Deslauriers and colleagues (1976) described a technique of mediastino-pleuroscopy (Fig. 164-3) to access the right pleural cavity and periazygos
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lymph nodes. However, the increased technical complexity and the inability to assess low-lying nodes have limited widespread clinical application of the extended cervical mediastinoscopy techniques. For bulky mediastinal tumors in close proximity to the anterior chest wall, we recommend an anterior mediastinotomy (Chamberlain's procedure) (Fig. 164-4).
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Fig. 164-1. Standard lymph node stations accessible by standard cervical mediastinoscopy (A); lymph node stations potentially accessible by extended cervical mediastinoscopy (B). |
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Fig. 164-2. Depiction of extended cervical mediastinoscopy as described by Kirschner. |
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Fig. 164-3. Depiction of right mediastinopleuroscopy as described by Deslauriers. |
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Fig. 164-4. Anterior mediastinal mass abutting the left anterior chest wall. This lesion is especially suited for an anterior mediastinotomy (Chamberlain's procedure). |
Hurtgen (2002), Leschber (2003), and Venissac (2003) and their co-workers have reported their experience with a recent addition to standard mediastinoscopy: video-assisted mediastinoscopic lymphadenectomy (VAML). This technique uses a two-blade speculum that, when opened in the mediastinum, creates an operative field for bimanual surgery, improving the ability of the surgeon to perform a complete mediastinal lymph node dissection. VAML is particularly suited to identify minor N2 disease in patients eligible for neoadjuvant therapy. In high-risk patients or before VATS lobectomy, lymph node metastases can be excluded with high sensitivity and make the thoracoscopic procedure easier.
Lardinois and associates (2003) have demonstrated that VAML is comparable to open mediastinal lymph node dissection in staging mediastinal lymph nodes in patients with lung cancer and can be performed safely after induction therapy. An additional advantage of VAML is that it makes teaching of mediastinoscopy easier for teachers and surgeons in training (Fig. 164-5).
Because of the access and visual limitations of cervical mediastinoscopy and anterior mediastinotomy, VATS techniques have been explored as an adjunctive modality to evaluate mediastinal lymphadenopathy. As one of us (RJL) and colleagues (1993a) demonstrated, VATS can provide a more comprehensive evaluation of the mediastinum when lymphadenopathy out of reach of the cervical mediastinoscope is present. VATS conveys the ability to assess the entire ipsilateral mediastinum in greater scope. It can directly access the lower subcarinal region and periazygos area, as
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well as the anterior and posterior mediastinal regions that are inaccessible to cervical mediastinoscopy. Anterior mediastinotomy with its limited visibility and its unsightly and time-consuming incision may also be avoided. Rendina and associates (1994) and one of us (RJL) and colleagues (1993a) have noted that the VATS approach is especially useful when multiple sites within the mediastinum require biopsy. Nakanishi and Yasumoto (1996) advocated aggressive use of VATS, in conjunction with cervical mediastinoscopy, to evaluate the mediastinum in patients with known bronchial malignancies of the left upper or the lower lobes or when the histology is known to be adenocarcinoma. They believed this approach provided the most accurate detection of mediastinal metastasis before thoracotomy. Brega Massone and associates (2002) also demonstrated that VATS might obviate the need for thoracotomy by demonstrating mediastinal lymph node involvement in patients with unsuspected mediastinal disease. Additionally, VATS can identify potential intrapleural metastases not recognized by preoperative radiographic studies, thus sparing the patient an unnecessary thoracotomy for advanced-stage disease, as described by Shields (1990). VATS mediastinal lymph node sampling allows immediate progression to definitive resection treatment by VATS or thoracotomy, avoiding the need to reposition the patient, if the lymphadenopathy is benign. A potentially useful technique to enhance the detectability of early metastatic deposits is the sentinel lymph node technique, as reported by Nakagawa (2003), Lardinois (2003), and Melfi (2003) and their associates. Although the thoracoscopic use of this technique has not been reported, potential benefits include (a) being able to sample the most likely nodes involved without decreasing the accuracy of the staging procedure, increasing the ability to detect a small tumor burden in the SLN; and (b) predicting a pathologic N0 staging when no metastases are present in the sentinel lymph node. Further advances in technique may allow the application of this novel approach to thoracoscopic staging of intrathoracic malignancies.
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Fig. 164-5. Video-mediastinoscope. The use of video-assisted mediastinoscopy improves the ability to perform a more extensive nodal biopsy. |
The focus of many of the reported experiences with VATS evaluation of mediastinal lymphadenopathy has been in the extended staging of potentially resectable lung cancer, as reported by Sagawa and co-workers (2002). The feasibility and accuracy of thoracoscopic lymph node staging in esophageal cancer have been reported by Krasna and Jiao (2000), Sonett and Krasna (2000), and Luketich (1997) and co-workers. Krasna (2002) and Luketich (2000) and their colleagues also used laparoscopy in addition to thoracoscopy. Unlike in lung cancer, in which mediastinoscopy has become a well-accepted procedure, the role of thoracoscopy and laparoscopy in staging esophageal cancer, as suggested by Krasna and co-workers (1996), remains to be realized. This technique may be especially applicable to patients suspected of having advanced locoregional disease to select them for clinical trials of preoperative chemotherapy, radiation therapy, or both.
VATS is also quite useful in the evaluation of primary mediastinal lymphadenopathy associated with benign and malignant lymphoid conditions. It can easily provide acquisition of sufficient tissue to establish the histologic diagnosis from benign or infectious etiologies, such as sarcoidosis or lymphoid hyperplasia, as Kern and associates (1993) noted. Large tissue samples necessary to evaluate lymph node architecture and to assess cellular clonal patterns characteristic of lymphoma are obtainable. As mentioned previously, VATS avoids the more extensive and cosmetically unappealing anterior mediastinotomy incision and allows for immediate use of radiation therapy through standard anteroposterior portals, without the fear of detrimental wound healing. In women, the anterior mediastinotomy incision through the breast is avoided with the use of the laterally orientated VATS intercostal access sites. At the present time, we believe the VATS approach is preferable to anterior mediastinotomy, (i.e., Chamberlain's procedure) for inaccessible lymphadenopathy by a standard cervical mediastinoscopy. However, as Rendina (1994) and Gossot (1996) and their associates, as well as our group, as reported by one of us (RJL) and co-workers (1993a), have noted, there remain a few selected indications for the anterior mediastinotomy. We still prefer the anterior mediastinotomy approach for the diagnosis of large anterior mediastinal mass lesions abutting the anterior chest wall (see Fig. 164-4). A simple anterior incision with standard endotracheal tube ventilation is preferable to the complications surrounding double-lumen endotracheal intubation, especially when the trachea may be distorted by the mediastinal
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mass, or when addressing mediastinal lymphadenopathy in elderly, frail individuals.
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Fig. 164-6. VATS approach for anterior mediastinal pathology. |
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Fig. 164-7. VATS approach for aortopulmonary window and midesophageal level pathology. |
Technical Considerations
Double-lumen endotracheal intubation and patient positioning are performed as detailed in Chapter 32. For the VATS approach to the anterior mediastinum (Fig. 164-6), the table is rotated posteriorly in order to expose more of the anterior chest. The thoracoscope is introduced at the fifth intercostal space (ICS) along the midaxillary line, and additional intercostal access sites are strategically positioned at the second-third ICS midaxillary line and the fifth-sixth ICS midaxillary line for the additional instruments in the manner described by our group and reported by one of us (RJL) and colleagues (1992c, 1993a, 1993b). Posterior rotation of the patient further allows the lung to fall posteriorly, enhancing visibility of the anterior mediastinal structures. A separate lung retractor may be used if visualization needs to be further enhanced. The intercostal approach to the right mediastinum is similar to the left, but for detailed evaluation of the aortopulmonary window (Figs. 164-7 and 164-8), the ICS access sites may be altered slightly (Table 164-2). Sharp dissection with the endoscopic Metzenbaum scissors (U.S. Surgical, Norwalk, CT, U.S.A.; Snowden Pencer, Atlanta, GA, U.S.A.) is used with judicious applications of electrocautery. Endoscopic clip ligature of vascular and lymphatic pedicles of the mediastinal lymph nodes is performed as needed. Alternatively, the ultrasonic coagulator can be used as the primary form of dissection and hemostasis. The locations of the phrenic, vagus, and recurrent laryngeal nerves are carefully identified, and dissection is directed to prevent injury to these structures.
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Fig. 164-8. Depiction of VATS visualization of aortopulmonary window lymph nodes. |
Table 164-2. Strategic Intercostal Access Locations for Mediastinal Video-Assisted Thoracic Surgery | ||||||||||||||||||||||||||||||||||||||||
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VIDEO-ASSISTED THORACIC SURGICAL MANAGEMENT OF ANTERIOR MEDIASTINAL MASSES AND CYSTS
The differential diagnosis of anterior mediastinal masses includes lymphomas, thymic neoplasms, mesenchymal tumors, germ cell tumors, and a variety of inflammatory or congenital or developmental abnormalities. This topic has been recently reviewed by Friedmann and co-workers (2003).
The VATS approach is well suited for resection of small benign tumors of the anterior mediastinum, as advocated by Yim (1996) and Pun (2002), Akashi (2001), Roviaro (2000), De Giacomo (2000), and Demmy (1998) and their colleagues, as well as by one of us (R.J.L.) and co-workers (1992a). Successful VATS resections of mediastinal teratomas have been reported by Pun (2002), Akashi (2001), Cirino (2000), Cheng (2001), Feo (1997), and Roviaro (1994) and their associates.
The thoracic surgeon may also occasionally be asked to obtain a biopsy of a persistent or an intrathoracic mass that recurs after treatment to assess response. In these cases, the surgical approach can present some technical problems owing to the reduction of the neoplastic mass and the reactive fibrosis induced by chemotherapy and radiation therapy. In these cases, VATS offers the advantage of providing a wide field of view to select the most appropriate location for biopsy and simultaneous access to other sites of potential involvement such as the lung and pleural surfaces.
Patients with ectopic mediastinal parathyroid glands or adenomas may be considered candidates for VATS resection, according to Medrano and associates (2000). Precise preoperative localization of the ectopic glands must be obtained, following a diligent cervical exploration for parathyroid glands in their normal position at the thoracic outlet. Most ectopic parathyroids are found in close proximity to the thymus gland. Sestamibi scan, CT scan, and MR imaging are of utility in preoperative localization of intrathoracic parathyroid glands (Fig. 164-9). Parathyroid glands larger than 1.5 cm are typically seen on CT scans, but smaller glands may be difficult to identify. It must be further stressed that the VATS parathyroidectomy is planned as a directed resection following preoperative localization, and not as a general exploration. Following such criteria, successful VATS mediastinal parathyroidectomy has been reported by Kao (2003), Kumar (2002), Onoda (2002), Medrano (2000), Knight (1997), Prinz (1994), Smythe (1995), Furrer (1996), and Gullstrand (1996) and their colleagues. To improve the detection of these small neoplasms, Onoda (2002) and O'Herrin (2002) and their co-workers have used radioisotope-navigated VATS and intraoperative parathyroid hormone testing to confirm cure and avoid additional neck exploration. VATS parathyroidectomy is indicated for the more common anterior mediastinal parathyroid but can be an equally effective approach to the more unusual posterior mediastinal ectopic location. Parathyroid cysts, as reviewed by Shields and Immerman (1999), are also readily and increasingly excised using VATS.
Although VATS has been accepted as a reasonable approach to thymic cysts, the optimal approach to accomplish thymectomy remains a controversial issue. This is reflected in the commentaries of Pairolero (1992), Cooper (1998), Mack (2001), Masaoka (2001), and Yim (2002), as well as by Jaretzki and coinvestigators (2003).
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Fig. 164-9. Sestamibi nuclear scan demonstrating uptake in the mediastinum. This parathyroid adenoma was resected thoracoscopically. |
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Accumulated clinical data have substantiated the utility of VATS in carefully selected patients with thymic disorders referred for surgical intervention, including thymic cysts, myasthenia gravis, and early-stage thymoma, as reported by Yim (1996, 2002), Roviaro (1994, 2000), and Mack (1996) and their colleagues, as well as by Mack and Scruggs (1998). Obviously, careful patient selection for VATS thymectomy is vitally important. This must also be combined with considerable experience in the more elementary VATS procedures before attempting thymic resection. Known malignant tumors and thymomas with preoperative evidence of local invasion should be resected through thoracotomy or sternotomy as deemed appropriate for the specific lesion. Furthermore, we recommend conversion to an open intervention when these unexpected findings are appreciated during VATS in order to minimize the likelihood of incomplete tumor resection.
One of us (RJL) and associates (1992a) first reported VATS resection of a stage I thymoma with subtotal thymectomy through the left chest (Fig. 164-10). This patient remains disease free nearly 12 years after complete VATS extirpation of the stage I thymoma. Nevertheless, we would agree with these critics that a total thymectomy is the appropriate and proper surgical treatment for thymoma and myasthenia gravis. Operative experience acquired since our early report has demonstrated that a total anatomic thymectomy can be performed by VATS, as detailed by Yim (1996, 1999, 2002), Mack (2001), and Mack and Scruggs (1998), as well as by Wright (2002), Savcenko (2002), Mineo (2000), Mack (1996), and Mantegazza (2003) and their associates (Fig. 164-11). Mantegazza (2003) and Novellino (1994) and their co-workers used a combination of cervical and bilateral thoracoscopic approach to achieve a video-assisted thoracoscopic extended thymectomy without sternotomy.
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Fig. 164-10. CT scan of the chest demonstrating a triangular-shaped mass lesion in the anterior mediastinal. This pathologically stage I thymoma was removed by VATS. |
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Fig. 164-11. Photograph of thymectomy specimen from Fig. 164-10 Note the well-circumscribed mass surrounded by remainder of thymus gland. |
Although VATS thymectomy has been criticized by some as an incomplete resection, Mack and associates (1996) reported on a series of 33 patients following VATS thymectomy for myasthenia gravis, with a mean follow-up of 23 months, and found that 88% were improved. This compares favorably to the report from Bril and co-workers (1998), who reported palliation in 83% and complete remission in 44% of the 52 patients following cervical thymectomy for myasthenia gravis, with a mean follow-up of 8.4 years postoperatively. Mack and co-workers (1996) and Mack and Scruggs (1998) have maintained that the midterm data following VATS thymectomy compare well with historical series with transsternal thymectomy and even maximal thymectomy, as advocated by Jaretzki and Wolff (1988). More recently, Yim (2002) and Mack (2001), as well as Mantegazza (2003), Savcenko (2002), and Mineo (2000) and their associates, have reported intermediate results of VATS thymectomy that are comparable to standard surgical approaches. Longer-term follow-up will be necessary before it can be stated that VATS thymectomy is as effective an approach as sternotomy in accomplishing thymectomy for the management of myasthenia gravis or stage I thymomas; however, the intermediate-term results are encouraging.
Technical Considerations
The general VATS surgical routine and intercostal access is the same as outlined for other anterior mediastinal pathology, as described by one of us (RJL) and co-workers (1992c). However, clinical experience gained since our early series have led to several technical refinements to our approach for VATS thymectomy. Most importantly, we have adopted a right-sided approach in lieu of a left-sided approach, as described by Mineo (2000) and one of us (RJL) and colleagues (1992a). However, we continue to advocate a left-sided approach if the thymic pathology is
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largely within the left chest. Although the right-sided approach makes evaluation of the aortopulmonary window difficult for ectopic thymic tissue, there is excellent visualization of the junction of the innominate vein and the superior vena cava during the course of the dissection, as described by Yim (1997). This exposure facilitates the dissection while avoiding troublesome bleeding from venous tributaries at this region. Tension on the thymus is avoided when dissection proceeds to the superior aspect of the thymus to avoid avulsion of the thymic veins (of Keynes) or injury to the innominate vein. The thymic veins are identified and doubly clipped on the side of the innominate vein before their transection. The phrenic nerve is carefully identified to avoid its potential injury, and the mediastinal pleura is incised well anterior to the nerve. Conversion to thoracotomy or sternotomy when intraoperative evidence of local invasion or other signs of malignant disease are present is appropriate, as discussed by Hazelrigg and associates (1993b). Mack covers specific details of VATS thymectomy in Chapter 178.
PARAVERTEBRAL SULCUS NEUROGENIC TUMORS: SIMPLE VERSUS COMPLEX DUMBBELL TUMORS
Paravertebral sulcus tumors are predominantly of neurogenic origin and account for 20% to 30% of all mediastinal masses. Most arise in the upper half of the chest with equal frequency in both paravertebral sulci. They can be further divided into categories based on the neural tissue of origin (neurilemoma, neurofibroma, ganglioneuroma, paraganglioma, or pheochromocytoma) and also classified into benign and malignant counterparts. Malignancy is unusual in adults because 90% of neurogenic tumors are of benign nerve sheath origin (schwannomas or neurilemomas) or are gangliomas. The clinical presentation is variable, and as many as 50% to 70% are found incidentally. When present, symptoms are vague and include pain, compressive symptoms (airway, esophagus, and spine), infectious complications (airway obstruction), and systemic effects (hypertension, tachycardia, malaise, fever). Appropriate management is by surgical excision, and recurrence is unusual. Malignant lesions may also be approached with surgical excision, but prognosis is generally dismal. Preoperative spinal MR imaging or CT scans are routinely indicated to evaluate the intraspinal extension of tumor ( the dumbbell tumor ), which is seen in 10% of patients, as noted by Akwari and associates (1978). Small posterior neurogenic tumors, without evidence of neural canal invasion (Fig. 164-12), can be readily approached using VATS techniques as first demonstrated by one of us (RJL) and colleagues (1992b) and more recently by Zierold and Halow (2000), Han and Dickman (2002), and by Kumar (2002), Negri (2001), Sakumoto (2000), and Bousamra (1996) and their associates. Hazelrigg and co-workers (1999) reported an 86% success rate in a series of 21 patients who underwent VATS resection of paravertebral sulcus neurogenic tumors. The pathology included ganglioneuroma, neurofibroma, malignant schwannoma, and ganglioneuroblastoma,
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with tumor sizes ranging from 7 to 13 cm. The mean operating time was 65 minutes. Postoperative morbidity was minimal, and the average hospital stay was 2 days.
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Fig. 164-12. A. Coronal magnetic resonance imaging view of paraspinous neurogenic tumor. B. CT scan of paraspinous neurogenic tumor. |
More complex dumbbell tumors with an intraspinal component have usually required a combined neurosurgical and thoracic surgical approach incorporating laminectomy followed by thoracotomy to resect the tumor, as Grillo and Mathisen (1983) described. The use of combined minimally invasive surgical techniques to manage such complex pathology has recently been described by Vallieres (1995), Ishikawa (2002), and Konno (2001) and their co-workers. Vallieres and associates (1995) described successful resection of a dumbbell tumor in four patients using a combined VATS and a posterior microsurgical approach. In general, the VATS approach to paravertebral sulcus neurogenic tumors is safe and effective. Malignancy, local invasion, and tumors larger than 5 cm may require an open procedure, as suggested by Zierold and Halow (2000).
Technical Considerations
The patient is prepared and intubated with a double-lumen endotracheal tube in standard fashion as for a thoracotomy. For better exposure of the posterior mediastinum, the patient is rotated anteriorly to facilitate exposure of the posterior mediastinum during the VATS intervention (Fig. 164-13). This anterior rotation allows gravity to improve exposure by allowing the lung to fall away from the paraspinous region. A lung retractor may be used, if necessary, to further enhance exposure. The thoracoscope is placed in the fifth to eight ICS along the midaxillary line, based on the location of the mediastinal mass. After the mass has been identified, the other instruments are placed in the second, forth, and sixth ICS along the anterior to midaxillary line to create the best convergence on the mass, as described by one of us (ADH) and Sundaresan (2001). Note that this arrangement forms an L shape with the thoracoscope on the left, which is a slight departure from the triangular intercostal access site arrangement usually employed for VATS. As Mack and associates (1993a) reported, this intercostal access arrangement is similarly useful for VATS-directed anterior approaches to the spine (i.e., discectomy, corpectomy, and spinal ligamentous release). In addition to experience in advanced VATS techniques, several considerations must be followed when operating in the paraspinous region. The pleura is incised circumferentially around the lesion, and then the lesion is mobilized with the use of sharp dissection. The sympathetic nerve trunks and larger blood vessels (>2 mm) are clipped as they are encountered. Nerve trunks or intercostal bundles intimate with the mass may also be ligated with clips and divided with endoscopic scissors. Smaller vessels may be managed by electrocautery. The use of monopolar diathermy should be avoided around the spinal foramen. Bipolar diathermy is employed for coagulation in this region to prevent injury to the spinal cord or nerve roots. Alternatively, the harmonic scalpel can be used as described by Pons and associates (2003). Strict hemostasis should be achieved to avoid complications of epidural hematoma. Similarly, the use of Gelfoam or oxidized cellulose to pack the neuroforamen should be avoided because it may expand within the spinal canal and cause compression of the spinal cord structures. Ruurda and associates (2003) demonstrated the feasibility of robot-assisted thoracoscopic resection of a neurogenic tumor of the paravertebral sulcus region.
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Fig. 164-13. VATS approach for posterior mediastinal pathology. |
BRONCHOGENIC, PERICARDIAL CYSTS AND PERICARDIAL EFFUSION
Mediastinal cysts may arise from numerous sources and include lymphangiomas (cystic hygromas), meningoceles, thymic cysts, parathyroid cysts, pericardial cysts, pancreatic cysts, thoracic duct cysts, teratomatous cysts, and foregut cysts (bronchogenic, esophageal, and neuroenteric). Mediastinal cysts are reported to represent 18% to 25% of all primary mediastinal mass lesions. Bronchogenic cysts and pericardial cysts are the most common according to Takeda (2003), Magee (2000), and St-Georges (1991) and their colleagues. Bronchogenic cysts are most commonly found in the middle mediastinum, but they may also occur in any of the mediastinal compartments according to Ribet (1995) and Cioffi (1998) and their associates.
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Bronchogenic and pericardial cysts in adults are typically asymptomatic and present as an incidental finding on routine chest roentgenograms. Diagnosis is usually confirmed with chest CT demonstrating a simple cyst with low attenuation. Expectant management in the young asymptomatic patient with classic features of a bronchogenic or pericardial cyst on CT scan is suggested, with appropriate follow-up by interval CT scans. However, if the diagnosis of a simple cyst is uncertain because the attenuation of the cyst contents is high or if the cyst is multiloculated, then surgical resection may be indicated. Likewise, if the cyst becomes clinically symptomatic or infected, then cyst excision is warranted. Mediastinal cysts often represent ideal lesions for resection by minimally invasive techniques. Surgical excision offers the advantages of complete and definitive treatment, elimination of the mediastinal mass and prevention of any potential complications, relief of symptoms when present, and histologic evaluation as suggested by Pons (2003) and Rios (2002) and their colleagues. Successful thoracoscopic excision of bronchogenic cysts has been reported by Martinod (2000), Kanemitsu (1999), Cioffi (1998), Michel (1998), and Hazelrigg (1993a, 1993b) and their co-workers, as well as others. It is important to emphasize that these cysts can be very adherent and difficult to excise from adjacent vital structures. When the cyst cannot be removed completely, partial excision with cautery destruction of the epithelial mucosal lining is an acceptable alternative, as described by Ferguson (1993).
The cystic structures are generally easily dissected or marsupialized after they are decompressed by intraoperative needle aspiration, as noted by Mouroux (1996), Schwarz (1994), and Furukawa (1994) and their co-workers. The phrenic nerve must be clearly identified and protected during the dissection. Complete resection is ideal, but when the wall of the cyst is firmly adherent to vital mediastinal structures, the posterior wall of the cyst is left in situ, and the endothelial lining of the cyst is cauterized, as advocated by Hazelrigg and associates (1993b).
Incomplete resection may result in a recurrence or continued fluid production by the residual cyst wall. Therefore, it is important to resect cystic mediastinal tumors completely and remove them without rupture. The aspiration of fluid at the beginning of the procedure is often helpful because it allows the cyst to be more easily grasped and manipulated. Naunheim and Andrus (1993) and Lewis and co-workers (1992) have used a needle technique to decompress the cysts, whereas Iwasaki (2001) and Shimokawa (2001) and their colleagues have used a balloon catheter technique to decompress and easily manipulate the cyst and facilitate dissection.
Pericardial cysts are uncommon mediastinal anomalies. They result from failure of one or more fetal lacunae to coalesce into the pericardium. They commonly appear multilocular, but most are unilocular and contain clear, water-like fluid. Most cysts are found in the right costophrenic angle, and as many as one third of patients may have associated symptoms. Unlike bronchogenic cysts, which carry a risk for infection, pericardial cysts usually follow a benign course and infrequently need intervention. Thoracoscopy is recommended for symptomatic lesions and when the diagnosis is uncertain, as suggested by Song and coinvestigators (2002).
The role of VATS in the management of malignant and idiopathic benign pericardial effusions has been examined. Malignancy is the single most common source of pericardial effusions, accounting for 30% to 50% of the cases, as reported by Gregory and associates (1985). Yim and colleagues (1996) noted that the development of a malignant pericardial effusion is often a terminal manifestation of their systemic malignant disease. Hazelrigg and associates (1993c) found a mean survival time of 2.8 months in patients with bronchial carcinoma who presented with a pericardial effusion. Certainly, patients with advanced malignancies or with poor functional status should be temporized with a simpler and less physiologically taxing procedure than thoracotomy or VATS. Percutaneous pericardiocentesis is appropriate initial treatment. Failing pericardiocentesis, a subxiphoid pericardial window can be performed. However, for patients with malignant effusions resulting from diseases with reasonable hopes for treatment (i.e., breast cancer, lymphoma), VATS is a good alternative to thoracotomy when a more extensive pericardial resection is indicated, as suggested by Mack and associates (1993b).
The VATS approach should be considered for elective treatment of hemodynamically stable patients with postcardiotomy effusions and idiopathic benign recurrence (i.e., postviral effusions), in which a more extensive pericardial resection is often recommended. The hemodynamically unstable patient with tamponade physiology should undergo a catheter-based decompression before the surgical intervention.
Technical Considerations
When the VATS approach is chosen to manage such patients, it is preferable to approach the patient after an initial percutaneous drainage procedure to decompress the pericardium partially. This allows for a safer induction of general anesthesia and easier manipulation of the pericardium during the VATS procedure. A left chest approach can be used to perform the VATS pericardiectomy (Fig. 164-14); however, a right-sided approach, as described by Flores and associates (1998), allows for greater instrument access (Fig. 164-15). Generally, a left-sided approach is now used only when an associated idiopathic pleural effusion exists on the left side. This is counter to our earlier recommendations for a left-sided approach to pericardiectomy. Upon entry into the chest and visualization of the pericardium, the phrenic nerve is identified. Pericardiectomy is performed with endoscopic scissors anterior, and posterior if necessary, to the phrenic nerve pedicle. Minor bleeding from the pericardial edge can be managed
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by judicious use of diathermy. Care should be taken to avoid injuring the atrial appendage when the pericardial incision is carried superiorly. External defibrillation pads should be placed preoperatively on these patients routinely because of the potential risk for ventricular dysrhythmias precipitated by the use of electrocautery during the procedure.
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Fig. 164-14. Left-sided VATS approach for pericardial effusion. A similar approach on the right can be used for pericardiectomy or resection of pericardial cysts. |
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Fig. 164-15. Right-sided VATS pericardiectomy anterior to the lung hilum and phrenic nerve. Creating the window is simplified by the use of the D-loop forceps to grasp the pericardium. |
DRAINAGE FOR MEDIASTINITIS
Descending necrotizing mediastinitis occurs when a pharyngeal, periodontal, or cervical abscess dissects along anatomic fascial planes down the neck into the mediastinum through the thoracic inlet. This can be a catastrophic condition associated with significant morbidity and mortality rates exceeding 50%, as described by Pearse (1938). Treatment of this condition centers on broad-spectrum antibiotics and aggressive wide surgical d bridement and drainage of the mediastinum and posterior pharyngeal space. Cervical drainage alone is generally not sufficient treatment, and mediastinal drainage has usually required thoracotomy, particularly if the abscess extends to the level of T4 or below as supported by the reports of Howell (1976), Estrera (1983), and Wheatley (1970) and their associates. Recently, Chung and Ritchie (2000), Laisaar (1998), and Roberts and co-workers (1997) described anecdotal case reports of successful VATS drainage of the mediastinum in the setting of descending necrotizing or acute purulent mediastinitis. The application of VATS will have merit if adequate drainage can be achieved easily and consistently for this most serious condition.
NERVE ABLATION-SYMPATHECTOMY, SPLANCHNIECTOMY
There are two thoracic sympathectomies, upper and lower, as described by Kohno and Takamoto (2000). Upper thoracic sympathectomy is indicated for facial, palmar or axillary hyperhidrosis, causalgia, Raynaud's disease, and other vascular disorders in the upper extremities. Lower thoracic sympathectomy is useful for relief of intractable upper abdominal pain. These procedures are effective treatment options that have been overlooked by the medical community largely because of the tainted history of imprecise indications for the procedure (Table 164-3) as well as the additional morbidity of thoracotomy necessary to perform the ablation. The efficacy of these procedures for idiopathic palmar or axillary hyperhidrosis has been well documented since the initial report by Kotzareff in 1920. Dorsal sympathectomy has been performed through cervical, transaxillary, and thoracic
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incisions. In 1942, Hughes performed the first thoracoscopic sympathectomy, as noted by Drott (1994). By 1954, Kux reported on his experience of 1,400 thoracoscopic sympathectomies primarily for vasospastic conditions of the upper extremities. His colleague, Wittmoser (1954), developed the first thoracoscope with multiple working channels that allowed for successful sympathectomy through a single intercostal access technique in 1950. The relatively simple technical nature of these nerve ablative procedures and the reduction in pain-related morbidity relative to thoracotomy have made these conditions ideally suited for thoracoscopic intervention. Interest in thoracoscopic sympathectomy was maintained by Kux (1978) throughout the succeeding decades. Urschel (1993), as well as Shachor (1994), Hsu (1994), and Nicholson (1994) and their colleagues, subsequently described the successful application of VATS techniques to perform thoracic sympathectomy. In general, sympathectomy can achieve 85% to 95% success in relieving palmar hyperhidrosis and 60% to 80% for axillary hyperhidrosis. Gossot and co-workers (2003) reported recurrence rates in 6.6% and 65% of patients with palmar and axillary hyperhidrosis, respectively. Long-term patient satisfaction in general is excellent, as reported by Gossot (2003) and Alric (2002) and their associates. A common side effect, however, is the development of compensatory or truncal gustatory sweating, which may be experienced in up to 50% of patients, as reported by Gossot (1997) and Zacherl (1998) and their colleagues. Postsympathectomy compensatory hyperhidrosis (PCH) varies with patient's geographic location, working environment, humidity, temperature, and the season when it is surveyed, so that the reported incidence varies from 30% to 85%, as described by Kao and associates (1996a, 1996b). Compensatory hyperhidrosis does not improve with time and is the main cause of dissatisfaction. Patients suffering from isolated axillary hyperhidrosis should be treated by local therapy, and patients should be thoroughly informed of potential side effects before the operation, as emphasized by Gossot and co-workers (2001, 2003). Furthermore, Kao and colleagues (1996a, 1996b) emphasized that the severity, rather than the incidence, of PCH is related to the extent of sympathectomy, so that the more extensive the sympathectomy, the more serious the PCH. This supports the use of physiologic monitoring (palmar skin temperature and Doppler blood flow) to confirm an adequate sympathectomy that will lead to definite therapeutic results and minimize PCH, as demonstrated by Kao (2001).
Table 164-3. Indications for Thoracic Dorsal Sympathectomy | |
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Lin and associates (2001) and Lin and Chou (2002), in an effort to decrease the incidence of PCH, developed the technique of reversible endoscopic clipping of T2 or T3 to T4 rather than division for palmar and axillary hyperhidrosis, respectively.
Injury to the stellate ganglion may result in temporary Horner's syndrome in 2% to 5% of patients and in permanent Horner's syndrome in 1% to 2%.
VATS approaches to thoracodorsal sympathectomy have also been successfully used to treat patients with severe vasospastic conditions (i.e., Raynaud's syndrome) and reflex sympathetic dystrophy following upper extremity trauma, as reported by Bandyk and colleagues (2002). Although the results with VATS sympathectomy for these latter conditions are generally favorable (60% to 80% success), they do not uniformly approach the success rates of sympathectomy for hyperhidrosis.
Severe chronic intractable pain from pancreatic or hepatobiliary cancer, chronic pancreatitis, and other advanced intraabdominal cancers is mediated through the celiac plexus, celiac ganglia, and the greater and lesser splanchnic nerves. Interruption of the pathway with alcohol or phenol injection of the celiac plexus can be temporarily effective in controlling this visceral pain, but diminishing results are noted with repeated injections. Complications related to the injury of vascular structures in proximity to the neural structures are recognized. Surgical interruption of the splanchnic nerves with or without vagotomy through left thoracotomy can be performed to interrupt the afferent visceral pain pathway, and its efficacy has been reported by Stone and Chauvin (1990). Although concurrent bilateral thoracic truncal vagotomy was advocated by Stone and Chauvin (1990) for chronic pancreatitis to interrupt the pain sensory pathways and to reduce gastric and pancreatic stimulation, Testart (1994) advocated limiting the vagotomy to the posterior trunk to interrupt the pain fibers to the pancreas. They believe this may avoid the complication of delayed gastric emptying resulting from dividing the vagal innervation to the pylorus. They were able to demonstrate short-term relief of pain in all patients following a left thoracic splanchnicectomy and bilateral vagotomy. Long-term relief was sustained in 67% of patients. The performance of a subsequent right thoracic sympathectomy among patients with persistent pain increased the long-term pain control to 80%. The technique of VATS left thoracic splanchnicectomy, as reported by Worsey and co-workers (1993), has also resulted in excellent short-term palliation of pain in these patients.
Technical Considerations
Several approaches have been described for VATS sympathectomy. For the lateral decubitus approach, the patient is positioned to enhance exposure of the posterior mediastinum by anterior rotation. A bilateral VATS sympathectomy can also be performed in the supine position (Fig. 164-16). Strategic placement of the intercostal access sites is selected for the specific operation splanchnicectomy or dorsal sympathectomy (see Table 164-2). Techniques for single, two, and three ports have been reported by Kohno and Takamoto (2000), Ng and Yeo (2003), and Lardinois and Ris (2002) and by others, including Gossot (2003) and Leao (2003) and their co-workers. The lung is retracted, if necessary, with a separate retractor. The thoracic sympathetic ganglia rest against the heads of the ribs. The first thoracic ganglion is usually fused with the inferior cervical ganglion to form the stellate ganglion (cervicothoracic ganglion). The next ganglion, which rests on the head of the second rib, is called the second
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thoracic ganglion. Each of the thoracic ganglia corresponds to the number of a rib. In some cases, one or more accessory sympathetic fibers, known as the Kuntz fibers, are found lateral to the thoracic sympathetic chain. Anatomic variations of the T2 nerve root, including the nerve of Kuntz, have been characterized by Chung and associates (2002). Kuntz fibers communicate with the sympathetic system and must be treated at the same time. These accessory fibers may be the cause of inadequate operation or recurrence of symptoms.
A 5-mm 0-degee angle telescope is generally used. Carbon dioxide insufflation is generally not necessary for the three-port technique but is recommended for the single- and two-port techniques. The patient is positioned in full lateral position or in a semisitting position with the patient's arms up for bilateral access. Yim and colleagues (2000) and others have recently reported the use of ultra-fine (2-mm) equipment for thoracoscopic sympathectomy, although limitations in field of vision, lower resolution, and difficulty in maintaining fine control were reported. The thoracoscope is usually inserted in the third or fourth intercostal space at the anterior axillary line. The parietal pleura is opened over the sympathetic chain from the second to the third ribs with an electrode or a pair of endoscopic scissors. The classic method of sympathectomy involves division of the interganglionic sympathetic chain below the stellate ganglion to T2 or T3. Our group commonly uses resection of the ganglia to the T4 level in patients with concomitant axillary hyperhidrosis. It is effective, but its critics maintain that this (nonselective) method may result in a higher incidence of Horner's syndrome and PCH. The sympathetic nerve, as well as the accessory fiber of Kuntz, is divided at the rib by electrocautery with a power of 15 to 25 watts. The use of electrocautery near the stellate ganglion should be avoided to prevent current diffusion and Horner's syndrome. A selective technique of interrupting the preganglionic or postganglionic rami communicantes has been described, and Friedel and associates (1998) advocate the postganglionic technique, based on the pioneering work of Wittmoser. Friedel and co-workers (1993, 1998) maintain that the postganglionic technique is the most effective method of sympathectomy, while avoiding or minimizing the undesired complications of Horner's syndrome or compensatory sweating. On the other hand, the dissection is somewhat more demanding and complicated than the classic interganglionic sympathectomy. Most surgeons rely on palmar temperature monitoring to guide sympathectomy, as reported by Chiou and Chen (1999), Kao (2001), and Saiz-Sapena and associates (2000). Kao (2001) has demonstrated that en bloc ablation of the T2 sympathetic segment overlying the bony head of the second rib should be considered as an adequate extent of sympathectomy for isolated palmar hyperhidrosis. More recently, Ng and Yeo (2003) and Sano and associates (1999) used laser Doppler blood flow as a guide for success after endoscopic thoracic sympathectomy. At
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the end of the procedure, if bleeding is negligible, no chest tube is usually necessary. If pleural drains are inserted, they can be removed later that day. Ninety percent of the patients are discharged from the hospital the next day.
For VATS splanchnicectomy, the patient is placed in the right lateral decubitus position, with the table rotated anteriorly to expose the posterior mediastinum (Fig. 164-17). The splanchnic nerves should be visible beneath the pleura, arising from and coursing medial to the sympathetic ganglia and chain. The greater splanchnic nerve may arise from as high as the fifth thoracic sympathetic ganglion and as low as the tenth. The lesser splanchnic nerve usually arises from the ninth to eleventh thoracic ganglia. Once identified, the nerves are clipped and divided at their origin, then traced down to the diaphragm, where they are clipped and divided again.
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Fig. 164-16. Bilateral VATS approach for sympathectomy in a supine position. From Leao LEV, et al: Role of video-assisted thoracoscopic sympathectomy in the treatment of primary hyperidrosis. Sao Paulo Med J 121:191, 2003. With permission. |
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Fig. 164-17. Thoracic splanchnicectomy (left). SC, sympathetic chain; S, splanchnic nerve; IV, intercostal vessels; A, aorta. |
SPINAL DEFORMITIES
The conventional approaches to the spine have been posterolateral, costotransverse, and anterior. To reach the anterior spine, anterior thoracotomy has traditionally been used. Problems associated with thoracotomy for spine procedures include a long incision, rib resection, significant rib spreading, alteration in pulmonary function and shoulder girdle function, as well as significant pain and poor cosmesis. VATS offers the potential of performing the same goals and objectives of the open procedure with significant reduction in morbidity. Since the first report by Mack and associates (1993a), other authors, including Huang (2002), Burgos (1998), and Kokoska (1998) and their co-workers, as well as Mehlam and Crawford (1997), have described the use of VATS for anterior spinal release and arthrodesis in the treatment of spinal deformities. Anand and Regan (2002) reported their experience with VATS in the treatment of patients with disc herniation, achieving an overall long-term satisfaction rate of 84% and a clinical success rate of 70% for refractory thoracic disc disease. Arlet (2000) presented a meta-analysis and review of anterior thoracoscopic spine release in spine deformity. The indications for thoracoscopic spinal release and arthrodesis are similar to those for open thoracotomy, namely, a rigid spinal deformity that needs an anterior release to improve the flexibility of the spine. It can also be used in growing children to prevent a so-called crankshaft deformity when a posterior spinal arthrodesis is performed simultaneously, as reported by Gonzalez-Barrios and associates (1995). Other indications are listed in Table 164-4 and include not only release but also correction, instrumentation, and fusion. Relative contraindications include the following: inability to tolerate single-lung ventilation; severe or acute respiratory insufficiency; high airway pressures with positive pressure ventilation; pleural symphysis; empyema; and previous thoracotomy with extensive adhesions.
Technical Considerations
General anesthesia is administered through a double-lumen endotracheal tube or bronchial blocker, and the patient is turned to the lateral decubitus position. Because most thoracic deformities appear on the right side, the patient is usually placed in the left lateral decubitus position with a kidney-rest support. The topographic anatomy, specifically the scapular borders, the twelfth rib, and the iliac crest, are identified and outlined. Usually four to five ports are necessary in a reverse L-shaped configuration. The first port is most frequently placed at or about the T6 7 interspace in the posterior axillary line. Entry at this level usually avoids the diaphragm. A second port is inserted at the apex of the spinal deformity in the anterior or midaxillary line, depending on the amount of kyphosis and the severity of the deformity. The rest of the ports are placed along the anterior axillary line once the spine is exposed. The 30-degree angled scope allows direct vision into the intervertebral disc spaces without either impeding the surgical instrumentation or obscuring the operative field. Rotating the table anteriorly and using the Trendelenburg or reverse Trendelenburg position allows exposure of the lower and upper thoracic spine, respectively. Retraction of the diaphragm is necessary below T9 to T10.
Once the spinal anatomy has been identified, it is important to select the levels to perform annulotomy and discectomy. The ribs are counted by palpation with a blunt grasping instrument. If there is a question of the specific level, a spinal needle is inserted into the intervertebral disc, and a radiograph is taken, as in the open procedure. The spine is approached through the parietal pleura using the harmonic scalpel to open the pleura longitudinally over the vertebral column along the length of the operative field in a fashion similar to the open procedure. The intervertebral disc is identified by the mounds observed on the spinal column, and the vertebral bodies are identified by the valleys. The segmental vessels are noted to nest in the valleys directly
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overlying the bodies. Multilevel anterior discectomies are necessary for correcting severe spinal deformity. This anterior release of the spinal curvature usually requires discectomy at six to eight levels. For simple discectomy and arthrodesis, the segmental vessels are not disturbed. However, in patients with substantial kyphosis, the anterior aspects of the vertebral bodies are very narrow at the apex of the deformity, making the segmental arteries very close to one another and at risk for injury during a discectomy. Therefore, the segmental vessels are cauterized at the apex of a kyphotic deformity over two to three segments but are left undisturbed in a scoliotic deformity, as described by Hanley and colleagues (2003). Any vessels that appear to be at risk for bleeding are coagulated with a bipolar electrocautery or harmonic scalpel as described by Ohtsuka and associates (2000). The pleura is elevated and retracted with thoracoscopic periosteal elevators and blunt dissectors. The anterior longitudinal ligament and anulus are incised, and the anulus is freed from the superior and inferior vertebral plates with an osteotome. Excision of the anulus is performed in an orderly and sequential fashion. A transverse cut is made across the anulus and continued down to the level of the nucleus pulposus. Rongeurs, curets, and periosteal elevators are then used as necessary to ensure complete removal of the disc material. The spinal column segment should be stressed by rotating the periosteal elevator in the disc space, exercising moderate force after each release to determine whether mobility has been achieved. The complete anterior release should improve the mobility and correction of the spine substantially. The disc space is packed to control bleeding, and the remaining discs are excised in a similar manner. To supply bone graft, several ribs are exposed through the portal incisions. They are split longitudinally, taking off the superior half of the rib while leaving the inferior half intact. This autologous bone graft is cut into small pieces and packed through a metal funnel. Fibrin glue containing autologous bone growth factors may then be placed to enhance fusion as well as to stabilize the bone graft that was inserted into each disc space. After completion of the procedure, efforts are made to remove all disc fragments and debris from the thoracic cavity. No attempt is made to close the pleura. Hemostasis is achieved, and a chest tube is inserted alongside the vertebral column. The patient is reintubated with a single-lumen tube and turned to the prone position for a posterior spinal fusion.
Table 164-4. Indications for Video-Assisted Thoracic Surgical Approach to Spine Deformities | |
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Potential complications of VATS spine approaches include bleeding, dural tear, spinal cord and lung injury, lymphatic injury, and sympathectomy, as described by Crawford and Wolf (2000) as well as by McAfee and colleagues (1995).
THORACOSCOPIC FIRST RIB RESECTION FOR THORACIC OUTLET SYNDROME
Although the transaxillary approach is the most commonly used method for the removal of the first rib, a thoracoscopic approach permits excellent visualization of the first rib and adjacent surrounding structures. According to Wolf and associates (2000), the rib is identified as a wide, flat structure that has the appearance of a C in the thoracic apex. The adjacent arteries, veins, and neurologic structures can be readily identified (Fig. 164-18). The development of new endoscopic instruments, as noted in Chapter 32, including the harmonic scalpel, endoscopic elevators, curettes, rongeurs, and, most importantly, a thoracoscopic rib cutter, have permitted the safe removal of the first rib in its entirety.
Technical Considerations
Ohtsuka and associates (1999) have described the thoracoscopic approach to the first rib, and Wolf and colleagues (2000) have succinctly described the operative removal of the first rib.
 |
Fig. 164-18. Thoracoscopic view of the left first rib. From Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, et al (eds): Minimal Access Cardiothoracic Surgery. Philadelphia: W.B. Saunders Company, 2000, p. 328. |
 |
Fig. 164-19. Initial dissection of the pleura overlying the first rib as performed with the harmonic scalpel. From Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, et al (eds): Minimal Access Cardiothoracic Surgery. Philadelphia: WB Saunders, 2000, p. 328. |
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The patient is placed in the lateral decubitus position with the arm extended upward to expose the axilla and the lateral chest wall. Three 10-mm thoracic ports are used. The highest is placed in the third intercostal space slightly anterior to the axilla, the middle port is placed in the fifth intercostal space first posterior and inferior to the axilla, and the third port is placed inferiorly and approximately just below the scapula in the sixth intercostal space, as suggested by Ohtsuka and colleagues (1999). After the exposure of the apex of the hemithorax is accomplished, the first rib and adjacent vascular and neurologic structures are identified. Next, as described by Wolf and co-workers (2000), the parietal pleura and intercostal muscles are dissected from the costal edge of the first rib by the use of the harmonic scalpel (Fig. 164-19). The subclavian vein and artery, as well as the brachial plexus, that are draped over the first rib are bluntly freed using an endoscopic Cobb elevator and endoscopic curettes. Next, the first rib is stripped of its periosteum circumferentially with the use of a spinous process elevator. The aforementioned authors recommend that the dissection be begun initially anterior to the vein. After the rib is free, it is divided anteriorly and posteriorly with the use of the thoracoscopic rib cutter and then removed from the chest. The remaining ends of the rib are trimmed back to the transverse process posteriorly and to the costochondral junction at the manubrium anteriorly with the use of endoscopic orthopedic rongeurs (Fig. 164-20). At this stage, it is important that the rib excision be complete. Wolf and co-workers (2000) note that any additional muscle attachments, such as the scalenus anticus or medius, can be divided under direct vision after the rib has been removed. The thoracoscopic procedure is completed in the standard manner.
Only a few of these procedures have been recorded, but the operation offers a minimally invasive alternative for resection of the first rib.
SUMMARY
In summary, VATS and concepts of minimally invasive thoracic surgery have revitalized many aspects of general thoracic surgery, including the surgical approach to diseases and conditions of the mediastinum. Proven surgical options that have been shunned by patients and referring physicians because of the perceived morbidity of thoracotomy are being reconsidered with the emergence of these minimally invasive surgical options. Critical review of the accumulating experience in VATS techniques will refine the surgical indications for VATS and its open thoracotomy counterpart.
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Fig. 164-20. A C. Thoracoscopic dissection and division of the first rib.From Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, et al (eds): Minimal Access Cardiothoracic Surgery. Philadelphia: WB Saunders, 2000, p. 328. |
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