[Organization and significance of quality control in recent surgical methods exemplified by 85 consecutive thoracoscopic interventions]

The rapid evolution or rather revolution of minimally invasive surgical techniques is stimulating new technical and clinical innovations. Quality control is of great importance in new areas of technical development where standards do not yet exist. By recording detailed documentation of patient data, indications, operative procedures and initial follow-up we can compare this new technology with the gold standard therapy. This documentation system for thoracoscopic interventions was developed together with the Swiss Group of Laparoscopic and Thoracoscopic Surgeons. This pilot project of 85 consecutive thoracoscopic interventions will demonstrate the acceptability, clinical application and ease with which data can be analyzed. Operative techniques are described in detail: 20 diagnostic interventions with biopsy, 19 apical parietal pleurectomies (+/- resections of bullous lung tissue), 10 therapeutic lung tissue resections, 19 palliative pleurodesis, 5 treatments of pleural empyema, 1 mediastinal tumor resection, 1 esophagectomy, 4 thoracic sympathectomies plus 6 other procedures. Data entry is efficient with mean total time of 10 min for each record. All of the data are entered into a computer database. The possibilities for interpreting and combining this data are presented. The operative techniques can easily be related with history, indications, anesthesia, complications and results. First evaluation of thoracoscopic efficiency is possible. In addition, a detailed analysis of intra- and postoperative complications and of the hospital course can be performed.

[Preliminary experiences with thoracoscopic operations]

During the period March 3, 1992 to September 30, 1993 36 video-assisted thoracoscopic operations were performed at the Surgical Department of the University of Cologne. In 12 cases wedge resection of peripheral pulmonary nodules were carried out. Two of the patients underwent video-assisted thoracoscopic lobectomy of the left lower lobe due to peripheral primary bronchogenic carcinoma. In 6 cases biopsy of the lung or pleura was undertaken. Further indications were partial pleurectomy and resection of blebs (n = 12). Pleural effusion was drained under thoracoscopic vision twice. No intraoperative complications occurred. Two patients proceeded to thoracotomy after persistence of pneumothorax following thoracoscopic pleurectomy. The postoperative course of the remaining patients was uneventful and was especially characterized by the reduction in pain and disability. In accordance to the experience of other authors we believe that thoracoscopic surgery is a method with a promising future. Further investigations have to evaluate indications, different techniques, and long term results.

Fetal chest wall hamartoma: a case report

A fetal chest wall hamartoma successfully treated by surgical resection after birth is described. Ultrasonography showing a heterogeneous partially calcified thoracic tumor allowed in utero diagnosis.

Prenatal diagnosis and management of fetal thoracic lesions

There have been significant strides made during the last decade in understanding the natural history and pathophysiology of fetal thoracic lesions. Largely as a result of advances in prenatal ultrasound, we are not only able to diagnose these lesions and advise parents about prognosis, but also offer the possibility of fetal intervention for the most severely affected fetuses. However, large gaps remain in the current state of knowledge of fetal thoracic lesions. We are unable to accurately predict pulmonary hypoplasia, the most devastating consequence of fetal thoracic lesions. In lesions, such as CDH, the selection criteria for fetal intervention remain ill defined. Proof of the efficacy and superiority of fetal surgery over conventional postnatal therapies for diaphragmatic hernia await the results of prospective trials. Fetal surgery in lesions such as CCAM and BPS is currently reserved for only those fetuses with hydrops and a uniformly fatal outcome. Whether fetal surgery in these cases would be beneficial in the absence of hydrops is difficult to say especially given the possibility of spontaneous regression. During the next decade we anticipate continued growth in our understanding of these lesions, refinement in selection criteria for intervention, and advances in techniques for salvaging these severely compromised fetuses. The diagnosis and treatment of fetal thoracic lesions remains a formidable challenge, but one which can be met with cautious optimism, due to the availability of fetal interventions not previously available.

[Plasma cell granuloma of the chest and lung in childhood]

Plasma cell granuloma is a benign, non-neoplastic lesion rarely found in children. It occurs mainly in the chest and lungs, the right lung mostly. Most cases are asymptomatic and are discovered incidentally on routine chest X-ray, although there may have been atypical upper respiratory symptoms. The X-ray findings, as well as those of other imaging modalities, are nonspecific, making the exact localization and diagnosis of the lesion difficult, as demonstrated in the cases of 2 boys aged 8 and 9 years, respectively. Locating the right diaphragm and its relation to the large lesion by various imaging modalities was unreliable in 1 of the cases. The large, dense, firm, adherent lesions were carefully and completely resected in both cases. In 1 case it was located in the right lung, pulmonary hilum and mediastinum. In the other, in the right pleural space in the supradiaphragmatic region, adherent to the posterolateral aspect of the lower ribs. Biopsies for frozen section should always be taken before deciding on the extent of surgery. Radical resection of normal surrounding tissue should be avoided. Our cases have been followed for 2 and 3 years respectively, with no evidence of recurrence. Prognosis is excellent when lesions are completely removed.

[Minimally invasive thoracic surgery]

Surgery of the intrathoracic organs may be performed without compromise of respiratory mechanics considering minimally invasive principles. An analysis of our experience of 373 thoracoscopic interventions reveals that the diverse procedures performed on the pleura (pleurectomy, pleurodesis), on the lung (wedge resection, fistula closure, ligature of parenchymatous leaks) and on other definec anatomical structures such as the sympathetic nerve or the thoracic duct, are effective in the therapy of intrathoracic disease. The most important pathological conditions which may be treated by thoracoscopy are listed. The range of complications (7%) and their causes are discussed. Current developments and innovations are summarized by a short review of the literature.

Resection of chest wall and central veins for invasive cutaneous aspergillus infection in an immunocompromised patient

Primary cutaneous invasive Aspergillus infection at a Hickman catheter site led to chest wall involvement and central venous suppurative thrombophlebitis in a patient with relapsed acute myelogenous leukemia. Therapy included high-dose amphotericin B, serial wound debridements pending bone marrow recovery, and definitive resection of the infected chest wall and thrombosed internal jugular, subclavian, and innominate veins. To our knowledge, this procedure for control of invasive fungal infection has not been reported previously.

Chest wall echinococcosis

The chest wall is an uncommon localization for hydatid cyst. In this article, six patients were operated on because of chest wall hydatid cysts between the years 1989 to 1991 have been reported. Four of them had previously undergone surgery for pulmonary or hepatic hydatidosis; the chest wall was the primary site in two patients. Operative procedures for chest wall echinococcosis were cystectomy (four patients), cystotomy and evacuation (one patient), and chest wall resection (one patient). There was no mortality. Mean follow-up was 26 months (range, 14 to 36 months). No recurrence has occurred yet.

Video-assisted thoracic surgery: experience with 126 cases

VATS was performed in 126 patients at the Medical Center of Delaware from December 1991 to August 1993, with no major complications and no mortality. A definitive diagnosis was made in all cases. Results with VATS therapeutic procedures appear to equal those of the standard open technique. Operating time was comparable to that with the open technique. Length of stay and pain and suffering were dramatically reduced when compared with those associated with the open technique. We now consider VATS to be the preferred procedure in cases of: 1. Undiagnosed pulmonary infiltrate in the nonventilator-dependent patient 2. Indeterminate pulmonary nodule 3. Undiagnosed disease of the pleural space 4. Recurrent or persistent pneumothorax 5. Mediastinal or pericardial cystic tumors 6. Thoracic sympathectomy 7. Selected patients requiring esophagocardiomyotomy. The utilization of VATS for resection of a pulmonary mass in patients with cardiopulmonary compromise (i.e., FEV < 1) is being studied. Further development of this technique and expansion to formal pulmonary resection and cardiovascular procedures must follow the philosophy presented in our conclusion. The place of VATS in the management of penetrating thoracic trauma has been studied at several centers, with excellent results when precise guidelines have been followed. Obviously, one-lung anesthesia is not well tolerated when a patient is in profound shock, but if the patient can be stabilized before thoracotomy, the introduction of a camera to diagnose a carotid or internal mammary artery laceration or to staple an easily accessible pulmonary tear could obviate the need for a thoracotomy and its consequences for the patient. Again, as in all surgical operations, common sense and good judgment must prevail.

Retrospective analysis of the utility of video-assisted thoracic surgery in 100 consecutive procedures

One hundred consecutive video-assisted thoracic surgery (VATS) procedures, diagnostic (n = 54) and therapeutic (n = 46), in 90 patients over a 2-year period are reviewed. Hospital mortality was 2%. Conversion to formal thoracotomy was required in 3%, and re-exploration for bleeding in 1%. Seven patients required intensive care unit facilities postoperatively. The technique described was safe and there was minimal postoperative morbidity. Diagnostic VATS was of particular use in cases of indeterminate pulmonary masses (Sensitivity of 96%), anterior mediastinal masses and in immunocompromised patients. Video-assisted thoracic surgery may now be the treatment of choice for recurrent pneumothoraces and it demonstrated potential for development in a variety of other benign thoracic disorders. This method had a limited role in the management of empyaema with a 60% conversion rate to formal thoracotomy. Pulmonary resections were feasible but its role in the treatment of malignancy is questioned.

Video-assisted thoracic surgery: the approach of choice for selected diagnosis and therapy

Unconvinced of the benefits of video-assisted thoracic surgery (VATS) over conventional posterolateral thoracotomy (PLT) we undertook an evaluation of the VATS approach for various diagnostic and therapeutic intrathoracic procedures. For the 18 months ending December 31, 1992, 55 consecutive patients (28 males, 27 females, age 48 +/- 17 years) were eligible to undergo VATS for diagnosis and/or treatment of a variety of conditions. Thirty-eight were chosen for VATS and 17 for PLT. Three VATS patients were converted to PLT (7.9%). Thus 35 VATS patients formed our first experience with the minimally invasive approach. We observed operating time (OT), length of stay (LOS), days of postoperative narcotic use (DNA), achievement of diagnostic and/or therapeutic objectives and morbidity and mortality. For analysis of LOS and DNA due to the procedure alone patients were outliers if LOS was prolonged for reasons other than the procedure, pain or related complications. For estimation of anticipated LOS and DNA due to VATS, 9 of the 35 VATS patients were outliers. For the remaining 26, LOS was 4.9 +/- 2.5 days and DNA was 2.6 +/- 1.7 days after surgery. For the 35 VATS patients OT was 87 +/- 30 minutes. Complications after VATS were few and similar to those experienced after PLT. A diagnostic and/or therapeutic objective was achieved in all patients without mortality. We found that definitive procedures carried out with VATS require fewer hospital days and less postoperative analgesia than expected after similar procedures performed through standard PLT. Diagnostic and therapeutic objectives are easily attainable and complications are few. (ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic and therapeutic thoracoscopy: lessons from the learning curve

A variety of video-assisted thoracic operations are being reported with increasing frequency. Problems encountered during the development of this technology have received less attention. During the course of 27 months, 69 consecutive patients underwent minimally invasive procedures at our institution. Conversion to thoracotomy was required in 16 of 49 (33%) patients undergoing diagnostic procedures and 1 of 20 (5%) patients undergoing therapeutic interventions. Fewer complications occurred in those patients with diagnostic procedures (10 of 49, 20%) versus therapeutic interventions (10 of 20, 50%; p = 0.01). Logistic regression analysis showed chronic obstructive pulmonary disease to be an independent risk factor for complications. The mean postoperative stay was 7.9 +/- 6.8 days for diagnostic and 12.8 +/- 9.7 days for therapeutic interventions (p = 0.02). As new technologic improvements were introduced, the mean hospital stay decreased (first 10 months: 14.6 +/- 10.0 days, 10 to 20 months: 9.8 +/- 9.6 days, more than 20 months: 5.2 +/- 3.0 days, p < 0.004). The surgeon's thoracoscopic experience was not as strongly predictive (5 or fewer cases: 8.9 +/- 5.9 days, 6 to 15 cases: 13.1 +/- 12.6 days, more than 15 cases: 5.0 +/- 2.0 days). Although thoracoscopic surgery is promising, the potential for problems requires careful surgical judgment and expertise in dealing with thoracic complications.

Thoracoscopic instruments and ancillary equipment

Thoracoscopic instruments of today are rooted in surgical innovations which began over 100 years ago. The advent of modern video-optical equipment and endoscopic techniques has given birth to a wide array of new instruments and surgical uses. This process is still in full swing. An overview of the most important developments is given, and future lines of development are explored.

Anesthetic considerations for video-assisted thoracic surgery

VATS presents new challenges to the surgeon and anesthesiologist. Although simple diagnostic procedures on the pleura can be performed with local, regional, or general anesthesia with conventional ventilation, more complicated VATS requires general anesthesia with one-lung ventilation. Several techniques can be used to obtain one-lung anesthesia and should be tailored to the patient, proposed procedure, and comfort level of the anesthesiologist. The overall anesthetic management of these patients is similar to those having posterolateral thoracotomies and includes the ability of the anesthesiologist to react to rapid changes in the procedure as well as the overall condition of the patient.

Thoracic surgery: the irreversible evolution toward endoscopic surgery

Endoscopic techniques have established themselves as an important means for reducing the traumatic impact of thoracic surgery on the patient. They considerably lighten postoperative pain and are cosmetically much more pleasing. Procedures such as lung biopsy, pericardial window, treatment of spontaneous pneumothorax, mediastinal benign tumour excision and sympathectomy have become routine, other such as oesophagectomy require further evaluation. Advanced procedures such as lobectomy and pneumonectomy require further clinical and technological development prior to a conclusive assessment.

Development of a basic instrumentation for operative thoracoscopy

The basic instrumentation for operative thoracoscopy presented here comprises mechanical instruments used for dissection as well as HF instruments and flexible trocars. Their basic shapes and dimensions are adapted to the anatomy of the thorax. Separating the mechanical and optical elements permits a high degree of precision and safety in operations ranging from the thoracic wall, the mediastinum and the oesophagus to the lung.

Video-assisted thoracoscopic excision of intrathoracic masses in children: report of two cases

Video-assisted thoracoscopy was used to remove a bronchogenic cyst in a 6-year-old boy and a foregut duplication cyst in a 2-year-old girl. Access ports were placed along the site of a proposed thoracotomy incision and chest tube exit site. Thoracoscopic excision was uneventful, and each child left the hospital on the second postoperative day. Video-assisted thoracoscopy has a role in the evaluation and the definitive treatment of intrathoracic masses in children.