Technical aspects of curved instruments and flexible cannulae

This paper deals with the technological aspects of the design of curved instruments for endoscopic surgery. Straight and rigid instruments in combination with the fixed trocar site have the disadvantage of limiting the freedom of surgical manoeuvres, especially in thoracic procedures. Curved or articulated shafts increase the space accessible to these instruments and facilitate surgery. However, they require not only a flexible cannula for their insertion but also additional training on the part of the surgeon. The design and production of such instruments requires considerable care in order to ensure their durability and reliability.

[Surgical treatment of tuberculous abscess in chest wall]

A case of chest wall tuberculosis with empyema is reported. A 45-year-old woman with a history of right lung pleuritis was admitted to our hospital with right shoulder pain. The chest X-ray film showed abnormal shadow in the right lower lung field. Chest CT revealed right posterior chest wall abscess and localized empyema. Bacterial examination of the chest wall abscess obtained by needle aspiration biopsy disclosed positive acid-fast bacilli. Three months after starting antituberculous therapy with INH, RFP and SM, the chest wall abscess had been increased and abscess drainage was performed. After two months of tube drainage, the abscess was diminished in size and enucleation with primary closure was performed. Antituberculous chemotherapy was continued. One year after surgery, no sign of recurrence was observed and the residual empyema was decreased.

Thoracoscopic surgery: the Belgian experience

Despite the already wide experience with video-assisted techniques in laparoscopic surgery, video-assisted thoracic surgery only recently came to be developed. This is clearly seen in a survey reflecting the experience among Belgian surgeons. A majority of the surgeons (63%) had limited experience (1 to 5 interventions), and only 28.5% had fairly considerable (between 11 and 20 interventions) or considerable (more than 20 interventions) experience. The majority of interventions performed were the treatment of pneumothorax, lung biopsies, wedge resections, and intrathoracic staging procedures, accounting for 209 (70%) of the 296 interventions collected in this survey. The remaining interventions display a wide variety of different thoracic procedures including lobectomy (4) and esophagectomy (20) for carcinoma. The overall technical success rate was 91% in this survey. Our own experience with 71 interventions or attempts reflects the same evolution with an overall technical success rate in 85% (60 patients). Pneumothorax was the most frequently performed intervention (35 patients), with a technical success rate of 94.5% (32 patients). Recurrences requiring further treatment occurred in 5 of the 32 patients (14.3%). All recurrences occurred before endostaplers were available, after which there were no failures in 12 consecutive cases. Other procedures successfully performed were lung biopsy/wedge resection (6), lung cancer staging procedures (3), lobectomy (1), hemothorax (3), chest wall neurinoma (2), sympathectomy (5), dorsal mediastinal neurinoma (1), thymectomy (1), esophagectomy (3), benign esophageal tumor enucleation (2), and Belsey Mark IV antireflux procedure (1). Furthermore, special emphasis was given to the development of video-assisted mediastinoscopy, which greatly facilitates teaching and interpreting this operation. Endoscopic myotomy using endostaplers was performed in 2 patients with Zenker's diverticulum. From our experience, however, it becomes clear that thoracoscopic approaches do not always result in a distinct benefit for the patient, as these procedures are more time consuming and usually require one-lung ventilation (probably the cause of the only fatal outcome in this series: a lung biopsy in an 85-year-old patient). In conclusion, video-assisted thoracic and thoracoscopic surgery is a new surgical modality offering new perspectives. However, careful patient selection and the same expertise as in open procedures are essential in determining the final outcome of each procedure.

Thoracoscopic procedures in children

Although thoracoscopy was initially reported in 1910, the first specific report in children came in 1976. Over the past 15 years, reports from a small number of institutions have described experience with this technique. For the past 2 years, as pediatric surgeons have become involved with minimally invasive abdominal surgery, there has been renewed interest in the application of endoscopy for thoracic disorders in children, the most common indication for thoracoscopy is evaluation of mediastinal masses. Other common indications include evaluation of localized or diffuse pneumonia, management of pleural diseases such as refractory empyema, and management of recurrent pneumothorax, with either pleurodesis or excision of subpleural blebs.

Videothoracoscopic surgery

Although thoracoscopy has been used for diagnostic and minor therapeutic procedures for many years, there have been few reports of its use in performing major intrathoracic procedures which have traditionally required formal thoracotomy. We report our initial experience in this field. Fifty patients (M:F = 1.63:1, mean +/- SD age = 41.8 +/- 20.4 years, range = 14-80) underwent 54 endoscopic intrathoracic operations. The procedures carried out included wedge excision of solid pulmonary mass (10), pleurectomy (25), lung biopsy (14), and miscellaneous procedures (5). Under general anaesthesia a laparoscope attached to a video monitor was introduced into the chest. One or two additional stab incisions were made as needed for the introduction of standard surgical or endoscopic instruments and staplers. There were no deaths. One patient developed a second pneumothorax 7 days after endoscopic pleurectomy, necessitating open pleurodesis. All patients were discharged home between 2 and 11 days after surgery (mean +/- SD = 3.8 +/- 2.0 days). Endoscopic thoracic surgery is a safe and useful technique for certain cases. It merits further investigation and assessment.

[Thoracoscopic surgery: current indications]

Recent advances in the technologies for minimal invasive surgery have expanded the indications for thoracoscopic surgery. The thoracoscopic approach is for various operations, including pleurectomy, decortication, pulmonary wedge resection, pericardial window, the approach of first choice. Other operations such as resection of tumors in the mediastinum or thoracic wall, lobectomies or others, can often be performed by thoracoscopy. Indications and technical details are described.

Radiology, surgery, and the pediatric chest

Preoperative imaging of the tracheobronchial tree should focus on identifying the location, severity, and extent of tracheal narrowing, as well as possible causes of extrinsic compression. Plain film radiography and esophagography can be supplemented with CT or MR imaging for the evaluation of mediastinal masses or vascular abnormalities impinging on the airway. Surgical planning for the removal of intrathoracic tumors or cysts requires a detailed evaluation of the location and extent of the lesion, identification of encasement or compression of vital structures, and intraspinal extension to determine resectability and the need for neurosurgical consultation. Precise preoperative histologic diagnosis in most patients is not essential for surgical planning. Although the anatomic information provided by CT and MR imaging is comparable, MR offers the advantage of multiple imaging planes and allows the identification of intraspinal involvement of posterior mediastinal tumors or neuroenteric cysts without the use of intrathecal contrast agents. Conversely, MR imaging has little role in the assessment of pulmonary parenchymal abnormalities. These are best imaged with radiography and CT. Plain film radiography and contrast esophagography are often sufficient for the identification and delineation of postoperative complications in the chest. Complex air or fluid collections, however, may require further study with CT or ultrasonography for better characterization.

Thoracic complications of deeply situated serous neck infections

Nine cases of complicated deep neck infections, occurring during a period of twelve years are presented. Complications observed were cervico-thoracic necrotizing fasciitis in 3 cases, purulent pleural effusion in 6 cases, pericardial effusion in 2, mediastinitis in 8 cases, jugular vein thrombosis and rupture of the innominate artery in one case each. Although 2 cases were managed initially with blind endotracheal intubation, all cases finally required tracheostomy. A cervico-mediastinal approach was useful for the early mediastinal involvement. Two patients died because of inadequacy of the multiple surgical procedures resulting in persistent infection and multi-organ failure and one because of uncontrollable bleeding after innominate artery rupture.

[Inflammation of the anterior chest wall: its assessment by magnetic resonance]

Magnetic resonance (MR) is the imaging method used to assess primary and secondary inflammatory lesions of the chest wall. Five patients with inflammatory lesions of the anterior chest wall were submitted to MR examinations in order to define the role of this method in both identification and assessment of the extent of tissue involvement. In all the examined patients MR Imaging accurately showed the involved muscle groups and the presence/absence of mediastinitis. MR Imaging easily detected sternal and clavicular osteomyelitis; in one patient only MR failed to detect osteomyelitis of the first rib. The accurate assessment of soft tissue infections enabled us to select the most suitable surgical therapy to reduce esthetic damage. Two cases were restudied after chest wall reconstruction by means of rotated pectoral flaps. In the 2 patients in whom the differential diagnosis between inflammatory lesion and recurrent tumor could not be made by means of MR Imaging, CT-guided needle biopsy was performed.

[A case of chest wall abscess due to Salmonella newport]

A 18-year-old female with a history of precordial pain was admitted. There was a mass (3.5 x 2.5 cm) in the right inframammary region which was suspected to be chest wall tumor on the basis of CT scan and Ga scintigraphy findings. Exploratory surgery, consisting of total resection of the tumor without removing the ribs, was performed and revealed an abscess. Culture of pus from the abscess grew Salmonella newport (0 antigen 8, H antigen eh; 1.2). Focal infection with Salmonellosis is discussed. Surgical treatment is necessary in addition to chemotherapy.

[Intrathoracic meningocele. A case report and review of the literature]

In this article the Authors describe a case of intrathoracic meningocele. That was diagnosed in a young asymptomatic woman after surgical resection. After a complete and accurate review of the literature, the Authors underline the rarity of the find while they also note the association of this pathology with Von Recklinghausen's neurofibromatosis. They also discuss etiology and clinical diagnostic aspects as well. In conclusion the Authors insist that with new diagnostic imaging techniques available today it is possible to accurately diagnose this disease preoperatively in most patients. This fact along with improved therapeutic regimens makes surgical excision almost free from the complications that were at one time observed.

Preliminary experience with thoracoscopic surgery

Thoracoscopic surgery was accomplished in 12 patients utilizing thoracoscopic instruments and a stapler. Five patients were treated for recurrent, spontaneous pneumothoraces, for which blebectomies were done; three patients for pulmonary nodules, for which wedge resections were done; one patient for cryptogenic pleural effusion; one patient for debridement of an empyema cavity; one patient for traumatic bronchopleural fistula; and one patient with AIDS for interstitial lung disease. All patients were done under general anesthesia in the lateral decubitus position and were prepped and draped for a standard thoracotomy. They underwent endobronchial double-lumen ventilation so that the ipsilateral lung could be deflated to create a working space. In addition, insufflation of 4 to 5 mmHg was also used. Trocars were placed using a blunt technique. The mid-axillary trocar was at about the eight intercostal space and was used for the endoscope, and then additional trocars were placed, usually on the anterior axillary line and posterior axillary line at about the fifth intercostal space. If adhesions were encountered, the lung was grasped atraumatically with a clamp or retractor used to give counteraction, and the adhesions were lysed with shears or electrocautery. After a thorough exploration of the hemithorax involved, the area of pathology was grasped with the clamp, which was used for countertraction. Through a 12 mm trocar, a stapler was introduced and fired. This staples and also transects on a 3 cm length. Several firings were usually necessary to remove the pathology, which, if malignant, was placed in a retrieval bag.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous needle aspiration biopsy in intrathoracic lesions]

The authors report their experience of transthoracic needle biopsy of the lung based on 68 consecutive cases from 1984 to 1990. In 55 cases significant data has been found: in 44 cases the diagnosis was exact, instead in other 11 cases it was only indicative. The overall complications were 11.7% and in particular were as follow: pneumothorax in 5 cases, hemoptysis in 2 cases and a temporary Horner syndrome in one case. The authors conclude by confirming the utility of transthoracic needle biopsy of intrathoracic tumors in which there is not other way to obtain a diagnosis. This technique is reliable and its complications can be disregarded.

Reconstruction of the chest wall with e-PTFE following major resection

Nine patients underwent major chest wall resection at Thomas Jefferson University Hospital (Philadelphia, PA) over a 19-month period. Chest wall reconstruction was performed with an expanded polytetrafluoroethylene (e-PTFE) soft tissue patch (Gore-Tex) and vascularized flaps in all patients. The size of the skeletal defects ranged in area from 60 to 400 cm2. The primary indications for resection included chest wall sarcoma and radiation ulcer. Aggressive chest wall resection may be a patient's only opportunity for cure and an improved quality of life. In this series, chest wall resection was able to be performed with a low morbidity and no mortality. This study also demonstrates many of the advantages of e-PTFE as a chest wall substitute compared with other previously described prosthetic materials. The use of a Gore-Tex patch along with described flaps for soft tissue coverage provides good functional and aesthetic results.

Present role of thoracoscopy in the diagnosis and treatment of diseases of the chest

Since thoracoscopy was originally described in 1910, the application has been limited mainly to the diagnosis and treatment of pleural disease. Recent advancements in endoscopic equipment and refinement of surgical techniques have expanded the application of this procedure. Using video thoracoscopic techniques in 70 patients over the past 9 months, we have been able to perform a variety of procedures previously accomplished by "open" techniques. These procedures include (1) wedge resections of pulmonary nodules in 21 patients, using endoscopic mechanical stapling devices; (2) excision of the pericardium and drainage of the pericardial space in 6 patients; (3) dorsal thoracic sympathectomy in 6 patients; (4) apical blebectomy and pleurodesis in 6 patients; (5) lung biopsies for diagnosis of diffuse lung disease in 5 patients. Additional procedures performed include biopsy of hilar masses (3), biopsy of esophageal mass, excision of a mediastinal cyst, and the drainage of a spinal abscess. The remaining 20 procedures were performed for the diagnosis and treatment of pleural disease. There was no mortality associated with the procedure and morbidity was lessened, compared with standard thoracotomy procedures. The postoperative hospital stay after elective procedures performed in well patients averaged 3 days and was often as short as 1 day. Our experience indicates a markedly expanded role for thoracoscopy in the diagnosis and treatment of thoracic diseases with less postoperative morbidity.

[Selective control of blood supply to part of thoracic wall before resecting intrathoracic lesions with adhesions rich in systemic bypass]

Five patients with intrathoracic lesions with dense adhesions containing rich systemic-pulmonary were treated with selective control of blood supply to part of thoracic wall. Four of five patients were followed up for more than five years and were found excellent in health. Operative method and high lights were described. During the operation, this method for the prevention or control of severe bleeding was proved to be useful in above mentioned cases.

Extrusion of peritoneal catheter through a thoracic skin fistula: report of a rare complication of ventriculoperitoneal shunt

A very rare complication of ventriculoperitoneal shunt is presented. The tip of the distal catheter extruded through a skin fistula in the right subclavian region. After the replacement of a new catheter in the peritoneal cavity, inflammation of the overlying scar occurred. Then, a ventriculoatrial shunt was carried out. The authors suggest a possible mechanism of this complication.