Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients

Nonintubated Needlescopic Thoracic Sympathectomy for Primary Palmar Hyperhidrosis: A Randomized Controlled Trial

BACKGROUND

Conventional endoscopic thoracic sympathectomy (ETS) is usually performed with 5-mm thoracoscope under general anesthesia with endotracheal intubation. Needlescopic thoracic sympathectomy under total intravenous anesthesia without intubation has rarely been attempted. This randomized controlled trial assesses the feasibility and safety of this minimally invasive therapeutic procedure in managing primary palmar hyperhidrosis.

METHODS

From July 2012 to July 2014, 221 patients with severe primary palmar hyperhidrosis underwent bilateral ETS and were randomly allocated to group A or group B. Patients in group A (n=108) underwent nonintubated ETS using a needle endoscope, whereas those in group B (n=113) underwent traditional transaxillary single-port ETS using a 5-mm thoracoscope.

RESULTS

ETS was successfully performed in all patients. The palms of all patients became dry and warm immediately after surgery. The mean resuscitation time was significantly shorter in nonintubated patients than in intubated patients (P<0.01). Postoperative sore throat occurred in 37 patients in group B, whereas none of the patients in group A complained about sore throat after surgery (P<0.01). The mean incision length was 5.1±0.1 mm with needle endoscope and 11.0±0.8 mm with traditional thoracoscope (P<0.01). The mean postoperative pain score was 1.1±0.8 in group A and 3.2±0.8 in group B (P<0.01). The mean cost of anesthesia was considerably lower in nonintubated patients than in intubated patients (P<0.01). Follow-up was 100% completed. The mean cosmetic scores were higher in group A than in group B (P<0.01). Residual pain occurred in 2 patients in group A and in 18 patients in group B (P<0.01).

CONCLUSIONS

Nonintubated needlescopic thoracic sympathectomy is a safe, effective, and minimally invasive therapeutic procedure, which has the advantages of a smaller incision with less pain, shorter resuscitation time, and better cosmetic results.

Transumbilical thoracic sympathectomy: a single-centre experience of 148 cases with up to 4 years of follow-up†

OBJECTIVES

Thoracic sympathectomy is considered as the most effective method to treat palmar hyperhidrosis (PH). Here, we report our experience of transumbilical thoracic sympathectomy with an ultrathin flexible endoscope for PH in a series of 148 patients with up to 4 years of follow-up.

METHODS

A prospective database was used in this retrospective analysis of 148 patients (61 males, 87 females, with a mean age of 21.3 years) with PH who were operated on by the same surgeon in a single institution from April 2010 to March 2014. All procedures were performed under general anaesthesia involving intubation with a double-lumen endotracheal tube. Demographic, postoperative and long-term data of patients were recorded and statistical analyses were performed. All patients were followed up at least 6 months post procedure through clinic visits or telephone/e-mail interviews.

RESULTS

The procedure was performed successfully in 148 of the 150 patients. Two patients had to be converted to conventional thoracoscopic procedure because of severe pleural adhesions. The mean operating time was 43 min (ranging from 39 to 107 min) and the mean postoperative length of stay was 1 day (range 1-4 days). All patients were interviewed 6-48 months after surgery and no diaphragmatic hernia or syndrome was observed. The rate of resolution of PH and axillary hyperhidrosis was 98 and 74.6%, respectively. Compensatory sweating was reported in 22.3% of patients. Almost all of the patients were satisfied with the surgical results and the cosmetic outcome of the incision.

CONCLUSIONS

This preliminary human experience suggested that transumbilical thoracic sympathectomy was a safe and efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paraesthesia that are associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits.

Recent advances in natural orifice transluminal endoscopic surgery†

Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.

Nonintubated Transareolar Endoscopic Thoracic Sympathectomy with a Flexible Endoscope: Experience of 58 Cases

OBJECTIVE

Natural orifice transluminal endoscopic surgery (NOTES) has recently become a hot spot in the field of minimally invasive surgery. But, most of the procedures are still in the early stages of development and limited to animal experiments. Transareolar endoscopic surgery could work as a viable intermediate step before thoracic NOTES. Under intravenous anesthesia without endotracheal intubation, transareolar endoscopic thoracic sympathectomy (ETS) with a flexible endoscope has rarely been attempted. The objective of this study is to evaluate the feasibility and safety of this novel minimally invasive technique in managing primary palmar hyperhidrosis (PPH).

METHODS

From June 2012 to July 2014, a total of 58 male patients with severe PPH underwent transareolar ETS by use of a flexible endoscope. Under intravenous anesthesia without endotracheal intubation, a flexible endoscope was introduced through the incision on the edge of the areola into the thoracic cavity. The thoracic sympathetic chain was ablated at the level of the fourth rib.

RESULTS

All procedures were successfully performed with a mean operating time of 33.6 ± 8.3 min. All patients regained consciousness rapidly and none of them complained about sore throat after surgery. There were no operative mortality and conversion to open procedure. The symptoms of all patients disappeared as soon as the sympathetic chain was cut off. Fifty six patients (96.6%) were discharged from the hospital on the first postoperative day. The postoperative complications were minor, and no patients developed Horner's syndrome. At 3 months postoperatively, there was no obvious surgical scar on the chest wall, and none of the patients complained about postoperative pain. Compensatory hyperhidrosis (CH) appeared in 19 patients. No recurrent symptoms were observed in our study. One year follow-up revealed an excellent cosmetic result and degree of satisfaction.

CONCLUSION

Nonintubated transareolar ETS with a flexible endoscope is a safe, effective and minimally invasive therapeutic procedure, which has the possible advantages of thoracic NOTES and can be performed in routine clinical practice for male PPH patients.

Hemodynamic and inflammatory responses following transumbilical and transthoracic lung wedge resection in a live canine model

BACKGROUND

Single-port transumbilical surgery is a well-established platform for minimally invasive abdominal surgery. The aim of this study was to compare the hemodynamics and inflammatory response of a novel transumbilical technique with that of a conventional transthoracic technique in thoracic exploration and lung resection in a canine model.

METHODS

Sixteen dogs were randomly assigned to undergo transumbilical thoracoscopy (n = 8) or standard thoracoscopy (n = 8). Animals in the umbilical group received lung resection via a 3-cm transumbilical incision in combination with a 2.5-cm transdiaphragmatic incision. Animals in the standard thoracoscopy group underwent lung resection via a 3-cm thoracic incision. Hemodynamic parameters (e.g., mean arterial pressure, heart rate, cardiac index, systemic vascular resistance, and global end-diastolic volume index) and inflammatory parameters (e.g., neutrophil count, neutrophil 2',7' -dichlorohydrofluorescein [DCFH] expression, monocyte count, monocyte inducible nitric oxide synthase expression, total lymphocyte count, CD4+ and CD8+ lymphocyte counts, the CD4+/CD8+ratio, plasma Creactive protein level, interleukin-6 level) were evaluated before surgery, during the operation, and on postoperative days 1, 3, 7, and 14.

RESULTS

Lung resections were successfully performed in all 16 animals. There were 2 surgery-related mortality complications (1 animal in each group). In the transumbilical group, 1 death was caused by early extubation before the animal fully recovered from the anesthesia. In the thoracoscopic group, 1 death was caused by respiratory distress and the complication of sepsis at 5 days after surgery. There was no significant difference between the two techniques with regard to the hemodynamic and immunologic impact of the surgeries.

CONCLUSION

This study suggests that the hemodynamic and inflammatory changes with endoscopic lung resection performed by the transumbilical approach are comparable to those after using the conventional transthoracic approach. This information is novel and relevant for surgeons interested in developing new surgical techniques in minimally invasive surgery.

Transumbilical Thoracoscopy Versus Conventional Thoracoscopy for Lung Wedge Resection: Safety and Efficacy in a Live Canine Model

PURPOSE

Transumbilical single-port surgery has been associated with less postoperative pain and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. This study compares the safety and efficacy of transumbilical thoracoscopy and conventional thoracoscopy for lung wedge resection.

METHODS

The animals (n = 16) were randomly assigned to the transumbilical thoracoscopic approach group (n = 8) or conventional thoracoscopic approach group (n = 8). Transumbilical lung resection was performed via an umbilical incision and a diaphragmatic incision. In the conventional thoracoscopic group, lung resection was completed through a thoracic incision. For both procedures, we compared the surgical outcomes, for example, operating time and operative complications; physiologic parameters, for example, respiratory rate and body temperature; inflammatory parameters, for example, white blood cell count; and pulmonary parameters, for example, arterial blood gas levels. The animals were euthanized 2 weeks after the surgery for gross and histologic evaluations.

RESULTS

The lung wedge resection was successfully performed in all animals. There was no significant difference in the mean operating times or complications between the transumbilical and the conventional thoracoscopic approach groups. With regard to the physiologic impact of the surgeries, the transumbilical approach was associated with significant elevations in body temperature on postoperative day 1, when compared with the standard thoracoscopic approach.

CONCLUSIONS

This study suggests that both approaches for performing lung wedge resection were comparable in efficacy and postoperative complications.

Feasibility of transumbilical anatomic pulmonary lobectomy in a canine model

PURPOSE

Transthoracic thoracoscopic lobectomy is the preferred method of surgical treatment for early lung cancer. Current methods require a transthoracic approach and are associated with chronic postoperative pain in up to 25% of patients. Single-port transumbilical uniport surgery may offer advantages over multiport surgery with less postoperative pain and better cosmetic results. The aim of this study was to evaluate the feasibility of a transumbilical anatomic lobectomy of the lung (TUAL) in a canine model.

METHODS

TUAL was performed in 12 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. Variables evaluated for surgical outcomes were operating time, operative complications, body rectal temperature, respiratory rate, white blood cell count, and arterial blood gases.

RESULTS

TUAL was successfully completed in ten animals. There were six bleeding complications related to surgery. In four animals, an avulsion of pulmonary vessel causes intraoperative bleeding, requiring simultaneous pulmonary artery and bronchus resections. In one animal, slipping of endoclip after vessel clipping caused perioperative bleeding. The other animal encountered bleeding complication during dissection of inferior pulmonary vein. Both animals required conventional thoracotomy to complete the surgery.

CONCLUSIONS

TUAL in the canine model is feasible but associated with significant morbidity. With further development and refinement of instruments, comparative studies between the novel transumbilical lobectomy and the current video-assisted transthoracic lobectomy will clarify the role of transumbilical lobectomy in thoracic surgery.