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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Thoracoscopic pulmonary surgery

and .

Klinik für Allgemein-, Thorax- und Gefäβchirurgie, Nordwest-Krankenhaus Sande, Germany

Thoracoscopy - first introduced into clinical medicine in 1912 by Jacobeus - was used extensively during the following decades in patients with suspected tuberculosis, but essentially remained a diagnostic tool. After the first description of a laparoscopic cholecystectomy by Dubois in 1989, however, minimal invasive surgery expended rapidly to the thoracic cavity and thoracoscopy evolved from a diagnostic to a therapeutic technique (1). The purported advantages of thoracoscopy over conventional thoracotomy are decreased postoperative impairment of pulmonary function, less postoperative pain, avoidance of postthoracotomy syndrome, shorter hospital stay, and earlier return to full activity. Therefore, the method has gained rapid acceptance not only with surgeons, but especially with patients. However, the exact place of thoracoscopic procedures in the surgical treatment of pulmonary disease often is not well defined and conclusive data showing its advantages over conventional surgical techniques are often missing. Nevertheless, certain indications have been generally accepted, others, still being questioned (table I).

Table I. Indications for thoracoscopic pulmonary surgery (modified from (2)).

Table I

Indications for thoracoscopic pulmonary surgery (modified from (2)).

Thoracoscopy is a technical method which competes with open thoracotomy. The main question to be answered in this chapter is: What is the evidence that thoracoscopy can accomplish the same as does open thoracotomy and is thoracoscopy or video-assisted thoracic surgery (VATS) superior to open thoracotomy in certain situations. Therefore, we will not discuss the pathophysiology, diagnosis and general treatment of the diseases in question, but concentrate on the place of thoracoscopy or VATS in the treatment of pulmonary disease.

The general surgical technique for thoracoscopic surgery is as follows. After the patient is intubated with a double lumen endotracheal tube he is placed in a lateral thoracotomy position and a standard laparoscope usually with a 30° angle optic is inserted through a 1 cm incision in the 6–8 interspace in the mid axillary line. The lung is then allowed to collapse and usually two additional ports are inserted for instrumentation depending on the location of the disease process. At the end of the procedure the chest tube is inserted and the lung is inflated under vision.

Thoracoscopic surgery is a safe procedure. The mortality rate is under 1% and the complication rate between 10% and 15%. The most common procedure specific complication is a prolonged air leak. Depending on the procedure performed the conversion rate to open thoracotomy ranges from 10% to 20% (3, 4, 5). There are very few studies assessing the functional differences after thoracoscopy compared to thoracotomy. In general it is stated that patients after thoracoscopy have less pain, less impairment of shoulder and pulmonary function than after open thoracotomy (6, 7). However, these results could not be confirmed in a prospective randomized study (8).

In the following the specific indications for thoracoscopic surgery will be discussed.

Trauma

The main indication for the therapeutic thoracoscopy in trauma is the evacuation of a clotted hemothorax. Aside from this the procedure can also be used to diagnose intrathoracic injuries. The early use of thoracoscopy in the treatment of hematothorax seems to be justified because it could be shown that it reduces the time of chest tube drainage, hospital stay as well as the hospital cost when compared to simple chest tube drainage (9).

Pleural empyema

Pleural empyema is classified in three phases: The exudative or acute phase, the fibropurulent or transitional phase and the organizing or chronic phase. The aims of surgical treatment are the evacuation of pus, control of infection, prevent entrapment of the lung and return pulmonary function to normal. In the fibropurulent phase this is achieved by thoracotomy and early decortication. Even though most reports about the use of thoracoscopy in the treatment of stage II empyema retrospective the results seem to be equivalent to thoracotomy and empyema recurs in less than 10% of the patients. There is also evidence that even in stage I thoraco-scopy results in a lower time of chest tube drainage and hospitalization as compared to treatment with a chest tube alone (11, 12).

Recurrent or persistant pneumothorax

Recurrent and persistant pneumothorax is considered an indication for the thoracoscopic approach. The recurrence rate is under 10% provided the parenchymal fistula can be identified and stapled (13). Stapling seems to be superior to other modalities of parenchyma closure (14). Waller (1994) in a prospective randomized study showed that the decrease of FEV1 72 hours after the procedure was significantly less with thoracoscopy as compared with open thoracotomy (15).

Pulmonary resection

Pulmonary wedge resection is a procedure easily performed by thoracoscopy. These applies for diffuse pulmonary disease as well as for the resection of peripheral pulmonary nodules. In large series the mortality is under 3%, and the complication rate around 5%. In early the thoracoscopic area laser resection has been tried, however, it has been shown that stapled resection is safer and quicker (16). It has also been shown that impairment of pulmonary function, postoperative pain and hospital stay is decreased after thoracoscopic wedge resection as compared to open wedge resection (17, 18). The sensitivity and specificity of wedge resection is the same regardless if performed by thoracoscopy or open thoracotomy. This applies to diffused pulmonary disease as well as pulmonary nodules (19, 20). These results have also been confirmed in a prospective randomized study (18). Video-assisted lobectomy, however, is still controversial in particular if it is performed for malignancy. It seems, however, that it can be performed safely with a low mortality and a complication rate. It is usually done for small malignant tumors without evidence of hilar or mediastinal lymph node enlargement (21).

Thoracoscopy in cancer patients

The value of thoracoscopy in the staging of pulmonary malignant disease is indisputed. This applies to the evaluation of malignant pleural effusion as well as to their treatment (22). In addition, thoracoscopy has to be shown of value in the evaluation of mediastinal lymph nodes which cannot be reached by mediastinoscopy (23).

Wedge resections for metastases has also been done with a five years survival of 50% and a local recurrence rate of around 20%. However, the number of patients who have been observed a long term is still small (24).

Parenchyma saving surgery for primary lung cancer in patients with poor pulmonary reserve be it by wedge resection or formal lobectomy has not gained wide acceptance. This relates to two problems. Firstly, there is a small, but definite incidence of dissemination of tumor cells through thoracoscopic surgery (25). Secondly, in 26% of all patients with T1 carcinomas lymphnode metastases are present (26). In addition, long term studies about the outcome of patients with primary pulmonary carcinomas operated by the thoracoscopic approach are still missing. One retrospective analysis of thoracoscopic limited resection for patients with T1 carcinomas showed a two year survival of 80% and a five year survival of 31% (27). On the other hand, a systematic lymph adenectomy of mediastinal nodes seems to be possible (28).

Surgical treatment of pulmonary emphysema

Thoracoscopic surgery has also been applied to the treatment of pulmonary emphysema in the form of the resection of bullae or unilateral or bilateral volume reduction. As with other pulmonary resections it has been shown in prospective randomized studies that the stapled resection is safer than the use of a laser (29). Both procedures, the resection of bullae as well as the volume reduction in diffused pulmonary emphysema, seem to be possible with a similar mortality and complication rate as with an open approach (30). There is controversy if the improvement after unilateral volume reduction is sufficient to warrant this procedure (31, 32). All procedures can be performed with a mortality from 0 – 10%. They result in an improvement of FEV1 between 16 and 40% and in an improvement in exercise tolerance of roughly 30% (33).

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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6960

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