Video-Assisted Thoracic Surgery Current State of the Art

Transcription

1 ANNALS OF SURGERY Vol. 220, No. 6, J. B. Lippincott Company Video-Assisted Thoracic Surgery Current State of the Art Larry R. Kaiser, M.D. From the Department of General Thoracic Surgery, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania Objective The author reviews the current state of the art of video-assisted thoracic surgery in the context of modern thoracic surgical practice. Summary Background Data Thoracoscopy has been a part of thoracic surgical practice for many years, but was used mainly for diagnosis of pleural disease. The development of laparoscopic cholecystectomy awakened a new interest in this technique and led to the development of many new therapeutic and diagnostic applications of video-assisted thoracic surgery. Methods Current literature and the author's personal experience with more than 500 cases are reviewed. Results Video-assisted techniques have proven useful for the performance of a broad spectrum of thoracic surgical procedures. Patients may experience less pain and have a shorter hospital stay after a video-assisted procedure. Definitive proof of less morbidity when compared with the analagous open procedure remains to be determined. Patient acceptance has been high, and most thoracic surgeons use these techniques in their practice. Conclusions Video-assisted thoracic surgical procedures have made a significant impact on the practice of thoracic surgery. Advantages and disadvantages of specific procedures remain to be definitively determined. Surgeons have learned these techniques and have kept morbidity to acceptance levels during the learning phase. Where these techniques ultimately fit into the overall practice remains to be determined as more experience is gained. The development of video thoracoscopy or video-assisted thoracic surgery (VATS) potentially represents the most significant development in general thoracic surgery in the past 20 years. These procedures stand to benefit thou- Address reprint requests to Larry R. Kaiser, M.D., Hospital ofthe University of Pennsylvania, 3400 Spruce St., 4 Silverstein, Philadelphia, PA Accepted for publication May 18, sands ofpatients every year, resulting in less morbidity and potentially shorter hospital stays than the analagous open procedure. In the span of 3 years, VATS has been widely accepted, and these procedures currently constitute a significant portion ofthe practice of many thoracic surgeons. In this review I will detail the current practice of VATS, including results and early experience with complications and problems associated with these procedures. In 1910, Hans Christian Jacobaeus, a Swedish physician, theorized that a cystoscope could be placed into

2 Vol No. 6.. ; e iir"" A.I. I Figure 1. Professor H. C. Jacobaeus pictured with Dr. Edward Churchill during a 1937 visit to the Massachusetts General Hospital. Churchill had previously visited Jacobaeus in Sweden where he had seen thoracoscopy being performed to lyse tuberculous adhesions (photo from the author's collection). the thoracic cavity to aid in the diagnosis and treatment of pulmonary tuberculosis, an extremely common disease at the time and one that defied most efforts at treatment.' (Fig. 1) Subsequently, he reported success in endoscopically lysing pleural adhesions under local anesthesia as an adjunct to collapse therapy.2 Of even greater significance was his report on the use of thoracoscopy to localize and diagnose benign and malignant lesions of the pleura and pulmonary parenchyma.3 Jacobaeus' work was known in the United States, and thoracoscopic procedures were performed, but the techniques were never embraced. In one of the earliest textbooks of thoracic surgery, Lilienthal discussed the endoscopic technique of Jacobaeus, but warned against its routine use in tuberculosis because of fear of bleeding and the risk of spreading infection to the pleural space.4 Over the years thoracoscopy evolved mainly as "pleuroscopy", used by some thoracic surgeons as an adjunct Video-Assisted Thoracic Surgery 721 to other procedures in the diagnosis of pleural pathology, specifically in cases of an effusion of unknown etiology, where pleural fluid cytology was negative and a closed pleural biopsy was nondiagnostic. In many ofthese cases, the presence of malignancy could be proven at the time of pleuroscopic examination. A number ofinstruments have been employed, including rigid bronchoscopes, mediastinoscopes, flexible bronchoscopes, and specialized rigid fiberoptic thoracoscopes. A mediastinoscope offers a large working channel and excellent visualization ofthe pleural space; effusions may be drained, biopsies can be taken, and pleural symphysis can be effected.5 The procedure was used mainly for diagnostic purposes and, other than pleurodesis, offered little in the way of therapeutic possibilities. The occasional biopsy of lung parenchyma could be performed, but this was unusual. Several papers summarize the state of the art of thoracoscopy before the current era of video thoracoscopy.6'7 The development ofthe charged coupling device, a silicon chip that is light sensitive, led to the sufficient miniaturization of a video camera. When attached to a fiberoptic telescope, this is of a size practical for use in the operating room and produces a well-defined, magnified image on a video monitor that allows the operating surgeon to work with an assistant. Previously, the surgeon had to hold the thoracoscope, and only he was able to look into it while working, which did not allow for the aid of an assistant and thus, limited the complexity of the procedure. The videothoracoscope frees up the surgeon's hands, allowing for the performance of significantly more complex procedures that may be aided by the use of one or more assistants working in concert with the surgeon. The power ofthis technology had been demonstrated amply by the rapid, almost meteoric rise oflaparoscopic cholecystectomy, a procedure that literally changed the specialty of general surgery in a remarkably short period of time. The extension of laparoscopic techniques to a variety of other general surgical procedures is further proof that minimally invasive procedures are here to stay; however, it remains to be defined which procedures actually result in less morbidity. Issues of cost effectiveness also remain to be determined. With these developments occurring in general surgery, it was not long before thoracic surgeons began to adapt this new technology for work in the chest, despite the fact that thoracoscopy had never been a mainstay ofthe practice of most thoracic surgeons. In fact, the initial efforts at video-assisted thoracoscopic surgery mimicked almost exactly what was being done in the abdomen, including the use of the same instruments and insufflation of carbon dioxide. CURRENT TECHNIQUES The bony thorax, unlike the abdomen, provides its own fixed space once the lung is collapsed so insufflation,

3 722 Kaiser used in the abdomen to create a space, is unnecessary and potentially dangerous. The space in the chest is created simply by placing a double-lumen endobronchial tube and ventilating only the lung opposite to the side of the operative procedure. This requires a general anesthetic, but less complex procedures, namely those involving the parietal pleura, can be performed readily using regional anesthesia and intravenous sedation because the lung collapses quite nicely in the spontaneously breathing patient once the negative intrathoracic pressure is lost when the pleural space is exposed to atmospheric pressure.8 In general, VATS procedures have been performed mainly by surgeons in an operating room setting, but an experienced operator may perform certain procedures in an endoscopy suite using regional anesthesia techniques, a fact that has not been lost on our medical pulmonology colleagues. Experience of the operator is the key to performing these procedures safely, and despite an interest on the part of many pulmonologists, it will not be easy for them to acquire the necessary experience, although many are engaged in an attempt. The essential technique itself is not difficult, but the judgment involved in making certain decisions that relate to various technical aspects comes only with experience. Whether these procedures should be performed by anyone who is not competent to perform the identical open procedure is a matter of serious concern. Technical Aspects of Video Thoracoscopy The patient is placed on the operating table in the lateral decubitus position, and the chest is prepared and draped as for a thoracotomy. Incision placement depends somewhat on the procedure to be performed, but we attempt to be consistent in the placement of our initial incision, through which we insert the video telescope. This initial incision is located along an imaginary line drawn longitudinally upward from the anterior superior iliac spine in approximately the seventh or eighth intercostal space. A 1-cm transverse skin incision is made and carried down to the intercostal muscles as ifone were inserting a chest tube; indeed, it is through this incision that the chest tube is placed at the conclusion of the operative procedure. The entry into the chest is made with the index finger to define the space with the greatest degree of safety. Occasionally, the lung is adherent to the chest wall, and these adhesions often may be bluntly taken down with the index finger, allowing for placement of a trocar sheath. Additional incisions are made as needed in a triangular configuration, an arrangement that facilitates instrument placement and allows one to work in coordination with an assistant. (Fig. 2) Care is taken to place these incisions far enough apart so the in- \' ' s > -' 1' o''- S ~~~~~~~~~~~~~~~~~~~~~~~~~ : Ann. Surg. * December 1994 V Figure 2. Triangular configuration for placement of incisions useful for the majority of video-assisted procedures. The inferior incision, used for telescope placement, becomes the site for chest tube insertions at the conclusion of the procedure. The other two incisions are placed along the line of a proposed thoracotomy incision should it become necessary to convert to an open procedure. struments do not "fight" with one another. The additional incisions are placed along a line of a proposed thoracotomy incision so if a thoracotomy is required, the incisions simply are joined. It is most convenient to work with two video monitors, one on each side, at the head of the table, so that both the operator and the assistant may have an unobstructed view. As long as one maintains the area of interest between oneself and the video monitor, the image is as it seems, i.e., forward is forward, backward is backward, etc. Instrumentation for VATS has been slowly improving; initially, instruments designed for laparoscopy were used, but were notoriously poor, especially for grasping lung parenchyma which, under the best of circumstances, has a tendency to tear when grasped over a small surface area. By modifying standard chest instruments, particularly ring forceps, which are able to grasp the lung in an atraumatic fashion, we developed a series of instruments specifically for thoracoscopic procedures (Kaiser-Pilling Thoracoscopy Instruments, Pilling-Rusch Co., Fort Washington, PA) (Fig. 3) The longer length and various... <.. };... }. S; }......~~~~~~~~~~~~.... Figure 3. Set of instruments used without cannulas and placed directly through small incisions as seen in Fig. 2. These instruments (Kaiser-Pilling, Pilling Weck Co., Fort Washington, PA) are longer and curved specifically for use in the chest, features that make the exact location of incision placement less important.

4 Vol No. 6 Video-Assisted Thoracic Surgery 723 Table 1. CURRENT INDICATIONS FOR VATS Indications generally accepted Diagnostic Lung biopsy in nonventilator-dependent patients Biopsy of pleural disease Biopsy of mediastinal mass Staging of lymph nodes of the aortopulmonary window Excision of an indeterminate pulmonary nodule Therapeutic Sclerosis of the pleural space for metastatic malignancy (following failure of tube placement and sclerosis) Excision of benign pleural lesions Excision of benign lung tumors Sympathectomy for hyperhidrosis and upper extremity pain syndromes Stapling of blebs for pneumothorax Indications not yet generally accepted, but commonly performed Excision of mediastinal tumors (i.e., thymoma, posterior mediastinal masses) Pericardial biopsy or fenestration Wedge excision of Ti lung cancer as definitive treatment in patients with poor pulmonary reserve Excision of bullous lung disease Indications not yet generally accepted and uncommonly performed Video-assisted lobectomy Esophageal myotomy Excision of esophageal leiomyoma Ligation of thoracic duct for chylothorax Staging lymph nodes in esophageal cancer curves of these instruments allows for access to any part of the hemithorax and makes the exact site of incision placement less important; in fact, the incisions may be placed in standard locations for most indications, with exceptions mainly for procedures in the anterior or posterior mediastinum. The most significant advance in instrumentation leading to the tremendous growth of VATS procedures was the development of an endoscopic linear stapler which simultaneously cuts while laying down parallel rows of staples which are both hemostatic and aerostatic. (EndoGIA, U.S. Surgical Corporation, Norwalk, CT) This instrument, more than any other, propelled thoracoscopy from an occasionally used diagnostic procedure into the therapeutic realm of video-assisted thoracic surgery, a term that encompasses an entire spectrum of procedures. The currently recognized indications for VATS are summarized in Table 1. Contraindications for VATS are few and include the inability to tolerate onelung ventilation and pleural symphysis with adhesions dense enough to preclude entry into the chest. Specific Procedures Pleural Disease Closed pleural biopsy has become a lost art and perhaps it should be with the emergence of VATS tech- Figure 4. Diffuse pleural malignant disease seen on both the visceral and the parietal pleural surface. niques that allow one to perform biopsies on specific areas of the pleura under direct vision (Fig. 4) Most indications for VATS in the management of pleural disease arise from the presence of the undiagnosed pleural effusion, where fluid cytology is negative. However, the use ofvats for other types ofpleural pathology is becoming more frequent. In the past, a patient with an empyema often was forced to undergo a formal decortication to permit lung re-expansion, especially when the peel had organized. Using VATS techniques, many of these patients now are able to avoid thoracotomy, especially if they are seen relatively early in the course of the empyema. Video-assisted debridement and decortication is indicated in the febrile patient with a pleural effusion in whom complete drainage cannot be effected via tube thoracostomy, and we encourage early referral of these patients. When one sees the fibrinous material that is present, it is obvious why tube thoracostomy drainage only incompletely evacuates the chest (Fig. 5). Likewise, videothoracoscopic techniques have proven useful in the management of the organized post-traumatic hemothorax where, again, a chest tube is unable to drain completely the organized clot and debris. The occasional pleural-based neoplasm may be sampled and, at times, resected using a VATS procedure. Benign pleural tumors, specifically solitary fibrous tumors (formerly called benign mesotheliomas), which usually arise from the visceral pleural surface are ideal lesions for VATS resection if recognized before they reach massive size. Video-assisted thoracic surgery also has increased our ability to successfully treat malignant pleural effusions, especially ones with multiple loculated collections. When tube thoracostomy results in incomplete drainage

5 724 Kaiser Figure 5. The organized fibrinous exudate associated with an early empyema being debrided off the visceral pleural surface. This material would not be expected to be drained via tube thoracostomy. or the patient has failed one attempt at chest tube pleurodesis, we proceed to VATS pleurodesis. To accomplish this, the chest is evacuated completely under direct vision, usually achieved through one incision, and powdered talc, which causes a significant inflammatory pleuritis and subsequent pleural symphysis, is insufflated. This may be performed under local anesthesia. Hartman and colleagues, at the University ofindiana, in a nonrandomized trial, compared a group of patients with malignant effusions who had thoracoscopic insufflation oftalc with a group who had undergone tube thoracostomy and sclerosis with either tetracycline or bleomycin.9 In this study, thoracoscopic talc pleurodesis was performed by chest physicians in an endoscopy suite using local anesthesia supplemented with intravenous sedation. For patients undergoing talc pleurodesis, there was a 97% rate of successful pleurodesis at 30 days and 95% at 90 days. This is significantly better than results seen in the tube thoracostomy group, where successful pleurodesis was achieved in only 33% at 30 days and 47% at 90 days. The use of bleomycin as the sclerosing agent improved these results slightly. Patients sclerosed with talc seemed to have less pain after the procedure, but documentation of lessened morbidity from this procedure awaits completion of a prospective, randomized trial. The ability to perform thoracoscopic talc pleurodesis under local anesthesia makes the technique attractive for the majority of patients with malignant effusions, especially ifthese early data are reproduced in subsequent studies. We have performed 113 videothoracoscopic procedures for pleural disease during an 18-month period. The majority of these (36) were carried out for malignant effusions, which were drained, and pleurodesis was accomplished with talc, a procedure that was successful in Ann. Surg. * December 1994 all but two patients. Twenty-four patients had the procedure performed to obtain pleural biopsies with diagnoses being made in all cases, whereas an additional 24 patients underwent thoracoscopic decortication. Of the remaining patients, 12 underwent excision or biopsy of a discrete pleural mass, 9 had evacuation ofa hemothorax, and 8 underwent exploration only. Video-assisted thoracic surgery techniques have expanded and improved our ability to efficiently manage the group of patients with pleural pathology, and it is in this group that our pulmonology colleagues seek to stake a claim. Parenchymal Disease The broad category of lung parenchymal pathology encompasses an area in which we feel that VATS techniques have made, and will continue to make, significant inroads, specifically with regard to patient comfort and potential outcome. One must distinguish between diagnostic and therapeutic procedures when we consider VATS procedures in this group ofpatients. Patients with either a diffuse or localized interstitial process comprise the group in whom VATS may play a significant role in establishing a diagnosis. Before the advent of VATS, many of these patients were treated empirically with steroids and, occasionally, other cytolytic agents. Lung biopsy, which required a thoracotomy-albeit a limited one, was reserved for those patients who either failed empiric therapy or who were desperately ill in the intensive care unit, with all other options seemingly exhausted. The empiric approach probably is warranted and may in fact be preferred in the non-neutropenic cancer patient with acute pneumonitis, for whom broad spectrum antibiotic therapy usually is the treatment of choice.'0 It is the nonimmunocompromised patient, usually with a chronic interstitial process, in whom serious consideration should be given to obtaining a piece of lung tissue. The pulmonologist and other treating physicians must make a judgment as to whether a transbronchial lung biopsy is indicated, a decision that must take into account the most likely diagnostic possibility and whether the specimen obtained with a transbronchial biopsy forceps will be adequate to establish that diagnosis. There also is the small, but very real risk of pneumothorax or hemorrhage, especially in the thrombocytopenic patient." Will a transbronchial biopsy be just one extra procedure, or will it save the patient a potentially more invasive procedure, recognizing that open lung biopsy is significantly more likely to yield a diagnosis? Burt found a 94% diagnostic yield from open lung biopsy versus 59% for transbronchial biopsy in a series of 20 patients subjected to both procedures.'2 This discrepancy could certainly be smaller, however, depending on the clinical situation (i.e., immunocompromised vs. nonimmunocompromised, chronic vs. acute, etc.).

6 Vol No. 6 Before the introduction of VATS, the thought of subjecting a patient to a thoracotomy solely for the purpose of obtaining a piece of lung tissue, which still might not influence therapy, was a sobering one but often was the only choice, despite the associated morbidity. 13 The thoracotomy need not be accomplished via a formal posterolateral incision, and ideally, it should not be. A small inframammary incision allowing entry into the chest through the fourth or fifth intercostal space is a simple procedure that may be done expeditiously and allows one to obtain adequate lung parenchyma to give the best possible opportunity to establish a specific diagnosis. There should be minimal morbidity associated with this approach, and I believe that this still represents the best approach to obtain lung tissue in the critically ill, hemodynamically fragile patient who is ventilator dependent, and for whom transport to the operating room may in itself present a substantial risk.'4 This "mini" anterior thoracotomy does not require single lung ventilation and thus, avoids the potential morbidity associated with exchanging the endotracheal tube for a double-lumen endobronchial tube in these high-risk patients. However, the exposure achieved by the anterior approach can limit significantly the area of lung that may be accessible for biopsy, a potential disadvantage. It also is difficult through the anterior approach to obtain material from more than one site. For patients who are not ventilator dependent, however, VATS wedge lung biopsy, which we and others have referred to as closed lung biopsy, represents the best alternative to even the mini thoracotomy. It offers the advantage of excellent visualization of the entire lung so that questionable areas may be sampled under direct vision, and all areas of the lung may be reached with ease. The technique avoids rib spreading, seemingly one ofthe factors responsible for the pain that results after thoracotomy, including anterior thoracotomy. We believe that VATS lung biopsy results in less postoperative pain, which may be important in avoiding mechanical ventilation in the immediate postoperative period, and a shorter hospital stay. Ferson and colleagues from two other centers in a nonrandomized, retrospective study compared a group of 47 patients undergoing thoracoscopic lung biopsy with a group of 28 patients who had open wedge resections via limited thoracotomies. ' Adequate tissue for diagnosis was obtained in all patients from both groups. Mean operative time was significantly longer in the VATS group (69 vs. 93 min), but the time decreased as additional experience was gained. For this study, the authors excluded patients requiring mechanical ventilation and found that hospital stay was significantly shorter in the group undergoing thoracoscopic VATS lung biopsy (4.9 vs days). There were significantly more complications in the open group (50% Video-Assisted Thoracic Surgery 725 incidence) than in the VATS group (19%), a finding that likely explains the variation in duration of hospital stay. All surgeons involved in the study believed that VATS biopsy provided better visualization of the entire lung than a mini thoracotomy. Our own experience with 21 VATS lung biopsies in nonventilator-dependent patients confirms the above findings; diagnostic tissue was obtained in all cases, and in several, our ability to provide tissue from different areas of the lung greatly aided in establishing a diagnosis. The mean hospital stay in our series was 1.9 days, significantly shorter than that of Ferson and colleagues. '4 There was no mortality and no significant morbidity, including no instances of prolonged air leaks. When lung biopsy is indicated, VATS biopsy is our procedure of choice for patients not on ventilators. For patients requiring mechanical ventilation, in most cases, we prefer a limited anterior thoracotomy with minimal rib spreading, a simple procedure that may be performed expeditiously with minimal morbidity, which provides an adequate sample of lung tissue. Several authors reported on a thoracoscopic approach for lung biopsy before the advent of VATS techniques and before the linear stapler was available.'6"'7 Pieces of lung parenchyma were obtained with a cup biopsy forceps with an insulated electrocautery providing the only means of hemostasis. Daniel and colleagues, who had a long experience with thoracoscopy before VATS techniques became established, recently compared results obtained in the era before video equipment with those obtained by current methods.'8 In 30 patients undergoing thoracoscopic cup biopsy, there were ten deaths and one prolonged air leak that ultimately required a thoracotomy. Mean hospital stay was 16.6 days. In contrast, 11 patients underwent VATS biopsy, with only one death and a mean hospital stay of 8.2 days. The significantly better hemostatic and aerostatic qualities of the linear stapler, compared with a cup biopsy forceps, make it obvious which is the procedure of choice. The authors also point out that they see no advantage to either endoscopic approach over limited thoracotomy in patients requiring mechanical ventilation. The availability of VATS lung biopsy in lieu of even a limited thoracotomy has prompted the earlier referral of patients with interstitial disease who either would likely have been treated empirically or would have been referred in desperation at the time of marked decompensation, usually after being intubated and ventilated. Daniel also has observed this phenomenon.'7 We hope that these techniques, which prompt an earlier tissue diagnosis in patients with interstitial lung disease, will have an impact on long-term outcome. Video-assisted thoracic surgery techniques also play a major role in the management of spontaneous pneumo-

7 726 Kaiser Figure 6. A typical apical bleb seen in a young patient presenting with a spontaneous pneumothorax. Often the blebs are small and multiple, but almost always are found either at the lung apex or at the apex of the superior segment of the lower lobe. thorax, both in the young patient with apical blebs and in the older patient with emphysema. Primary spontaneous pneumothorax in a young person typically may be managed nonoperatively, and the chance for recurrence is in the 30% range.'9 Operative treatment for a first time pneumothorax classically has been reserved for those patients with persistent air leaks (> 1 week), those whose occupations require them to experience extremes in atmospheric pressure, and those who live in isolated areas without access to medical care.20 Otherwise, operation is indicated after a first recurrence or in the patient who has experienced bilateral pneumothoraces. In the past, the operative management of a spontaneous pneumothorax required either a thoracotomy, with stapling of apical blebs and at times a pleurectomy,2' or more recently, a transaxillary thoracotomy with excision of blebs and pleural abrasion or pleurectomy to create pleural symphysis.22 These both are substantial procedures for what is a trivial problem in terms of what needs to be done intraoperatively. Alternative approaches to management included talc or other sclerosants placed via tube thoracostomy into the pleural space.23'24 Video-assisted thoracic surgery management of spontaneous pneumothorax offers a simple surgical alternative that is associated with minimal morbidity. Recognizing that in young patients pneumothorax usually results from rupture of a bleb located at the lung apex (Fig. 6), the operative procedure entails excising the apical blebs and creating adhesions between the visceral and parietal pleura (pleural symphysis). The blebs are visualized easily through the thoracoscope and excised by several applications of the stapler. We prefer to mechanically abrade the pleura with a gauze sponge, which Ann. Surg. * December 1994 creates enough inflammation to affect adequate pleurodesis. We do not use talc or other chemical sclerosing agents in these young patients. Obliteration of the apical blebs alone probably is sufficient, and the contribution of the pleurodesis is additive. One would expect a very low recurrence rate (<5%) after this procedure, just as was the case after a transaxillary procedure or formal thoracotomy; the handling of the blebs is identical, no matter which approach is used. Cannon performed thoracoscopic excision of apical blebs in nine patients with primary spontaneous pneumothoraces and noted one recurrent small apical pneumothorax, which resolved without treatment.25 We performed 23 thoracoscopic procedures for primary spontaneous pneumothoraces during a 2-year period. We noted three recurrences, two in patients with catamenial pneumothoraces at the time of their first menstrual period after the procedure and one in a patient with routine apical blebs. The lesion that is responsible for catamenial pneumothorax is unknown, and we were unable to visualize any pathology at the time of the procedure.26 These patients recurred despite the performance of what we felt was adequate pleurodesis, but they recurred early, likely before the development of respectable pleural adhesions. We now manage these patients in cooperation with the gynecologists who pharmacologically stop ovulation for a period of 2 to 4 months after the surgical procedure. Overall, we and others have observed a slightly greater incidence of recurrent pneumothorax after VATS procedures than that observed after treatment by an open procedure. Indications for operation in the patient with a spontaneous pneumothorax have changed slightly with the availability ofvats techniques that allow most patients to leave the hospital on the first or second postoperative day. Patients who present with primary pneumothoraces are treated with either aspiration ofthe pneumothoraces or chest tube placement. Previously, we allowed these patients 7 days to seal an air leak before proceeding to operation and repair. Currently, we wait only 48 to 72 hours before recommending a thoracoscopic procedure that will allow the patient to leave the hospital sooner than if managed in the conventional fashion. The decision for earlier operation is justified by the lesser morbidity ofthe VATS procedure when compared with an open procedure, even the transaxillary approach. For the patient treated conservatively after a first episode of pneumothorax, a recurrent pneumothorax is an indication for operation. If it occurs on the same side as the first one, we operate only on that side. If it occurs on the contralateral side, both sides should be done because the consequences of spontaneous bilateral pneumothoraces, although an unlikely event, may be devastating. Bilateral VATS procedures under a single anesthetic may be per-

8 Vol No. 6 formed with no significant additional morbidity as we have done in 12 patients. Pneumothorax or air leak occurring secondary to a process other than apical blebs also may be managed with a VATS approach. In these situations, the pathology may be somewhat more complex, and one needs to search for the air leak and repair it. This usually is done by stapling, but fibrin glue, the neodymium:yttrium-aluminum garnet (Nd-YAG) laser, and the argon beam coagulator also have been used with success. We have performed 13 procedures for so-called secondary pneumothoraces-6 in patients with emphysema who had respiratory distress after developing pneumothoraces, 2 for persistent air leaks after thoracotomy and lobectomy, 2 in a patient with acquired immune deficiency syndrome and bilateral pneumothoraces secondary to Pneumocystis carinii infection causing necrotic parenchymal cavitary lesions, and 3 in patients with metastatic sarcomas. In 12 cases, we were successful in managing the air leak; one patient was converted to open thoracotomy. Cannon operated on six patients with secondary pneumothoraces, two of whom subsequently required thoracotomies to deal with persistent air leaks after the thoracoscopic procedures.23 Recognizing that some patients may require thoracotomies, we still prefer to attempt a VATS approach to an air leak in this patient population, many of whom have significantly compromised pulmonary function and would do well to avoid thoracotomies. If a surgeon develops the interest and gains experience with VATS techniques, the frequency of conversion to an open procedure should be quite low. It does require a commitment on the part of the surgeon, especially early in one's experience, to take the extra time that may be required to complete some of these cases rather than quickly converting to an open procedure. The management of bullous lung disease also has undergone something of a Renaissance because of the development of VATS techniques. Despite the fact that some authors advocate surgical management of even diffuse bullous disease,27 the main indication for operation in patients with bullous emphysema is the presence of a giant bulla causing significant compression of adjacent lung parenchyma (Fig. 7). These giant bulla are readily recognizable on plain chest radiograph, and a computed tomography scan helps to define the presence and extent of compressed lung tissue. The major factor involved in the decision whether excision of the bulla is likely to result in improvement of a patient's symptoms revolves around the issue ofthis compressed lung parenchyma and whether there is significant parenchyma that will expand to completely fill the space after bullectomy. A residual space left after bullectomy is an ideal setup for a persistent air leak, and thus, a long hospitalization, and in a small percentage of cases, an empyema, with resul- Video-Assisted Thoracic Surgery 727 Figure 7. A giant bulla as seen through the video thoracoscope. The bulla remains inflated long after the rest of lung deflates upon the institution of one lung ventilation. tant devastating consequences. It often is helpful in these cases to review a series of chest radiographs done for several years to see the progression in the size of the bulla; often, one sees a striking increase in size with compression of adjacent tissue and a decrement in pulmonary function and activity level over a relatively short period of time. These patients are the ideal candidates for bullectomy. The procedure itself requires obliteration of the bulla with the avoidance of air leaks, if possible. We prefer to use the argon beam coagulator that, when applied at a low power setting, causes the wall ofthe bulla to contract but remain intact. Once the bulla has shrunk, the base of it may be delineated and ideally stapled to minimize the risk of air leak from the stapled closure through this fragile lung tissue. Recently, we have used prosthetic material, specifically bovine pericardium (PeriGuard, Biovascular Medical, St. Paul, MN) to buttress the staple line to further prevent air leaks. Performing a VATS procedure seems to be significantly more desirable than open thoracotomy in these markedly compromised patients, most ofwhom are oxygen dependent and have and FEV1 well under 1 liter. It is the early postoperative period when these patients are most at risk of secretion retention and pneumonia, which for many would be a terminal event. Thus, postoperative pain management and chest physiotherapy are key. We prefer to use thoracic epidural analgesia with a continuous infusion of narcotic for pain management in the early postoperative period so that we may keep the patient comfortable enough to allow for an effective cough. Patients are extubated as early as possible, ideally at the completion of the operative procedure. We have performed 23 consecutive VATS bullecto-

9 728 Kaiser mies for giant bulla with no mortality. Conversion to thoracotomy was not required for any patient. All patients have shown a significant functional improvement, and we are in the process of evaluating incremental improvement in pulmonary function. In the few patients in whom we have measured late postoperative pulmonary function, FEV, has increased by at least a factor of 2. Quantitative exercise testing needs to be performed to further evaluate the improvement. Many of these patients could not have tolerated thoracotomies, and in the past, an operation would not have been considered. The VATS approach has made it possible for patients with bullous lung disease to obtain relief from their symptoms; whether their long-term outlook is improved remains to be determined. We consider bullectomy an initial procedure for some patients referred for lung transplant in the hope that we may offer them a few years before transplant, with its attendant morbidity due mainly to immunosuppression, is required. Giant bullae occur in only a small minority ofpatients with bullous emphysema, and whether obliteration of diffuse bullous disease, a procedure being performed by some surgeons, results in improvement of pulmonary function and exercise capability remains controversial. Functional improvement in this group of patients may result from lung volume reduction achieved, allowing for an improvement in elastic recoil of the bony thorax and improved motion of the diaphragm. Wakabayashi identified only 17 cases of giant bullous disease out of more than 500 cases ofbullous disease seen over a 3-year period.28 Out of more than 2000 thoracoscopic cases reported to the Video-Assisted Thoracic Surgical Study Group Registry, only 33 (1.8%) were for excision ofgiant bullae.29 These are high-risk patients who need to be selected carefully, even for a VATS procedure. Pulmonary Nodules By far the most significant impact made in the practice of thoracic surgery by VATS has been in the management of the patient with a pulmonary nodule. Videoassisted thoracic surgery procedures have had far-reaching consequences on the practice ofpulmonary medicine as well. The solitary indeterminate pulmonary nodule is a problem confronted on a routine basis by pulmonologists. In light of the emergence of VATS as a minimally invasive tool that may be performed with minimal morbidity, even in compromised patients, we must examine closely the current management of the patient who presents with an indeterminate nodule. Whereas in the past, definitive management involved open thoracotomy with its attendant morbidity, this no longer is the case. Videoassisted thoracic surgery offers the opportunity to both definitively make a diagnosis and treat many of these lesions. Ann. Surg. * December 1994 The salient question posed by the presence of a nodule seen on chest radiograph is a very simple one: is it malignant? If a previous chest radiograph is available that demonstrates the lesion has not changed in size over several years, one can be reasonably certain of the benign nature of that lesion. Unfortunately, our job usually is not so simple. Depending on the series, approximately 40% of resected nodules are malignant, and primary carcinoma of the lung accounts for the majority of malignant nodules.30 There are a number of factors that point to a benign diagnosis, although none are absolute. We are far less suspicious of a nodule occurring in a nonsmoker, especially if the individual is less than 35 years old. Lesions larger than 3 cm are likely malignant.3' Specific patterns of calcification also may be associated with benign lesions, and computed tomography comparison with a phantom of known density may further support a benign diagnosis. Even taking all of these factors into consideration, a histologic diagnosis is required in the majority of cases. If benignity cannot be proven, malignancy must be assumed. This, in reality, is the conservative approach. The procedures available to the pulmonary physician are very good at establishing a diagnosis of malignancy, but fall short at obtaining a positive diagnosis of benign disease. The diagnostic yield from fiberoptic bronchoscopy varies from 20% to 80%, but a specific benign diagnosis is made only 10% of the time.3234 With these figures, it is hard to justify the performance of a bronchoscopy if one is looking to make a diagnosis of benign disease. Unfortunately, percutaneous needle aspiration biopsy does not fare much better. Although its sensitivity in making the diagnosis of malignancy is high (64% to 97%),35 a specific benign diagnosis can be made only about as frequently as the rate achieved bronchoscopically.36 A negative needle biopsy is of no help and mandates the need for a further diagnostic procedure, whereas a diagnosis of malignancy essentially tells us what we already know-i.e., the lesion has to come out. It is difficult to justify the performance ofa transthoracic needle biopsy other than in the patient with multiple nodules in need of a tissue diagnosis or in the patient with an absolute contraindication to operation. Mack and colleagues, in a multicenter study, have looked closely at the role ofvats in the diagnosis ofthe indeterminate solitary pulmonary nodule.37 During an 18-month period, 242 patients with indeterminate solitary nodules underwent VATS excision as the primary diagnostic maneuver. A wedge excision of the lesion, including surrounding normal lung parenchyma, was accomplished with an endoscopic stapler alone in the majority of cases, although the Nd-YAG laser occasionally was used, either as an adjunct or as the sole method of excision. A definite diagnosis was obtained in all cases;

10 Vol No. 6 there was no mortality or major morbidity, and minor complications (atelectasis, pneumonia, prolonged air leak) occurred in only nine patients (3.6%). In two patients, the nodules could not be located and thoracotomies were required. Otherwise, a benign diagnosis was obtained in 127 patients (52%), whereas malignancy was found in 1 15 (48%). For cases in which primary lung cancer was identified, formal open thoracotomies and anatomic resections were carried out in those patients with adequate pulmonary reserve. The average hospital stay for those patients undergoing thoracoscopy alone was 2.4 days. It is hard to argue with a technique that has a sensitivity and specificity of 100% and which may be done with no mortality and minimal morbidity. But is it necessary to excise so many benign lesions? If we could be certain of the benignity of a lesion, there is no reason to excise it. It is the uncertainty of the benign diagnosis, in most cases, that presents the most compelling argument for VATS excision of the majority of solitary pulmonary nodules. All questions are answered, and the uncertainty disappears with one procedure. Certain lesions are not considered for VATS excision. For lesions larger than 3 cm, the likelihood of malignancy is so high (>90%) that in the absence of metastatic disease, thoracotomy and anatomic resection (i.e., lobectomy) should be the first procedure undertaken.38 The computed tomography scan aids greatly in localizing the nodule, and we have found it to be the only "localizing" study that is required. Deep lesions may be palpated and located, a technique which becomes easier with practice, and if a lesion is not easily amenable to stapled excision, the Nd-YAG laser may be used as an adjunctive technique to facilitate stapling. In our experience with 200 thoracoscopic excisions ofpulmonary nodules, we failed to locate the nodule in only two cases, both very early in our experience. Our technique relies heavily on instruments specifically designed for thoracoscopy that greatly facilitate the procedure, especially in grasping or moving the lung to the palpating finger (Fig. 8). Centrally located lesions, i.e., those in close proximity to hilar structures, are not suitable for VATS wedge excision and require open thoracotomy and formal anatomic resection. Controversy arises when we consider the optimal management of the solitary nodule that proves to be a carcinoma. Is a VATS wedge excision sufficient treatment for a T1 (<3 cm) primary lung carcinoma? Based on current knowledge, we believe that wedge excision is not optimal therapy for primary lung cancer, even a small T1 lesion, in a patient with adequate enough pulmonary reserve to permit anatomic resection. Currently, although our knowledge remains incomplete, we consider a wedge excision a compromise that is acceptable for the patient who otherwise cannot tolerate formal an- Video-Assisted Thoracic Surgery 729 Figure 8. The grasping forceps are used to move the lung to the examining finger, allowing palpation of all areas of the pulmonary parenchyma so that a nodule may be identified even when there are no visceral pleural visual clues. atomic resection. Among other factors, a wedge excision is not an anatomic resection, and no regional lymph nodes are removed, thus providing inadequate information regarding stage. We do not yet know the true incidence of local recurrence after VATS wedge excision, but in our experience, we have seen three local recurrences in 200 cases, one occurring at 7 months, one at 9 months, and one at 15 months. Several authors have demonstrated the value of nonanatomic resections for patients with marginal pulmonary function, and the option ofbeing offering these patients a VATS excision, with its low morbidity, may prove to be of benefit in this group.394' But in a landmark study for which the final results are not yet available, the Lung Cancer Study group addressed the question of limited resection versus lobectomy for T1 NO lesions in a prospective randomized trial.42 In this study of carefully staged patients proven conclusively to have NO disease, there was a significantly higher incidence of local recurrence in those who underwent limited resections, but at 3 years, there was no survival difference between the two groups. It remains to be seen whether a survival advantage will become apparent for the lobectomy group as follow-up for all patients is ongoing. The problem with extrapolating these data to justify VATS wedge excision has to do with the lack of staging information provided by this procedure, particularly the lack of information regarding peribronchial lymph nodes (levels 11, 12, 13). Currently, we continue to perform anatomic resections (lobectomy or segmentectomy) for primary lung cancer in all patients except those in whom limited pulmonary reserve precludes it. Anatomic resections have been performed using a VATS technique that requires a small (6-cm) "utility"

11 730 Kaiser incision, but usually without the need for rib spreading, which theoretically should have a beneficial effect on postoperative pain.43 In practice, despite the technical feasibility of the procedure, there does not seem to be any decrease in postoperative pain or a decrease in the number ofdays spent in the hospital. In the early experience, there has been an increased incidence of postoperative air leaks. It remains to be determined whether video-assisted lobectomy will find a place in our therapeutic armamentarium, but further refinements in instrumentation will likely be required for this even to be a possibility. In our experience with a limited number of these procedures, we find that patients have not fared any better in the early postoperative period, and they do not seem to return to normal activities any sooner than patients undergoing formal open thoracotomies. A randomized trial comparing VATS lobectomy with standard muscle-sparing thoracotomy and lobectomy also has failed to show significant enough differences to justify the routine use ofthe VATS approach, which probably subjects the patient to a slightly greater risk of intraoperative catastrophe, although no intraoperative deaths have been reported." Mediastinal Procedures Video-assisted thoracic surgery has proven useful as an adjunct to more conventional procedures used in the invasive staging of lung cancer. Mediastinoscopy remains the gold standard for invasive staging of the mediastinum, but the posterior subcarinal lymph nodes and the nodes in the subaortic window (level 5) are not accessible by standard cervical mediastinoscopy. Video-assisted thoracic surgery offers an unmatched ability to visualize the subaortic window and biopsy lymph nodes in this region (Fig. 9); the same is true for the subcarinal space when approached from the right side. A VATS staging procedure is not a substitute for mediastinoscopy but in certain cases, based on information obtained from the chest computed tomography scan, it may add valuable additional staging information. This is particularly important because of the interest in the thoracic oncology community in preoperative therapy (neoadjuvant) for patients proven to have N2 (mediastinal) lymph node disease. The usefulness of VATS for assessing resectability, especially if one is trying to document direct invasion of mediastinal structures (either T3 or T4), is limited, but occasionally may be of use. Dissection often proves difficult and potentially hazardous, and there is no substitute for putting one's hand on a lesion of questionable resectability. It is quite useful, however, to introduce the thoracoscope to document the absence of diffuse pleural metastatic disease if this possibility has been raised, usually by the presence of a pleural effusion. Ann. Surg. * December 1994 Figure 9. The subaortic window (aortopulmonary window) may be easily visualized and lymph nodes may be biopsied to provide staging for left upper lobe tumors. This area is inaccessible by classic cervical mediastinoscopy. Primary lesions of the mediastinum prove to be ideal for VATS management. Lesions in all locations of the mediastinum are easily accessible, and whether biopsy only, or complete excision is the intent, VATS techniques save many patients from having to undergo thoracotomies. Video-assisted thoracic surgery provides excellent exposure of the anterior mediastinum and offers an option in the management ofthese patients. To approach a lesion in the anterior mediastinum the patient is positioned with the operated side tilted up at approximately 30 degrees instead of in the full lateral position. Often, a small inframammary incision is employed, but without rib spreading. We have used a VATS approach to accomplish 15 thymectomies, 9 of these for encapsulated thymomas (Fig. 10). A VATS procedure is not applicable for invasive thymomas and these patients should have either sternotomies or thoracotomies. In the patient with myasthenia gravis and a thymoma, a total thymectomy is mandatory, which is facilitated by combining a transcervical approach with the VATS exposure. The thymus gland initially is mobilized in the neck, and branches to the innominate vein are divided. Using a retractor specifically designed for transcervical thymectomy (Cooper Thymectomy Retractor, Pilling- Weck Inc, Research Triangle Park, NC), the dissection is carried into the mediastinum until the thymoma is encountered. The mobilized gland then is tucked down into the mediastinum, the neck is closed, and the patient is positioned for VATS. The thymoma is mobilized, and the dissection is completed with the removal ofthe gland and tumor through one of the chest incisions. Excision of the tumor and total thymectomy via a VATS approach alone is feasible but more difficult, especially dis-

12 Vol No. 6 section of the gland up into the neck; also, one runs the risk of leaving residual portions of the thymus gland. The patient with a nondiscrete mediastinal mass, usually lymphoma but occasionally thymoma or a germ cell tumor, that requires a tissue diagnosis also may benefit from a VATS approach. Many of these lesions are more easily reached and subjected to biopsy through parasternal incisions with excisions of pieces of costal cartilage (usually the second), allowing one to stay out ofthe pleural space altogether. Those lesions that are not in close proximity to the anterior chest wall may be subjected readily to biopsies using a VATS approach. We have used a VATS procedure in 14 patients to perform biopsies on mediastinal mass. In all cases, adequate tissue was obtained that allowed a definitive diagnosis to be made. The posterior mediastinum also is the site of either solid or cystic lesions that are amenable to VATS resection. We have resected eight posterior mediastinal lesions, including schwannomas4 and bronchogenic cysts4 (Fig. 1 1). Incisions used to approach these posterior mediastinal lesions differ slightly form those used for access to the anterior mediastinum. Overall, we have performed 68 VATS procedures for mediastinal pathology without mortality and with minimal morbidity. Esophagus Because the esophagus resides, for the majority of its length, in the posterior mediastinum, it is not a great leap to imagine that VATS procedures have proven their merit when applied to esophageal pathology. Several European groups have been particularly aggressive in using these techniques to accomplish total esophagectomy This may be somewhat of an overuse of the technology because we already use an excellent minimally invasive Figure 10. A small encapsulated thymoma along with the rest of the thymus gland after mobilization off the pericardium. The proximal portion of the gland has been dissected via the transcervical route and placed into the mediastinum for removal with the thymoma. Video-Assisted Thoracic Surgery 731 Figure 11. A schwannoma (melanocytic type) in the posterior mediastinum in a paravertebral location at the apex of the chest (T2). The subclavian artery is in close proximity. The lesion is still ensheathed by the pleura. approach for esophagectomy that avoids a chest incision, namely transhiatal esophagectomy. Surgeons in the United States have not yet embraced the concept of VATS esophagectomy, but have used a VATS approach for staging esophageal cancer.47 Whether this information is useful remains debatable because most patients with esophageal cancer present with lymph node involvement, a situation that does not preclude resection; endoscopic ultrasound, a noninvasive technique, may provide the same information.48 Perhaps of somewhat greater interest is the use of VATS as an adjunct to transhiatal esophagectomy especially for lesions located at the level of the carina. It is safe to say that currently, the use of a VATS approach in the treatment of esophageal cancer remains to be defined. Such is not the case with benign disorders ofthe esophagus in which VATS techniques have been well described and experience with various procedures has accrued. Pellegrini described the initial experience with VATS myotomy for achalasia and found the technique to be feasible and, perhaps, the procedure of choice (Fig. 12).49 He performed the procedure on 24 patients who had a median hospital stay of 3 days. For the first three patients, who did not undergo simultaneous esophagoscopies, the myotomies were incomplete and second myotomies were required, which were done laparoscopically in two. Late follow-up showed excellent swallowing in 17 patients and fair/good swallowing in 4. The ability to perform this procedure without a thoracotomy should pique the interest of gastroenterologists and lead to the referral of these patients earlier in their course as opposed to repeating pneumatic dilatation ad infinitum. Longer follow-up with manometric and ph monitoring will be required before VATS myotomy is widely embraced, however. The procedure itself can be technically

13 732 Kaiser Figure 12. The esophageal mucosa viewed at the conclusion of a videoassisted myotomy. The longitudinal and circular muscular layers not only have been divided but peeled off the mucosa as well. Air is being insufflated through the indwelling esophagoscope, causing the mucosa to bulge and demonstrating the mucosa to be intact. demanding and should be performed only by those with considerable thoracoscopic experience. We have performed eight VATS myotomies with excellent early results in six; one patient required conversion to an open procedure to repair a mucosal rent, and she subsequently has required esophageal dilatation. One other patient continues to have occasional food sticking and may ultimately require a second procedure. Similar to performing a myotomy, excision of an esophageal leiomyoma, a benign submucosal tumor, is a procedure ideally suited to VATS techniques. We have performed two VATS leiomyoma excisions and have found no difficulty in obtaining exposure or dissection of the lesion offthe mucosa (Fig. 13). Other Procedures Ann. Surg. * December 1994 Pericardial Window. It is possible from either the right or left side to perform a pericardial drainage procedure when indicated for effusive disease to accomplish both diagnostic and therapeutic aims. It is, in fact, often easier to perform this procedure from the right side. We have performed only ten VATS pericardial windows because we feel that a subxiphoid approach for pericardial drainage is simpler, less invasive, more expeditious, and accomplishes the same goals. If there is a need to make as large a window as possible, then a thoracoscopic approach may be warranted. Sympathectomy. The sympathetic chain is readily visualized as it lies along the vertebral bodies (Fig. 14). The magnification provided by VATS facilitates the performance of a sympathectomy. Either dorsal or lumbar sympathectomy may be performed, and bilateral procedures may be accomplished at the same anesthetic. Dorsal sympathectomy may be indicated for palmar hyperhidrosis, reflex sympathetic dystrophy, or other upper extremity pain syndromes. The superior cervical ganglion may be easily visualized and preserved to avoid producing a Horner's syndrome. Bilateral lumbar sympathectomy has proven useful for the management of pancreatic pain, particularly when caused by malignant disease. When indicated, thoracic vagotomy may be performed with VATS techniques, and the thoracic duct may be ligated for chylothorax. The thoracic duct is most readily identified as it courses through the aortic hiatus where, in most patients, it still is a single trunk along the vertebral bodies between the aorta and the esophagus. We have performed six thoracic duct ligations for chyle leaks. In one patient early in our experience, a limited thoracotomy was required to complete the procedure. Video-assisted thoracic surgery provides excellent exposure to the thoracic spine, and procedures such as drainage of abscesses, biopsy of vertebral bodies, discectomy, and anterior releases for kyphoscoliosis all have been carried out successfully, avoiding thoracotomy.50 Because of the early success and significantly less morbidity in this patient population, this approach to the spine is becoming quite common in a number ofcenters. COMPLICATIONS We reviewed the compslications that resulted from our initial 266 VATS procedures.5' There were no deaths, and complications were mainly minor, with no residual sequelae. Ten patients had air leaks lasting longer than 7 days. Eleven patients were electively converted to open procedures when the intended VATS procedures could Figure 13. An esophageal leimyoma being mobilized off the mucosa after splitting of the layer of the muscularis. These are submucosal lesions which may be removed without disrupting the mucosa. Ocassionally, these may be quite large.

14 Vol. 220 No. 6 Video-Assisted Thoracic Surgery ,2'... Figure 14. The sympathetic chain encircled with a hook probe after mobilization off the vertebral bodies. The structure is seen easily along its entire course up to the level of the superior cervical ganglion. not be completed successfully. Bleeding requiring blood transfusion occurred in five patients, and there were five patients who developed superficial wound infections. Data collected on 1358 patients from the Video-Assisted Thoracic Surgical Study Group Registry shows a similar spectrum of complications, along with a 2% mortality.2 Prolonged air leak, as in our series, was the most frequent complication; significant bleeding resulting in transfusion occurred in only 15 cases (1%). To date, no consistent pattern of major complications resulting from VATS has been reported. We are aware of at'least ten instances of tumor seeding of VATS incisions, and further data are in the process of being collected. There appears to be a slightly higher incidence, although still around 3%, of recurrent pneumothorax after VATS procedures for spontaneous pneumothorax. Whether this simply is a function of the "learning curve" remains to be determined. The fact that VATS procedures in general have been performed with minimal major morbidity is commendable, because the technology and skills are new to most surgeons. CONCLUSIONS Video-assisted thoracic surgical procedures have proven to be extremely useful in the diagnosis and treatment of multiple thoracic problems. Improvements in video technology have made it feasible for a surgeon and an assistant to work together, and developments in instrumentation, especially staplers, have made many procedures commonplace that previously seemed impossible. Cost issues still need to be examined carefully. Is the more sophisticated technology and more expensive equipment saving money or expending more resources? --- If- we are.expendin greater s s tr s_if- a cant enough benefit to the patient to justify the added expense in this time of cost consciousness? In at least one study, the cost of a thoracoscopic wedge excision (n = 45) was less than that of a wedge excision done via thoracotomy (n = 31), but the difference was not statistically significant.52 Disposable instrument costs were significantly higher in the thoracoscopy group. There was no significant difference in the length of hospital stay for the two groups, but in the thoracoscopy group, the length of stay was longer than I would have expected. Cost savings potentially should come from a shorter length of stay and, ultimately, if patients return to work sooner, the overall cost to society should be less, although admittedly, this is difficult to measure. With the tremendous strides made in the development of equipment for VATS, there was a great rush on the part of thoracic surgeons to perform as many types of procedures as possible with this new technology. Now that the initial rush is over, we are beginning to appreciate just where these techniques have the greatest application. Some procedures for which there was tremendous early enthusiasm are being performed with less frequency; others have withstood the early shakedown period and proven their worth versus the conventional open procedure. Critical comparisons between VATS procedures and open techniques still are required before we have definitive answers to many questions raised by these new procedures. Individuals completing a cardiothoracic fellowship and some completing pulmonary medicine fellowships will be well trained in these techniques. Video-assisted thoracic surgery has found a place in the modern practice ofthoracic surgery and, with further refinement in equipment, should play an ever-increasing role in the management of diseases of the chest. References 1. Jacobaeus HC. Possibility of the use of the cystoscope for investigation ofserous cavities. Munch Med Wochenschr 1910; 57: Jacobaeus HC. The cauterization of adhesions in pneumothorax treatment oftuberculosis. Surg Gynecol Obstet 1921; 32: Jacobaeus HC. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922; 34: Lilienthal H. Thoracic Surgery. Philadelphia: WB Saunders Co, Kaiser LR. Diagnostic and therapeutic uses of pleuroscopy (thoracoscopy) in lung cancer. Surg Clin North Am 1987; 67: Lewis RJ, Kunderman PJ, Sisler GE, Mackenzie JW. Direct diagnostic thoracoscopy. Ann Thorac Surg 1976; 21: Oakes DD, Sherck JP, Brodsky JB, Mark JBD. Therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1984; 87: Rusch VW, Mountain C. Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease. Am J Surg 1987; 154: Hartman DL, Gaither JM, Kesler KA, et al. Comparison of insufflated talc under thoracoscopic guidance with standard tetracy-

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