Trans Oral-Substernum Incision Thoracic Endoscopic Surgery: A Minimally Invasive Endoscopic Approach in Thoracic Surgery

Abstract

Flexible endoscope is used in Natural Orifice Trans-luminal Endoscopic Surgery. Cervical incision thoracic surgery has recently been described. The use of a flexible endoscope through a natural orifice into the thoracic cavity still remains ethically doubtful. The authors present a surgical experimental study using a flexible endoscope through oral-substernum incision for the exploration of both the thoracic cavity in dog model. An experimental work on 5 male mongrel dogs was initiated. Through a small incision at oral floor, we performed simultaneous exploration of the pleural cavities. Identification and biopsies of pleural and lung was performed. None chest tube was placed in the thoracic cavity at the end of all pleural procedures. The potential advantages of this approach are exploration of the thoracic cavity and the performance of several thoracic interventions through oral floor. The flexible endoscope could become a surgical tool for thoracic surgery. The treatment of lung cancer and other thoracic tumors usually involves thoracic surgeries. Cancer staging is a necessary step before cancer treatment. Mediastinal lymph nodes, pleural biopsies and lung biopsies are frequently needed for staging tumors. Despite the development of less invasive techniques, such as trans-bronchial needle aspiration (TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), and more recently, endobronchial ultrasoundguided fine-needle aspiration (EBUS-FNA), mediastinoscopy and video-thoracoscopy still remain the more satisfactory and commonly performed invasive techniques for mediastinal and pleural staging of thoracic tumors [1,2]. The development of thoracoscopic approaches during the early 1990s excited thoracic surgeons due to multiple advantages of this technique. Thoracoscopy unquestionably decreased the length of hospital stay, hospital cost, and rate of scar complications; and provided some cosmetic advantages. However, it did not significantly reduce postoperative pain. Thoracic ports and chest tubes are a major cause of persistent pain [3]. Minimally invasive techniques in thoracic surgery are evolving. And several recent thoracic surgical interventions were performed through cervical incisions [4,5]. There is a trend in favor of using flexible endoscopy in general surgery [6]. Flexible endoscope is used in Natural Orifice Trans-luminal Endoscopic Surgery (NOTES) techniques [7]; and few cases were reported on its application in abdominal surgery. Latest attempts in minimizing surgical trauma lead to an experimental trans oral access to the mediastinal for lymph node biopsies. Human application has been described for NOTES in thoracic surgery [8], but ethical restraints and the risk of major mediastinal complications limit its application on humans. The aim of this experimental work on animal is to evaluate the use of flexible endoscope for the exploration of thoracic cavity and pleura through a single trans oral incision.