4th Intercostal Space Research Articles

Case 2/2014 - 20-year-old Woman with Corrected Transposition, Pulmonary Atresia and Aortopulmonary Collateral Arteries

Clinical data: In the course of life, the patient developed three types of clinical manifestations. The first one was characterized by dyspnea and tachypnea, from birth to five months of age, increased pulmonary flow and heart failure, with cardiomegaly and hepatomegaly. The second phase was characterized by stability without significant symptoms, which lasted until the age of three, presumptive of balanced aortopulmonary flow. The third phase, with decreased pulmonary flow, had mild cyanosis that worsened two years ago. Exertion fatigue was noted for four years ago. The patient maintained saturation above 85% and up to 75% two years ago, hemoglobin = 17 g/dL and hematocrit = 62%. Physical examination: Eupneic, cyanotic +++, normal pulses, no jugular venous distention. Weight: 54 kg; height: 160 cm; BP: 115/60 mmHg; HR: 78 bpm; oxygen saturation = 78%. Aorta was palpated ++ in the suprasternal notch. In precordium, apical impulse in the 4th right intercostal space and discrete systolic impulses at the right sternal edge. Second hyperphonetic heart sound, +++, at pulmonary area, increases toward the lower left sternal edge. Discrete and mild continuous murmur, +/++, at pulmonary area, irradiating to the back. Liver was not palpated.

Abnormal regurgitation in three cows caused by intrathoracic perioesophageal lesions

BackgroundThree Brown Swiss cows with abnormal regurgitation because of a perioesophageal disorder are described.Case presentationThe cows were ill and had poor appetite, salivation and regurgitation of poorly-chewed feed. Collection of rumen juice was successful in one cow, and in another, the tube could be advanced to the level of the 7th intercostal space, and in the third, only saliva could be collected. In one cow, oesophagoscopy revealed a discoloured 10-cm mucosal area with fibrin deposits. Thoracic radiographs were normal. The cows were euthanased and examined postmortem. Cow 1 had a large perioesophageal abscess containing feed material at the level of the thoracic inlet, believed to be the result of a healed oesophageal injury. Cow 2 had an abscess between the oesophagus and trachea 25 cm caudal to the epiglottis with the same presumed aetiology as in cow 1. Cow 3 had a mediastinal carcinoma that enclosed and constricted the oesophagus.ConclusionsAbnormal regurgitation in cattle is usually the result of an oesophageal disorder. Causes of oesophageal disorders vary widely and their identification can be difficult.

Unidirectionally progressive left pneumonectomy & mediastinal lymph node dissection.

The patient has lower left lung tumor and adenocarcinoma at the openings of both upper and lower left lung. Preoperative bronchoscopic biopsy has confirmed the diagnosis. The surgical approach is unidirectionally progressive left pneumonectomy + mediastinal lymph node dissection. The layers of structure are treated one after another until the fissure from a single direction through the working port. Hence, the resecting order should be left superior pulmonary vein-left lower pulmonary vein-left main bronchus-left pulmonary artery. The vessels and bronchi are cut using an endoscopic linear stapler or the Hemolock clips. The resected lobe is placed into a large-size specimen bag and retrieved through the working port to prevent contamination of the chest incision by any tumor tissue. Mediastinal lymph node dissection is performed at the end. The surgery is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in a 90-degree position lying on the unaffected side. Similar to traditional resection of left lung lobes, an approximately 1.5-cm observation port is created in the 7th intercostal space between the middle and anterior axillary lines, an approximately 4-cm working port in the 4th intercostal space between the anterior axillary line and the midclavicular line, and an approximately 1.5-cm auxiliary port in the 9th intercostal space between the posterior axillary line and the subscapular line. The operator stands in front of the patient, manipulating the endoscopic instruments while watching the monitor.

Dilated cardiomyopathy secondary to chronic cocaine abuse: a case report

BackgroundCocaine is a potent sympathomimetic agent associated with the development of possible fatal cardiovascular complications. Dysrhythmias, acute myocardial infarction, hypertension and dilated cardiomyopathy are just some of many cardiovascular effects related to the abuse of cocaine.Case presentationA 38-year-old Hispanic male with a past medical history of hypertension presented with a chief complaint of progressive shortness of breath. The patient confessed to the use of cocaine for almost 18 years once per week. On examination he was hypertensive and tachycardic with a systolic murmur over the 5th intercostal space at the level of the left mid-clavicular line. Laboratory workup revealed an elevated Brain natriuretic peptide; urine toxicology was positive for cocaine. 2D-echocardiogram showed dilated cardiomyopathy. Cardiac catheterization excluded angioischemic cause. He was managed medically and subsequently discharged with drug rehabilitation. On follow-up diagnostic evaluation after 5 months of cocaine cessation, his ejection function improved significantly.ConclusionThe exact incidence of cocaine related cardiomyopathy is unknown and likely underreported. The clinical course is abrupt and comparatively similar to other types of cardiomyopathy. The management is like other forms of cardiomyopathy; however β-blockers should be avoided. The myocardial dysfunction is reversible with abstaining from additional cocaine ingestion. Non-invasive testing should be performed after several months to re-evaluate the treatment response.

A mandatory modification in extracorporeal biventricular assist device (BIVAD) implantation: intercostal tunnel application: a case report

In this case, our patient was a heart transplant candidate connected to a respiratory system. An extracorporeal biventricular assist device (BIVAD) was the only option in order to bridge to transplantation. In routine procedures, it is recommended that Berlin Heart Excor cannulas be removed through the subfascial subcostal tunnel. As the severely dilated right ventricle compressed the apex of the left ventricle, which was also dilated to the mid-back zone of the left hemithorax, the whole length of the Extracorporeal BIVAD apical cannula had to remain within the thorax; however, the cannula was removed from the body by creating a tunnel at the 7th intercostal space. In the long-term follow-up, this compulsory modification has proven to be safe and effective.

Acute respiratory failure due to giant aortic aneurysm mimicking massive pulmonary embolism in a patient with Marfan’s syndrome

A 41-year-old male with Marfan’s syndrome was admitted to the emergency department with severe dyspnoea. On his medical history, an operation of tube graft interposition to ascending aorta and aortic valve replacement ten years ago was remarkable. On physical examination, respiratory sound was almost inaudible on the left side of the chest. Cardiac auscultation revealed a grade 2/6 systolic murmur on the left 4th to 6th intercostal spaces. His pulse rate was 108 bpm and blood pressures were measured as 112/73 and 124/82 mm Hg in the left and right arm, respectively. The patient’s neck veins were distended. From the analysis of arterial blood gas on 10 L/min oxygen inhalation, pH 7.45, PaCO2 67 mm Hg, PaO2 71 mm Hg, SaO2 80%, and HCO3 – 20.1 mmol/L were obtained. A chest X-ray revealed widening of the mediastinum and collapsed left lung (Fig. 1). Transthoracic echocardiography revealed mitral valve prolapses, moderate degree of mitral regurgitation, normal left ventricular systolic function (LVEF 60%) and normal functioning of prosthetic aortic valve and significant dilatation and dissection of the descending aorta (Fig. 2). Aortic angiography by computed tomography (CTA) displayed the dissection and dilatation of the descending aorta accompanied by a thrombosed false lumen (Fig. 3A). Dissection membrane was extending from the origin of the left subclavian artery to the right iliac artery and was causing the compression of the left lung and right pulmonary artery (Fig. 3B). The patient was intubated and transferred to the intensive care unit. Unfortunately he died because of acutely developed progressive renal failure, cardiac and pulmonary failure complicated by lung infections over the subsequent ten days. In patients with Marfan’s syndrome, the risk of aortic dissection is approximately 1%. Aortic dissection is a tear within the layers of the aortic wall and the separation of them. An aortic aneurysm may present with symptoms of compression due to mass effect to the adjacent organs. Although the thoracic aorta is a close neighbour to the bronchus, pulmonary atelectasis and obstruction of the pulmonary artery due to an aortic aneurysm is uncommon. In our case, a giant thoracic aortic aneurysm had reached a large enough size to cause left sided collapse of the lung. Collapsed pulmonary volume and decreased aeration was complicated by oxygen and carbon dioxide exchange and led to hypercapnia and inability to respiratory compensation of acidosis induced by acute renal failure due to aortic dissection. Also, compression of the contralateral right pulmonary artery reduced the perfusion and aggravated the scenario.

Effect of ultrasound-guided intercostal nerve block on postoperative pain after percutaneous nephrolithotomy

The aim of the study was to investigate the effect of preoperative ultrasound-guided (US) intercostal nerve block (ICNB) in the 11th and 12th intercostal spaces on postoperative pain control and tramadol consumption in patients undergoing percutaneous nephrolithotomy (PCNL). After obtaining ethical committee approval and written informed patient consent, 40 patients were randomly allocated to the ICNB group or the control group. For the ICNB group US-guided ICNB was performed with 0.5 % bupivacaine and 1/200,000 epinephrine at the 11th and 12th intercostal spaces after premedication. A sham block was performed for the control group and postoperative pain and tramadol consumption were recorded by anesthesiologists blinded to the treatment. Postoperative visual analog scale scores at all follow-up times were found to be significantly lower in the ICNB group than in the control group (p < 0.05). The mean 24 h intravenous tramadol consumption was 97.5 ± 39.5 mg for the ICNB group which was significantly lower than the 199.7 ± 77.6 mg recorded for the control group (p < 0.05). In PCNL with nephrostomy tube placement US-guided ICNB performed at the 11th and 12th intercostal spaces provided effective analgesia.

Ultrasonography of the spleen, liver, gallbladder, caudal vena cava and portal vein in healthy calves from birth to 104 days of age

BackgroundMany of the ultrasonographic abdominal findings of adult cattle probably also apply to calves. However, significant changes associated with ruminal growth and transition from a milk to a roughage diet occur in young calves during the first few months, and it can be expected that ultrasonographic features of organs adjacent to the rumen such as spleen and liver also undergo significant changes. These have not been investigated to date and therefore the goal of this study was to describe ultrasonographic findings of the spleen, liver, gallbladder, caudal vena cava and portal vein in six healthy calves from birth to 104 days of age. Standing calves were examined ultrasonographically six times at three-week intervals starting on the first or second day of life using a 5.0-MHz transducer and techniques described previously.ResultsThe spleen was imaged on the left at the 5th to 12th intercostal spaces. The dorsal and ventral visible limits ran from cranioventral to caudodorsal because of superimposition of the lungs. The size of the spleen was largest at the 7th and 8th intercostal spaces and the maximum thickness was measured at the 9th to 12th intercostal spaces. The liver was seen in all calves on the right and could be imaged at the 5th to 12th intercostal spaces and the area caudal to the last rib. Similar to the spleen, the dorsal visible margin of the liver ran parallel to the ventral border of the lungs. The visible size of the liver was largest at the 8th to 11th intercostal spaces and the maximum thickness was measured at the 8th and 9th intercostal spaces. The parenchymal pattern consisted of numerous fine echoes homogeneously distributed over the entire organ. The gallbladder was most commonly seen at the 9th intercostal space and was circular, oval or pear-shaped on ultrasonograms. It extended beyond the ventral border of the liver depending on the amount of bile. The caudal vena cava was triangular in cross section but sometimes had a round or oval profile and was always seen in at least one intercostal space. The maximum circumference was measured at the 10th and 11th intercostal spaces. The portal vein was circular or oval in cross section and was characterised by stellate ramifications branching into the liver parenchyma. The portal vein could always be imaged at the 7th to 11th intercostal spaces and its mean diameter at the 9th to 11th intercostal spaces ranged from 1.2 cm to 1.8 cm.ConclusionsThe ultrasonographic findings of the spleen, liver, gallbladder, caudal vena cava and portal vein in six healthy Holstein-Friesian calves from birth to 104 days of age serve as reference values for the examination of these anatomical structures in diseased calves.

Ultrasonography of the lungs and pleura in healthy camels (Camelus dromedarius)

This study describes ultrasonography of the lungs and pleura in healthy camels (Camelus dromedarius). The different layers of the thoracic wall appeared as narrow bands of variable echogenicity. Reverberation artefacts appeared as lines of variable echogenicity that ran parallel to the pulmonary surface medial to the pleura. Because of its air content, the pulmonary parenchyma was not visualised in all camels. On the right side, the pulmonary surface was seen in the 5th through the 10th intercostal space (ICS). In addition, it was imaged in the 11th ICS in 20 camels and in the 4th ICS in three camels. The dimension of the ventral lung border was largest at the 4th ICS and smallest at the 11th ICS. The echogenic line on the surface of the lung, consisting of the costal and the parietal pleurae, was 1 to 4 mm thick. The left pulmonary surface and pleura were imaged with approximately the same frequencies as the right side. At this side, only the pulmonary surface and pleura were imaged in 15 camels in the 11th ICS. In conclusion, ultrasonography of the lungs and pleura provides information that can be used as a reference when examining camels suspected to have respiratory diseases.

Optimally invasive mitral valve surgery: a safe and effective approach

Methods Between April 2007 and December 2012, we used a sternum-sparing but optimally invasive approach to MV surgery on 99 patients (mean age 60.71 ± 12.9 years) with mean preoperative EF and LVEDD of 53.8 ± 11.4 % and 56.13 ± 6.9 mm, respectively. Twenty seven patients had previous coronary artery bypass and MV surgeries. All patients had severe mitral insufficiency (MI) from chordal rupture; prolapse of the anterior leaflet, paravalvular leak, endocarditis, floppy MV, and from previous MV surgery. The optimally invasive approach was a rightsided anterolateral thoracotomy at the 5th intercostal space with an approximately 10 cm skin incision. Cardiopulmonary bypass (CPB) was through either cannulation of the ascending aorta or femoral artery with direct bicaval cannulation. Modified Gerbode-Hetzer plication for ruptured chordae and modified Paneth-Hetzer posterior annulus shortening annuloplasty, for annulus dilatation or leaflet prolapse were employed. Paravalvular leaks were closed. Intraoperative TEE was used to evaluate the adequacy of repair or replacement.

An effect of the outpatient rehabilitation programme in patients with chronic respiratory diseases

BACKGROUND: Pulmonary rehabilitation is a common type of complex treatment especially in patients with chronic obstructive pulmonary disease (COPD). By contrast, only few rehabilitation centres in the Czech Republic provide pulmonary rehabilitation programme to non-COPD patients. OBJECTIVE: To find out if the rehabilitation programme has a similar effect in patient with obstructive and restrictive ventilatory disorder. METHODS: Twenty-eight patients with either COPD or pulmonary sarcoidosis (PS) have been enrolled for the 6-week rehabilitation programme. Lung functions, maximal inspiratory (MIP) and expiratory (MEP) mouth pressures, chest expansion at the level of the 4th intercostal space (IC) and at the level of the xiphoid process (XP), sixminute walk test, health-related quality of life using the St. George's Questionnaire (SGRQ) and fatigue occurrence using the Multidimensional Assessment of Fatigue scale (MAF) were tested at the baseline and after 6 weeks. The rehabilitation programme consisted of exercise training, ventilatory muscle training, respiratory physiotherapy and soft-tissue techniques. RESULTS: Patients with COPD improved significantly (p ＜ .05) in MIP by 17% (10.5 cm H_2O), MEP by 18% (16.8 cm H2O), IC by 65% (1.7 cm), XP by 90% (1.9 cm), six-minute walk distance (6MWD) by 15% (64.1 m) and SGRQ by -28% (-12.3 points). Patients with PS improved significantly (p ＜ .05) in MIP by 25% (20.1 cm H_2O), IC by 29% (1.3 cm), XP by 29% (1.3 cm) and 6MWD by 6% (31.6 m). The change in lung functions and MAF in both groups; MEP and SGRQ in PS group were insignificant after the 6-week rehabilitation programme. CONCLUSIONS: The 6-week rehabilitation programme produces similar responses in functional health status of patients with either obstructive or restrictive ventilatory disorder. However, patients with restrictive ventilatory disorder in particular should be encouraged to continue in the programme to enhance the health-related quality of life, which might not be sufficiently affected after 6 weeks.

Fat-forming variant of solitary fibrous tumor (lipomatous hemangiopericytoma) of the chest wall: a rare tumor in a rare location

Methods A 18-year-old, non smoking, male, patient, with no significant medical history, was referred with a 6-month history of right-sided chest pain. On physical exam, an oval-shaped mass was palpated in the right supraclavicular area. Imaging findings revealed a well-circumscribed, inhomogeneous tumor in the posterior compartment of the right thoracic inlet, with dimensions of 5.3 X 8.9 X 10.8 cm. The tumor seemed to compress the adjacent structures, but not clearly to infiltrate them, while it’s lower limit reaching the 4th intercostal space. Results An incisional biopsy was performed, resulting in the early diagnosis of LHPC. A right upraclavicular incision was performed at a second time to access the tumor. The clavicle was transected at its middle in order to enlarge the surgical field, allowing that way excision of the tumor with intact capsule, through a combination of sharp and blunt dissection. A lot of feeding vessels were clipped or ligated during dissection within the thoracic inlet. The patient had an uneventful short postoperative course. The diagnosis of LHPC was confirmed by two more laboratories. He underwent adjuvant radiation therapy in the right thoracic inlet and supraclavicular area, to reduce the risk of recurrence, because the tumor was violated during the incisional biopsy. Conclusion The thoracic inlet is one more location for the very rare LHPC. The anatomic topography of the mass requires special maneuvers to achieve safe removal of tumor with intact capsule, such as transection of the clavicle. Adjuvant radiation should be discussed within the multidisciplinary oncology team, as the global experience with these rare tumors is limited.

P 99. Effects of transcranial direct-current stimulation on diaphragm corticospinal pathway excitability

Background Transcranial direct-current stimulation (tDCS) applied over the primary motor cortex induces polarity-dependent changes in excitability: anodal tDCS enhances cortical excitability as assessed using transcranial magnetic stimulation (TMS), whereas cathodal tDCS has the opposite effect. Objective In this randomized study, we assessed effects of anodal, cathodal, and sham tDCS on the diaphragmatic primary motor cortex. Methods Twelve healthy right-handed men received anodal, cathodal, and sham tDCS applied to the left diaphragmatic motor cortex. Motor-evoked-potential (MEP) recruitment curves were obtained by recording the surface electromyogram at the right 8th intercostal space during TMS at intensities ranging from the resting motor threshold (MT) to 130% of MT. For each condition, MEPs were recorded before (Pre) tDCS then after 10 min (Post1, at tDCS discontinuation in the anodal and cathodal sessions) and 20 (Post2) minutes. Results Both anodal and cathodal tDCS significantly decreased MEP amplitude at the right hemidiaphragm at both Post1 and Post2, versus Pre. MEP amplitude was unchanged versus Pre during the sham condition. Conclusion The effects of cathodal and anodal tDCS applied to the diaphragm motor cortex differ from those observed during tDCS of the limb motor cortex. This difference may be related either to the mechanisms involved in the effects of tDCS or to the diaphragm contractions during tDCS.

Video-assisted thoracic surgery right upper lobectomy and lymph node dissection.

We described a 55-year-old male smoking patient, who came to our institute with the diagnosis of a right upper lobe lesion. Computed tomographic (CT) guided biopsy confirmed a diagnosis of lung adenocarcinoma. The preoperative clinical diagnosis was stage I primary lung adenocarcinoma. The standard three-port video-assisted thoracoscopy surgery (VATS) was performed in this case. After the resection of the right upper lobe, the 2(nd), 4(th), and 7(th) groups of lymphatic nodes were removed with Harmonic scalpel. A closed drainage catheter was placed adjacent to the lateral chest wall through the port in the 7th intercostal space. Postoperative pathologic diagnosis was T2aN0M0 adenocarcinoma.

Right lower lobe resection.

This video (Video 1) describes the right lower lobe resection. A 1.5-cm incision was made at the 7th intercostal space along the midaxillary line as the main operation port. A 3.5-cm incision was made at the fourth intercostal space, in which an incision protection sleeve was attached. The operator then explored the thoracic cavity to identify that the lesion was located at the right lower lobe.

Unidirectionally progressive resection of lower right lung cancer under video-assisted thoracoscopy.

The surgery is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in a 90-degree position lying on the unaffected side. An approximately 1.5-cm observation port is created in the 7th intercostal space between the middle and anterior axillary lines, an approximately 4-cm working port in the 4th intercostal space between the anterior axillary line and the midclavicular line, and an approximately 1.5-cm auxiliary port in the 9th intercostal space between the posterior axillary line and the subscapular line. The operator stands in front of the patient, manipulating the endoscopic instruments while watching the monitor. since the patient has right lower lung cancer, a unidirectional procedure is adopted for the surgery, in which the layers of structure are treated one after another until the fissure from a single direction through the working port. Hence, the pulmonary vein, bronchi, pulmonary artery and the poorly developed fissure of the right lower lobe are treated successively during lobectomy. The vessels, bronchi and fissures are cut using an endoscopic linear stapler or the Hemolock clips. The resected lobe is placed into a size 8 sterile glove and retrieved through the working port to prevent contamination of the chest incision by any tumor tissue. Mediastinal lymph node dissection is performed at the end.

Treatment of coronary artery disease via MIDCAB in a patient with severe thalidomide phocomelia

In the late 1950s and early 1960s, more than 10,000 children in 46 countries were born with deformities, such as phocomelia and/or amelia, as a consequence of maternal thalidomide use. Application of thalidomide during weeks 3–8 of gestation causes multiple birth defects such as limb, ear, cardiac and gastric malformations [1, 2]. Patients with thalidomide-caused disabilities represent a small but complex patient population when it comes to diagnostic and therapeutic cardiac procedures. In this case, we detail our experience with a patient presenting severe phocomelia in combination with several other disorders including vascular abnormalities who suffered from coronary artery disease (CAD) with complex stenosis of the left anterior descending artery (LAD). A 52-year-old male patient presented in an outside hospital with symptoms of angina pectoris and shortness of breath. The patient’s history consisted of multiple birth defects due to maternal thalidomide use, hyperlipoproteinemia, adiposity, and smoking. ECG diagnostics and laboratory analysis revealed a ST-elevation myocardial infarction with a maximum creatine kinase level of 1,030 mg/dl. As such, the decision to perform emergency coronary angiography was made. After several efforts to place the cath-sheath transcutaneously, even surgical attempts to expose the femoral artery remained unsuccessful due to the underlying anatomic disorders. As the patient was in a stable condition, he was transferred to the intensive care unit for further monitoring and observation. To gain further insights in the coronary status as well as to detect the vascular access site options for coronary angiography or angioplasty, an ECG-triggered CT angiogram of the coronary arteries and of the existing vessels was performed. CT analysis identified a significant left anterior descendent artery (LAD) stenosis (culprit lesion) and a moderate stenosis of the left circumflex coronary artery. Analysis of the vascular status revealed no suitable access for catheterization. After interdisciplinary discussion, surgical revascularization via minimal invasive direct coronary artery bypass grafting (MIDCAB) was considered as the only viable treatment option in this particular case. After initiation of general anesthesia with a double lumen endotracheal tube, placement of the central venous and the arterial line for invasive blood pressure monitoring showed to be complicated and had to be performed under ultrasonographic guidance. An anterolateral thoracotomy was performed using the 5th intercostal space. After deflation of the lung, the left internal mammarian artery (LITA) was identified and dissected in the usual fashion. The vessel appeared to be small with a diameter of 1.5–2 mm, but showed no signs of affected or impaired condition. After heparinization and division of the mammarian artery, the pericardium was opened longitudinally. The LAD was identified in the epicardial fat and dissected. After chest tube placement and placement of a retractor stabilizer, temporary occlusion of the LAD with encircling 4-0 tourniquets sutures over silicone tubing was achieved. After incision of the target vessel and 2-mm shunt placement, the anastomosis between LITA and LAD was performed under direct vision using an 8/0 monofilament suture. Following completion of the anastomosis, the pedicle was fixed with two sutures to avoid torsion of the M. Scherner (&) M. Mihaijlova N. Madershahian T. Wahlers J. Wippermann Department of Cardiothoracic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50925 Cologne, Germany e-mail: maximilian.scherner@uk-koeln.de

Novel body surface electrical restitution based marker is predictive of sudden cardiac death risk independent of existing risk markers

Methods: Sixty healthy male subjects (mean age 38 ± 8.76 years) and fifteen male patients with AV block (mean age 68 ± 5.43 years) were studied. In addition to a standard 12-lead ECG, an MLL ECG was recorded with the RA electrode placed at the 3rd right intercostal space a little to the right of the parasternal line, the LA electrode placed in the 5th right intercostal space slightly to the right of the mid clavicular line, and the LL electrode placed in the 5th right intercostal space on the mid clavicular line. ECGs were recorded for 60 s each with an EDAN SE-1010 PC ECG system.

The feasibility of a Two-incision video-assisted thoracoscopic lobectomy

BackgroundThis study is to evaluate the feasibility and safety of video-assisted thoracoscopic (VATS) lobectomy with two incisions.MethodsA total of 73 patients (male 47, female 26; mean age 61.2 ± 12.00 years old) who underwent major pulmonary resection, through VATS, using two incisions were included in this study. The thoracoscopy port was placed at the 7th or the 8th intercostal space in the mid-axillary line, and the working port, 3~5 cm long, at the 5th intercostal space, on the operator’s side.ResultsThe preoperative diagnosis was benign lung disease in 8 patients (11.0%) and malignant lung disease in 65 (89.0%). Two patients (3.1%) needed a third port during surgery due to severe pleural adhesion, and conversion to thoracotomy was needed in 5 (6.8%), due to bleeding at pulmonary arterial branch (n = 3), anthracofibrotic lymph nodes around pulmonary artery (n = 1), and severe pleural adhesion (n = 1). The mean duration of the operation in the 66 patients, completed by a two-incision VATS lobectomy, was 163.4 ± 30.40 minutes. In 56 cases, which were completed by a two-incision VATS lobectomy for primary lung cancer, a total number of dissected lymph nodes per patient were 20.2 ± 11.2. The chest tube was removed on postoperative day 5.4 ± 2.8, and there was no occurrence of major perioperative morbidity and mortality.ConclusionsTwo-incision VATS lobectomy is applicable in the selected cases, and may obtain similar results with the conventional VATS lobectomy, through a certain period of learning curve.

Video‐assisted Thoracoscopic Surgery Sleeve Lobectomy with Bronchoplasty

We review our experiences with video-assisted thoracoscopic surgery (VATS) sleeve lobectomy with bronchoplasty for NSCLC. The safety, effectiveness, indications, and operation precautions of this approach were examined. From September 2011 to September 2012, 11 patients underwent VATS sleeve lobectomy with bronchoplasty in our hospital (right upper lobe = 8, left lower lobe = 2, left upper lobe = 1). The operation consisted of VATS anatomic sleeve lobectomy with bronchoplasty combined with systematic lymph node dissection. Three incisions were made. Bronchial anastomosis was combined with simple continuous suture anastomosis of the membranous part of the bronchus and simple interrupted suture anastomosis of the cartilaginous part of the bronchus. All procedures went uneventfully. Median operative time was 178 min; median bronchial anastomosis time was 42 min; median blood loss was 180 ml. There was no case of conversion to thoracotomy. Pathological examination showed 10 squamous cell carcinomas and 1 adenocarcinoma. All patients recovered well, except one who suffered minor complications. Median postoperative chest tube drainage duration was 6.8 days, and median hospital stay was 8.9 days. All patients were followed up for 2-13 months without recurrence. Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty is a safe and effective surgical approach in the treatment of non-small cell lung cancer. The operating incision placed at the 4th intercostal space on the anterior axillary line is convenient for anastomosis our experience shows that anastomosis combining simple continuous suture of the membranous part of bronchus and simple interrupted suture anastomosis of the cartilaginous part of the bronchus is fast and secure. Moreover, preserving the azygos vein does not affect the anastomosis.