4th Intercostal Space Research Articles

The “loop” technique for primary spontaneous pneumothorax: a retrospective study of 18 patients

Background: Primary spontaneous pneumothorax (PSP) is a well-known disease but with multiple different surgical approaches. The objective of our study is to present the results of an innovative minimal uniportal approach for patients with such a disease. This will be able to reduce postoperative pain simultaneously considering the cosmetic problems of otherwise ‘healthy’ patients. Methods: We retrospectively evaluated the surgical results of 18 patients who underwent single incision thoracoscopic surgery (SITS) using a loop at our institution between January 2015 and August 2016. Single access of 20 mm was done at the level of the 8th intercostal space. We used a ‘loop’ of a non-absorbable braided suture inserted through the IV intercostal space to isolate and suspend any dystrophic area to resect. In every patient, the pulmonary ligament was dissected and pleurodesis done with pleural abrasion. Results: We had no complications after SITS. The mean operative time for SITS was 55±7.36 (standard deviation) minutes. Usually, the chest tube is removed in the 2nd postoperative day, and the patient discharged the day after. There were no conversions from SITS to three-port VATS or thoracotomy. Nobody reported chronic pain and paraesthesia. No patients had an ipsilateral recurrence of pneumothorax in the 2 years after surgery. Conclusions: The operation we propose is safe and easily reproducible. Considering the small number of patients, this technique offers excellent results regarding the duration of recovery, postoperative pain and paraesthesia, without increasing the risks of complications for the patient and the costs of surgery.

EP23 MINIMALLY INVASIVE MITRAL SURGERY THROUGH A RIGHT VERTICAL AXILLARY MINITHORACOTOMY: PRELIMINARY EXPERIENCE

Abstract Background and Aim: right antero-lateral minithoracotomy through the 3rd or 4th intercostal space is the classic approach for minimally invasive mitral surgery. We report our experience with an alternative and more cosmetic minimally invasive port-access through a right vertical axillary minithoracotomy (RVAMT). Methods: between July 2016 and April 2018, 60 patients (32 females and 28 males, mean age 66.2 ± 11.1 years) underwent mitral valve surgery through a RVAMT. Forty-six mitral valve repairs were performed, 4 associated to tricuspid repair. Only 14 pathological mitral valves have been replaced. RVAMT was performed by a 5–6 cm incision through the 4th intercostal space placed vertically along the antero-axillary line rather than antero-laterally along the intercostal space. All surgical procedures were performed without an endoscopic system. Results: mean CPB time and aortic cross clamp were 130.2 ± 26.1 minutes and 90.6 ± 16.6 minutes, respectively. There was no approach-related limitation to surgical exposure. Bleeding requiring surgical revision occurred in two patients. Median intensive care unit stay and mean mechanical ventilation time were 24 and 8.3 ± 5.4 hours, respectively. In-hospital mortality was 1.7% (1/60 patients). Overall survival at 6 months follow-up was 100%. Conclusions: RVAMT is a safe alternative, reproducible, cosmetic and minimally invasive approach for mitral valve surgery. It provides an optimal surgical viewing perpendicular to the mitral plane with satisfactory valve exposure and the possibility to perform surgery under direct vision. The cosmetic advantage of the RVAMT is the short incision under the armpit that is often invisible.

Internal Mammary Lymph Nodes Involvement in Patients with Breast Cancer: Anatomical Characteristics and Implication for Target Definition

Internal mammary nodes (IMN) as one of the regional lymph nodes (RLN) in breast cancer, its importance to be included in regional nodes irradiation (RNI) has been assessed by important prospective trials. Optimal definition of target volume is critical in balancing target coverage and toxicity to normal tissues. The imaging and anatomical information for IMN metastasis are less described than other RLN in breast cancer. The current study aims to collect and analyze the imaging information of IMN involvement so as to provide information for optimize IMN delineation. Patients with IMN involvement were identified from single-center breast cancer database with imaging data. The image information including thoracic CT, breast MRI, and PET/CT. Anatomical characteristics from axial imaging including distribution of involved ribs, distance from the internal mammary vessels (IMV) were collected for each metastatic nodes. IMNs greater than 5 mm in short axis was defined as metastasis in this study. A total of 53 breast cancer patients with a total number of 63 metastatic IMN met the criteria for INM involvement were identified and located in this study. In 27 patients (50.9%), more than one intercostal spaces were involved, of which the second rib space was the most involved (26/27). The number of metastatic nodes in the 1st, 2nd, 3rd and 4th intercostal space were 26 (41.3%), 43 (68.3%), 21 (33.3%) and 4(6.3%) respectively. The maximal radial distance from center of metastatic nodes to the IMV in each patient were measured. The percentage of including IMN with a 4mm, 5mm, 6mm and 7mm medial/lateral distance to the IMV were 56.6% (30/53), 75.5% (40/53), 90.6% (48/53) and 96.2% (51/53) respectively. While in maximal dorsal/ventral distance, all extension of the IMN nodes were in dorsal direction, the percentage of including IMN with a 4mm, 5mm, 6mm and 7mm depth to the IMV were 85%(45/53), 90.6% (48/53), 94.3%(50/53) and 98.1%(52/53) respectively, one case had enlarged mass invading the fourth rib, in which the identification was difficult. In total, 28 of 53 patients had no documentation of IMN disease on imaging report regardless of the visible IMN mass on thoracic CT. The most common description was parasternal mass (50%, 14/28), chest-wall mass (7.1%, 2/28) and no description at all (32.1%, 9/28). All these 12 patients had thoracic CT as the only image evaluation. In 12 patients combined with breast MRI and one patient combined with PET/CT, none had miss diagnosis of IMN disease. In most of the patients indicated for IMN irradiation in the adjuvant setting, clinical target volume of IMN can be delineated with a 6mm medial/lateral distance and a 5mm depth to the IMV on the same axial CT image. This optimization in delineation might facilitate the balance of target coverage and normal tissue constraints. Multimodal image information may help to improve the sensitivity of diagnosis in IMN metastasis.

P3.CR-33 Trichoptysis, Hemoptysis and Chest Pain: A Very Rare Presentation of Anterior Mediastinal Teratoma in a Young Patient

1/Case History: A 28-year old patient who presented to the Emergency Department for a 2-week history hemoptysis, right chest pain and intermittent sebaceous expectorations. He had such intermittent chest pain for the last 2 months. He had no fever, breathlessness, loss of weight, joint pain or renal symptoms. He had no significant personal or family history of tuberculosis. On examination, he was afebrile.Full clinical examination revealed decreased breath sound in the left lung with a dull-percussion note. 2/Investigations: Laboratory investigations were normal.The coagulation tests were normal. The Tuberculin skin test was negative. The Chest CT-scan revealed a large well-circumscribed anterior mediastinal mass with heterogeneous mixed density (fat, soft tissue and calcifications), in the left hemi-thorax. It also showed intra-tumoral bleeding associated with a left massive hemomediastinum. This radiological aspect suggested a teratoma. Preoperative labs showed normal carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), CA-125 and beta-HCG level were normal. 3/Treatment: The multidisciplinary team decision was to perform surgery. A standard posterolateral thoracotomy was performed in the 5th intercostal space. Immediately upon entering the thoracic cavity, a bulky mediastinal mass was found to have a strong adhesion to the upper left lobe. The mass itself was originating from the thymus and extending down to the left lung. A complete thymectomy with a total removal of the tumor was therefore performed. The total amount of bleeding was about 900ml.This was completely evacuated from the thoracic cavity. The patient is currently doing well one year from his initial diagnosis. Although he had a benign teratoma, he was referred to a medical geneticist for further evaluation and management. 4/Discussion and conclusion: Teratomas are germ cell tumors arising from pluripotent cells. Most of them are asymptomatic. Hemoptysis is rare. It may result either from communication with tracheobronchial tree or they may result from bronchial bleeding due to the irritation caused by the tumor. In this case, the presence of hypervascularisation depending on the left internal mammary artery in the chest CT-scan suggests that the teratoma developed systemic blood supply which make our case original. Another pathognomonic symptom is Trichoptysis which is extremely rare . All these symptoms may mimic a pulmonary tuberculosis in young patients especially in our tuberculosis-endemic country. In our case, the tuberculin tests were negative. To conclude, it is a rare case of Teratoma of the anterior mediastinum. It should be considered in the differential diagnosis of Hemoptysis..

PC03.05 Debate on Standard Surgical Approaches - Open Thymectomy

PC03.05 Debate on Standard Surgical Approaches - Open Thymectomy

A Dynamic Anatomical Description of the Parietal Pleura Setting Safety Limits for Intercostal Percutaneous Access.

We came up with a dynamic anatomical study intended to validate the safety of intercostal approach used by our center to access the upper pole of the kidney during percutaneous surgery. A total of 101 patients presenting randomly to the radiology department for CT evaluation of the abdomen and superior pelvis were involved in this study. Deep inspiration and expiration sequences in the prone position were evaluated to establish the location of the parietal pleura in relation to different anatomical landmarks. Three-dimensional reconstruction was performed to simulate the access needle course through the retroperitoneum. Our data show that the position of parietal pleura is invariably higher on the right side irrespective of anatomical relation or respiratory changes. Higher position of the parietal pleura was noted in all considered landmarks upon full expiratory sequences. Using the midclavicular line as a landmark, our data show that on the right side, the parietal pleura was higher than the 10th intercostal space (ICS) in 100% of patients. Going up to the level of the ninth and eighth ICS, the pleura is higher in 89.1% and 66.3% of patients, respectively. Moreover, on the left side, the level of the parietal pleura was higher than the 11th ICS in 100% of patients. Reaching the 10th ICS, the parietal pleura still is higher in 92.07% of cases. Going up to the ninth ICS reduces the margin to 64.35% and using the eighth ICS would convey a margin of 24.7%. Supracostal access for percutaneous nephrolithotomy carries a risk of pulmonary complications, limiting its use worldwide. We have shown in this study that using the differences in inspiration and expiration along with the right anatomical landmarks could substantially lower the risk of complications. However, regardless of the side or landmark used, supracostal access is safe in >90% of cases.

Regional analysis of airway abnormalities in cystic fibrosis employing Electrical Impedance Tomography

Abstract To estimate the severity of airway abnormalities in cystic fibrosis (CF) Brody et al. developed a computed tomography (CT) scoring system. Each pulmonary lobe is analyzed separately considering various morphological defects. A study from Zhao et al. demonstrates that this CTbased score correlates with regional airway obstruction (RAO) measured by the real-time imaging method Electrical Impedance Tomography (EIT). Zhao et al. performed EIT measurements at the 5th intercostal space (ICS) and median RAO, including both lungs, was correlated with the associated score. In the present feasibility study, it was investigated if RAO determined by EIT within the left and right lung respectively at the 3rd and 5th ICS corresponds with the scores of the left and right lobes. EIT measurements and CT-based scoring were carried out on two CF patients. RAO was identified by ratios of impedance values associated to the maximal forced expiratory flow at 25% and 75% of the forced vital capacity. Mean RAO of each lung within both thorax sections was compared with the lobar scores. Airway abnormalities within upper lobes are assigned to RAO measured within the 3rd ICS, whereas abnormalities of the right middle lobe, both lower lobes and the lingula are mainly represented by EIT images of the 5th ICS. Results show that differences in the CT-based score between the left and right lung concur with differences in EIT derived RAO. The regional information provided by EIT might be used for a more targeted therapy of CF-related lung diseases.

Intercostal and Glissonian Pedicle Approach in Laparoscopic Liver Resection for Bilobar Tumors

BackgroundBilobar liver metastasis is challenging for laparoscopic liver resection. Especially, subphrenic liver tumors in S7 or S8 are technically difficult to be resected out because the space is limited and the angle of instruments to lesions cannot be perpendicular.1,2 Major liver lobectomy is also challenging for laparoscopic liver resection. Glissonian pedicle approach has benefit that any variation of vascular and bile duct elements does not need to be considered in the hepatoduodenal ligament under the hilar plate. Glissonian pedicle approach is simpler and faster than individual dissection of hepatoduodenal ligament. MethodsThis video illustrates a hand-assisted laparoscopic left lobectomy and partial liver resection of S8 in a 48-year-old male with metastatic colorectal carcinoma to the liver. He received 6 cycle of FOLFOX as neoadjuvant chemotherapy. The patient was positioned in semi left lateral decubitus so that a lesion in S8 was easily approached. A tumor in S8 was approached after right lobe mobilization. The liver resection was performed by a harmonic scalpel. A 5-mm balloon port was placed in 6th intercostal space to approach the lesion perpendicular. For left hepatectomy, glissonian pedicle approach was applied to control vascular inflow. Dissections was performed at bifurcation on the right glissonian and left glissonian pedicles. Dissection direction to the left side was above hepatogastric ligament. The tunnel was created including all left glissonian sheath, and a vessel loop was taped. An endovascular stapler was inserted and fired with dividing the left glissonian pedicle as en bloc. Hepatic parenchymal dissection was performed by the harmonic scalpel. Left hepatic vein was divided using an endoscopic vascular stapler. The specimens were removed from a hand-port. ResultsThe operative time was 290 min. Blood loss was 250 ml, and no blood transfusion was required. He resumed a regular diet the next day and was discharged on postoperative day 4. ConclusionsIntercostal approach is useful for subphrenic liver tumors, and glissonian pedicle approach is also useful for major lobectomy for laparoscopic liver resection.

Siesmocardiographic Changes with HF Status Change: Observations from a Pilot Study

Introduction Many strategies and technologies have been developed to minimize readmissions and manage HF. These strategies are often either labor intensive, invasive and/or expensive. New methodologies for accurate, rapid and low-cost ambulatory metrics of HF status are needed, of which seismocardiography (SCG) may be particularly useful. SCG uses accelerometer sensors to detect both audible, and sub-audible (i.e., below the frequencies detectable by the human ear) vibration signals. Although described decades ago, new sensor and digital processing capabilities are expanding the possible utility of this approach. Objective To investigate the use of SCG for HF monitoring. Methods Twenty patients (ages 51 to 75, 30 % female) admitted for HF were studied with a contact SCG sensor on the left lower sternal border of the chest wall at the 4thintercostal space for 1 min at two points in time with an interval of 2 to 48 hrs between assessments. The collected data contained 34 SCG waveform pairs: 17 pairs for patients with a NYHA class change from IV to III and 17 pairs for patients who stayed in class III. Results SCG signal waveform time-amplitude features were analyzed and the waveform variation quantified between the recording pairs. Results showed that the waveform variation was significantly different for those w/ and w/o NYHA class change (p Conclusions SCG changes may be a useful, safe and inexpensive modality for outpatient HF monitoring, enabling more timely intervention. These preliminary findings are supportive of an ability to differentiate HF functional status change. Further prospective studies are warranted.

Validation of Displayed Electrocardiographic Rhythms at the Central Monitoring Station

Scenario: The monitor technician made an overhead announcement to the intensive care unit (ICU) staff “bed check room 10” after seeing what appeared to be ventricular tachycardia (VT) in lead V1 at the central monitoring station (see box below). The ECG below was automatically printed from the central monitoring station following an alarm for “VTach.” The alarm occurred in a 72-year-old man admitted to the medical/surgical ICU for sepsis.False alarm caused by artifact mimicking VT in lead V1 at twice the actual heart rate. Sinus rhythm at a rate of 88 beats per minute. Possible ST-segment depression in inferior leads II and III, but wandering baseline is present.Although lead V1 shows a wide complex tachycardia suggestive of VT, the other simultaneously recorded leads show normal sinus rhythm. Note that the pulse waveform of the oxygen saturation (Spo2) is normal, indicating that the arterial pressure waveform did not change during this false alarm and the oxygen saturation is 99%. The respiratory waveform is unchanged as well. Of note, algorithms used in bedside ECG monitors often do not use all available leads for arrhythmia detection; hence, false alarms can occur. In addition, central monitoring stations typically display only 1 or 2 selected ECG leads, thus one may observe, as in this case, what appears to be VT on the central monitoring station. Verification of arrhythmias by examining all of the available leads should be standard protocol.The nurse should assess the patient immediately to ensure that no acute changes or symptoms are apparent. In addition, the nurse should check the patient’s chest to verify that lead V1 is in the correct location (4th intercostal space, right sternal border) and ensure that nothing is causing the artifact (ie, other devices, lead wires). The ST segments are consistently flattened in leads II and III. Because the T wave is also inverted in these leads, ischemia should be ruled out. Obtain a clean standard 12-lead ECG to verify that these T-wave changes are valid, and compare that ECG with a prior 12-lead ECG to determine if these changes are new.

Right upper sleeve lobectomy by video-assisted thoracic surgery

With accumulation of experiences in video-assisted thoracic surgery (VATS) lobectomy, complete VATS sleeve lobectomy (SL) has been carried out in more and more medical centers. We here presented a procedure of sleeve right upper lobectomy by complete VATS for a 62-year-old male patient with central squamous cell carcinoma. Traditional three incisions VATS technique was applied and the utility incision located on anterior axillary line of the 4th intercostal space. Continuous sutures were chosen for bronchial anastomosis using 3-0 prolene sutures. The chest drainage was removed on the postoperative fourth day.

GASTROPLEURAL FISTULA DUE THORACOABDOMINAL TRAUMA BY THE FIREARMS PROJECTILE, REPORT OF A CASE

The gastropleural fistula is an unusual pathological condition that requires a high index of diagnostic suspicion. A 30-year-old male patient was admitted to the María Auxiliadora Hospital due to a thoracoabdominal trauma opened by a firearm projectile, with an entrance hole in the left anterior hemithorax at the level of the 6th intercostal space and exit orifice in the right posterior hemithorax at the D10 level. When a hemopneumothorax was suspected, a thoracic drainage tube was placed and an exploratory laparotomy was performed after suspicion of gastric perforation. On the ninth day, 400cc of smelly greenish-green discharge with food debris in a thoracic drainage bottle was evident. The diagnosis of gastropleural fistula was made through upper gastrointestinal endoscopy and thoracoabdominal multislice spiral tomography. The treatment was by laparotomy and thoracotomy. Conclusions: Gastropleural fistula due to firearm projectile is an infrequent entity, with multiple diagnosis and surgical treatment. This requires early diagnosis for timely management, which depends on the prognosis of patients. Key words: Thoracic Injury; Gastropleural fistula; Intercostal drainage, Gun injury (source: MeSH NLM) DOI:  10.25176/RFMH.v18.n3.1600

Pneumotórax fechado em tamanduá mirim (Tamandua tetradactyla)

Background: Pneumothorax is characterized by the accumulation of air in the pleural space, either due to trauma or secondary to other conditions. Typically, pneumothorax is correlated with blunt trauma of the pulmonary parenchyma or penetrating trauma of the thoracic cavity, such as on being trampled upon or bitten, respectively. The therapeutic approach of this condition is rarely described in wild animals; therefore, the present study aims to describe the clinical manifestations, diagnostic method, and therapeutic aproach in a specimen of Tamandua tetradactyla with closed pneumothorax received for emergency care after being hit by a vehicle.Case: A southern tamandua (T. tetradactyla) was received in our hospital after being hit by a vehicle. The patient presented with a state of stupor, nystagmus, a restrictive respiratory pattern, and muffling on auscultation of respiratory and cardiac sounds in the left antimer. Simultaneously with the physical examination, venous access was established, pain control was intravenously performed and oxygen therapy was started. After stabilization, the patient underwent abdominal ultrasound (abdominal-focused assessment with sonography for trauma) and thoracic radiographs. The abdominal ultrasound confirmed the presence of a small amount of free fluid in the evaluated recesses, i.e., hepatodiaphragmatic, splenorenal, cystocholic, and hepatorenal, suggesting the need for periodic ultrasonographic monitoring associated with the clinical evaluation of the patient because of suspicion of active hemorrhage. The thoracic radiographic image (ventrodorsal recumbency) revealed increased pulmonary opacity due to lobar retraction, marked by an enlarged gap between the pulmonary lobes and thoracic wall, and the formation of a radiolucent area between both structures. The lateral recumbency evidenced the dorsal displacement of the cardiac apex in relation to the sternum. In addition to the thoracic alterations, a transverse fracture in the middle third of the diaphysis of the left fibula was identified by radiographic examination. After extensive hair clipping and skin antisepsis of the left hemithorax, thoracentesis (an adapted technique from that used in domestic animals) was performed with access via the 8th intercostal space in its most dorsal presentation using a 21-gauge Butterfly needle attached to a three-way medical valve and 20-mL syringe. The procedure allowed 100 mL air to be drained until the negative pressure of the cavity was restored. At the end of the drainage, the patient showed a remarkable improvement in the respiratory pattern, and follow control radiographs showed full pulmonary expansion and no recurrence. The possibility of active abdominal hemorrhage was disregarded because ultrasound monitoring after 6 h revealed no change in the amount of free fluid in the suppressed recess.Discussion: Pneumothorax is an important condition that can be detected in injured domestic and wild animals that are run over. The association between a detailed clinical evaluation and radiographic examination was essential for the diagnosis and initiation of the appropriate therapy, contributing to the prognosis of the patient. The adaptation of the thoracocentesis technique used in domestic animals proved to be suitable for the treatment of this Tamandua tetradactyla.

Evaluation of the Mandibular Incisive Canal by Panoramic Radiography and Cone-Beam Computed Tomography

Background: Radiofrequency ablation (RFA) in Brugada syndrome (BrS) has been performed both endocardially and epicardially. The substrate in BrS is thus unclear. Objectives: To investigate the functional endocardial substrate and its correlation with clinical, electrophysiological and ECG findings in order to guide an endocardial ablation. Methods: Thirteen patients (38.7±12.3 years old) with spontaneous type 1 ECG BrS pattern, inducible VF with programmed ventricular stimulation (PVS) and syncope without prodromes were enrolled. Before to endocardial mapping the patients underwent flecainide testing with the purpose of measuring the greatest ST-segment elevation for to be correlated with the size and location of substrate in the electro-anatomic map. Patients underwent endocardial bipolar and electro-anatomic mapping with the purpose of identify areas of abnormal electrograms (EGMs) as target for RFA and determine the location and size of the substrate. Results: When the greatest ST-segment elevation was in the 3rd intercostal space (ICS), the substrate was located upper in the longitudinal plane of the right ventricular outflow tract (RVOT) and a greatest ST-segment elevation in 4th ICS correspond with a location of substrate in lower region of longitudinal plane of RVOT. A QRS complex widening on its initial and final part, with prolonged transmural and regional depolarization time of RVOT corresponded to the substrate locateded in the anterior-lateral region of RVOT. A QRS complex widening rightwards and only prolonged transmural depolarization time corresponded with a substrate located in the anterior, anterior-septal or septal region of RVOT. RFA of endocardial substrate suppressed the inducibility and ECG BrS pattern during 34.7±15.5 months. After RFA, flecainide testing confirmed elimination of the ECG BrS pattern. Endocardial biopsy showed a correlation between functional and ultrastructural alterations in two patients.

The Voice of the Heart: Vowel-Like Sound in Pulmonary Artery Hypertension.

Increased blood pressure in the pulmonary artery is referred to as pulmonary hypertension and often is linked to loud pulmonic valve closures. For the purpose of this paper, it was hypothesized that pulmonary circulation vibrations will create sounds similar to sounds created by vocal cords during speech and that subjects with pulmonary artery hypertension (PAH) could have unique sound signatures across four auscultatory sites. Using a digital stethoscope, heart sounds were recorded at the cardiac apex, 2nd left intercostal space (2LICS), 2nd right intercostal space (2RICS), and 4th left intercostal space (4LICS) undergoing simultaneous cardiac catheterization. From the collected heart sounds, relative power of the frequency band, energy of the sinusoid formants, and entropy were extracted. PAH subjects were differentiated by applying the linear discriminant analysis with leave-one-out cross-validation. The entropy of the first sinusoid formant decreased significantly in subjects with a mean pulmonary artery pressure (mPAp) ≥ 25 mmHg versus subjects with a mPAp < 25 mmHg with a sensitivity of 84% and specificity of 88.57%, within a 10-s optimized window length for heart sounds recorded at the 2LICS. First sinusoid formant entropy reduction of heart sounds in PAH subjects suggests the existence of a vowel-like pattern. Pattern analysis revealed a unique sound signature, which could be used in non-invasive screening tools.

Investigation on the optimal implantation site and setting of Reveal LINQ® avoiding interference with performance of transthoracic echocardiography.

BackgroundThe optimal implantation site of a new implantable cardiac monitor (ICM) named Reveal LINQ® may be limited based on a sufficient amplitude of R wave potential (AEP) acquisition because it is the same anatomic area used for transthoracic echocardiography (TTE).MethodsAmong 18 healthy volunteers, we assessed AEPs in 3 combinations through parasternal placement of 2 electrodes, (i) in the 4th intercostal space (ICS; site A/setting a; A/a), (ii) the same setting in the 5th ICS (site B/setting a; B/a), and (iii) in a sagittal plane relative to the left sternal border at the 4th ICS (site A/setting b; A/b), and further measured AFPs in several body positions in all site‐setting combinations: supine, left and right lateral decubitus, sitting, and standing. The degree of interference with TTE performance was assessed by placement of an imitation ICM in setting a at both sites A and B.ResultsOnly the AEPs in A/a and B/a met the criteria (AEP ≥ 0.3 mV) in all positions. The AEPs in the supine position with all combinations were higher than those achieved in other positions (P < .001). The imitation interfered with TTE performance at site A among 78% of subjects, but only 17% at site B (P = .0006). The end‐diastolic dimension of the left ventricle at site A was decreased after the imitation placement (P = .028). At site B, all female subjects complained of discomfort because their brassieres overlaid the imitation.ConclusionThe B/a combination is optimal; however, the personal discomfort related to brassieres should be considered.

Un hémithorax blanc chez une jeune portant des tâches café au lait

Neurofibromatosis type 1 (NF1) or Von Recklinghausen disease is an autosomal dominant genetic disorder with multivisceral manifestations. We report the case of a spontaneous haemothorax in a young lady wearing this genetic pathology. A 31-year-old woman with kyphoscoliosis developed acute chest pain and dyspnea. The physical examination revealed a right pleuritic syndrome, coffee and milk spots and neurofibromas of the trunk. Biological assessment showed anemia at 6.4g/dl. Chest x-ray revealed a right side opacification. The pleural puncture showed an incoagulable hemorrhagic fluid. The chest CT scan showed no vascular abnormalities. The diagnosis of spontaneous haemothorax, revealing NF1, was retained. Transfusion and thoracic drainage were performed followed by haemostasis surgery. Pleural exploration showed pleural hematoma with regard to the 5th intercostal space. Electrocoagulation and declogging were performed. The evolution of the patient was favorable. Haemothorax is a rare and serious complication which may reveal NF1. It must be suspected when sudden and spontaneous white haemithorax occurs in NF1.

Use of the iTClamp versus standard suturing techniques for securing chest tubes: A randomized controlled cadaver study

ObjectivesTube thoracostomy (TT) is a common yet potentially life-saving trauma procedure. After successful placement however, securing a TT through suturing is a skillset that requires practice, risking that the TT may become dislodged during prehospital transport. The purpose of this study was to examine if the iTClamp was a simpler technique with equivalent effectiveness for securing TTs. Materials and methodsIn a cadaver model, a 1.5 inch incision was utilized along the upper border of the rib below the 5th intercostal space at the anterior axillary line. TTs (sizes 28Fr, 32Fr, 36Fr and 40Fr) were inserted and secured with both suturing and iTClamp techniques according to the preset randomization. TT were then functionally tested for positive and negative pressure as well as the force required to remove the TT (pull test-up to 5 lbs). Time to secure the TT was also recorded. ResultsWhen sutured is placed by a trained surgeon, the sutures and iTClamp were functionally equivalent for holding a positive and negative pressure. Mean pull force for both sutures and iTClamp exceeded the 5 lb threshold; there was no significant difference between the groups. Securing the TT with the iTClamp was significantly faster (p < 0.0001) with the iTClamp having a mean application time of 37.0 ± 22.8 s and using a suture had a man application time of 96.3 ± 29.0 s. ConclusionThe iTClamp was effective in securing TTs. The main benefit to the iTClamp is that minimal skill is required to adequately secure a TT to ensure that it does not become dislodged during transport to a trauma center.

Robot-assisted thymectomy via subxiphoid approach: technical details and early outcomes.

Trans-subxiphoid thoracoscopic thymectomy is a promising procedure but technically demanding associated with ergonomic discomfort. In order to facilitate this complex procedure, the authors present a modified trans-subxiphoid thymectomy by the use of the Da Vinci robotic system. A 2-cm longitudinal incision for camera was made below the xiphoid process. Through this incision, the space among the posterior surface of the sternum, bilateral mediastinal pleura and diaphragm (extra pleural space) was enlarged blindly with a finger. Additional two operation holes were created below bilateral costal arches, and then two 8-mm robotic trocars were inserted into the extra pleural space. A third robotic instrument was placed in the 5th intercostal space after bilateral mediastinal pleura were dissected. The whole thymus was excised for patients with thymic tumor, and simultaneous resection of surrounding adipose tissues was performed for patients with myasthenia gravis. Clinical characteristics and early surgical outcomes of the patients were retrospectively collected and analyzed. Between August 2016 and September 2017, 70 consecutive patients with myasthenia gravis or thymic neoplasm were successfully treated by the described surgical procedure. The median overall operative time was 115 (range, 60-150) min. The median hospital stay was 5 (range, 4-7) days. The median duration of chest tube was 3 (range, 1-8) days. The blood loss was minimal for all the patients. There was no mortality, conversion or postoperative complication during the postoperative and follow-up period. Based on our preliminary experience, the described technique of thymectomy is safe and feasible, and provides an optimal access for the robot camera and the instruments.

Intercostal and glissonian pedicle Approach in laparoscopic liver resection for bilobar tumors

Bilobar liver metastasis is challenging for laparoscopic liver resection. Especially, subphrenic liver tumors in S7 or S8 are technically difficult to be resected out because the space is limited and the angle of instruments to lesions cannot be perpendicular.1,2 Major liver lobectomy is also challenging for laparoscopic liver resection. Glissonian pedicle approach has benefit that any variation of vascular and bile duct elements does not need to be considered in the hepatoduodenal ligament under the hilar plate. Glissonian pedicle approach is simpler and faster than individual dissection of hepatoduodenal ligament. This video illustrates a hand-assisted laparoscopic left lobectomy and partial liver resection of S8 in a 48-year-old male with metastatic colorectal carcinoma to the liver. He received 6 cycle of FOLFOX as neoadjuvant chemotherapy. The patient was positioned in semi left lateral decubitus so that a lesion in S8 was easily approached. A tumor in S8 was approached after right lobe mobilization. The liver resection was performed by a harmonic scalpel. A 5-mm balloon port was placed in 6th intercostal space to approach the lesion perpendicular. For left hepatectomy, glissonian pedicle approach was applied to control vascular inflow. Dissections was performed at bifurcation on the right glissonian and left glissonian pedicles. Dissection direction to the left side was above hepatogastric ligament. The tunnel was created including all left glissonian sheath, and a vessel loop was taped. An endovascular stapler was inserted and fired with dividing the left glissonian pedicle as en bloc. Hepatic parenchymal dissection was performed by the harmonic scalpel. Left hepatic vein was divided using an endoscopic vascular stapler. The specimens were removed from a hand-port. The operative time was 290 min. Blood loss was 250 ml, and no blood transfusion was required. He resumed a regular diet the next day and was discharged on postoperative day 4. Intercostal approach is useful for subphrenic liver tumors, and glissonian pedicle approach is also useful for major lobectomy for laparoscopic liver resection.