Sixth Intercostal Space Research Articles

MID–TERM OUTCOMES OF ENDOSCOPIC MITRAL VALVE REPAIR VIA RIGHT ANTERIOR MINI–THORACOTOMY

Abstract The adoption of less–invasive mitral repair (MVr) surgery is increasing, backed by evidence of satisfactory short–term results and lower major morbidity. We assessed mid–term follow–up results of our experience, and compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet (PML) prolapse. Between 2012–2021, 700+ operations were performed with a video–assisted right mini–thoracotomy (RMT) approach. We report 309 consecutive patients who had endoscopic MVr, including those receiving concomitant tricuspid repair, ablation for atrial fibrillation, closure of patent foramen ovale and/or left atrial appendage. The early and mid–term follow–up results were ascertained. Primary outcome was the incidence of mortality and significant mitral regurgitation (MR) during follow–up which were summarized by Kaplan–Meier estimator and compared between treatment arms via log–rank test. Secondary outcomes were the early–postoperative results including 30–days mortality and major complications. All patients had endoscopic MVr via RMT at the 3rd/4th intercostal space (IS). A soft–tissue retractor is used, accompanied or not by a rib spreader, and two ports in the fourth and sixth IS are used for 3D thoracoscopy and carbon dioxide insufflation. Femoral vessels exposure through a right groin incision and echo–guided cannulation sec. Seldinger is achieved post–heparinization. Thoracic fascia bisection is performed during single–lung ventilation using a double–lumen endotracheal tube, integral to our anesthetic management, including percutaneous right internal jugular vein cannulation. The pericardium is opened and an aortic root cannula for cardioplegia delivery and venting is placed via working incision. After establishing cardiopulmonary bypass, a Chitwood clamp is passed through the second IS and cardioplegia is delivered. Endoaortic balloon clamping is primarily used in redo cases. With ring annuloplasty, 136 (44%) patients received PML resection (122 isolated) and 97 (31%) PML chords implantation (88 isolated). Forty–nine patients had annuloplasty alone. In–hospital mortality was 1.0%. Mean follow–up was 29±22 months (max 8.3 years). Kaplan–Meier 5–year survival was 97.3±1.0%. MR (3/4+) free–survival at 5 years was 94.5±2.3%. Subgroup time–to–event analysis for the indexed outcomes showed no statistical significance between techniques. In conclusion, endoscopic MVr is safe with excellent mid–term outcomes.

Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study

IntroductionThe optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2–T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection...

Factors related to post-thoracotomy pain following robotic-assisted thoracic surgery.

Robotic-assisted thoracic surgery (RATS) is a minimally invasive procedure; however, some patients experience persistent postoperative pain. This study aimed to investigate factors related to postoperative pain following RATS. The data of 145 patients with lung cancer, who underwent RATS with a four-port (one in the sixth intercostal space [ICS] and three in the eighth ICS) lobectomy or segmentectomy between May 2019 and December 2022, were retrospectively analyzed. Factors associated with analgesic use for at least 2 months following postoperative pain (PTP group) were analyzed. Patients who underwent preoperative pain control for any condition or chest wall resection were excluded. Among the 138 patients, 45 (32.6%) received analgesics for at least 2 months after surgery. Patient height and transverse length of the thorax correlated with PTP in the univariate analysis (non-PTP vs. PTP; height, 166 vs. 160 cm; p < .001; transverse length of the thorax, 270 vs. 260 mm, p = .016). In the multivariate analysis, height was correlated with PTP (p = .009; odds ratio, 0.907; 95% confidence interval, 0.843-0.976). Height correlated with the transverse length of the thorax (r = .407), anteroposterior length of the thorax (r = .294), and width of the eighth ICS in the middle axillary line (r = .210) using Pearson's correlation coefficients. When utilizing a 165-cm cutoff value for height to predict PTP using receiver operating characteristic curve analysis, the area under the curve was 0.69 (95% confidence interval, 0.601-0.779). Short stature is associated with a high risk of postoperative pain following RATS.

Determining the Optimal Position of Surface Electrodes for Diaphragm Electromyography: A Cross-Sectional Study.

Placing electrodes on different aspects of the chest determines the motor firing from the diaphragm. The electrode placement close to the extent of the muscle gave promising readings as compared to the ones that were placed away. The position with the maximum amplitude and least duration was chosen. Positions of the electrodes were decided as per the extent of the muscle. The aim is to determine the appropriate position of surface electrodes for surface diaphragm electromyography (EMG). Thirty healthy individuals of age ranging from 21 to 45 years were included in the study. Participants were made to lie down in a supine position and different positions like G1 (recording electrode) 5 cm superior to the tip of the xiphoid process and G2 (reference) 16 cm along the costal margin from G1, G1 over the xiphoid tip and G2 at the seventh intercostal space at the costochondral junction and G1 over the xiphoid tip and G2 at the eight intercostal space at the costochondral junction were used for assessing maximum amplitudes and durations were observed by using a Octopus New Wave EMG machine (Octopus Medical Technologies, Vadodara, IND). After observing all the positions, an optimum position for maximum amplitude and least duration was analyzed. As per the study, out of the four positions, the electrode placements on the tip of the xiphoid process and 16 cm away diagonally on the sixth intercostal space showed maximum amplitude and the least duration with maximum mean amplitude and less mean duration of 232.35 and 7.316. On the seventh intercostal space it was 199.15 and 7.887 and on the eighth intercostal space was 176.055 and 8.639. The tip of the xiphoid process and 16 cm away diagonally on the sixth intercostal space is chosen as the appropriate position for electrode placement for EMG of the diaphragm. We conclude that the best electrode position was when the electrodes were placed 5 cm superior to the xiphoid process, i.e., G1, and 16 cm away from the recording electrode on the costochondral junction, i.e., G2, at the sixthintercostal space. Ground electrode placement is the nearest bony prominence, i.e., xiphisternum.

Ruptured Pulmonary Hydatid Cyst with Multiple Small Bronchopleural Fistula Formations: A Case Report

Hydatid disease is a zoonosis caused by Echinococcus granulosus. It manifests as cystic lesions, most commonly found in the liver and lungs, and rarely in other parts of the body. The disease occurs when a human host accidentally ingests contaminated food containing eggs from canine waste products. Since the clinical characteristics of this disease are nonspecific, radiological investigations play a crucial role in diagnosis. Diagnostic challenges arise due to atypical imaging features of complicated hydatid cysts. A 40-year-old female patient presented with fever, breathlessness, chest pain, and an unproductive cough persisting for eight days. Upon examination, she was in hypovolaemic shock, and an intercostal drainage tube had been inserted in the left sixth intercostal space. The chest radiograph revealed a dense, homogeneous opacity in the left hemithorax, partially compressing the left lung medially. An High-resolution Computed Tomography (HRCT) thorax showed a thick-walled cavity with an air-fluid level and layered membranes in the dependent part of the cavity, indicating a water lily sign in the left lower lobe of the lung, suggesting a ruptured hydatid cyst. The patient underwent cystectomy with suturing of a small bronchopleural fistula. Computed Tomography (CT) is the preferred imaging modality, especially for assessing associated complications and ruling out differentials in cases of ruptured pulmonary hydatid cysts.

Anatomical considerations for the surgical approach to the canine accessory lung lobe.

To describe (1) the surgical anatomy of the accessory lung lobe (ALL) including vasculature and pulmonary ligamentous attachments and (2) lobectomy through a right thoracotomy and median sternotomy. Cadaveric anatomical study. Nine adult canine cadavers, free of disease affecting the thoracic cavity and lung parenchyma. Median sternotomy and right and left lateral thoracotomies were performed to describe and image relevant variations in anatomy using accompanying photographs and thorough voice notes. Consideration for ALL removal via right thoracotomy at the fifth through seventh intercostal spaces and median sternotomy were documented and compared. The median weight of the cadavers was 20.85 kg (6.9-45.5 kg). Variation in the configuration of venous drainage of the ALL was identified. The lateral vein varied in its location and was also observed to combine with the medial vein in one cadaver. The pulmonary ligament attached to the ALL in a caudally pointing apex on the dorsal process of the lobe. Medial and lateral extensions of the ALL parenchyma were found. The ALL was most easily accessed by a right lateral thoracotomy at the sixth intercostal space. Although not optimal, removal of this lung lobe via median sternotomy was feasible. Significant variations were found in the blood supply to the ALL. A right lateral thoracotomy at the sixth intercostal space was preferred for a surgical approach to the ALL. Surgeons should be aware of several anatomical particularities including the venous drainage, ligamentous attachments, and parenchymal extensions of the ALL.

Sub-axillary cosmetic incision versus single-incision thoracoscopic surgery for primary spontaneous pneumothorax

BackgroundIn recent years, single-incision thoracoscopic surgery (SITS) has been increasingly applied as an optimal treatment option for primary spontaneous pneumothorax (PSP). However, most SITS techniques are used in the fourth to sixth intercostal space between the anterior axillary and mid axillary lines. To find out more concealed incisions, this study performed PSP surgery via the sub-axillary cosmetic incision (SACI) technique.MethodsA total of 128 PSP patients were subjected to video-assisted thoracoscopic surgery (VATS) between January 2017 and January 2019 at our institution. These patients were evaluated and assigned into SACI (n = 21) and SITS (n = 57) groups. Propensity score matching (PSM) was performed based on patients’ backgrounds, and the enrolled cohort was divided into 21 pairs. The incision satisfaction was assessed at 2 weeks and 6 months post-surgery.ResultsThe 21 pairs with matching baseline characteristics in the two groups did not exhibit significant differences in their backgrounds and surgical results. However, compared with the SITS group, the operation time was longer in the SACI group (p = 0.013). There were no post-operative complications in both groups. At 2 weeks and 6 months, incision satisfaction scores in the SACI group were significantly lower than those in the SITS group (p = 0.022 and p = 0.039, respectively). There were no recurrences of ipsilateral pneumothorax in both groups.ConclusionsSACI is a safe and feasible surgical method for PSP treatment. In addition, incision concealment can be used for patients with incision needs.

PO-01-045 INJURY TO THE LEFT INTERNAL THORACIC ARTERY DURING PERCUTANEOUS EPICARDIAL ACCESS FOR CATHETER ABLATION: PREVENTION AND MANAGEMENT

Damaging the left internal thoracic artery (LITA) is considered to be a possible complication of percutaneous epicardial catheter ablation. The LITA typically courses approximately 1cm from the sternal margin and bifurcates around the sixth intercostal space and may be located in the epicardial needle trajectory. However, reports of this complication are scarce. We report two cases of epicardial ablation: one with an uncommon LITA injury complication during epicardial access (EA) and another showing its preventive measures. N/A Case 1. A 39 year-old man with Brugada syndrome underwent epicardial catheter ablation. Since the initial EA from the subxiphoid region failed, we alternatively performed a parasternal intercostal EA at the fifth intercostal space 2cm from the sternal margin and placed a guidewire in the pericardial space. Shortly after the puncture needle was removed, we observed active bleeding from the puncture site and a drop in the blood pressure. We replaced the guidewire with an 8F drainage catheter and removed the arterial blood from the pericardial space, which stopped the bleeding and stabilized the blood pressure. The arteriography revealed a penetration of the LITA by the drainage catheter (Fig 1A). We secured the pericardial space with a second guidewire (GW2) inserted from an adjacent site. Then, we performed a percutaneous coil embolization of the LITA (VortX™ 18 Diamond Shape Fibered Platinum Coils, Boston Scientific). During the procedure, when the drainage catheter was removed, we confirmed the extravasation of the contrast medium from the injured site (Fig 1B). Finally, hemostasis was achieved (Fig 1C). A sheath was advanced into the pericardial space with a GW2 and the epicardial catheter ablation was successfully performed (Fig 1D). No blood transfusion was required. Case 2. A 25 year-old man with Brugada syndrome underwent epicardial catheter ablation with a subxiphoid anterior EA. Bi-plane angiography performed prior to the EA clearly delineated a tortuous and branching LITA (Fig 1E). The EA was securely obtained with the on-site anatomical information. Case 1 demonstrated direct evidence of a LITA injury occurring during an EA. Angiography immediately before an EA can visualize the detailed LITA anatomy and may ensure safety during a subsequent EA. If a LITA injury occurs, a coil embolization of the LITA may be a feasible and effective treatment.

650. ROBOTIC ESOPHAGEAL LEIOMYOMA ENUCLEATION

Abstract Leiomyomas are rare benign esophageal neoplasms. Surgery is indicated in symptomatic patients or if malignancy is suspected. A 20-year-old female presented with dysphagia to solids. Contrast enhanced computed tomography showed a 33-mm by 30-mm by 51 mm well circumscribed lobulated mass arising from the right anterolateral wall of the upper thoracic esophagus, causing luminal narrowing and abutting the azygos vein. An esophageal ultrasound performed for confirmation showed the lesion arising from the muscularis propria. Patient was scheduled for a robotic leiomyoma excision. Patient was placed in left lateral position, lung isolation was obtained with a double lumen tube. Four standard ports were placed in the sixth intercostal space. Robotic instruments used were the monopolar scissors, Maryland bipolar forceps, fenestrated bipolar forceps for dissection and needle holder for suturing. The leiomyoma was identified, mediastinal pleura and muscle layer were incised longitudinally. The leiomyoma was dissected all around in the submuscular plane taking care not to injure the underlying mucosa. However, while delivering the deep lobulated portion, there was an inadvertent injury to the mucosa. The mucosal tear was repaired with interrupted sutures utilising 4-0 Polydiaxanone sutures and the muscle layer was closed with V-Lock sutures. A check endoscopy was performed on table along with air insufflation with saline in the pleural cavity to check for an air leak. A nasogastric tube was placed, specimen was retrieved in a bag through the assistant port. Surgery was completed in 155 minutes with 50 ml blood loss. Post-operative course was uneventful, and the patient was discharged on full diet on the fourth post-operative day. Histopathology showed a SMA and desmin-positive spindle cell neoplasm without conspicuous mitotic activity. Precise dissection in a confined space is possible due to wrist-like movements, three-dimensional view and magnification offered by the robot. Repair of the injured mucosa and myotomy closure to prevent future diverticulum formation is easily accomplished with robotic suturing. Intraoperative endoscopy is useful in evaluating the integrity of the mucosa and muscle repair. Hence a robotic approach may be superior to a thoracoscopic/open leiomyoma enucleation and can be utilised even in moderate size masses.

A Two-Point Ultrasound-Guided Injection Technique for the Transversus Thoracis Plane Block: A Canine Cadaveric Study

Simple SummaryThe transversus thoracis plane block is a locoregional technique recently described in canine cadavers to desensitize the intercostal nerves running through this plane. In canine cadavers, a transverse approach through a single injection point at the fifth intercostal space has been described, although consistent staining of the intercostal nerves was not completely achieved. The objective of this study was twofold: (1) to evaluate if the transverse approach is feasible at the third and sixth intercostal spaces and (2) to compare, by anatomical dissection, the spread of a dye solution and the staining of the intercostal nerves when a low volume (0.5 mL kg−1) or a high volume (1 mL kg−1) was equally divided at a two-point injection in the same hemithorax. Our results showed that the injection of the high-volume dye solution, equally injected at the third and sixth intercostal spaces using the transverse approach, achieved a consistent staining of from T2 to T7 intercostal nerves. This block could achieve adequate desensitization of the ventral chest wall during sternotomy in the dog. Clinical studies in live animals are necessary to confirm the efficacy of this technique.The transversus thoracis plane (TTP) block desensitizes the intercostal nerves that run through this plane, providing analgesia to the ventral thoracic wall. Two canine cadavers were used to assess the feasibility of the transverse approach for the TTP (t-TTP) under ultrasound guidance to inject a solution at the third and sixth intercostal spaces. Eight cadavers were used to compare the spread and number of intercostal nerves that were stained when a low volume (LV) 0.5 mL kg−1 or a high volume (HV) 1 mL kg−1 of a dye-lidocaine solution was injected into the same hemithorax, injecting the volume equally at these intercostal spaces using the transverse approach. Fisher’s exact test and Wilcoxon signed-rank test were used to contrast the spread of the different volume solutions. The injectate spread along the TTP after all injections, dying a median number (range) of 3 (2–5) and 6 (5–6) nerves with LV and HV, respectively (p = 0.011). The two-point injection of HV, using the t-TTP approach, is a feasible technique that provides a consistent staining from T2 to T7 intercostal nerves. The injection of HV instead of LV increases the spread and enhances the number of stained intercostal nerves.

Rerouting the internal thoracic vessels as recipient vessels in head and neck reconstruction: Comparison of two anatomic approaches

IntroductionThe vessel-depleted neck situation is a challenge for the surgeon in search of suitable recipient vessels for microvascular reconstruction of the head and neck. The internal thoracic vessels (ITVs) have proven useful as “rescue” recipient vessel resource. The objective of this report is to assess the feasibility of using ITVs by rerouting the pedicle for free flap reconstruction of the head and neck by comparing two different approaches. Material and MethodsTwo surgical approaches were assessed: the classical one is parasternal, but cardiac surgeons commonly use median sternotomy. We conducted an anatomical study, comparing on the same subject the lengths and diameters of both internal thoracic artery (ITA) and internal thoracic vein (ITV) at the sixth, fifth, and fourth intercostal spaces (ICSs) through parasternal approach on one side and by median sternotomy on the other side. ResultsThe study was performed on 13 subjects. We found a superiority of length of the ITVs with the median sternotomy approach. Regarding the mean length of the ITA, the sternotomy approach allowed a significant greater length with 119/89/67 mm, compared with parasternal approach with 91/62/42 mm, respectively at the sixth, fifth, and fourth ICS (p<0.001). Similarly, we observed a significant greater length of the ITV with 116/85/63 mm versus 89/62/42 mm (p<0.001).The mean arterial and venous diameters were 2.9 mm and 2.1 mm in the sixth ICS, 3.3 mm and 2.3 mm in the fifth ICS, and 3.9 mm and 2.9 mm in the fourth ICS, respectively. ConclusionThese results help to guide the choice of surgical approach and the level of harvesting.

Evaluation of lung ventilation distribution using electrical impedance tomography in standing sedated horses with capnoperitoneum

ObjectiveTo determine changes in distribution of lung ventilation with increasing intra-abdominal pressure (IAP) from carbon dioxide (CO2) insufflation in standing sedated horses. Study designProspective experimental study. AnimalsA group of six healthy adult horses. MethodsEach horse was sedated with acepromazine, detomidine and butorphanol and sedation maintained with a detomidine infusion. The horse was restrained in a stocks system and a 32 electrode electrical impedance tomography (EIT) belt was wrapped around the thorax at the fifth–sixth intercostal space. EIT images and arterial blood samples for PaO2 and PaCO2, pH and lactate concentration were obtained during capnoperitoneum at 0 (baseline A), 5, 8 and 12 mmHg as IAP increased and at 8, 5, 0 (baseline B) mmHg as IAP decreased. At each IAP, after a 2 minute stabilization period, EIT images were recorded for ≥ 2 minutes to obtain five consecutive breaths. Statistical analysis was performed using anova for repeated measures with Geisser-Greenhouse correction and a Tukey’s multiple comparison test for parametric data. The relationship between PaO2 and the center of ventilation in the ventral-dorsal (CoV-VD) and right-left (CoV-RL) directions or total impedance change as a surrogate for tidal volume (ΔZVT) were tested using linear regression analysis. Significance was assumed when p ≤ 0.05. ResultsThere were no significant changes in CoV-VD, CoV-RL, PaO2, PaCO2, lactate concentration, pH, heart rate and respiratory rate with targeted IAP. There was a significant decrease in ΔZVT compared with baseline A at 5 mmHg IAP as IAP was increased. Conclusions and clinical relevanceCapnoperitoneum causes a significant decrease in ΔZVT in standing sedated horses with increasing IAP.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Tachycardiomyopathy Due To Hyperthyroidism: Case Report

Introduction High output heart failure (HF) is one of the complications of hyperthyroidism. Some patients may evolve with reduced ejection fraction HF (HFREF) due to tachycardiomyopathy. The most prevalent arrhythmias are atrial fibrillation and atrial flutter, which, when controlled, improve HF. Hypotheses: Tachycardiomyopathy resulting from hyperthyroidism. Methods Descriptive, qualitative, and documentary study of the “case report” type. Case report Male, 35 years old, with no previous comorbidities, sought emergency with signs of decompensated HF associated with palpitations, hyperthermia, sweating, anterior neck pain, and extremity tremors. Thyroid with increased volume resulting from multiple nodules, without murmurs; bilateral exophthalmos; propulsive ictus with two digital pulps, in the sixth left intercostal space, irregular heart rhythm, HR 140bpm, pathological jugular venous pressure, bilateral crackles up to middle third. Lower limbs with edema + 3 / + 4. EKG in high-response atrial fibrillation rhythm reversed during hospitalization with amiodarone. ECHO with severe global LV systolic dysfunction with Simpson's ejection fraction 12%. He was discharged from the hospital with carvedilol, furosemide, amiodarone, and oral anticoagulant, being referred to primary care. Doppler ultrasonography of the thyroid showing increased volume, lobulated contours with diffuse heterogeneous parenchyma of multinodular aspect, and increased vascularity. Laboratory tests confirmed hyperthyroidism (TSH 0.008 mU / L; T4L 2.22 ng / dL; TRAB 9.58 IU / L). Optimized treatment for HF (added enalapril and spironolactone), it evolved in NYHA I, with a new ECHO after 3 months showing mild LV dysfunction with 45% EF. In a joint follow-up with endocrinology, under treatment with Methimazole, awaiting thyroidectomy. Conclusion Hyperthyroidism increases metabolic demand and can lead to cardiovascular complications such as HF and atrial arrhythmias. This occurs by increasing blood volume, reducing systemic vascular resistance and reducing circulation time, triggering LV hypertrophy, and reducing myocardial contractile reserve. The hyperthyroidism with decompensated HF is a medical emergency with up to 30% mortality. It is a treatable entity, and its complications are potentially reversible. High output heart failure (HF) is one of the complications of hyperthyroidism. Some patients may evolve with reduced ejection fraction HF (HFREF) due to tachycardiomyopathy. The most prevalent arrhythmias are atrial fibrillation and atrial flutter, which, when controlled, improve HF. Hypotheses: Tachycardiomyopathy resulting from hyperthyroidism. Descriptive, qualitative, and documentary study of the “case report” type. Male, 35 years old, with no previous comorbidities, sought emergency with signs of decompensated HF associated with palpitations, hyperthermia, sweating, anterior neck pain, and extremity tremors. Thyroid with increased volume resulting from multiple nodules, without murmurs; bilateral exophthalmos; propulsive ictus with two digital pulps, in the sixth left intercostal space, irregular heart rhythm, HR 140bpm, pathological jugular venous pressure, bilateral crackles up to middle third. Lower limbs with edema + 3 / + 4. EKG in high-response atrial fibrillation rhythm reversed during hospitalization with amiodarone. ECHO with severe global LV systolic dysfunction with Simpson's ejection fraction 12%. He was discharged from the hospital with carvedilol, furosemide, amiodarone, and oral anticoagulant, being referred to primary care. Doppler ultrasonography of the thyroid showing increased volume, lobulated contours with diffuse heterogeneous parenchyma of multinodular aspect, and increased vascularity. Laboratory tests confirmed hyperthyroidism (TSH 0.008 mU / L; T4L 2.22 ng / dL; TRAB 9.58 IU / L). Optimized treatment for HF (added enalapril and spironolactone), it evolved in NYHA I, with a new ECHO after 3 months showing mild LV dysfunction with 45% EF. In a joint follow-up with endocrinology, under treatment with Methimazole, awaiting thyroidectomy. Hyperthyroidism increases metabolic demand and can lead to cardiovascular complications such as HF and atrial arrhythmias. This occurs by increasing blood volume, reducing systemic vascular resistance and reducing circulation time, triggering LV hypertrophy, and reducing myocardial contractile reserve. The hyperthyroidism with decompensated HF is a medical emergency with up to 30% mortality. It is a treatable entity, and its complications are potentially reversible.

Uniportal VATS Approach in Esophageal Cancer - How to Do It Update.

The adoption of minimally invasive esophagectomy has been used for over a decade, and the chest part is evolving into a uniportal video-assisted thoracoscopic surgery (VATS) approach. Uniportal esophageal mobilization and anastomosis have many peculiar aspects, which include placement of the incision, alignment of instruments, and anastomosis. The incision is placed over the sixth intercostal space posterior axillary line. The esophagus is usually encircled at the level of the inferior pulmonary vein. The use of curved suction helps in the retraction of the esophagus and the exposure of the left main bronchus deep in the mediastinum. For intrathoracic anastomosis in Ivor Lewis esophagectomy, a completely side-to-side linear-stapled anastomosis is preferred. This anastomotic technique results in a long stapler line. The correct alignment of tissues and adequate anastomotic circumference are of utmost importance to prevent leaks or strictures. Perioperative and oncologic results in several series with uniportal VATS, esophageal mobilization, and anastomosis are comparable with open or other types of minimally invasive esophagectomy. Uniportal VATS for esophagectomy is feasible and fast with good results.

Triple Intercostal Transthoracic Ports in Laparoscopic Hepatectomy for a Tumor in a Cranially Protruded Liver (with Video).

It is difficult to laparoscopically approach tumors of the anatomically anomalous right lobe of the liver, such as cranially protruded liver. The intercostal port has been useful for laparoscopic hepatectomy, especially for tumors located in the dome of the liver. PLoS One. 15:e0234919; Surg Endosc. 31:1280-1286; J Gastrointest Surg. 21:2135-2143; J Hepatobiliary Pancreat Sci. 21:E65-68; Surg Oncol. 38:101576; Thus, we introduce our technique using triple intercostal transthoracic ports for laparoscopic hepatectomy for hepatocellular carcinoma located in segment 8. The right lobe of the liver was cranially protruded and located at the same level of the heart. The patient was placed in left lateral decubitus position. After the pneumoperitoneum and adhesiolysis, the hepatoduodenal ligament was controlled. Three additional intercostal ports with balloons were introduced transdiaphragmatically for liver parenchymal resection after confirmation of the lung edge by mandatory ventilation. A 12-mm and a 5-mm port were inserted into the sixth and seventh intercostal space for the operator's hands, while a 5-mm port was inserted into the fourth intercostal space for the assist's right hand. The liver parenchymal resection was performed using a cavitron ultrasonic surgical aspirator (CUSA) through the 12-mm intercostal port, followed by its completion without exposing the tumor. The 12-mm port hole on the diaphragm was sutured and a 12-Fr chest tube was introduced in the right thoracic cavity. The operation time was 131 min, and the blood loss was 20 g. The patient was discharged on postoperative day 7 without any complication. Triple intercostal ports could be a feasible procedure for a tumor with limited laparoscopic access from the abdominal port due to the anatomically anomalous liver.

Matching the perforating branch of the internal thoracic artery and the deep inferior epigastric artery for breast reconstruction using multi-detector row computed tomography.

Matching the diameter of the deep inferior epigastric artery (DIEA) and perforating branch (PB) of the internal thoracic artery (ITA) is important for arterial anastomosis during breast reconstruction using the DIEA flap. An anatomic investigation of these arteries was performed using multidetector row computed tomography (MDCT). Contrast-enhanced MDCT data of 50 women (aged 18-90years) covering the neck to the groin were analyzed. The diameter of the PBs of the ITA at their origins from the first to the sixth intercostal space and of the DIEA 20mm from the bifurcation of the external iliac artery were measured. The mean diameters of the right and left DIEAs were 1.53 ± 0.263mm and 1.53 ± 0.306mm, respectively. The diameter of the PBs in the second and third intercoastal spaces was the same as the diameter of the DIEA, bilaterally. It is suggested that anastomosis of the DIEA with PBs of the ITA in the second and third intercoastal spaces is optimal for DIEA flap grafting. Our results could contribute to making vascular anastomosis easier, thereby reducing the burden on both surgeons and patients.

Robotic transthoracic diaphragmatic hernia repair.

Robotic transthoracic diaphragmatic hernia repair.

A Novel Technique to Optimize Uniportal Thoracoscopic Right Middle Lobectomy

The study aimed to describe a novel port design and simple surgical strategy for uniportal thoracoscopic right middle lobectomy. In this approach, a 3- to 4-cm incision was created at the sixth intercostal space posterior to the scapular line. The surgery was performed by serial division of the anterior oblique fissure, vein, bronchus, artery, and horizontal fissure. Based on our preliminary experience, this approach could provide an appropriate direction and angle for dissection and stapling, solving the challenge of conventional uniportal right middle lobectomy.

A Novel Anatomic Landmark to Target the Left Ventricle During Chest Compressions in Cardiac Arrest.

BackgroundResuscitation guidelines recommend that chest compressions be performed over the lower sternum. Current computed tomography and magnetic resonance imaging studies suggest that the current area of compression does not target the left ventricle (LV). Using transthoracic ultrasound, we sought to identify potential anatomic landmarks that would result in compressions over the LV in the majority of our study participants.MethodologyWe recruited 64 healthy men and women (over the age of 40) from the Simulated Patient Program at the University of Saskatchewan. Using ultrasound, we identified the LV and the associated surface anatomy in terms of intercostal space (ICS) and parasternal or mid-clavicular lines. We also collected biometric data including body mass index, chest circumference, and the corresponding inter-nipple line ICS.ResultsThe LV was located along the left sternal border in 62 (96.9%) participants. The most frequent LV location was along the left sternal border at the sixth ICS in 26 (40.6%) participants, with 13 (20.3%) at the fifth and 10 (15.6%) participants at the seventh ICS. In two (3.1%) participants, the LV was found along the mid-clavicular zone at the fifth ICS. The area from the fifth to seventh ICS on the left sternal border, typically covered by an adult palm centered at the sixth ICS, overlaid 49 of 64 (76.6%, 95% confidence interval [CI]: 64.3-86.2%) identified LV locations. By comparison, centering the heel of the palm over the inter-nipple line at the left sternal border would cover the LV in 46 (71.9%, 95% CI: 59.2-82.4%) participants. ConclusionsA novel area of compression over the left sternal border at the inter-nipple line would result in compressions over the LV in nearly three-quarters of our study participants. Future research should investigate whether this proposed area of compression is applicable to a broader population including those with cardiac and thoracic disease.