Standard Posterolateral Thoracotomy Research Articles

The dawn of surgical treatment of aortic insufficiency.

The dawn of surgical treatment of aortic insufficiency.

Video-Assisted Thoracoscopic Surgery (VATS) for Spontaneous Pneumothorax and Emphysematous Bullous Lung Disease: A Study From Northern India.

Introduction: Bullous lung disease is the most common cause of spontaneous pneumothorax. The management of the same is primarily surgical, aiming at the bullectomy, which was earlier performed by standard postero-lateral thoracotomy. The last two decades have seen more frequent use of video-assisted thoracoscopic surgery (VATS) for the same and has been shown to be a low morbidity, efficacious, and cost-effective method. In this study we assess the role of VATS in the spectrum of bullous lung disease.Method: The study was conducted in the Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, for a period of three years from January 1, 2016 to December 31, 2019 in which patients with bullous lung diseases were enrolled and the role of video-assisted thoracoscopic surgery was assessed in them.Results: The study included a total of 75 patients who were managed operatively either by VATS or open thoracotomy. In the study group, the average age of patients was 35.6 years (range 16-68 years). The most common presentation was only bullous lung disease (BLD) in 40% of patients followed by 32% of patients having both BLD and broncho-pleural fistula (BPF). Apical segmentectomy/non-anatomical wedge resection was done in 36% of patients whereas VATS bullectomy was done in 36% of patients. Elective conversion to thoracotomy was planned in six patients because of dense adhesions and thick pleural peel. We performed pleurodesis in almost all cases (96%). Mean blood loss in the VATS procedure was 48.7 ml and mean operative time was 67.2 minutes. Mean duration of hospital stay was 4.8 days. Forced expiratory volume (FEV1) increased significantly from a mean of 65.80% to 77.60%. There was significant increase in forced vital capacity (FVC) mean from 70.30% to 79.50%.Conclusion: VATS can be used as a safe, feasible and effective procedure in patients presenting with spontaneous pneumothorax and bullous lung disease with or without a broncho-pleural fistula or parenchymal leak. It should be preferred over the traditional open thoracotomy procedure, whenever feasible to do so, in view of decreased perioperative morbidity and better functional outcome.

Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief

BackgroundSystemic analgesia with paracetamol and nonsteroidal anti-inflammatory drugs plus opioids as a rescue medication had reported to be better than that depend mainly on opioids for postoperative pain relief. Thoracic paravertebral block reported to provide a comparable postthoracotomy pain relief to epidural analgesia, with fewer side effects due to its unilateral effect. Thoracic paravertebral catheter can be inserted intraoperatively under direct vision during thoracic surgery (Sabanathan’s technique). This prospective randomized study was designed to evaluate the safety and efficacy of this technique with continuous infusion of lidocaine compared to systemic analgesia for postthoracotomy pain relief.ResultsSixty-three patients were randomized to receive a continuous infusion of lidocaine in the paravertebral catheter for 3 postoperative days (thoracic paravertebral group, n = 32) or systemic analgesia (systemic analgesia group, n = 31). All patients underwent standard posterolateral thoracotomy. There were no significant differences between both groups in age, sex, side, type, and duration of operation. Pain scores measured on visual analogue scale and morphine consumption were significantly lower in thoracic paravertebral group in all postoperative days. Spirometric pulmonary functions were not reaching the preoperative values in the third postoperative day in both groups, but restorations of pulmonary functions were superior in paravertebral group. No complications could be attributed to the paravertebral catheter. Side effects, mainly nausea and vomiting followed by urinary retention, were significantly more in systemic analgesia group (P = 0.03). Also, pulmonary complications were more in systemic analgesia group but not reaching statistical significance (P = 0.14).ConclusionContinuous paravertebral block by direct access to the paravertebral space using a catheter inserted by the surgeon is a simple technique, with low risk of complications, provides effective pain relief with fewer side effects, and reduces the early loss of postoperative pulmonary functions when compared to systemic analgesia.

Giant Mediastinal Ganglioneuroma in a Female Child

We report an eight year female patient admitted to the department of pediatrics at Abbasia Pulmonary Hospital at Cairo, Egypt. The child was complaining of pain on the right lower chest and upper abdome. On evaluation by CT of the chest, there was a huge posterior mediastinal mass occupying more than three quarters of the right hemithorx. Preoperative histopathology using CT guided needle biopsy revealed ganglioneuroma. The tumor was resected completely via right standard posterolateral thoracotomy without complications. Postoperative histopathology confirmed the diagnosis of ganglioneuroma.

Giant Mediastinal Ganglioneuroma in a Female Child

We report an eight year female patient admitted to the department of pediatrics at Abbasia Pulmonary Hospital at Cairo, Egypt. The child was complaining of pain on the right lower chest and upper abdome. On evaluation by CT of the chest, there was a huge posterior mediastinal mass occupying more than three quarters of the right hemithorax. Preoperative histopathology using CT guided needle biopsy revealed ganglioneuroma. The tumor was resected completely via right standard postero-lateral thoracotomy without complications. Postoperative histopathology confirmed the diagnosis of ganglioneuroma. Keywords: Ganglioneuroma; Posterior mediastinum; Pediatrics

Surgical Management of Herniated Intrathoracic Gastric Perforation in Traumatic Diaphragmatic Rupture: An Unusual Two Rare Cases

Gastric perforation into the thoracic cavity through a diaphragmatic rupture is rare but, when it occurs, patients present in severe distress, with mortality approaching 50%. We present our experience of two rare and unusual cases of traumatic diaphragmatic rupture from penetrating chest injury associated with herniated intrathoracic gastric perforation over a five-year period from January 2015 to December 2020 at the cardiovascular and thoracic surgery department of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Both patients underwent successful surgical repair through standard posterolateral thoracotomy with one having earlier negative exploratory laparotomy. The essence of the paper is to share and discuss the clinical presentation, diagnostic challenges, surgical management and the postoperative care of this very rare complication of traumatic diaphragmatic rupture.

IBS26.03 Surgical Technique of Pleurectomy/Decortication

IBS26.03 Surgical Technique of Pleurectomy/Decortication

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..

Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial

ObjectivesPost-thoracotomy pain leads to patient discomfort, pulmonary complications, and increased analgesic use. Intercostal nerve injury during thoracotomy or its entrapment during closure can contribute to post-thoracotomy pain. We hypothesized that a modified technique of posterolateral thoracotomy and closure, preserving the intercostal neurovascular bundle, would reduce acute and chronic post-thoracotomy pain. MethodsWe randomized 90 patients undergoing posterolateral thoracotomy for pulmonary resection at a tertiary level oncology center to standard posterolateral (control arm) or modified nerve-sparing thoracotomy. All patients received morphine via patient-controlled analgesia pumps. The primary outcome was the worst postoperative pain score in the first 3 postoperative days. Secondary outcomes included the average pain score and analgesic requirements in the first 3 postoperative days and the incidence of post-thoracotomy pain 6 months after surgery. ResultsNo significant differences were seen between the groups in acute or chronic post-thoracotomy measured by the numeric rating scale. There was no difference seen in the worst (mean) postoperative pain scores (3.71 vs 3.83, difference 0.12; 99% confidence interval [CI], −0.7 to +0.9; P = .7), average (mean) pain scores in the first 3 postoperative days (1.77 vs 1.85, difference 0.08; 99% CI, −0.4 to +0.6; P = .69), mean consumption of morphine (mg/kg) (1.45 vs 1.40, difference −0.05; 99% CI, −0.4 to +0.3; P = .73), or incidence of chronic postoperative pain (37.8% vs 40%, difference 4.9%; 99% CI, −22.8 to +30.7%; P = .73). ConclusionsThe modified nerve-sparing thoracotomy technique does not reduce post-thoracotomy pain compared with standard posterolateral thoracotomy.

Totally Cystic Schwannoma in the posterior mediastinum on right side- A rare presentation

A 54 year old female presented with a short history of dyspnoea on exertion and pain right hypochondrium, radiating to back. X-Ray chest showed a well-defined opaque mass in the posterior mediastinum. A computed Tomography (C T) scan chest done revealed a thick walled cystic lesion in the posterior mediastinum compressing the right lower lobe bronchus along with minimal pleural effusion on same side. Ultrasound guided aspiration was done and clear watery fluid aspirated. Standard postero-lateral thoracotomy was under taken and the whole cystic mass was excised. Postoperative period was uneventful. Histopathological examination of the cyst wall revealed it to be a cystic schwannoma.

Transcutaneous electrical nerve stimulation effect on postoperative complications.

Objectives Transcutaneous electrical nerve stimulation has been used to control post-thoracotomy pain, with conflicting results. We aimed to assess its efficacy on post-thoracotomy pain and early complications. Methods Between January 2012 and December 2014, 87 patients underwent a standard posterolateral thoracotomy and were randomized in 2 groups: group T was 43 patients who had transcutaneous electrical nerve stimulation and group C was 44 patients who had placebo stimulation with an inoperative device. Pain score was measured using a visual analogue scale ranging from 0 to 10. The frequency of the device was set at 100 Hz and pulse width at 100 ms. Results There were no statistically significant differences in the demographic characteristics of the 2 groups, and there was no difference in the duration of hospitalization (4.74 ± 1.6 vs. 5.23 ± 1.5 days; p = 0.06). Postoperative pain scores of the two groups showed that on postoperative day 0, 1, and 2, the mean pain scores of group T were significantly lower ( p = 0.001, p < 0.001, and p = 0.003). There were no significant differences in early complications or surgical technique. Conclusion We concluded that electrical stimulation is a safe and effective adjunctive therapy for acute post-thoracotomy pain control. However, it does not affect the duration of hospitalization or early pulmonary complications.

Minimally invasive bronchoplastic resections

Background: Minimally invasive lung surgery has recently proven to be superior to anterolateral thoracotomy in terms of postoperative pain and quality of life for early stage lung cancer. With these advantages, it is not surprising that surgeons all around the world try to push the limits of Video-assisted thoracoscopic surgery (VATS). Aim of this study was to explore the feasibility of a minimally invasive approach to bronchoplastic resection and to point out specific technical considerations. Methods: Between 2009 and 2015, 15 minimally invasive bronchoplastic resections were performed using a standard 3 port VATS technique. During the same time, 463 patients underwent some form of anatomic VATS lung resection (lobectomy, segmentectomy, bilobectomy or pneumonectomy) and 21 open bronchoplastic resections using a standard posterolateral thoracotomy approach. Perioperative results of the minimally invasive group were collected in a prospectively maintained database. Results: Median age of the patients was 57 years (17–75 years). There were 8 (53.3%) female patients. Reason for resection was primary lung cancer in all patients. Final pathology was adenocarcinoma in 4, squamous cell cancer in 5, carcinoid tumors in 4 and other types of histology in 2 patients (mucoepidermoid tumor and large cell tumor). Type of bronchoplastic procedure was simple closure of the bronchus in two patients, wedge bronchoplasty in 12 patients and circumferential sleeve in one patient. Median operative time was 217 minutes (141–390 minutes). Median chest tube duration and hospital stay was 4 days (2–50 days) and 9 days (6–63 days), respectively. Postoperative complications occurred in 2 patients (13.3%), with one atelectasis prompting bronchoscopy and one chylothorax who needed re-thoracoscopy and ligation of the cystic duct. Conclusions: Minimally invasive bronchoplastic lung resections are feasible with a low perioperative morbidity and mortality in an experienced center. Surgeons should share their experience to clarify technical considerations like optimal sewing technique.

Muscle-sparing Axillary Thoracotomy

The standard posterolateral thoracotomy provides excellent exposure to the chest and has traditionally been the incision of choice for major intrathoracic operations. However, this approach comes at the cost of muscle-splitting, with significant postoperative pain and impairment in function, particularly in elderly patients. Consequently, muscle-sparing approaches have been met with enthusiasm due to improvements in postoperative pain, morbidity, and cosmesis. Although concerns regarding exposure initially limited the use of this incision, advances in technology and experience have led to more widespread use of the muscle-sparing approach. Today, the muscle-sparing thoracotomy is the incision of choice for many surgeons, as it can be used as an adjunct to video-assisted thoracoscopic surgery and has successfully been employed in complex thoracic procedures.

P1.08-042 Overall Survival and Tumor Recurrence after VATS Lobectomy of N1 Positive NSCLC is Equal to Open Resection

Video-assisted thoracoscopic surgery (VATS) is an accepted alternative to open resection for early stage non-small cell lung cancer. This study was performed to analyze survival after primary VATS anatomic resection for nodal positive NSCLC compared to an open approach. The prospective institutional VATS database was searched for pN1 patients after primary surgery for NSCLC (62/504 patients between February 2009 and December 2015). Exclusion criteria were neoadjuvant treatment and conversion to thoracotomy. Demographics and survival were compared to a historic group of N1 positive patients, who underwent primary open surgery via a standard posterolateral thoracotomy for lung cancer between 2002 and 2007 (57 patients). Age (65 vs 61.5 years), gender and stage distribution (UICC IIA vs >IIA) did not differ between the VATS and open group. Half of the patients in the VATS group had clinical stage N0 (31/62) confirmed by PET-CT. More people received adjuvant therapy after VATS lobectomy (50/62 vs 31/57, p=0.003). Median follow up was 22 months in the VATS group and 47 months in the open group (p<0.0001). Disease recurrence occurred in 16/62 and 22/57 patients after a median of 13 and 12 months, respectively, (p=0.1692). Overall survival did not differ between the two groups (Figure 1, log rank, p=0.4006). No survival difference was found between unforeseen and clinically evident nodal positive patients in the VATS group (p=0.9686). VATS lobectomy in nodal positive lung cancer patients is oncologically equal to open resection with similar survival and recurrence rates. Half of the lymph node metastases have been missed by clinical staging. Interestingly, the higher rate of patients receiving adjuvant chemotherapy after VATS lobectomy did not result in significant better survival.

P2.04-050 Giant Solitary Fibrous Tumor of the Pleura Saved by Biopsy and Following Extended Resection: A Long Term Surviving Case: Topic: Esophageal Cancer and Other Malignancies

Giant tumor almost occupied the entire one-side thoracic cavity could be surgically resected completely is rare. Solitary fibrous tumor of the pleura (SFTP) is less common, giant SFTP, which could be surgically resected completely, could survive long term, is rare. Here we report one case giant SFTP. A male aged 39 in Dec 2008, with chest distress, fatigue and low-grade fever for 2 weeks, chest pain and dyspnea for 1 week, no bleeding sputum; chest CT revealed a giant tumor almost occupied the entire left-side thoracic cavity, with pleural effusion. Bloody pleural fluid was drawn but no malignant tumor cell was confirmed. Malignant mesothelioma was diagnosed at local hospital, not operable, no effective chemotherapy or radiation available. The patient was referred to our Lung Cancer Center. Biopsy was first advised. Biopsy pathology: SFTP (malignant). Surgical resection should be of the best choice even though the young patient seemed to be too fatigue to endure the large-incision traditional standard posterolateral thoracotomy (TSPT, 30∼40cm long chest incision, with the latissimus dorsi and serratus anterior muscles being cut, usually one rib being cut). Posterolateral incision was about 40cm long, S shape, with one rib cut, but the surgery space was still too limited to explore the giant tumor, to separate the intrathoracic adhesion. Incision was extended, and another rib was cut to enlarge the surgical field. The tumor occupied the whole thoracic cavity, bottom originated from visceral pleura of left apicalposterior (S1+2) and superior (S6) segments. Tumor 22cm×15cm×7cm was completely separated and en bloc resected, with S1+2 and S6 segments wedge-resected (cutting edges at least 2cm far from tumor). Postoperative pathology: SFTP (malignant). The patient recovered surprisingly quickly, drainage tube pulled out at 5th day, he was discharged at the 8th day postoperatively. No adjuvant treatment was used. Follow-up shows no recurrence and metastasis. The patient is now alive healthily in his 8th year postoperatively. Giant SFTP is rare, easily to be misdiagnosed to malignant mesothelioma, losing opportunity of being cured. Biopsy is the key point to make a right diagnosis. Giant SFTP, benign or malignant, usually is operable; complete en bloc resection of the whole tumor and enough resection of originated visceral pleura and lung tissue is the key point to avoid recurrence, to cure SFTP. (This study was partly supported by Science Foundation of Shenyang City, China, No. F16-206-9-05).

P3.04-043 Minimally Invasive Small Incision, Muscle- and Rib-Sparing Thoracotomy (miMRST) for Multiple Sclerosing Pneumocytomas: Topic: Miscellaneous II

Sclerosing pneumocytoma is less common, multiple sclerosing pneumocytomas are rare. Sclerosing pneumocytoma was called sclerosing hemangioma of the lung before WHO new classification of lung tumors was published in 2015. Here we report two cases, one was multiple sclerosing pneumocytomas, both received surgical resection via minimally invasive small incision, muscle- and rib-sparing thoracotomy (miMRST). Case 1: a female aged 60 in Aug 2012, chest CT was taken because of cough and fever 38.5°C, a 5cm tumor at right lower lobe, and a 0.8cm nodule at right middle lobe were found. The patient feared of the 30∼40cm long “large-incision” of traditional standard posterolateral thoracotomy (TSPT), miMRST was scheduled. Case 2: a male aged 50 in Nov 2012, chest CT revealing an asymptomatic 2cm tumor at right upper lobe. The patient refused TSPT, preferred to accept miMRST. About 10cm lateral chest incision was enough for lung lobectomy and mediastinal lymph node dissection, with the latissimus dorsi and serratus anterior muscles were protected, no rib cut needed. Case 1: right lower lobe lobectomy was performed first, frozen pathological diagnosis: inflammatory lesion with pneumocyte dysplasia, locally with hemangioma-like lesion. Wedge resection was performed to remove the nodule at right middle lobe. Postoperative pathology: both tumors were sclerosing hemangioma of the lung (Aug 2012). Case 2: enucleation was performed, frozen pathological diagnosis: sclerosing hemangioma of the lung, malignancy should be excluded by later paraffin slides staining. Right upper lobe lobectomy with mediastinal lymph node dissection was performed. Postoperative pathology: sclerosing hemangioma of the lung, no lymph node metastasis (Nov 2012). Both patients recovered much better and more quickly than other patients who underwent TSPT in the same ward at that time. Regular follow-up: both are alive healthily in their 4th year postoperatively, no recurrence and metastasis. No adjuvant treatment was used. Multiple sclerosing pneumocytomas are rare. For sclerosing pneumocytoma, surgical resection is of first choice. Limited resection should be enough and reasonable for this kind of benign tumor, however, lobectomy becomes essential once the tumor size is too big, further, mediastinal lymph node dissection is to be performed when malignancy is suspected. miMRST, is minimally invasive thoracic surgery, with no need to use expensive thoracoscopic devices, is very suitable for lung surgery in developing countries. (This study was partly supported by Science Foundation of Shenyang City, China, No. F16-206-9-05).

P3.04-041 Giant Solitary Fibrous Tumor of the Pleura Saved by Biopsy and Following Extended Resection: A Long Term Surviving Case: Topic: Miscellaneous II

Giant tumor almost occupied the entire one-side thoracic cavity could be surgically resected completely is rare. Solitary fibrous tumor of the pleura (SFTP) is less common, giant SFTP, which could be surgically resected completely, could survive long term, is rare. Here we report one case giant SFTP. A male aged 39 in Dec 2008, with chest distress, fatigue and low-grade fever for 2 weeks, chest pain and dyspnea for 1 week, no bleeding sputum; chest CT revealed a giant tumor almost occupied the entire left-side thoracic cavity, with pleural effusion. Bloody pleural fluid was drawn but no malignant tumor cells was confirmed. Malignant mesothelioma was diagnosed at local hospital, not operable, no effective chemotherapy or radiation available. The patient was referred to our Lung Cancer Center. Biopsy was first advised. Biopsy pathology: SFTP (malignant). Surgical resection should be of the best choice even though the young patient seemed to be too fatigue to endure the large-incision traditional standard posterolateral thoracotomy (TSPT, 30∼40cm long chest incision, with the latissimus dorsi and serratus anterior muscles being cut, usually one rib being cut). Posterolateral incision was about 40cm long, S shape, with one rib cut, but the surgery space was still too limited to explore the giant tumor, to separate the intrathoracic adhesion. Incision was extended, and another rib was cut to enlarge the surgical field. The tumor occupied the whole thoracic cavity, bottom originated from visceral pleura of left apicalposterior (S1+2) and superior (S6) segments. Tumor 22cm×15cm×7cm was completely separated and en bloc resected, with S1+2 and S6 segments wedge-resected (cutting edges at least 2cm far from tumor). Postoperative pathology: SFTP (malignant). The patient recovered surprisingly quickly, drainage tube pulled out at 5th day, he was discharged at the 8th day postoperatively. No adjuvant treatment was used. Follow-up shows no recurrence and metastasis. The patient is now alive healthily in his 8th year postoperatively. Giant SFTP is rare, easily to be misdiagnosed to malignant mesothelioma, losing opportunity of being cured. Biopsy is the key point to make a right diagnosis. Giant SFTP, benign or malignant, usually is operable; complete en bloc resection of the whole tumor and enough resection of originated visceral pleura and lung tissue is the key point to avoid recurrence, to cure SFTP. (This study was partly supported by Science Foundation of Shenyang City, China, No. F16-206-9-05).

Vertical thoracotomy versus conventional posterolateral thoracotomy

Objective The aim of the study was to evaluate the use of vertical thoracotomy as a thoracic approach. Background A carefully planned thoracic incision should provide effortless and excellent exposure, preservation of the underlying anatomy and function, and a cosmetically acceptable result. Materials and methods We conducted a prospective, cohort study in which 30 consecutive patients were exposed to two types of thoracotomies performed by the surgeons of the cardiothoracic surgery Department in Menoufia University Hospital from October 2012 to October 2014. The patients were classified randomly into two groups: group A (n = 15) in which vertical thoracotomy was performed and group B (n = 15) in which standard posterolateral thoracotomy was performed. Operative data were collected from all patients in both groups as regards indication of operation, type of operation, intraoperative complications such as bleeding, need of extension of the incision, total operative time, and time of opening and closure of the thoracotomy. Results Results showed that vertical thoracotomy can be used for a wide range of procedures in different age groups and in both sexes. Shoulder joint movement was significantly better when vertical thoracotomy was used (P = 0.044), and cosmetic results are better. Conclusion Vertical thoracotomy offers specific advantages of minimum trauma and maximum preservation of chest wall function with a cosmetically acceptable scar.

From open to single port video-assisted thoracoscopic lobectomy: a stepwise and return progression of the experience from Department of Thoracic Surgery, General Hospital of Guangzhou Military Command of P.L.A.

Department of Thoracic Surgery, General Hospital of Guangzhou Military Command of P.L.A was founded in 1954, and the first lobectomy using standard posterolateral thoracotomy was performed in the same year. For about half a century, more than 5,000 open lobectomy have been performed at the department. With the wide acceptance of video assisted thoracoscopic surgery (VATS) lobectomy all over the world, more than a thousand cases of multiport VATS lobectomy have been performed at our department. Since 2013, without any training and operation observation, single port VATS lobectomy has been successfully developed after the reading of a series of papers by Dr. Gonzalez-Rivas, and nearly 200 single port VATS lobectomy have been performed at our department up to now. Moreover, we have developed our own unique surgical skills and process without any major intra-/and post-operative complications. In order to verify the advantages of single port, we launched a prospective study to compare the short and long term outcomes between multiple and single port VATS lobectomy recently. Here, we firstly introduce the evolution of lobectomy approach at our department, and give the story how we develop surgical approach from open to single port VATS step by step. Then, the characteristic of single port lobectomy and our unique experience will be described. We think single port VATS lobectomy is a kind of return progression from open lobectomy with the same surgical vision and technique maneuver. At last, we will discuss a few potential improvements of single port lobectomy and give a glimpse into the future.

Reconstruction using a divided latissimus dorsi muscle flap after conventional posterolateral thoracotomy and the effectiveness of indocyanine green-fluorescence angiography to assess intraoperative blood flow.

In most general thoracic operations performed via standard posterolateral thoracotomy, such as for descending aortic aneurysms and lung cancer, the latissimus dorsi (LD) muscle is divided. However, division of the LD can hamper reconstructive surgery because the initial operation creates unstable blood flow to the divided LD. We conducted this study to assess blood flow in a divided distal LD muscle flap using intraoperative indocyanine green-fluorescence angiography (ICG-FA) with the Hyper Eye Medical System(®) (Mizuho Medical Co., Ltd., Tokyo, Japan). The subjects were 11 patients who underwent posterolateral thoracotomy with reconstructive surgery using a divided distal LD and other peripheral muscle flaps. Intraoperative ICG-FA was conducted to assess blood flow to the LD. Intraoperative ICG-FA revealed that at least two intercostal perforators from the sixth to the tenth intercostal spaces were preserved as feeding vessels to the divided distal LD. There were no major complications associated with inadequate blood flow to the muscle flaps. Intraoperative ICG-FA proved extremely useful for assessing altered blood flow of the divided LD and for selecting preserved intercostal perforators.