Thoracoscopic Approach Research Articles

A comparison of total thoracoscopic versus robotic approach for cardiac myxoma resection: a single-center retrospective study

Advances in instrumentation and technique have facilitated minimally invasive surgeries for cardiac myxoma treatment. This study aims to compare the clinical outcomes between the thoracoscopic and robotic approaches for myxoma resection. Intraoperative data and postoperative data of 46 patients who underwent either thoracoscopic (n = 15) or robotic (n = 31) cardiac myxoma resection in our center between July 2013 and September 2022 were retrospectively compared. There was no in-hospital death in either group. Meanwhile, the operative time and cardiopulmonary bypass time were significantly shorter in the robotic group than in thoracoscopic group (P = 0.015 and P = 0.035, respectively). Furthermore, shorter ICU stays (P = 0.006), shorter postoperative mechanical ventilation time (P = 0.035) and less thoracic drainage (P = 0.040) were observed in the robotic group. However, the operating room costs and total hospital costs were both significantly lower in thoracoscopic group (P = 0.004 and P = 0.007, respectively). There was no significant difference between two groups regarding the incidence of postoperative complications (P > 0.05). Lastly, a faster return to exercise was noted in robotic group than in thoracoscopic group (Log-Rank χ2 = 4.094, P = 0.043). Both approaches can be safe and feasible for myxoma resection. However, regardless of higher expenses, the robotic myxoma resection approach provides shorter operation time, less postoperative thoracic drainage, and faster recovery than total thoracoscopic technique.

Ectopic Mediastinal Parathyroid Adenoma Excision via Video Assisted Thoracoscopic Approach: A Case Report

Ectopic parathyroid adenomas can be a cause of recurrent and refractory hyperparathyroidism. Majority of parathyroid adenomas are located in the neck region, however in very few cases they are located within the mediastinum. In such cases excision via cervical approach is not possible and it becomes a diagnostic as well as surgical challenge. Excision via thoracoscopic approach is a preferred approach in this regard. Here we represent a case of ectopic parathyroid adenoma embedded within thymus gland which underwent surgical excision via thoracoscopic approach.
 Key words: Ectopic, Parathyroid adenoma, Thoracoscopy

Robotic First Rib Resection Utilizing the Da Vinci Xi System

Thoracic outlet syndrome (TOS) is a relatively rare but debilitating disease primarily effecting young adults. Surgical resection of the first rib is an effective treatment for clinically apparent TOS. The Xi robotic platform allows for superior visualization of the first rib during resection as well as continuous and improved visualization of the neuro-vasculature without the need for potentially harmful retraction of these vital structures. Fine dissection is easily accomplished with the robotic instruments with greater ease than that experienced with non-robotic thoracoscopic approaches. Lysis of scar tissue restricting the neurovascular structures is possible with the robotic platform whereas this is not typically feasible with most open and standard thoracoscopic approaches. The objective of this article is to highlight these advantages while detailing the key operative steps of a robotic first rib resection using the Xi system.

The Thoracoscopic Approach in Spinal Cord Disease.

Most VATS approaches are from the right side for pathologies involving the middle and upper thoracic spine because there is a greater working spinal surface area lateral to the azygos vein than that lateral to the aorta. Below T-9, a left-sided approach is made possible because the aorta moves away from the left posterolateral aspect of the spine to an anterior position as it passes through the diaphragm. VATS has been used extensively in spinal deformities such as scoliosis. The use of VATS in spine surgery includes the treatment of thoracic prolapsed disk diseases, vertebral osteomyelitis, fracture management, vertebral interbody fusion, tissue biopsy, anterior spinal release, and fusion without or with instrumentation (VAT-I) for spinal deformity correction. As the knowledge and the comfort of using such techniques have expanded, the indications have extended to corpectomy for tumor resections. In the field of minimally invasive surgery, VATS now acts as a keyhole to the thoracic spine and an alternative to open thoracotomy for the treatment of several spinal conditions.Although VATS can be performed in such spine conditions, it is most beneficial in the treatment of scoliotic deformity, which requires taking a multilevel approach, from the upper to the lower thoracic spine.

Combined spinal and video-assisted thoracoscopic (VATS) approach to thoracic neurogenic dumbbell tumour in the prone position: a case report

Combined spinal and video-assisted thoracoscopic (VATS) approach to thoracic neurogenic dumbbell tumour in the prone position: a case report

Minimally invasive transthoracic resection of a segment eight liver tumor

Despite advances in technology and technique of minimally invasive liver surgery, resection of lesions in the posterosuperior segments such as segment 8 (S8) remains challenging. Compared to open surgery, there are specific differences that make minimally invasive access to S8 challenging. These include the caudal view along the axis of the hepatoduodenal ligament, increased distance between trocars and the operative field, and the liver fulcrum created by the anterolateral segments limiting the view. However, several advancements have helped to overcome these challenges, such as the use of intercostal trocars (combined lateral-abdominal approach) and a flexible tip camera. Consequently, a total thoracoscopic (transthoracic) approach was developed to resect subdiaphragmatic tumors, which may particularly benefit patients with a hostile abdomen. This article summarizes the anatomic, technical, and technological considerations for safe resection of lesions in S8.

Minimally invasive esophagectomy for cancer in a patient with giant paraesophageal hernia

Minimally invasive esophagectomy in prone position is a procedure during which the patient is placed in a prone position during the thoracoscopic approach. A 67-year-old male patient consulted whit giant paraesophageal hernia and esophageal cancer. The treatment should be focused on the oncological resection of the esophagus despite the technical difficulties caused by the presence of a large hernia. A minimally invasive approach in the prone position and laparoscopic hernia repair can be considered an appropriate option for the resolution of both diseases with satisfactory results.

The thoracoscopic approach in the management of parapneumonic pleural effusion in children

Background: Parapneumonic pleural effusion is a relatively common entity and continues to be a major cause of morbidity in children. However, managing this disease is still a matter of controversy between surgical and non-surgical options. With the advancement of mini-invasive surgery, video-assisted thoracoscopic surgery (VATS) has become a mainstay in the treatment of parapneumonic effusion in children. This study aimed to evaluate the clinical characteristics and pathological features of parapneumonic pleural effusion in children and to explore the feasibility and safety of the thoracoscopic approach in the pediatric population. Methods: The clinical data of all patients who underwent VATS for parapneumonic effusion between 2007 and 2021 were analyzed retrospectively. Factors that were documented included demographic criteria, clinical manifestations, preoperative examinations, therapeutic procedures, intraoperative findings, postoperative complications, and outcomes. Results: Totally, 35 patients with a mean age of 5.14 ± 3.9 years were operated on thoracoscopically. The mean duration of evolution before VATS was 9 days ± 4. All children were hospitalized in a Pediatric Continuing Care Unit. Antibiotic therapy was administrated in combination in all cases. Corticosteroid therapy was used in 2 patients. Thoracentesis was performed in 6 patients. Thoracostomy tube drainage was placed before surgery in 11 patients. The average duration of drainage before VATS was 6 days ± 4. VATS decortication and/or debridement was indicated as second-line in 23 patients. The average duration of the surgery was 51 minutes (20 min - 115 min). There is no conversion to open surgery and no intraoperative procedure-dependent complication. 4 children have early complications after the VATS and one patient had a late postoperative complication. There were no deaths during the hospital stay or follow-up. Conclusion: In skilled hands, VATS is safe, feasible, and effective in the management of parapneumonic pleural effusion in children with excellent outcomes.

A uniportal video-assisted thoracoscopic surgery hybrid approach for posterior mediastinal dumb-bell tumours

Posterior mediastinal dumb-bell tumours are neurogenic tumours that extend from the mediastinum to the intraspinal canal. They represent a surgical challenge because they may be resected using a staged or a single-stage approach. Until recently, a classic posterolateral thoracotomy was the gold standard for surgical resection for the intrathoracic segment. In the meantime, video-assisted thoracoscopic surgery has gained great acceptance among most thoracic surgeons because of the decreased surgical trauma, less operative blood loss and fewer postoperative complications and the shorter hospital stays. Proper selection of cases for thoracoscopic excision is crucial for ensuring good surgical outcomes. Factors such as tumour size, location and presence or absence of features suggesting malignancy should be considered. This procedure can offer great help in different case scenarios involving posterior mediastinal dumb-bell tumours. For giant tumours that will eventually need a thoracotomy, video-assisted thoracoscopic surgery helps the surgical team to choose an optimal site for a tailored thoracotomy incision and rule out any metastatic pleura seedings. In cases of small intrathoracic segments of dumb-bell tumours (≤ 6-8 cm) that require combined spinal and thoracic procedures in a single-stage approach, a combined posterior and video-assisted thoracoscopic surgical approach can be implemented for total resection of the tumour.

186 RARE CASE OF A GIANT THYMIC CYST: A CHALLENGING DIFFERENTIAL DIAGNOSIS OF A PARACARDIAC CYSTIC LESION

Abstract Background Benign thymic cysts are a rare clinical entity, representing approximately 3% of all mediastinal masses. Thymic cysts can be congenital or acquired. We describe a case of a 58-year-old female with a giant benign thymic cyst which entered in differential diagnosis with a pericardial cyst and pericardial effusion. Case presentation A 58-year-old female was brought to our hospital due to new onset dyspnoea and fatigue. She had a history of a liquid mediastinal mass accidentally discovered 9 years before which was interpreted at that time as a loculated pericardial effusion (Fig. 1). An echocardiogram was performed which showed increased size of the known lesion without any signs of hemodynamic compromise (Fig. 2). A magnetic resonance showed a voluminous liquid lesion that originated from the anterior mediastinum, extending caudally to the diaphragm with maximum dimensions on the right hemithorax of 16×12×9 cm (antero-posteriorly, transversely and cranio-caudally respectively) and of 10×5×13 cm on the left hemithorax (Fig. 3). It was initially interpreted as a pericardial cyst. All the findings were then collegially reviewed and for the first time it was suspected of being a giant thymic cyst, especially due to its spatial distibution and growth over time; in particular the cranio-caudal growth in both the hemithoraxes suggested that it might have originated from the thymus gland and then, by force of gravity, extended downword bilaterally. The cyst was surgically removed using a unilateral thoracoscopic approach. Histological examination confirmed the thymic origin of the cyst and excluded malignancy. At the three month follow up, the patient presented no symptoms, and the echocardiogram was normal. Discussion The echocardiographic features of mediastinal cysts are not lesion-specific, so the origin and location of the cyst can be used for differential diagnosis. Computed tomography has the best spatial resolution, while the magnetic resonance has better capacity to differentiate the content of the cyst, especially when it is not a homogeneous liquid lesion. In our case, spatial distribution and, in particular, growth over nine years were crucial hints to suspect the thymic origin of the lesion. Indeed, the sole evaluation of the last imaging exam would have made the diagnosis more problematic because of its huge dimensions, which made the exact site of origin very challenging to identify. Conclusion Our case is a rare example of a giant thymic cyst which was extremely difficult to differentiate from other paracardiac cystic lesions and required integrated imaging and discussion by a team of experts of different specialties to make the correct diagnosis.

A descriptive comparison of postoperative outcomes between hybrid mediastino-thoracoscopic approach and conventional thoracoscopic esophagectomy for esophageal cancer.

The purpose of this study was to compare the results of the hybrid mediastino-thoracoscopic approach with that of the conventional thoracoscopic approach and to identify the advantages and disadvantages of the hybrid approach. We retrospectively analyzed 172 patients who underwent thoracoscopic esophagectomy for esophageal cancer from July 2009 to June 2021, excluding salvage surgery. In the mediastinoscopic approach, the lymph nodes were dissected from a small incision in the left aspect of the neck to the aortic arch with supine double-lung ventilation. Thereafter, the middle-to-lower mediastinum and right superior mediastinum were dissected thoracoscopically in the prone position. The patients' demographics, surgical outcomes, postoperative complications, and postoperative recurrence patterns were compared between 51 patients in the hybrid approach and 121 patients in the conventional approach. The hybrid group had more elderly patients (71years vs. 67years; P = 0.010), more cardiovascular disease (33.3% vs. 16.7%; P = 0.021), lower rates of preoperative chemotherapy (49.0% vs. 69.4%; P = 0.015), and shorter right lung collapse time (196min vs. 264min; P < 0.001). Postoperative hoarseness was not different between the two groups (31.4% vs. 27.3%; P = 0.584), and there was a significant difference in the sternal-vertebral distance at the level of the sternal notch (41mm in the hybrid group vs. 48mm in the conventional group; P = 0.029). The sternal-vertebral distance of less than 45mm was an independent risk factor for postoperative hoarseness in the logistic analysis (odds ratio 3.636, 95% confidence interval 1.054-12.546; P = 0.041). The hybrid mediastino-thoracoscopic approach could be safely adapted to elderly or cardiopulmonary diseased patients; however, short sternal-vertebral distance might be a risk factor of postoperative recurrent laryngeal nerve palsy.

Elimination of a right-sided accessory pathway using a videothoracoscopic approach after failed recurring catheter ablation: clinical case

The description of the clinical case presents a rare observation of a multi-stage approach to the treatment of right-sided accessory pathway. There are presented the results and features of successful epicardial ablation using a minimally invasive thoracoscopic approach, which made it possible to eliminate accessory pathways for right-sided epicardial localization after failed recurring cataract ablations.

Using the robotic platform in the therapy of multifocal ground glass opacities.

Due to their association with invasive adenocarcinoma, ground glass opacities that reach 3 cm in size, develop a solid component ≥2 mm on mediastinal windows, or exhibit ≥25% annual growth warrant operative resection. Minimally invasive techniques are preferred given that approximately one third of patients will present with multifocal focal disease and may require additional operations. A robotic-assisted thoracoscopic surgical approach can be used with percutaneous or bronchoscopic localization techniques and are compatible with developing intraoperative molecular targeting techniques.

Attempt to shift from traditional to minimal invasive treatment of congenital diaphragmatic hernia at a low volume center

Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal morbidity and mortality. During the last 10-years, the progress on minimal invasive surgical techniques, has stimulated many Pediatric Surgical centers to switch from traditional open surgery to thoracoscopic or laparoscopic repair. We report our experience to convert treatment of CDH from traditional to minimal invasive. We have reviewed the charts of 10 neonates with diagnosed CDH over the period 2016–2021. On all of them, we collected pre, intra and post-operative information. Interestingly, none of neonates had prenatal diagnosis of CDH but this didn't impact on morbidity or mortality. None of them was extremely preterm or had major cardiac anomalies. Thoracoscopic or laparoscopic approach was attempted in 3 cases but only in one patient was successful. In the other 2 neonates we had to switch to open surgery because of anatomical conditions. In our opinion, the learning curve needed to achieve minimal invasive treatment of CDH is associated with a high conversion rate often, as a consequence of anatomical conditions.

Short-term and mid-term effects of thoracoscopic repair of esophageal atresia: No anastomotic leaks or conversions to open technique.

The frequency rate of esophageal anastomosis leaks after thoracoscopic correction of esophageal atresia (EA) in the current literature is reported as 5.6%-24.7% and a conversion rate of 2%-53%. The objective of this retrospective study was to examine the characteristics of EA and analysis of the safety and efficacy of EA repair with the use of the thoracoscopic approach in a single academic center, as well as risk factors analysis in the context of short-term and mid-term follow-up status. A retrospective analysis of the management of all consecutive newborns affected by EA hospitalized in our department over a period between 2013 and 2022, including preoperative, perioperative, and postoperative management, together with the outcome, complications and long-term follow-up status was performed. A total of 38 patients with a median birth weight of 2,570 g (range; 1,020-3,880) were treated over the study period, including 30/38 (78.9%) with additional congenital anomalies. Overall, 30 patients underwent primary anastomosis of the esophagus and eight underwent a multistaged procedure, with or without an initial ligation of the tracheoesophageal fistula and delayed primary anastomosis. Overall survival for all patients was 0.894 ± 0.050, with a median follow-up of 4.5 years. We noted neither anastomotic leaks nor conversions to open technique in our cohort. Implementation of vancomycin prophylaxis was successful in preventing postoperative central venous access-related infectious complications. At the end of the follow-up, 85% of patients have a Lansky performance score ≥80. Risk factors analysis for length of hospitalization, overall survival, Lansky performance status, and neurological impairment were analyzed. In conclusion, we have found that the outcome of thoracoscopic repair of EA in terms of surgery-dependent morbidity (anastomosis leakage, conversion rate to open surgery), provides benefit to those previously reported in the literature, regardless of the prognostic criteria of the classification system.

Robotic-assisted laparoscopic and thoracoscopic approach: a challenging multidisciplinary minimally invasive surgery of intravascular leiomyomatosis with intracardiac extension

To show a case of severe intravascular leiomyomatosis with intracardiac extension treated by a multidisciplinary minimally invasive surgery. Stepwise demonstration of the technique with a video. General Hospital. A 40-year-old woman with palpitation and dyspnea. The patient was diagnosed with intravascular leiomyomatosis by computed tomography scan. She underwent a successful single-stage minimally invasive surgery with complete excision. The feasibility and safety of using this technique for intravascular leiomyomatosis with intracardiac extension. A combined thoracoabdominal surgery was successfully performed. During the procedure, cardiopulmonary bypass was maintained for 72 minutes. The patient soon recovered and was discharged. Minimally invasive surgery is a possible choice for intravascular leiomyomatosis with intracardiac extension.

Thoracoscopic approach of a left accessory lobe associated with a congenital pulmonary airway malformation

Thoracoscopic approach of a left accessory lobe associated with a congenital pulmonary airway malformation

Hybrid ablation of atrial fibrillation: A unilateral left-sided thoracoscopic approach.

Hybrid ablation (HA) of atrial fibrillation (AF) combines minimally invasive thoracoscopic epicardial ablation with transvenous endocardial electrophysiologic validation and touch-up of incomplete epicardial lesions if needed. While studies have reported on a bilateral thoracoscopic HA approach, data on a unilateral left-sided approach are scarce. To evaluate the efficacy and safety of a unilateral left-sided thoracoscopic approach. Retrospective analysis of a prospectively gathered cohort of all consecutive patients undergoing a unilateral left-sided HA for AF between 2015 and 2018 in the Maastricht University Medical Centre. One-hundred nineteen patients were analyzed (mean age 64 ± 8, 28% female, mean bodymass index 28 ± 4 kg/m2 , median CHA2 DS2 -VASc Score 2 [1-3], [longstanding]-persistent AF 71%, previous catheter ablation 44%). In all patients, a unilateral left-sided HA consisting of pulmonary vein (PV) isolation, posterior left atrial (LA) wall isolation, and LA appendage exclusion was attempted. Epicardial (n = 59) and/or endocardial validation (n = 81) was performed and endocardial touch-up was performed in 33 patients. Major peri-operative complications occurred in 5% of all patients. After 12 and 24 months, the probability of being free from supraventricular tachyarrhythmia recurrence was 80% [73-87] and 67% [58-76], respectively, when allowing antiarrhythmic drugs. Unilateral left-sided hybrid AF ablation is an efficacious and safe approach to treat patients with paroxysmal and (longstanding) persistent AF. Future studies should compare a unilateral with a bilateral approach to determine whether a left-sided approach is as efficacious as a bilateral approach and allows for less complications.

Image-guided video assisted thoracoscopic surgery (iVATS) and the future of surgical management

: The increased utilization of computed tomography for diagnostic imaging has led to an influx of incidentally discovered pulmonary nodules. Both thoracic surgeons and radiologists are burdened with risk stratifying these lesions for observation versus biopsy or resection. The diagnostic accuracy of percutaneous biopsy is dependent on the lesion’s size, density, and anatomic location. Nodules that are not amenable to percutaneous biopsy are often referred to surgeons for excisional biopsy. Certain characteristics make some lesions more difficult to resect than others. Small (<1 cm), partially solid, pure ground glass, and central lesions can be difficult to palpate intraoperatively. These lesions can be challenging to resect with thoracoscopic and robotic assisted approaches due to diminished tactile feedback and smaller incisions. Over the past 30 years, techniques have been developed to assist surgeons in locating these lesions with the use of hook wires, fiducials, dyes, and radiolabeled isotopes. These markers are placed preoperatively but are prone to migration or diffusion. In this chapter a new localization and resection technique, image-guided video assisted thoracoscopic surgery (iVATS) is reviewed. iVATS is an attractive option for both patients and surgeons since the localization procedure and parenchymal resection are performed under a single anesthetic. A detailed description of the iVATS technique, success rate, and common complications are reviewed. For pulmonary nodules that are centered within a defined bronchovascular segment, upfront segmentectomy is a reasonable option for obtaining pathologic diagnosis. Since segmentectomy relies on surgeon knowledge and experience with segmental anatomy, non-palpable lesions can be easily treated with this technique. Pearls and pitfalls of the most common segmental resections are addressed. Despite the refinement of localization techniques, small pulmonary nodules continue to present a diagnostic challenge. Ongoing innovation of new clinical tools has generated promising options for the future. In this chapter, we will review some of the tools undergoing development including computer generated algorithms for nodule risk assessment, liquid biopsy, three-dimensional printing, and superselective segmentectomy. Some technologies are focused on creating non-invasive methods to determine if a nodule is benign or malignant, while others seek to improve localization techniques. All of the described tools will need further validation but will potentially streamline the diagnosis and treatment of pulmonary nodules for future clinical practice.

Experience with the use of Reverdin needle in neonatal thoracoscopic congenital diaphragmatic hernia repair

Background: Congenital diaphragmatic hernia is the total or partial absence of the diaphragm, which can be unilateral or bilateral. Becmeur et al. in 2001 mentioned the thoracoscopic management approach for the first time. Methods: The medical record of neonatal CDH thoracoscopic management (using the Reverdin Needle) from January to May 2021 at Dr. Roberto Gilberto Elizalde Children's Hospital located in Guayaquil, Ecuador was retrieved. Various parameters and characteristics were studied. Results: Four patients were included in this study. M:F ratio was 3:1 with all having a type B left sided defect. The average duration of surgery was 157.5 minutes and 2 of them developed pulmonary hypertension in post-op period. All had good outcomes. Conclusion: We propose that the possibility of a successful thoracoscopic surgery in congenital diaphragmatic hernia is increased with use of the Reverdin needle.