Thoracoscopic Visualization Research Articles

The future of thoracoscopes

Designs of thoracoscopes have undergone radical transformation on the growing predominance of minimally invasive surgical techniques over the open thoracotomy method for a multitude of thoracic indications. The actualized benefits and remaining challenges identified amongst commercial and experimental thoracoscopes must to be consolidated to formulate a clear direction for further advancement of the field. As such, a review of published literature on thoracoscopes, or more broadly, visualization systems employed in minimally invasive thoracic surgery has been performed. Via PubMed, 46 articles met the inclusion/exclusion criteria for this review. The thoracoscope designs were summarized into seven categories: (I) rigid thoracoscopes; (II) flexible thoracoscopes; (III) miniaturized thoracoscopes; (IV) flexible thoracoscopes for Natural Orifice Transluminal Endoscopic Surgery (NOTES); (V) thoracoscopes embedded in robotic systems; (VI) 3-dimensional thoracoscopes; and (VII) thoracoscopes with intra-parenchymal visualization. The appraisals were made according to the clinical data, experience and feedback from the experimenters within the respective category. The results were then compared across the different categories. Insights gleaned through this review reveal that commercial and experimental thoracoscopes have been making strides to overcome the two major challenges in thoracoscopic visualization: limitations in view maneuverability and misaligned intuition in control. Additional objectivity is required for comparison across the various categories of thoracoscopes to further ascertain clinical evidence regarding surgical performance and post-operative outcomes. Nevertheless, considerable room for innovation exists in tackling these two challenges, which, together, form the fundamental premise for future progression. A paradigm shift, therefore, from the current emphasis on hardware development is paramount to breakthroughs against the aforementioned challenges. The future of thoracoscopes points towards a complementary advancement of both hardware and software designs within visualization systems, with the ultimate ambition of replacing and surpassing the visual experience perceived through the open thoracotomy method.

Novel air leak test using surfactant for lung surgery.

Prolonged air leak is the most common complication after pulmonary resection surgery. Water submersion test (WST) has been used to check for air leak. However, it is cumbersome under the circumstances of video-assisted thoracic surgery (VATS). This study aimed to devise a new air leak detection method that is suitable for the VATS. We decided to utilize the properties of the surfactants to overcome the disadvantages of WST. To find the optimal surfactant, ex-vivo porcine lung experiments were prepared with a custom-made large glass vessel mimicking a human thoracic cavity. A fresh lung was put inside the glass vessel and connected with the ventilator. We made a needle injury on the lung surface and dropped various kinds of liquid surfactants to create air bubbles during the lung ventilation. The appearances of bubbles were recorded through 5mm thoracoscope. Considering the bubble forming ability, Pluronic F-127 solution (PF127), a well-known non-toxic and non-ionic colorless surfactant, was chosen as candidate substance. To find the optimal condition, various concentrations of PF127 (30%, 25%, 20%, 15%, 10%) were tested. Greater than 20% concentration of PF127 were not feasible due to its high viscosity; the bubbles kept increasing in size without popping and blocked the thoracoscopic vision. The 10% PF127 did not form any bubbles. On the contrary, the 15% PF127 formed bubbles that are 1-2 cm in size with dynamic movement allowing for clear visibility of the air leak point. We finally made a green colored 15% PF127 by mixing an indocyanine green to increase its visibility. All of the components in the solution are FDA approved and permissible to be used in the human body. Our bubble solution can easily detect the air leak even in small quantities and is expected to be useful in VATS with limited vision. However, in order for its full-scale clinical use, its safety in the human body must be verified.

Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction.

The aim is to stabilize the thoracolumbar spine with athoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision. Vertebral burst fractures at the thoracolumbar junction (A4AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis. Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions. The patient is lying in aright lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of achest tube and inflate the left lung. Chest × ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12patients received aVBR under 3D thoracoscopic vision. After amean follow up of 26months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with asmall pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.

Thoracoscopic segmentectomy: hybrid approach for clinical stage I non-small cell lung cancer.

Recently, minimally invasive surgical approaches have been developed, typified by video-assisted thoracic surgery (VATS). A meticulous surgical procedure to prevent local recurrence is required during segmentectomy for clinical stage I non-small-cell primary lung cancer. In this article, we demonstrated the validity of hybrid VATS segmentectomy. Of these 125 patients, 62 (49.6%) underwent intensively radical segmentectomy (RS). The remaining 63 (50.4%) patients underwent palliative segmentectomy (PS). We used two 2-cm ports and performed a muscle-sparing mini-thoracotomy in which a partially open metal retractor allowed direct, thoracoscopic visualization as hybrid VATS segmentectomy in 63.2% of our cases. The consolidation/tumor ratio obtained with thin-sliced computed tomography was significantly lower in RS cases than in PS cases (P=0.001). The proportion of pathological stage IA cases was significantly higher in RS cases (95.2%) than in PS cases (66.7%; P<0.01). Five-year overall survival (OS) for clinical stage I was 100.0% in RS cases and 73.5% in PS cases (log-rank P<0.001). Five-year disease-free survival (DFS) was 95.5% and 55.7%, respectively (log-rank P<0.001). During segmentectomy, the most critical consideration is establishment of sufficient surgical margins around the cancer. Our hybrid approach that includes meticulous surgical manipulations may produce sufficient surgical margins.

Subxiphoid Minimally Invasive Epicardial Ablation (Convergent Procedure) With Left Thoracoscopic Closure of the Left Atrial Appendage

The Convergent Procedure is a combined epicardial and endocardial ablation performed by a cardiac surgeon and electrophysiologist to treat symptomatic persistent and long standing persistent atrial fibrillation. The epicardial ablation is performed on the entire width of the posterior left atrial wall using monopolar radiofrequency via a subxiphoid incision. There is no sternotomy and cardiopulmonary bypass is not utilized. The surgical ablation is then followed by endocardial voltage mapping and ablation, allowing for complete lesion set creation. Left atrial appendage exclusion can be performed via left thoracoscopic approach at the same time as the surgical ablation. The Convergent Procedure is a truly hybrid, collaborative procedure which combines the strengths of minimally invasive cardiac surgery and percutaneous electrophysiologic techniques to treat a challenging disease process.

The effect of thoracoscopy upon the repair of pectus excavatum

The Nuss procedure is the most commonly performed operation to correct pectus excavatum (PE). Thoracoscopic assistance has been anecdotally noted to improve the safety of this operative approach. This study aimed to compare complications and clinical outcomes before and after the introduction of thoracoscopy in a single-center. A retrospective review was performed of all patients who underwent the Nuss procedure at The Royal Children's Hospital over an 11-year period (2005-2015), collecting data on all intra-operative and post-operative outcomes. A total of 217 Nuss procedures were performed (122 non-thoracoscopic pectus repairs, 95 thoracoscopic pectus repairs). Median patient age was 14.9years, with the majority male (185/217, 84.3%). Patient demographics (age, gender, defect severity) and postoperative recovery were comparable between the two groups. Major complications included cardiac arrest requiring internal cardiac massage, hemothorax, pneumothorax, empyema, bar displacement and infection. The overall major complication rate was low (19/217, 8.8%); however, there was a significant reduction in major complications in the thoracoscopic pectus repair group (13.1% versus 3.2%, p=0.02). Thoracoscopic vision during the Nuss procedure reduces the risk of major complications. Treatment study - Level III (Retrospective comparative study).

Hybrid approach for VATS pulmonary resection

Many different surgical VATS procedures are performed. In our thoracoscopic VATS, four ports are used with thoracoscopic vision alone. In our hybrid VATS, two 2-cm ports are combined with muscle-sparing mini-thoracotomy with a slightly opened metal retractor with direct vision and thoracoscopic vision. Both procedures are performed by an operator, one assistant, and a scopist. Forceps, electrocautery, and ultrasonic scissors were used. VATS segmentectomy is an ideal surgical procedure to treat primary lung cancer from the perspective of minimally invasive surgery. The most important issue in segmentectomy is to maintain a sufficient surgical margin from the tumor. We think that it is important to determine whether thoracoscopic VATS segmentectomy without direct visualization or rib spreading can achieve an adequate surgical tumor-free margin. Delicate surgery is required to keep the surgical margin in segmentectomy. Therefore, the hybrid approach seems to be reasonable for obtaining sufficient surgical margins.

Needle Decompression of Tension Pneumothorax with Colorimetric Capnography

The success of needle decompression for tension pneumothorax is variable, and there are no objective measures assessing effective decompression. Colorimetric capnography, which detects carbon dioxide present within the pleural space, may serve as a simple test to assess effective needle decompression. Three swine underwent traumatically induced tension pneumothorax (standard of care, n= 15; standard of care with needle capnography, n= 15). Needle thoracostomy was performed with an 8-cm angiocatheter. Similarly, decompression was performed with the addition of colorimetric capnography. Subjective operator assessment of decompression was recorded and compared with true decompression, using thoracoscopic visualization for both techniques. Areas under receiver operating curves were calculated and pairwise comparison was performed to assess statistical significance (P< .05). The detection of decompression by needle colorimetric capnography was found to be 100%accurate (15 of 15 attempts), when compared with thoracoscopic assessment (true decompression). Furthermore, it accurately detected the lack of tension pneumothorax, that is, the absence of any pathologic/space-occupying lesion, in 100%of cases (10 of 10 attempts). Standard of care needle decompression was detected by operators in 9 of 15 attempts (60%) and was detected in 3 of 10 attempts when tension pneumothorax was not present (30%). True decompression, under direct visualization with thoracoscopy, occurred 15 of 15 times (100%) with capnography, and 12 of 15 times (80%) without capnography. Areas under receiver operating curves were 0.65 for standard of care and 1.0 for needle capnography (P= .002). Needle decompression with colorimetric capnography provides a rapid, effective, and highly accurate method for eliminating operator bias for tension pneumothorax decompression. This may be useful for the treatment of this life-threatening condition.

SC20.04 Uniportal VATS

SC20.04 Uniportal VATS

Minimally invasive repair of pectus excavatum.

Pectus excavatum, an acquired or congenital depression of the anterior chest wall, is the most commonly occurring chest wall deformity. Patients with pectus excavatum experience psychosocial and physiologic consequences such as impaired social development and pulmonary and/or cardiac dysfunction as a result of the deformity. Traditionally, repair of the defect was performed with a major open operation, the most common being based on modifications of the Ravitch procedure. In the late 1990's, the operative approach was challenged with a new minimally invasive technique described by Dr. Donald Nuss. This approach utilizes thoracoscopic visualization with small incisions and placement of a temporary metal bar positioned behind the sternum for support it while the costal cartilages remodel. Since introduction, the minimally invasive repair of pectus excavatum (MIRPE) has become accepted in many centers as the procedure of choice for repair of pectus excavatum. In experienced hands, the procedure has excellent outcomes, shorter procedural length, and outstanding cosmetic results. However, proper patient selection and attention to technical details are essential to achieve optimal outcomes and prevent significant complications. In the following, we describe our perspective on pectus excavatum deformities, operative planning, and technical details of the MIRPE procedure.

Minimally invasive percutaneous pericardial ICD placement in an infant piglet model: Head-to-head comparison with an open surgical thoracotomy approach

Epicardial implantable cardioverter-defibrillator (ICD) placement in infants, children, and patients with complex cardiac anatomy requires an open surgical thoracotomy and is associated with increased pain, longer length of stay, and higher cost. The purpose of this study was to compare an open surgical epicardial placement approach with percutaneous pericardial placement of an ICD lead system in an infant piglet model. Animals underwent either epicardial placement by direct suture fixation through a left thoracotomy or minimally invasive pericardial placement with thoracoscopic visualization. Initial lead testing and defibrillation threshold testing (DFT) were performed. After the 2-week survival period, repeat lead testing and DFT were performed before euthanasia. Minimally invasive placement was performed in 8 piglets and open surgical placement in 7 piglets without procedural morbidity or mortality. The mean initial DFT value was 10.5 J (range 3-28 J) in the minimally invasive group and 10.0 J (range 5-35 J) in the open surgical group (P = .90). After the survival period, the mean DFT value was 12.0 J (range 3-20 J) in the minimally invasive group and 12.3 J (range 3-35 J) in the open surgical group (P = .95). All lead and shock impedances, R-wave amplitudes, and ventricular pacing thresholds remained stable throughout the survival period. Compared with open surgical epicardial ICD lead placement, minimally invasive pericardial placement demonstrates an equivalent ability to effectively defibrillate the heart and has demonstrated similar lead stability. With continued technical development and operator experience, the minimally invasive method may provide a viable alternative to epicardial ICD lead placement in infants, children, and adults at risk of sudden cardiac death.

Abstract 10987: Minimally Invasive Percutaneous Pericardial ICD Placement in an Infant Piglet Model: Head-to-Head Comparison With an Open Surgical Thoracotomy Approach

Introduction: Epicardial ICD placement in infants, small children, and patients with complex cardiac anatomy requires an open thoracotomy and is associated with increased pain, longer length of stay, and higher cost. We compared a surgical epicardial approach with percutaneous pericardial placement of an ICD lead system in an infant piglet model. Methods: Animals were randomized to undergo either epicardial placement by direct suture fixation through a left mini-thoracotomy or minimally invasive pericardial insertion with thoracoscopic visualization. Pericardial access was achieved through sub-xiphoid insertion of a pericardiocentesis needle followed by 7-French sheath insertion over a guide wire. An ICD lead (Medtronic) was passed through the sheath and fixed to the epicardium. In both groups, the lead was connected to an ICD generator placed within a sub-rectus abdominal pocket. Lead testing and defibrillation threshold testing (DFT) were performed. All piglets underwent a 2 week survival period followed by repeat lead testing and DFT prior to euthanasia. Results: Minimally invasive pericardial placement was performed in 8 piglets and surgical epicardial placement in 7 piglets (3-4 kg) without procedural morbidity or mortality. Mean initial DFT was 10.5 Joules (range 3-28J) in the pericardial group and 10 Joules (range 5-35J) in the surgical group (p = N.S.). After the survival period, mean DFT was 12 Joules (range 3-20J) in the pericardial group and 12.3 Joules (range 3-35J) in the surgical group (p = N.S.). All lead and shock impedances, R-wave amplitudes, and ventricular pacing thresholds remained stable throughout the survival period and showed no significant difference between the two groups. Conclusions: Compared to surgically placed epicardial ICD leads, percutaneous pericardial placement shows a nearly identical ability to effectively defibrillate the heart and has demonstrated similar lead stability. This can provide a means of defibrillator implantation without the need for open chest approach and its attendant pain and morbidity. With continued operator experience, the minimally invasive method may provide a viable alternative to epicardial ICD lead placement in infants, children, and adults at risk for sudden cardiac death.

Thoracoscopic-assisted pulmonary surgery for partial and complete lung lobectomy in dogs and cats: 11 cases (2008-2013).

To describe the use of thoracoscopic-assisted pulmonary surgery (TAPS) for partial and complete lung lobectomy in small animal patients and to evaluate short-term outcome. Retrospective case series. 11 client-owned dogs and cats. Procedures-Medical records of dogs and cats that underwent a partial or complete TAPS lung lobectomy were reviewed. All patients underwent general anesthesia and were positioned in lateral recumbency with the affected hemithorax uppermost. One-lung ventilation was not implemented in any patient. For initial exploration, a 5- to 10-mm incision was made for insertion of a 30° telescope approximately 5 to 7 rib spaces away from the site of the pulmonary lesion in the dorsal third of the thorax. All subsequent incision placements were case dependent and determined by the location of the lesion to be resected. Following lesion localization, a 2- to 7-cm minithoracotomy incision was made with direct thoracoscopic visualization without the use of rigid rib retractors. In 10 of 11 patients, a 360° wound retraction device was placed at the minithoracotomy site prior to exteriorization and resection of the affected lung. Lymph nodes were inspected intraoperatively, but biopsies were not performed; incisions were closed routinely, and a thoracostomy tube was placed in all patients. 3 cats and 8 dogs underwent successful partial (5) or complete (6) TAPS lung lobectomy over a 5-year period (2008 through 2013). Median surgery time was 92.7 minutes (range, 77 to 150 minutes). Thoracostomy tubes were removed a median of 22.3 hours after surgery (range, 18 to 36 hours). The median time to discharge was 3.1 days (range, 1 to 6 days). No intraoperative complications were encountered. All patients were discharged from the hospital, with 9 of 11 patients alive 6 months after surgery. Results of this study suggested that lung lobectomy by means of TAPS can be successfully performed in dogs and cats. When compared with total thoracoscopic surgery, TAPS may offer a more technically feasible approach from both a surgical and anesthetic standpoint, because it provides the benefits of minimally invasive thoracic surgery without the necessity of 1-lung ventilation.

Role of dynamic thoracoscopy in treatment of pleural complications of bacterial destruction of the lungs in children

A total of 93 children with pleural complications of destructive pneumonia were randomised, and all the patients get studymethod of dynamic thoracoscopy. Evaluation of changes in lung and pleura were made. Basing to this changes-the stages of destructive process were developed. On the base of the stages patogenetical treatment was suggested. In the treatment group (n=56) method of fractional washing of pleural cavity, and the method of local antibioticotherapy was used. No complications resulted from the thoracoscopies and there was no need for further surgical intervention in any of these patients. We conclude that dynamic thoracoscopy allows for minimally invasive, yet effective treatment pleural complications of destructive pneumonia. Thoracoscopic visualization of the pleural cavity permits efficient debridement, thorough adhesiolysis, and optimal placement of drainage tubes.

Video-Assisted Thoracoscopic Pneumonectomy: Retrospective Outcome Analysis of 47 Consecutive Patients

Although video-assisted thoracoscopic surgery (VATS) lobectomy is widely accepted, VATS pneumonectomy remains an uncommon procedure in patients with complicated diseases. Of 47 consecutive patients who were planned to undergo VATS pneumonectomy from May 2000 to May 2012 at the National Hospital Organization Himeji Medical Center, VATS pneumonectomy was completed successfully in 46 patients (2.1% conversion rate). Appropriate tissue retraction and cooperative dissection of hilum structures under only thoracoscopic visualization were applied to all candidates. We retrospectively reviewed morbidity, mortality, local disease control, and surgical considerations to evaluate the validity of this procedure. All patients had malignant tumors, including 45 with primary lung cancer. One patient with a severe adhesion around a tumor required conversion to open thoracotomy, with no subsequent specific complications. Of 46 patients in whom VATS pneumonectomy was completed, the mean operation time was 159 minutes and the mean blood loss was 258 g. Surgery-related death occurred in 1 patient (mortality rate: 2.2%) with recurrent heart failure after discharge. Seven patients (15.2%) had major complications defined as grade 3 or higher (Common Terminology Criteria for Adverse Effects, version 4.0) within 30 days postoperatively; however, no patients exhibited secretion retention that required bronchoscopy. There were no patients with locoregional recurrence within usual lymph node dissection areas and the ipsilateral thoracic cavity among 44 patients with primary lung cancer who underwent VATS pneumonectomy, with the median follow-up time of 27 months. Video-assisted thoracoscopic surgery pneumonectomy has developed into a common procedure with acceptable damage and lower morbidity among selected patients with complicated diseases.

Totally thoracoscopic repair of atrial septal defect reduces systemic inflammatory reaction and myocardial damage in initial patients

BackgroundTo compare the effect of totally thoracoscopic with conventional, open repair of atrial septal defect.MethodsForty atrial septal defect cases were divided into two groups by surgical approach: totally thoracoscopic approach (group A, n = 20) and conventional open approach (group B, n = 20). In group A, surgical procedures were performed through three portal incisions in the right lateral chest wall under thoracoscopic vision without the aid of a computerized robotic surgical system. Notably, all operations were completed by one surgeon who had just begun using this technique. In group B, the atrial septal defects were repaired in conventional open fashion. Clinical outcomes and serum levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), intercellular adhesion molecule 1 (ICAM-1), and creatine kinase isoenzyme-myocardial band (CK-MB) for the two groups were evaluated and compared.ResultsAll operations were performed successfully without serious complications. Durations of cardiopulmonary bypass (CPB), CPB setup, aortic cross-clamping, and operative procedure were significantly longer in group A than in group B (P < 0.05). The recovery times for body temperature and laboratory values of leukocytes were significantly shorter for group A than for group B (P < 0.05). There were no differences in durations of postoperative assisted ventilation or intensive care unit and hospital stays, volumes of blood transfused intraoperatively or thoracic drainage, or medical costs between the two groups. Serum levels of inflammatory factors (TNF-α, IL-6, IL-10, and ICAM-1) and CK-MB increased significantly in both groups after surgery. However, 6 h and 12 h after surgery, levels of these inflammatory factors and CK-MB were significantly lower in group A than in group B (P < 0.05).ConclusionsThoracoscopic cardiac surgery is technically feasible and safe, with less trauma and quicker recovery even when done by a surgeon newly introduced to the technique.

Total Muscle-Sparing Uniportal Video-Assisted Thoracoscopic Surgery Lobectomy

Conventional video-assisted thoracoscopic lobectomy uses multiple incisions, including an access incision and several port incisions. This series aims to evaluate the technical feasibility and early results of uniportal video-assisted thoracoscopic surgery (UVATS) lobectomy using a small, total muscle-sparing incision. We performed the first UVATS lobectomy in June 2009, and 38 major resections were attempted using this approach until September 2011. A single, small, muscle-sparing incision was made without rib spreading. True anatomic hilar dissection, individual vascular and bronchial ligation, and mediastinal lymph node dissection were performed under thoracoscopic visualization on a monitor. Thirty-two patients (84%) had malignant diseases, and 6 patients (16%) had benign diseases. Of the primary lung cancers, 85% were in stage I. Of the 38 attempted major resections, 32 UVATS lobectomies were successfully completed and 6 were converted to open thoracotomy. The early outcomes of successful UVATS lobectomy were analyzed (32 patients); 97% had no postoperative complications. There were no deaths. Mean pain score was 0.4 on postoperative day 1 and decreased to 0 by 1 week. Ninety-seven percent of patients received only oral analgesia postoperatively. Eight percent of patients experienced mild intercostal neuralgia not requiring treatment. No patients complained of shoulder dysfunction. The median duration of returning to full normal activities was 7 postoperative days. Total muscle-sparing UVATS lobectomy is technically feasible with low morbidity and mortality rates. Patients had minimal postoperative pain and narcotic use; and good functional outcomes with no shoulder dysfunction and early return to full normal activities.

Video-assisted thoracic surgery repair of subclavian artery injury following central venous catheterization: a new approach

Iatrogenic subclavian artery puncture following central venous catheterization is a rare but potentially fatal complication. There are very few reports in the literature on this condition. We propose the use of video-assisted thoracic surgery (VATS) in the management of these injuries. The technique of VATS to manage subclavian artery injury was described. We presented the first reported case of successful repair of subclavian artery injury using VATS. Using a two-incisional approach for VATS, the haemothorax was rapidly evacuated and the subclavian artery injury was successfully repaired using pledgetted sutures under direct thoracoscopic visualization. The patient had an uneventful postoperative recovery. VATS can be successfully applied to repair subclavian artery injury. The advantages include rapid intrathoracic access, excellent thoracoscopic visualization of the thoracic inlet, and avoidance of the morbidity associated with open thoracotomy.

The Nuss procedure made safer: an effective and simple sternal elevation manoeuvre

The Nuss procedure requires the creation of a substernal tunnel for bar positioning. This is a manoeuvre that can be dangerous, and cardiac perforation has occurred in a few cases. Our purpose was to describe two technical modifications that enable the prevention of these fatal complications. A series of 25 patients with pectus excavatum were treated with a modification of the Nuss procedure that included the entrance in the left haemithorax first, and the use of the retractor to lift the sternum, with the consequent lowering displacement of the heart. These modified techniques have certain advantages: (i) the narrow anterior mediastinum between the sternum and the pericardial sac is expanded by pulling up the sternum; (ii) the thoracoscopic visualization of the tip of the introducer during tunnel creation is improved; (iii) the rubbing of the introducer against the pericardium is minimized; (iv) the exit path of the introducer can be guided by the surgeon's finger and (v) haemostasis and integrity of the pericardial sac can be more easily confirmed. We observed that with these manoeuvres, the risk of pericardial sac and cardiac injury can be markedly reduced.

Pectus Excavatum Repair According to Nuss: Is It Safe to Place a Retrosternal Bar by a Transpleural Approach, Under Thoracoscopic Vision?

We present a new case of cardiac perforation during retrosternal dissection beginning a Nuss procedure for pectus excavatum repair in an 18-year-old boy. The true incidence of life-threatening complications, such as heart injuries during Nuss bar placement for pectus excavatum repair, as well as cardiac lacerations during removal of the bar, remains unknown. Many papers suggest measures to prevent these complications: approaching the retrosternal space through an additional subxiphoid short incision, lifting the sternum during bar placement, or placing the bar extrapleuraly. Nuss procedure is gaining more and more popularity due to its apparent simplicity; however, its operational complications should be well known and discussed to be avoided later on.