Video-assisted Surgical Techniques Research Articles

Thoracic outlet syndrome: first rib resection by video-thoracoscopy using two ports

: Thoracic outlet syndrome (TOS) is defined as the set of signs and symptoms due to compression of the neural and vascular structures that cross the opening of the upper thorax. It can involve the brachial plexus, subclavian artery and vein. Treatment can be medical or surgical. The latter is indicated when conservative management fails and is based on decompression of the compromised structures by resection of the first rib, scalenotomy and resection of the cervical rib, if present. Open extrathoracic approaches have been used over time. Ohtsuka et al. described the first endoscopic approach for resection of the first rib and since then the videothoracoscopic technique has been optimized, finding several fully endoscopic approaches in the literature. We present our video-assisted surgical technique with 2 ports. We have been performing this technique for several years and each patient who will undergo surgery is evaluated in a multidisciplinary way, with neurologists, vascular doctors and orthopedists. The main advantages of this technique have been in the illumination and the magnified view from the video-camera. Visualization of the full length of the first rib and the neurovascular bundle is excellent and there is no need to retract any of the elements of the neurovascular bundle, therefore eliminating the risk of brachial plexus injury. In this approach body mass index also becomes a less important factor. This technique can achieve significant advantages in a shorter overall operative time, a lower postoperative morbidity rate, and a milder impact on the inflammatory system. All of this leads to better patient satisfaction, a shorter hospital stay, and a lower financial costs. Clinical success is obtained in the majority of patients, with slightly more variable results for the neurogenic TOS.

Reducing the Duration and Improving Hospitalisation Time by Using New Surgical Tehniques and Psychotherapy

As far as surgical techniques are concerned, video-assisted thoracoscopy comes with lot of improved results compared to classical surgical techniques. This technique seems to reduce the parameters reflecting the period of hospitalization, exposure to analgesics, patient�s recovery rate, and the level of pain felt. Studies have been conducted that have demonstrated that, hypnosis can significantly improve the duration of pain exposure as well as the intensity perceived by the patient. In domain literature report cases in which hypnosis has been proven effective is in the preoperative preparation of surgical patients. furthermore, by applying hypnosis, positive results are found during the postoperative care of patients. This study aims at the results of video-assisted surgical techniques, and at the opportunity of integrating complementary therapeutic elements such as hypnosis to improve the parameters interested in perioperative care of the surgical patient.

Minimally invasive video-assisted thyroidectomy: Ascending the learning curve.

BACKGROUND:Minimally invasive video-assisted thyroidectomy (MIVAT) is a technically demanding procedure and requires a surgical team skilled in both endocrine and endoscopic surgery. The aim of this report is to point out some aspects of the learning curve of the video-assisted thyroid surgery, through the analysis of our preliminary series of procedures.PATIENTS AND METHODS:Over a period of 8 months, we selected 36 patients for minimally invasive video-assisted surgery of the thyroid. The patients were considered eligible if they presented with a nodule not exceeding 35 mm and total thyroid volume <20 ml; presence of biochemical and ultrasound signs of thyroiditis and pre-operative diagnosis of cancer were exclusion criteria. We analysed surgical results, conversion rate, operating time, post-operative complications, hospital stay and cosmetic outcomes of the series.RESULTS:We performed 36 total thyroidectomy and in one case we performed a consensual parathyroidectomy. The procedure was successfully carried out in 33 out of 36 cases (conversion rate 8.3%). The mean operating time was 109 min (range: 80-241 min) and reached a plateau after 29 MIVAT. Post-operative complications included three transient recurrent nerve palsies and two transient hypocalcemias; no definitive hypoparathyroidism was registered. The cosmetic result was considered excellent by most patients.CONCLUSIONS:Advances in skills and technology allow surgeons to easily reproduce the standard open total thyroidectomy with video-assistance. Although the learning curve represents a time-consuming step, training remains a crucial point in gaining a reasonable confidence with video-assisted surgical technique.

Zukunftsvisionen und neue Technologien in der chirurgischen Behandlung des Vorhofflimmerns

The Cox-Maze procedure and less complex modifications have gained widespread use as a treatment modality for patients with concomitant atrial fibrillation. Hypothermic or hyperthermic energy sources play a significant role in rapidly creating linear lesions. Endocardial ablation is easy to perform and effective with different energy sources. Epicardial techniques may simplify the procedure by allowing surgery on a beating heart. But epicardial fat and the heat sink effect of the flowing endocardial blood are obstacles to effective ablation. New devices using bipolar (irrigated) radiofrequency, microwave or laser energy, cryoablation or focused ultrasound are in clinical or pre-clinical stages and permit lesions to be created on a beating heart without cardiopulmonary bypass. Minimally invasive or video-assisted surgical techniques and effective devices for epicardial ablation will enable the treatment of patients suffering from lone atrial fibrillation. To facilitate the comparison between different techniques and devices, guidelines for reporting clinical results are necessary.

A simplified technique for implantation of left ventricular epicardial leads for biventricular resynchronisation using video-assisted thoracoscopy (VATS)

Cardiac re-synchronization therapy for treatment of heart failure requires transvenous insertion of both a right ventricular and left ventricular pacing lead. Implantation of the latter by way of the coronary sinus often fails. Therefore, alternative techniques for insertion are required. We applied a simple video-assisted surgical technique (VATS) using only two ports for the insertion of left-ventricular screw-in electrodes. Fifteen patients (M: 10; F: 5; mean age: 62.2 years; range: 46-76 years) with heart failure meeting the ACC/AHA guidelines for implantation of biventricular pacing underwent transvenous insertion of the right atrial sensor lead and the right ventricular pacing lead. In all of them transvenous implantation of the left ventricular pacing lead failed, and they were planned for VATS. In right-lateral decubitus position and under single-lung ventilation a camera port and a flexible instrumentation port were inserted in the forth intercostal space. By using routine instruments, a T-shaped incision was made lateral to the phrenic nerve and an electrode was screwed in. The lead was guided subcutaneously to the pacemaker. Mean skin-to-skin operating time was 55+/-16 min, no conversion to thoracotomy was necessary. All patients were extubated in the operating room and remained in the intensive care unit for less than 24h. Chest tubes were removed after a mean of 1.6+/-0.5 days and the patients were discharged after a mean of 4+/-1.3 days. Intraoperative and postoperative pacing thresholds at 1 and 7 months were satisfactory in all cases and there was no lead dislocation. All but two patients had an improvement of their NYHA function class. There was neither surgical morbidity nor mortality. Video-assisted thoracoscopy over two ports seems to be an excellent alternative procedure for epicardial lead implantation. It is readily available and produces good pacing results at a short intervention time and tolerable stress for the patients.

Complications of Thoracoscopy

Thoracoscopy is a minimally invasive thoracic surgical technique that is gaining widespread use for several surgical procedures. Although the complication rate is relatively low, there are definable risks associated with the technique. Careful attention to patient selection and an understanding of the complications associated with one-lung ventilation and video-assisted surgical techniques can help one to anticipate and prevent complications.

Development of a model for training and evaluation in subfascial endoscopic perforator surgery (SEPS)

We describe a training method with objective evaluation that enhances video-assisted surgical skills. Training is via a simulator for subfascial endoscopic perforator surgery (SEPS) and can assess whether specific training exercises are helpful in the acquisition of skills for video-assisted surgical techniques. Twenty-five surgeons, with or without experience in video-assisted surgical techniques, were asked to perform standardised drills connected with the SEPS technique. The SEPS simulator consisted of an artificially constructed subfascial space in a leg, in which false perforator veins had to be localised, clipped and cut. The participants performed two sequences of actions three times, in order to improve their dexterity. The time required to perform each sequence was recorded. All trainees showed a steady improvement in skill-acquisition of the SEPS technique; the difference was statistically significant ( p < 0.004). Despite its obvious importance in teaching programmes, the assessment and training of technical ability has not been fully developed. If virtual reality simulators are to become more important in the future, simulation models will have to approximate more closely the real operating theatre, and thus will become more valid in the training and evaluation of surgical technique.

Minimal damage during endoscopic latissimus dorsi muscle mobilization with the harmonic scalpel

Background. To reduce wound-related complications, a video-assisted surgical technique has been adopted for the mobilization of the latissimus dorsi muscle. We postulated that thermal damage to the muscle might be minimized by using a Harmonic Scalpel instead of electrocautery during this procedure.Methods. Canine latissimus dorsi muscles were mobilized through a small incision, assisted by a videoscope. In 6 dogs, dissection with electrocautery was used to mobilize the latissimus dorsi muscle. In 6 other dogs, the Harmonic Scalpel was used. We compared operation times, wound infection rates, histologic changes in the muscles, and ease of handling between these groups.Results. The operation time was significantly shorter in the Harmonic Scalpel group than in the electrocautery group (61.5 versus 106.5 minutes, p = 0.00014). The Harmonic Scalpel caused less histologic damage to the mobilized muscles and produced less vision-obscuring smoke.Conclusions. The Harmonic Scalpel shortens the operation, minimizes muscle damage, and facilitates the performance of video-assisted latissimus dorsi muscle mobilization.

Resection of anterior mediastinal masses through an infrasternal approach

A video-assisted surgical technique for benign anterior mediastinal lesions is described. In 3 patients, the Laparolift system was used to lift the lower sternum before resection. This operation is less invasive and cosmetically more pleasing than median sternotomy. Unlike thoracoscopy, this procedure avoids opening the chest and can be performed in patients with pleural adhesions or pulmonary insufficiency in whom differential lung ventilation is impossible. At present, this technique is considered suitable only for benign lesions.

Minimally Invasive Port-Access Mitral Valve Surgery

Objectives: This study evaluates the feasibility of video-assisted minimally invasive mitral valve surgery by means of the Port-Access system. The aim of the study was to minimize surgical access and to develop a video-assisted surgical technique. Methods: The Port-Access system allows for closed chest endoluminal aortic clamping, cardioplegic arrest, and decompression of the heart. The mitral valve was either repaired ( n = 28) or replaced ( n = 23) in 51 patients by means of a minimally invasive approach through a right lateral minithoracotomy and under videoscopic guidance. Results: Mean length of incision was 5.4 ± 1.8 cm (range 3.8 to 8 cm). Mean duration of operation, cardiopulmonary bypass, and crossclamp time was 196 ± 53, 133 ± 52, and 72 ± 27 minutes, respectively. Median intubation time was 25.5 hours (range 5 to 264 hours). Median duration of intensive care and hospital stay was 2 days (range 1 to 36 days) and 13 days (10 to 36 days), respectively. Hospital mortality was 9.8% (5/51). Overall morbidity was relatively high. In two patients acute retrograde aortic dissection led to conversion of the procedure. At follow-up (261 ± 13 days), three patients required reoperation for paravalvular leakage. Baseline mean Duke activity index score was 19.3 ± 11.3 before the operation and increased to 23.2 ± 10 at 6 weeks' and 24.2 ± 10.3 at 12 weeks' follow-up, respectively. Conclusion: The Port-Access system allows for video-assisted minimally invasive replacement and complex repair of the mitral valve through a right lateral minithoracotomy. However, morbidity and mortality associated with this novel technique were high. (J Thorac Cardiovasc Surg 1998;115:567-76)

Complications of video-assisted thoracic surgery: A five-year experience

Although thoracoscopy was originally described in 1910, recent developments in video-assisted surgical techniques and endoscopic equipment has expanded the application of video-assisted surgical procedures in the field of thoracic surgery. In an effort to define both high-risk patients for video-assisted thoracic procedures and high-risk video-assisted thoracic surgical procedures, we reviewed the experience of four surgical institutions from June 1991 through May 1995. We looked specifically at complications resulting from the 937 video-assisted thoracic procedures performed during this period. Perioperative incidents or complications occurred in 35 patients (3.7%), and 116 procedures (12.4%) were converted to a thoracotomy. The in-hospital mortality rate was 0.5%, and death occurred principally in patients operated on for malignant pleural effusion. The overall incidence of postoperative complications was 10.9%, and the most prevalent complications were prolonged air leak (6.7%) and pleural effusion (0.7%). The incidence of complications was acceptable and, except for that of prolonged air leak, did not differ significantly from that resulting from analogous open procedures. Video-assisted thoracic surgery appears safe and particularly useful for some indications. However, the possibility of dramatic life-threatening perioperative complications requiring emergency conversion to thoracotomy justifies the fact that only trained thoracic surgeons should perform video-assisted thoracic surgical procedures.