Surgical Innovation

Thoracoscopy is a useful tool for diagnosing and managing intrathoracic disease. With the new technologies in endoscopic surgery, a whole variety of diagnostic and therapeutic procedures is now possible thoracoscopically, which has led to an increase in both the therapeutic and diagnostic indications for thoracoscopic surgery. Thoracoscopy has therefore become an important part of the armamentarium of general thoracic surgery. Safe thoracoscopy includes the use of careful one-lung ventilation. New instruments are now available to allow thoracoscopy to be performed more easily. Thoracoscopy is a safe and effective technique that can be performed with minimal morbidity and excellent results. Copyright © 1996 by W. B. Saunders Company

Video-assisted thoracic surgery is increasingly being applied to treat a variety of intrathoracic disease processes. Numerous pleural, pulmonary, esophageal, autonomic nervous system, spinal, and even cardiac procedures are now being performed using this minimally invasive approach. An overview of these thoracoscopic interventions is the focus of this review. It must be realized that although the technical feasibility of these operations has been demonstrated, their role in the practice of general thoracic surgery remains to be defined by critical scientific comparisons with established standards. Copyright © 1996 by W. B. Saunders Company

Thoracic applications for thoracoscopy or video-assisted thoracic surgery (VATS) remain many. Wedge resection for lung nodules and lung biopsy remains the most frequently performed VATS procedure. Thoracoscopy has been very valuable as a diagnostic technique for undiagnosed lung nodules and infiltrates. Using VATS for therapeutic resection of metastatic nodules remains controversial with potential adverse consequences. Recently there has been a great deal of interest and enthusiasm for VATS techniques in emphysematous patients. Surgical procedures such as resection of apical blebs and bullae have become standard. However, VATS volume reduction is aimed at a different segment of the emphysema population. The theoretic and potential surgical role in emphysema is discussed. VATS offers decreased pain and shortened hospital stays for many disorders and as such remains a valuable tool for the surgeon. Copyright © 1996 by W. B. Saunders Company

Three techniques are currently used to perform video-assisted thoracic surgery (VATS) lobectomy:endoscopic hilar dissection, minithoracotomy, and mass stapling of the lobar pedicle at the hilum. The reported results demonstrate that VATS lobectomy is technically feasible and safe. In comparison with open lobectomy, it is associated with less postoperative pain and a reduced incidence of respiratory complications. Lymph node harvest is equal to that achieved at open surgery, and the available intermediate survival data for stage I or II bronchogenic carcinoma indicate that VATS resection is at least equal to open lobectomy. Preliminary laboratory data suggest that a VATS approach may result in decreased cytokine activation and cell immunity changes. Copyright © 1996 by W. B. Saunders Company

The majority of mediastinal structures and diseases can be approached thoracoscopically. Diagnostic procedures for anterior mediastinal masses, mediastinal cysts, and staging of lung cancer are well accepted. Small but increasing experience has been gained with posterior neurogenic tumors. Complete thymectomy for management of myasthenia gravis has been performed, but the efficacy of the procedure for this indication awaits longer-term results. Copyright © 1996 by W B. Saunders Company

Anterior approach to the thoracic spine has been limited by the morbidity of a thoracotomy. By a thoracoscopic approach, a majority of thoracic spine procedures can now be performed from the anterior approach including diskectomy for herniation, release for correction of spinal deformity and corpectomy for tumor. Although experience is limited and results still short term, the thoracoscopic approach appears to be a promising one for the treatment of thoracic spine disease. Copyright © 1996 by W. B. Saunders Company

Minimally invasive techniques have recently been introduced into cardiac surgical procedures. Opportunities to make coronary artery bypass less invasive include elimination or minimization of both incisions and cardiopulmonary bypass. The current spectrum of minimally invasive coronary bypass procedures range from the minimally invasive direct vision coronary artery bypass procedure, which eliminates both the sternotomy incision and cardiopulmonary bypass, to the port access approach, which uses femoral-femoral bypass. Current procedures are also being used to make mitral and aortic valve surgery as well as saphenous vein harvest less invasive. Copyright © 1996 by W. B. Saunders Company