indications for thoracoscopy in children george w. holcomb, iii, m.d., mba children’s mercy...

Indications for Thoracoscopy in Indications for Thoracoscopy in ChildrenChildren

George W. Holcomb, III, M.D., MBA

Children’s Mercy Hospital

Kansas City, Missouri

Indications for Thoracoscopic Procedures in Children

• Lung Biopsy• Lobectomy• Sequestration resection• Excision bronchogenic cyst• Foregut duplication resection• Esophageal myotomy• Anterior spine fusion• Debridement/decortication • Diaphragmatic

hernia/plication - ?

• Spontaneous ptx

• PDA ligation• Thoracic duct ligation• Esophageal atresia repair• Aortopexy• Mediastinal mass exc/bx• Thymectomy• Sympathectomy• Pericardial window• Division of vascular ring• Nuss operation• Anterior spinal operations

Musculoskeletal Sequelae From Thoracotomy

• Shoulder elevation

• Limitation shoulder movement

• Scoliosis

• Respiratory dysfunction

• Mammary maldevelopment

• Atrophy chest wall muscles

Post Thoracotomy Sequelae1. Durning RP, et al: J Bone Joint Am 62, 1980

2. Gilsanz V, et al: AJR Am J Roentgenol 1983

3. Jaureguizar E, et al: J Pediatr Surg 1985

4. Chetcuti P, et al: J Pediatr Surg 1989

5. Goodman P, et al: J Comput Assist Tomogr 1993

6. Frola C, et al: AJR Am J Roentgenol 1995

ThoracoscopyPatient Positioning

Data Points

• Age

• Weight

• Gender

• Type of operation

• Indication for operation

• Final diagnosis

• Chest tube

• Complications

• Length of stay

Children’s Mercy Experience

• Jan 2000 – June 2007

• 230 patients = 231 thoracoscopic operations

• Age = 9.6 ± 6.1 years

• Weight = 36.6 ± 24.1 kg

• 115 boys : 115 girls

JLAST 18:131-135, 2008JLAST 18:131-135, 2008

Thoracoscopic Operations Children’s Mercy Experience (2000-2007)

Diagnostic No. of Patients

Wedge biopsy of solitary lung lesions 37

Biopsy and excision of mediastinal masses 26

Wedge biopsy of diffuse parenchymal disease 15

Evaluation of penetrating thoracic trauma

1

Total 79

Therapeutic

Pleural decortication for empyema 79

Exposure for scoliosis 26

Bullae resection for pneumothorax 25

Lobectomy 9

Repair of esophageal atresia and fistula 8

Evacuation of hemothorax and pleural effusion 3

Repair of bronchopleural fistula 1

Total 151JLAST 18:131-135, 2008JLAST 18:131-135, 2008

Complications

• No intra-operative complications

• 3 conversions to open during lobectomy• 2 right upper lobectomies (visualization)• 1 left lower lobectomy

(infection/inflammation)

• 1 persistent pneumothorax after bleb resection

JLAST 18:131-135, 2008JLAST 18:131-135, 2008

Results

• Length of stay = 3.8 ± 4.0 days – Excluding esophageal atresia

and scoliosis

• Chest tubes in 211 patients (91%)– 2.9 ± 2.0 days – Excluding esophageal atresia

and scoliosis– 93 traditional chest tubes– 118 soft drains– 20 patients without post-

operative chest tubes(JLAST 19: S23-S25, 2009)

Conclusion

• Safe and effective

• Primary diagnostic and therapeutic application for most thoracic conditions at CMH

Thoracoscopy - EmpyemaTechnique

• Initial incision 4th or 5th ICS, AAL

• Use telescope to compress lung and create working space

• 2nd incision opposite 1st one, PAL

• 10 mm cannulas,insufflation to 6-8 torr 10 mm angled telescope

Thoracoscopy - EmpyemaTechnique

• 3rd incision (10 mm), 9th or 10th ICS, MAL

• Site for chest tube exteriorization

Thoracoscopy - EmpyemaTechnique

• Rotate instruments among the three incisions

• Can remove canula, insert curved ring forceps

Thoracoscopy - Empyema

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Thoracoscopy - Duplication

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Thoracoscopy – Lymph Node Bx

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Thoracoscopy – Left Lower Lobectomy

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Diagnosis of Malignancy via Thoracoscopy

• Alveolar Soft-part Sarcoma

• Ewing’s Sarcoma

• Ganglioneuroma

• Lymphoma

• Neuroblastoma

• Rhabdomyosarcoma

• Schwannoma

• Wilms’ Tumor

• Yolk Sac Tumor

Thoracoscopic RepairEA/TEF

EA/TEFPreoperative Evaluation

• Echocardiogram – assess cardiac anomalies

• Renal US – assess kidneys

• CXR/spine films – assess vertebral anomalies

• PE – assess limb, anorectal anomalies

• US great vessels – assess location of aortic arch

Thoracoscopic Repair EA/TEF

Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula: A Multi-Institutional Analysis

George W. Holcomb III, Steven S. Rothenberg, Klaas MA Bax, Marcelo Martinez-Ferro, Craig T. Albanese, Daniel J. Ostlie, David C. van der Zee, C K Yeung

American Surgical Association, 2005American Surgical Association, 2005

Ann Surg 242:422-430, 2005Ann Surg 242:422-430, 2005

Thoracoscopic Repair EA/TEF104 Patients

Waterston A: > 5.5 lb with no significant associated problemsWaterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomalyWaterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

Waterston A 62 Patients

Waterston B 30 Patients

Waterston C 12 Patients

Operation converted 2 2 1

Operation staged 1 - -

Esophageal anastomotic leak 2 3 3

Stricture (on initial esophagram) 3 1 -

Patients needing only 1 dilation 7 5 -

Patients needing 2 dilations 9 1 2

Patients needing 3 dilations - 3 1

Patients needing >3 dilations 3 2 -

Recurrent tracheoesophageal fistula 1 1 -

Fundoplication 19 6 1

Imperforate anus operations 4 4 2

Duodenal atresia repairs - 2 2

Aortopexy 6 1 -

Death 1 - 2

Preoperative Bronchoscopy

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Port/Instrument Positions

EA/TEF

89 pts/16 yrs

• shoulder elevation: 24%

• chest deformity: 20%

• abduction limited: 100%

• spine deformities: 18%

• breast deformities: 27% (3/11)

Why Thoracoscopy?

Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985

Thoracoscopic Repair EA/TEFFistula Ligation

• Metal clip

• Weck clip

• Tie (x2 ?)

• Suture ligature (x2 ?)

• Suture closure – tracheal side

Tips/Tricks

• Surgisis placed b/w

esophagus & tracheal

suture line to help

prevent recurrent TEF

J LAST 17:380-382, 2007J LAST 17:380-382, 2007

Tips/Tricks

• Oscillating ventilator

• U-clips anterior anastomosis

JLAST 21: 877-879, 2011JLAST 21: 877-879, 2011

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How To Get StartedNot The Ideal Case

• 2 - 2.5 kg

• Very high upper pouch

• Complex single ventricle physiology

• Prostaglandin dependent

How To Get StartedIdeal Case

• Baby – 2.5-3 kg; no other anomalies

• Esophageal segments close together (CXR, Bronchoscopy)

• Start thoracoscopically – Go as far as comfortable

• Try it again

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QUESTIONS