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