World J. Surg. 25, 157–161, 2001DOI: 10.1007/s002680020013 WORLD

Journal ofSURGERY© 2001 by the Societe

Internationale de Chirurgie

Place of Video-thoracoscopy in Thoracic Surgical Practice

Anthony P.C. Yim, M.D., Tak Wai Lee, M.B., Ch.B., Mohammad Bashar Izzat, M.D., Song Wan, M.D., Ph.D.

Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, HongKong

Published Online: February 16, 2001

Abstract. The advent of video-endoscopy revolutionizes the practice of sur-gery. Within a short span of time, video-assisted thoracic surgery (VATS) hasbecome an acceptable approach to a wide range of thoracic procedures. Theuse of VATS as a diagnostic modality is now well established. For therapeuticprocedures, VATS has also been generally accepted for the treatment of suchconditions as primary spontaneous pneumothorax, loculated effusions, tho-racodorsal sympathectomy, and resection of simple mediastinal cysts. Itsroles in more complex procedures such as thymectomy and anatomic lungresections, however, remain poorly defined at present, even though theexisting intermediate-term results are encouraging. VATS is still in evolution.Miniaturization of instruments promises to reduce access-induced traumaeven further. On the other hand, attention to cost-containment is essential ifVATS is to be applicable to patients in developing countries. Technology willcontinue to change. Carefully conducted clinical trials should precede thegeneral acceptance of any new technology, no matter how attractive it mayappear initially.

The last few years have seen video-assisted thoracic surgery(VATS) becoming an established technique in thoracic surgery. Asurvey conducted among North American thoracic surgeons in1995 showed that VATS has become the preferred or acceptedapproach over a wide range of thoracic procedures [1]. Recently,we conducted a similar questionnaire survey of thoracic surgeonsoutside North America. A questionnaire was sent to thoracicsurgeons from Australasia, Asia, Europe, and South Americaasking about the role of VATS in their practice and their opinionsregarding appropriate applications and limitations of the ap-proach [2]. A total of 210 completed questionnaires from Aus-tralasia (14%), Asia (50%), Europe (23%), and South America(13%) were analyzed. Most of the respondents work in govern-ment hospitals (45%) or in an academic setting (35%). Mostutilize VATS in fewer than 20% of their procedures, but theyanticipate an increase in the use of VATS in their practice. VATSwas considered the preferred approach for the management ofpleural disease, indeterminate lung mass, spontaneous pneumo-thorax, and thoracodorsal sympathectomy. It was considered anacceptable alternative to conventional thoracotomy for lung vol-ume reduction, pericardial window, management of anterior andposterior mediastinal masses, benign esophageal disease, lobec-

tomy, and thymectomy. Almost every respondent consideredVATS a valuable addition to thoracic surgical practice, but signif-icant concern was expressed over the cost and management ofoncologic diseases. There is little difference in opinion amongcontinents. Compared to a similar study conducted in NorthAmerica 3 years ago, this survey showed increased acceptance ofVATS for the more complicated procedures such as thymectomyand lobectomy. This may represent increased acceptance of theVATS approach with time and experience. Considerable concernexists over cost and the use of VATS as a therapy for oncologicdiseases.

Contraindications to VATS are relatively few. In addition to thegeneral contraindications, such as recent myocardial infarction andsevere coagulopathy, specific contraindications include pleural sym-physis and an inability to tolerate selective one-lung ventilation. Theformer is relatively uncommon, and moderate adhesions could usu-ally be taken down using a combination of sharp and blunt dissectionunder videoscopic vision. A prior operation in the ipsilateral chestshould not be regarded a contraindication [3].

Some of the common procedures performed by VATS are listedin Table 1. As experience is gained, more and more operations aretechnically approachable by VATS. However, clinical judgmentmust be exercised so we are not compromising the long-termbenefit for the sake of the minimal access technique. It is impor-tant to point out that although there is now a wealth of literatureon VATS there are relatively few publications comparing a VATSprocedure with its conventional (thoracotomy) counterpart in arandomized, prospective manner [4, 5]. Nonetheless, because oftheir low morbidity and the good short-term and long-term re-sults, many VATS procedures are now well accepted as the ap-proach of choice by the thoracic surgical community [5]. Detaileddiscussion of each procedure is beyond the scope of this article,and the readers are referred to our specialized textbook on thissubject [6]. We present here our view and personal bias on thisevolving technique.

Diagnostic Modality

The use of VATS as a diagnostic modality is well established andincludes biopsy of the pleura, a lung mass, a diffuse lung infiltrate,Correspondence to: A.P.C. Yim, M.D., e-mail: yimap@cuhk.edu.hk

a mediastinal mass, the pericardium, and the vertebral body [7].For simple procedures the use of miniaturized instruments(“needlescopic” instruments 2 mm or less in diameter) providesan attractive option that can reduce postoperative discomfort [8],although diminished illumination, reduced resolution, and flexi-bility of the equipment render it difficult to control fine move-ments. The use of VATS for staging intrathoracic tumors requiressome qualification. VATS is a useful adjunct to mediastinoscopyfor biopsy of several lymph node stations not accessible to thelatter approach (e.g., aortopulmonary, paraesophageal, and infe-rior ligament nodes) in patients with primary lung cancer. Medi-astinoscopy, however, should remain the principal diagnostic mo-dality as VATS would not be able to provide information oncontalateral mediastinal node involvement (N3 disease or stageIIIB). Nonetheless, VATS plays an important role in excludingpatients with pleural metastasis for an unnecessary thoracotomy.It is now part of our routine protocol to perform VATS explora-tion in all patients with intrathoracic malignancy, even before aplanned thoracotomy. VATS exploration could also provide in-formation regarding chest wall invasion to help proper planning ofsubsequent thoracotomy [9]. VATS also plays a role in the sec-ondary staging of lung cancer (i.e., patients with stage IIIA diseasewho underwent a course of neoadjuvant chemotherapy in whomrepeat mediastinoscopy may be technically difficult and potentiallyhazardous).

Therapeutic Modality

Pneumothorax

The significant success of VATS in the treatment of primaryspontaneous pneumothorax has led to earlier referral by physi-cians and increased acceptance by patients for surgery [10]. Sta-pled-resection of apical bullae followed by mechanical pleurodesisremains the most frequently used technique, although more cost-effective means of eliminating the bullae (e.g., suturing or loop-ing) have been developed [11]. Whereas primary spontaneouspneumothorax cases are easily approachable by VATS, treatmentof secondary spontaneous pneumothorax (with established lungpathology such as emphysema or pneumoconiosis) requires moreclinical judgment [12]. Patients with adhesions difficult to takedown may be more suitable for thoracotomy, and those who areelderly with multiple co-morbidities may benefit more from a

chemical pleurodesis (we prefer talc slurry) if the lung can be fullyreexpanded.

Pleural Effusions

For therapeutic procedures, the role of VATS in the drainage ofloculated effusions (including empyema and hemothorax) andpleural débridement is well established [13]. It is important toremember that if simple drainage is inadequate VATS explorationis recommended early, before the empyema progresses from afibrinopurulent phase to an organized fibrotic phase, resulting inrestricted pulmonary function from encasement or fibrothorax.The use of VATS to guide proper placement of a chest drainshould not be underrated [14]. For malignant pleural effusions, webelieve that patients who do not have trapped lungs are bettertreated with talc slurry than thoracoscopic talc insufflation, as theformer is simple, can be performed at the bedside, and does notrequire general anesthesia [9].

Sympathectomy and Splanchnicectomy

Thoracodorsal sympathectomy is indicated for patients with pal-mar and axillary hyperhidrosis, selected patients with reflex sym-pathetic dystrophy, and those with vasculopathies such asRaynaud’s or Buerger’s disease [15]. A segment of the sympa-thetic chain could be excised or ablated (e.g., with electrocautery),with the extent of intervention being dependent on the patient.For example, for palmar hyperhidrosis alone only the T2 segmentneeds to be excised, but if axillary hyperhidrosis is also a problemthe level of resection (or ablation) should be extended to includeT4. Even with VATS, a variety of surgical techniques are available.We continue to favor full lateral decubitus positioning and generalanesthesia with selective one-lung ventilation using three ports.The first rib could be identified by noting the position of thesubclavian artery (which crosses over the first rib to supply theupper extremities). The second intercostal vein usually crossesover the sympathetic chain just deep to the parietal pleura andmust be cauterized or clipped. We prefer to divide the sympa-thetic trunk proximally just below the stellate ganglion. Somesurgeons still prefer resecting part of the stellate ganglion (be-cause in 10% of patients sympathetic innervation to the upperextremity occurs through this ganglion). This has not been ourpractice because of the risk of Horner syndrome.

The success rate of this procedure for hyperhidrosis is high,ranging from 85% to 95% in large series from Taiwan [16, 17].Compensatory truncal hyperhidrosis occurs in about 20% of ourpatients and is occasionally difficult to treat. That possibility mustbe fully explained to the patient before surgery.

Splanchnicectomy is indicated for patients with intractable vis-ceral pain arising from the upper abdomen. The greater splanch-nic nerve arises from T5 to T10 and the lesser splanchnic nervefrom T10 to T11 of the sympathetic chain. Likewise, the nervescould be excised or ablated. In more than half of the patients aunilateral approach alone from the left is effective and should betried first before resorting to a bilateral approach [18].

Mediastinal Cysts

Benign mediastinal cysts, such as a desmoid cyst, esophagealduplication cyst, thymic cyst, and pericardial cyst, are often sur-

Table 1. Common indications for video-assisted thoracic surgery.

Diagnostic indicationsPleural biopsyStaging intrathoracic tumorsWedge resection of diffuse pulmonary infiltrateMediastinal mass biopsy

Therapeutic indicationsEmpysema and hemothoraxSpontaneous pneumothoraxSympathectomy/splanchnicectomyPericardial windowBenign esophageal disorderResection of a benign mediastinal massAnatomic lung resectionLung volume reduction surgeryThymectomy

158 World J. Surg. Vol. 25, No. 2, February 2001

prisingly easy to resect using VATS. Decompression of the cystwith a needle may be necessary to facilitate mobilization. Thephrenic nerve should be identified and carefully preserved. Foresophageal duplication cysts, a fiberoptic light source (from abronchoscope) placed in the esophagus can help identify thisstructure thoracoscopically during dissection. As a rule, for benigncysts the tissue plane is fairly well preserved. In fact, any suspicionof tissue plane invasion by tumor calls for conversion to a fullthoracotomy for further dissection [19].

Thymectomy

Thymectomy is an established therapy, in conjunction with med-ical treatment for generalized myasthenia gravis (MG). Whichtechnique to use, however, continues to be controversial. Severalsurgical approaches are currently being used, including transster-nal, transcervical, a combination of the two (for “maximal thymec-tomy”), and recently VATS [20]. Our own results and the collec-tive data from other centers show that there is little difference insymptomatic alleviation compared to that after thymectomy re-gardless of the surgical approach [21]. The complete remissionrate following VATS seems to be slightly lower than that using the“maximal thymectomy” approach, but we believe this is due to therelatively shorter follow-up of the VATS patients. The naturalhistory of MG following thymectomy is that more patients go intoand remain in complete remission with time. Therefore long-termfollow-up of these patients is important [21].

Although the thymus can be approached from either side withVATS, we prefer the right-side approach for several reasons: (1)The superior vena cava forms an easy landmark for dissection; (2)the confluence of the two branchiocephalic veins, which is adifficult area to dissect, can be easily approached from the right;and (3) it is easier for a right-handed surgeon to dissect thethymus from below up from the right side [22]. Care must betaken to dissect completely the superior horns, which can extendup into the neck. With firm, deliberate downward traction of themobilized gland (after all the vascular branches and tributarieshave been divided), the superior horns can be freed from theirfascial attachment (a continuation of the pretracheal fascia). Wehave found a dental pledget mounted on a conventional curvedclamp a useful device for blunt dissection of the thymus. Completeremoval of the thymus, irrespective of the approach, is importantto the success of this operation; therefore we advocate that theVATS approach be performed only by surgeons with considerableexperience with this technique.

Thymectomy by VATS has several distinct advantages over theother approaches. It is much less painful than the transsternalapproach, and recovery is much quicker. The thymus is essentiallyan anterior mediastinal structure; therefore approaching it fromthe chest rather than from the neck is more direct. The transcer-vical approach has the disadvantage of instruments crowdingthrough a small, single access. Cosmesis following VATS is excel-lent. Although this point, on its own, should be regarded as abonus rather than the main reason for choosing a particularsurgical approach, most MG patients are young women who caredeeply about surgical scars. There is some evidence that thesooner patients with generalized MG have surgery the better isthe long-term outcome; it therefore follows that the VATS ap-proach could encourage earlier acceptance of thymectomy by the

patients and earlier referral of these patients by their neurologists[22].

Pericardial Window

The VATS procedure provides a safe, effective approach to drain-ing pericardial effusions of both benign and malignant etiologies.Large pericardial windows could be created anterior and posteriorto the phrenic nerve for drainage [23]. When a pericardial effusionis associated with pleural effusion, the pericardium should beapproached from the side with the pleural effusion (or with moreeffusion in bilateral disease); otherwise a right-side approach isusually preferred, as the right hemithorax is larger than that onthe left, giving a better perspective for VATS evaluation. Cautionmust be exercised in the use of monopolar electrocautery to avoidtouching the heart and precipitating a dysrhythmia. Subxiphoiddrainage remains a viable alternative approach that can be per-formed under local anesthesia in patients who are extremely illand debilitated and in those with a history of bilateral chestsurgery or pneumonia when troublesome adhesions are antici-pated. The video-assisted subxiphoid approach using a video-mediastinoscope is a recent refinement of the old procedure [24].

Anatomic Lung Resection

Application of VATS to anatomic lung resections continues to bea subject of considerable controversy. Even among surgeons prac-ticing VATS, only a few use this approach for lobectomy [25].Anatomic dissection performed through a minithoracotomy in anessentially closed chest has raised questions on the safety of thetechnique; resection for intrathoracic malignancy casts doubt onadequate clearance; the long-term benefits of VATS over theconventional thoracotomy approach are uncertain [4, 26], and thehigh cost of the consumables and endoscopic equipment hasadded questions on the cost-effectiveness of this approach in thecurrent era of cost containment.

Despite all the skepticism, intermediate-term results from sev-eral centers performing VATS lobectomy have been encouraging[25]. The survival figures for patients with lung carcinoma follow-ing VATS resection are at least as good as, if not better, than thosefor a similar group of patients after resection through a conven-tional thoracotomy. If these reports can be substantiated by alarger experience, it could have an important impact on thesurgical management of thoracic malignancy. The reason for theimproved survival remains unclear at present, but there is circum-stantial evidence that by minimizing chest wall trauma the bodyinflammatory response is dampened and immune function is bet-ter preserved [27].

The technique of VATS lobectomy is by no means a unifiedapproach. Lewis and his group in New Jersey (USA) advocate asimultaneous stapling technique for the bronchus and pulmonaryvasculature [28]. Other surgeons, including us, continue an indi-vidual ligation technique of the hilar structures. There is littleconsensus on the size of the minithoracotomy and, more impor-tantly, the use of a rib spreader (Figs. 1, 2) [29, 30]. We recom-mend that the term “VATS lobectomy” be reserved for the pre-dominantly endoscopic technique with little or no rib spreading,and that the term “minithoracotomy with video assistance (MVA)lobectomy” be used instead when rib spreading is routine and thesurgeons operate by looking through the minithoracotomy [31].

Yim et al.: Video-thoracoscopy in Surgical Practice 159

Mediastinal lymph node sampling or dissection by the VATSapproach have been described.

Regardless of the exact technique, it is generally agreed thatcareful patient selection is essential. Our own patient selectioncriteria for tumor resection include stage I non-small-cell lungcancer (without evidence of endobronchial or chest wall involve-ment), tumor size , 4 cm, and complete or near-complete fissures(thoracoscopic assessment) [25].

We believe that VATS lobectomy is a feasible, safe procedure inexperienced hands and may be of particular benefit to the elderlyand patients with multiple co-morbidities who are otherwise poor-risk candidates for conventional thoracotomy. The exact role ofthis procedure awaits its long-term results compared with thora-cotomy [25].

Other Applications of VATS

Many thoracic procedures are being rediscovered through thora-coscopy, some of which involve other surgical subspecialties. Tho-

racoscopic spinal surgery is receiving increasing attention by theorthopedic community. For spinal deformity, anterior spinal re-lease and instrumentation are now feasible [32].

The VATS procedure is also playing an important role inminimal access cardiac surgery. The left internal mammary artery(LIMA) can be harvested with thoracoscopic assistance throughan anterior minithoracotomy [33]. This incision is subsequentlyused for the anastomosis of LIMA to the left anterior descendingcoronary artery in a procedure now referred to as minimallyinvasive direct coronary artery bypass grafting (MIDCABG). Thethoracoscope has also found use in minimal access mitral valvesurgery and in a totally endoscopic approach to valve replacementand coronary revascularization (port access approach) [34].

Future Prospects

Cardiothoracic surgery is undergoing rapid evolution as the de-velopment of video-thoracoscopy has revolutionized its practice.The question now is whether VATS, as we currently practice it,represents an endpoint that requires only minor refinements or anintermediate step to an even less invasive approach? We believethat both views may be correct. VATS represents a spectrum witha purely endoscopic approach at one end and a video-assistedapproach (with a utility minithoracotomy) at the other end. Forthe purely endoscopic procedures, there have been attempts tomodify further the surgical access and mode of anesthesia. Theformer resulted in the development of 2 mm “needlescopic”instruments and the latter in therapeutic thoracoscopy under localanesthesia. It is entirely possible that in the near future simplethoracoscopic procedures can be performed under local anesthe-sia via an essentially percutaneous route with miniaturized instru-ments as an outpatient procedure.

On the other hand, it is important to remember that to qualifyas a real advance in medicine a new surgical approach must becost-effective. It has to be at least as safe, at least as effective, andof equal or lower overall cost to the community as conventionalapproaches. Few would now argue that VATS, if applied properly,is of great benefit to patients. The true role of VATS must beexamined in the context of local socioeconomic factors. Costcontainment, although important in the West, is essential in de-veloping countries if VATS is not going to be limited to theprivileged few who can afford it [11].

The milieu for VATS is still evolving. No doubt improvedtechnique and refined instrumentation will emerge. It is importantfor us to remember that carefully conducted clinical trials shouldprecede the general acceptance of a new technique or technology,no matter how attractive it may appear initially. Charles E.Hughes said: “One of the most important lessons of life is thatsuccess must continually be won, and is never finally achieved. Itis not worthwhile to talk of the end of the period, for you arealways at the beginning of a new one.”

Résumé

La vidéo endoscopie a révolutionné la pratique de la chirurgie. Enpeu de temps, une large gamme d’interventions thoraciques estdevenue accessible par la chirurgie thoracique assistée par vidéoendoscopie (CTAVE). L’utilisation de la CTAVE commemodalité diagnostique est maintenant également bien établie.Pour des procédés thérapeutiques, la CTAVE est largement

Fig. 1. Flexing the operating table opens up the intercostal spaces forinstrumentation. (From Yim [29], with permission.)

Fig. 2. By opening up the intercostal spaces a 4 cm “gap” can be obtainedbetween ribs. Only soft tissue retraction is usually necessary for the entireoperation, including specimen retrieval. (From Yim [30], with permis-sion.)

160 World J. Surg. Vol. 25, No. 2, February 2001

acceptée pour le traitement d’affections comme le pneumothoraxprimitif spontané, les épanchements localisés, la sympathectomiethoracodorsale et la résection de kystes médiastinaux simples. Sonrôle dans des procédés plus complexes comme la thymectomie etles résections anatomiques du poumon, reste moins bien définipour l’instant, même si les résultats intermédiaires sont trèsencourageants. La CTAVE est toujours en évolution: avec laminiaturisation des instruments, on peut espérer réduire encored’avantage le traumatisme. D’un autre côté, si on veut que laCTAVE soit utilisable aussi pour des patients des pays en voie dedéveloppement, il faut porter l’attention aux coûts. La technologieva continuer à évoluer. Cependant, des essais cliniques doiventprécéder l’acceptation de toute innovation technologique, quellequ’en soit l’attrait initial.

Resumen

El advenimiento de la toracoscopía ha revolucionado la prácticade la cirugía. En muy poco tiempo la cirugía torácica videoasistida(CTVA) se convirtió en el aproche aceptable para una ampliagama de procedimientos, y el uso de la CTVA como modalidaddiagnóstica está plenamente establecida. En cuanto aprocedimientos terapéuticos, la CTVA recibe aceptación generalen el manejo de entidades tales como neumotórax espontáneo,derrames pleurales loculados, simpatectomía toracodorsal yresección de quistes mediastinales simples. Sin embargo, todavíano está definido su papel en procedimientos más complejos comotimectomía o resecciones pulmonares anatómicas, aunque losresultados a mediano término son prometedores. La CTVAcontinúa en desarrollo. La miniaturización de los instrumentospromete reducir aún más el trauma quirúrgico. Por otro lado, esnecesario prestar atención a los costos si se pretende que la CTVAsea también aplicable en los países en vía de desarrollo. Latecnología continuará cambiando, y se deben realizar estudiosclínicos cuidadosamente ejecutados antes de aceptar una nuevatecnología, así parezca inicialmente como muy atractiva.

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