Minimally Invasive Thoracic Surgery

Overview

Using thoracoscopic instrumentation, CUMC thoracic surgeons resect a pulmonary node.

Thoracoscopy was first performed in 1910 for the diagnosis of pleural diseases. The procedure was frequently performed under local anesthesia to diagnose and treat pleural tuberculosis. There was limited therapeutic application of this technology until the introduction of video-endoscopic instrumentation in the late 1980s.

Minimally invasive thoracic surgery allows the performance of surgical procedures in the chest cavity utilizing small incisions and specially-adapted, video-endoscopic instruments. This affords a quicker and less painful convalescence for the patient. Many procedures which were previously performed with larger incisions can now be done thoracoscopically, with comparable results. Thoracoscopy is useful for the diagnosis and treatment of a variety of intra-thoracic processes.

  Interstitial Lung Disease

There are a variety of diseases grouped together because of their common radiographic appearance and are collectively known as interstitial lung disease. These include interstitial fibrosis, sarcoid, asbestosis, hemosiderosis, bronchoalevolar carcinoma, and lupus, to name a few. The treatment of these various processes is very different and therefore, it is imperative to obtain accurate diagnosis. The attempt to make a diagnosis by randomly biopsying the lung is usually unsuccessfully. Thoracoscopy has significantly improved our ability to diagnose interstitial lung disease. Performed through two or three 1-cm. incisions, multiple areas of the lung can be biopsied, correlating to the abnormal regions on the CT scan, and also targeted because of the abnormal appearance. We routinely perform multiple biopsies for interstitial lung disease, and obtain an immediate frozen section diagnosis from our authoritative lung pathologist, therefore increasing the diagnosis yield. Most patients can leave the hospital in 2 or 3 days, with very little post operative discomfort. This procedure has significantly contributed to the early diagnosis of patients with interstitial lung disease.

  Pulmonary Nodules

Thoracoscopy plays a major role in the diagnosis of solitary pulmonary nodules. Depending on the radiographic qualities of the nodule, its size, the gender of the patient, and his or her smoking history, approximately 50% of nodules are malignant. The only radiographic test which can accurately determine if the nodule is benign is the presence of an old chest X-ray showing the presence of the nodule. Without such an existing X-ray, the nodule should be removed. Thoracoscopy significantly reduces the morbidity associated with removal of solitary lung nodules. We routinely remove nodules up to 2 cm. in diameter. Occasionally, the nodule may be deep within the lung substance and not readily apparent. In those situations, patients have gone to our X-ray department to have the nodules localized by a radiologist first. They are then brought to the operating room to have the nodule removed. We have had great success with this technique, avoiding the need for an open thoracotomy. Over the past five years, several hundred patients have undergone thoracoscopic removal of lung nodules, with a diagnosis success rate of well over 90%.

  Spontaneous Pneumothorax

There are two broad categories describing collapsed lungs. Patients with primary pneumothorax tend to be tall, young, and thin. Patients with secondary pneumothorax tend to be older, with moderate to severe emphysema, and large bullae. Primary spontaneous pneumothorax or secondary pneumothorax which does not resolve with a chest tube, or which recurs, should be treated surgically.

Patients who have primary spontaneous pneumothorax often can tolerate a pneumothorax with few symptoms. The source of the pneumothorax is usually a ruptured bleb from the top of either the upper or lower lobes. Approximately 20% to 40% will experience recurrence after a first episode. If that second event is similarly treated without surgery, the probability of a third occurrence is greater than 60%. Surgery will be necessary in about 20% of patients, usually because of recurrent pneumothoraces. Less common indications for surgery are: prolonged air leaks from the chest tube, and associated hemothorax, or patients at high risk because of their occupations or lifestyles. Our preferred surgical approach in patients requiring surgery for spontaneous pneumothorax is thoracoscopy, with resection of the apical blebs or bullae, and abrasion of the pleura producing firm adhesions between the lung and chest wall. Thoracoscopy affords better visualization of the entire lung surface, especially the lower lobe which cannot be seen when the traditional axillary approach is used. We tend to identify more blebs with the thoracoscopic approach. In our experience, patients treated for pneumothorax this way seem to experience less postoperative pain, both immediately after surgery, and when seen several months afterwards. There has been no difference in our experience with recurrent pneumothorax provided blebs are identified and removed. Despite advocating this less invasive procedure, the indications have not been changed. We reserve surgery for patients who either have recurrence or a persistent pneumothorax for five to seven days.

  Lung Cancer

Thoracoscopy has a large role in managing patients with lung cancer. We use this technique frequently to assist in the diagnosis, staging, and treatment of lung cancer. Solitary nodules are frequently resected this way. Any patient for which a minimally invasive procedure can help either in the diagnosis or treatment of lung cancer is offered this approach. This has significantly helped us reduce overall length of stay and shorten recovery time.