Thoracoscopy : beyond the key hole

Background Lateral thoracotomy or median sternotomy causes significant morbidity. Thoracoscopy reduces the morbidity of the incision and provides a clear and magnified display of anatomy. It involves a learning curve. Objectives To evaluate the safety, efficacy and advantages of thoracoscopy. Method A retrospective analysis of 67 thoracoscopic procedures performed at the university surgical unit, Teaching Hospital, Peradeniya. Results The total number of 67 procedures included thymectomy, lymph node biopsy, lymph node dissection, excision of retrosternal goitre, sympathectomy, splanchnicectomy, oesophagectomy, lung biopsy and diagnostic procedures. The time taken was acceptable with minimum blood loss and selective use of intercostal drainage. There were no conversions. Intensive care was needed only for oesophagectomy, thymectomy and excision of retrosternal goiter. The need for narcotic analgesics was minimal. Feeding, mobilization and discharge from hospital were early except after oesophagectomy. There was a mortality of 13% in the oesophagectomy group. No morbidity or mortality was recorded among others. Conclusion Thoracoscopy permitted a wide range of surgeries to be done safely with reduced morbidity. DOI: http://dx.doi.org/10.4038/sljs.v32i1.6869 The Sri Lanka Journal of Surgery 2014; 32(1): 29-34


Introduction
Diagnostic and therapeutic procedures of the thorax are performed by thoracotomy or median sternotomy.Open access causes significant morbidity, due to long incisions and division of muscles/ bone, use of prolonged retraction and significant post operetive pain which affects breathing.The result may be prolonged ventilatory support and extended intensive or high dependency care.Due to poor respiratory effort and coughing, chances of respiratory infections are higher [1].The risk of wound infections and wound dehiscence, especially in sternotomy, may have disastrous outcomes [2,3,4,5].Furthermore patients' return to work and resumption of a normal life is delayed [6].
Thoracoscopy is an established technique with the potential to minimise the morbidity of open access [7,8,9,10,11].Clear display of anatomy is an added advantage.The image is magnified and it is possible to get a closer view by zooming in.
Lack of tactile sensation, difficulties of hand eye coordination, obtaining space for dissection and methods of haemostasis are challenges [9,10,11].Specimen retrieval should be planned.Also an initial high cost will The Sri Lanka Journal of Surgery 2014; 32(1): 29-34 be incurred for equipment.The objective of this audit was to evaluate the safety, efficacy and advantages of thoracoscopic procedures performed at the university surgical unit, Teaching Hospital Peradeniya, Sri Lanka.

Materials and methods
A retrospective analysis was made of 67 thoracoscopic procedures done in the unit.In every case, the position of the camera and the working ports were planned with the computerized tomography images.All procedures were performed under general anaesthesia and endotracheal intubation.Space for dissection was obtained by collapsing the lung which was achieved by single lung ventilation or insufflation of carbon dioxide while ventilating both lungs.During single lung ventilation capnothorax was required initially to assist with collapse.
We used laparoscopic equipment available in the hospital.Bipolar diathermy and ultrasonic dissectors were used to achieve haemostasis and dissection.Larger vessels like the azygous vein and the thymic vein were controlled with Titanium clips or intracorporeal ligation.
Specimens were retrieved as follows.

Large lymph nodes, thymus -retrieved in a
fashioned endobag, at times requiring a mini incision over the lateral chest wall.Table 1: Patient position and procedure.Once the procedure was completed the lung was expanded under visual guidance of the camera using hand ventilation.

Results
A total of sixty seven operations were performed.
Patients were positioned supine for anterior and  superior mediastinal procedures and the prone position was used for posterior mediastinal procedures.These positions allowed the collapsed lung to fall away from the of dissection.
Two diagnostic procedures were performed in planned oesophagectomy which were abandoned as the tumours were deemed non-resectable.

Discussion
Thoracoscopy reduces the trauma of access and has the

Editorial note
This audit of thoracoscopic procedures reveals the variety of surgical operations that may be performed in the thoracic cavity using a minimally invasive approach.
While the effort from this very experienced team of surgeons is commendable, it may not be advised for all general surgeons without sufficient training, sans a multi-disciplinary team.Despite the availability of a specialist thoracic surgery unit in the country, the workload presented here makes a case for increasing the number of thoracic surgeons who undergo training.

Editor in chief
Each year the journal receives an overwhelming number of case report submissions which results in considerable delay in publication from the time of acceptance.To facilitate earlier publication of accepted case reports we are pleased to announce a new issue -Sri Lanka Journal of Surgery -Case Reports.This issue will be published annually in October commencing 2014.