Thoracoscopic Surgery in Neonates and Infants Principles and TechniquesSteven Rothenberg MD The Rocky Mountain Hospital For Children Denver, Colorado Clinical Professor of Surgery Columbia University College of Physicians and Surgeons Evolution Over 25 Years AdvantagesDecreased pain and morbidity associated with a major thoracotomy Decreased surgical stress/ quicker recovery Decreased incidence of scoliosis and shoulder girdle weakness Shorter hospitalization Quicker return to normal activity (Parents) Improved visualization Cosmetically superior
DisadvantagesNew Mind-set Technically demanding Requires special instrumentation Requires getting support of neonatology, pulmonologists, and anesthesia Learning curve/increased operative time Rib cage results in less freedom of movement/ Ports must be carefully planned Often requires single lung ventilation InstrumentationScopes - 4mm and 3mm short (18-20cm) 0 & 30 degree Instruments: 3mm short Trocars: short 50-75mm Camera: digital Light source & light cord Energy Sources Special Equipment•Endoloops •Endoclips •Endoscopic Stapler •Tissue /Vessel Sealing
Thoracoscopic Procedures Performed•Lung Biopsy •Lobectomy •Sequestration resection •Cyst excision •Decortication •Forgut duplication resection •Esophageal myotomy •Anterior Spine Fusion •Diaphragmatic hernia/plication PDA Ligation Thoracic Duct Ligation Esophageal atresia repair TEF repair Aortopexy Mediastinal mass excision Thymectomy Sympathectomy Pericardial window
Exclusion CriteriaHemodynamic Instability requiring significant pressor support Non-conventional ventilator support Patient cannot be transferred from ICU: i.e.- perforated NEC, CDH on ECMO Anesthesia•Single lung ventilation: Double lumen tube Bronchial blocker Mainstem intubation Tracheal intubation •Increase in PCO2/ Increase TV & PIP PositioningMaximize exposure Use gravity to retract lung Adequate access for trocars Don’t worry about conversion to an open thoracotomy
Set Yourself Up To Succeed Lateral DecubitusLung biopsy Lobectomy Decortication Modified SupineAnterior mediastinal mass Thymectomy Pericardial window Aortopexy
Modified PronePosterior mediastinal mass Forgut Duplication TEF repair Myotomy PDA ligation Anterior spine exposure Place NG, Bougie, Esophagoscope FeetHead Monitor MonitorSurgeon//////Assist Nurse Anesth Create PneumothoraxInsertion of CO2 aids with initial collapse Low flow – 1L/min Low pressure – 4mmHg Use valved trocars May increase PCO2
PDA Ligation3 Ports : 2-3mm & 1-5mm camera post ax line 4th space, Lt hand mid-ax 3rd space, Rt hand post-ax 5th space 5mm endoclip Modified prone PDA Ligation Forgut Duplication3 ports – 3 or 5mm (camera post. axillary line, working ports mid-axillary line) Hook cautery, Vessel Sealer (Ligasure, Harmonic scalpel , JRS) Intra-esophageal stent Modified Prone position
Mediastinal Tumors
Lung ResectionsInterstitial lung disease Metastatic or primary cancer Congenital lung lesions:CAM/ CLE/ Sequestration Bullous disease Infectious: Severe Bronchiectasis/ Cavitary lesion/ Aspergilloma Bronchopulmonary MalformationsBronchogenic cyst Congenital Pulmonary Airway Malformation (CPAM): Type 0 – IV Type 1 – single or multiple large cysts 50- 60% Type 2 – Multiple smaller cysts < 1 cm 10-40% Pulmonary sequestration: Intralobar vs Extralobar Congenital Lobar Emphysema: CLE A spectrum not discreet entities Work-upPrenatal Ultrasound Prenatal MRI? Chest xray UGI CT scan MRI Thoracoscopy
Lung Biopsy Thoracoscopic Lobectomy: Technique3 to 4 ports (3, 5, 12mm) Camera port mid ax line over major fissure, operating ports ant ax line Vessel Sealer Suction irrigator 5 mm Endoclip, EndoGIA: optional Lateral decubitus Operate front to back Two Decades of Experience with Thoracoscopic Lobectomy in Infants and Children: Standardizing Techniques for Advanced Thoracoscopic Surgery Steven S. Rothenberg, William Middlesworth, Angela Kadennhe-Chiweshe, Gudrun Aspelund, Keith Kuenzler, Robert Cowles, Lawrence Bodenstein, Saundra Kay, Kristin Shipman, Cathryn Rothenberg, Charles Stolar, Steven Stylianos. J Laproendosc Adv Surg Tech A 2015 May; 25(5) 423-8 Trocar Placement
Know Anatomic Relationships Extralobar Sequestration Extralobar Sequestration
Mechanical Failure Be Prepared RLL Intralobar Sequestration Create Space
Segmental Resection TechniqueLateral decubitus position Single lung ventilation and CO2 insufflation 3 ports Anatomic segmentectomy Identify and ligate segmental artery and bronchus of affected tissue Parenchymal division with tissue sealer or stapler along ischemic plane Chest tube left in all cases ResultsAll resections completed successfully thoracoscopically Operative time : 30 – 300 minutes (mean 120) Chest tube duration: <24 hours: 17 48 hours: 5 5 days : 1 (AVM) Hospital stay: 1-6 days (mean 2 days) Rothenberg SS, Shipman K, Kay S, Kadenhe-Chiweshe A, Thirumoorthi A, Garcia A, Czauderna P, Kravarusic D, Freud E.. THORACOSCOPIC SEGMENTECTOMY FOR CONGENITAL AND ACQUIRED PULMONARY DISEASE; A CASE FOR LUNG SPARING SURGERY. J Laparoendosc Adv Surg Tech. 2014 Jan; 24(1):50-4
Telementoring
CDH Repair TEF Repair TEF Repair Place More Prone30 degree scope, more posterior looks down on instruments.
Left%hand%moreposterior Steps of TEF RepairDivide Azygus vein Ligate and divide fistula (clip) Mobilize upper pouch Excise tip of pouch Single layer anastomosis Initial cases all knots extraluminal vs current 5-0 PDS- Back row intra-luminal, Front row extra-luminal (single interrupted)
Chest drain in all patients Contrast study day 4 or 5 Feeds started after contrast study FIRST 5 YEARSSECOND FIVE YEARS 28 pts Average time 95 2 leaks 1 conversion 8/28 required dilation (28.5%) 0 recurrent fistula 21 patients Average time 75 0 leaks 0 conversion 2/21 required dilatation (9.5%) 0 recurrent fistula Rothenberg*SS.*Thoracoscopic*repair*of*esophageal*atresia*and*tracheo6esophageal*fistula*in*neonates:*The*current*state*of*the*art.*PediatrSurgInt.*2014*Oct@30(10):979685*
Long Gap EA Rothenberg SS, Flake AW. Experience with thoracoscopic repair of long gap esophageal atresia in neonates. J Laparoendosc Adv Surg Tech 2015 Nov 25(11) 932-5. Long Gap with Proximal Fistula H type Fistula
Vascular RingsJanuary 2000 – December 2013 11 patients Age: 6 weeks – 8 years Weight: 3.6 - 38 KG W/U : ECHO, CT Angio, MRA 2 patients had a double arch and TEF 5 Patients Right Arch with Diverticulum of Kommerelli 3 patients right dominant arch and aberrant left subclavian and atretic left arch 1 right arch and suspected ring !10/ 11 completed thoracoscopically!5 division of ligamentum!4division atreticleft arch and ligamentum!1 complete double arch: converted to open after successful division of ligamentum!1 exploration only , followed by laparoscopic Nissen and G-button L eftarch Ligamentum Vascular Ring
Tips and TricksUse gravity Use Insufflation Bribe anesthesia! Patience! Beta Blockers (for the surgeon) Maintain anatomic dissection: Don’t take short cuts!!! First do no harm! Thoracotomy Thoracotomy
Victor HugoHISTOIRE D’UN CRIME 1852