Advanced Thoracoscopic Surgery Steven RothenbergDenver Colorado Over A Quarter Century of Eliminating Thoracotomies In Infants and Children. From Denver to Liverpool, Houston, and Beyond Steven Rothenberg MD The Rocky Mountain Hospital For Children Denver, Colorado Clinical Professor of Surgery Columbia University College of Physicians and Surgeons
Disclosures•Bolder Surgical (JustRight) •Conmed•Storz Endoscopy
Virtual Training
Facebook post: Born Unable To Swallow
Evolution Over 25 Years
Raymond Donnelly
!Lateral Thoracotomy!PosterolateralThoracotomy!Anterior Thoracotomy!Chamberlin Procedure!Muscle Sparing Procedures!Medianstinoscopy!Median Sternotomy
Advantages!Wide access to chest cavity!Easy access to anterior and posterior mediastinumand hilarstructures!Can enter at variable interspaces Disadvantages!Difficult to access apex of chest!Division of large chest wall muscles!Painful!Limited access between ribs
Thoracoscopy for diagnosis of intrathoracic lesions in children. Rodgers BM, Talbert JL. J Pediatr Surg. 1976 Oct;11(5):703-8.
InstrumentationScopes -4mm and 3mm short (18-20cm) 0 & 30 degreeInstruments: 3mm shortTrocars: short 50-75mm Camera: HD, 4KLight source & light cord Energy Sources
Anesthesia •Single lung ventilation: Double lumen tube Bronchial blocker Mainstem intubation Tracheal intubation •Increase in PCO2/ Increase TV & PIP
Special Equipment •Endoloops •Endoclips •Endoscopic Stapler •Tissue /Vessel Sealing
Exclusion Criteria Hemodynamic Instability requiring significant pressor support Non-conventional ventilator support Patient cannot be transferred from ICU: i.e.- CDH on ECMO Giant Tumor
Positioning Maximize 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 Decubitus Lung biopsy Lobectomy Decortication Modified Supine Anterior mediastinal mass Thymectomy Pericardial window Aortopexy Modified Prone Posterior mediastinal mass Forgut Duplication TEF repair Myotomy PDA ligation Anterior spine exposure Place NG, Bougie, Esophagoscope
Room Set-up : Thoracoscopy SurgeonAssist Nurse Lat DecubHead anterior monitor monitor
Create Pneumothorax Insertion of CO2 aids with initial collapse Low flow – 1L/min Low pressure – 4mmHg Use valved trocars May increase PCO2 •
Thoracoscopic Procedures Performed•Lung Biopsy•Lobectomy•Sequestration resection•Cyst excision•Decortication•Forgut duplication resection•Esophageal myotomy•Anterior Spine Fusion•Diaphragmatic hernia/plication PDA LigationThoracic Duct LigationEsophageal atresia repairTEF repairAortopexyMediastinal mass excisionThymectomySympathectomyPericardial window
PDA LigationLaborde. 1995Rothenberg SS, Chang JHT, Toews WH, Washington RL: Thoracoscopic Closure of Patent Ductus Arteriosus: A Less Traumatic and More Cost-Effective Technique. J Ped Surg 30: 1057-1060, 1995.2-3mm & 1-5mm camera post ax line 4thspace, Lt hand mid-ax 3rdspace, Rt hand post-ax 5thspace5mm endoclipModified prone
PDA Ligation 2.2 Kg
Lung Biopsy
Rothenberg SS, Chang JHT: Thoracoscopic Decortication in Infants and Children. Surgical Endoscopy. V ol II, 93-94, 1997
Forgut Duplication 3 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 cysts and tumors
Lung ResectionsInterstitial lung diseaseMetastatic or primary cancerCongenital lung lesions:CPAM/ CLE/ SequestrationBullous diseaseInfectious: Severe Bronchiectasis/ Cavitary lesion/ Aspergilloma
Bronchopulmonary Malformations Bronchogenic 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
Thoracoscopic Lobectomy:Technique3 to 4 ports (3, 5, 12mm) Camera port mid ax line over major fissure, operating ports ant ax line Vessel SealerSuction irrigator5 mm Endoclip, EndoGIA: optionalLateral decubitusOperate front to backTwo 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, CathrynRothenberg, Charles Stolar, Steven Stylianos. J Laproendosc Adv SurgTech A 2015 May; 25(5) 423-8
Trocar Placement Tip of Scapula
3.5 Kg LLL3.8 Kg RUL
Know Anatomic Relationships
Mechanical FailureBe Prepared!
Create Space
4 Kg LLL CPAM
ResultsMay 2019538/541 procedures completed thoracoscopically127upper/ 45 middle/ 369 lower lobectomiesOperative time: 25 min –240 min (mean 105)Average time for trainee : 130 minIntra-op complication rate: 1.1%Chest tube duration: 1.2 daysHospital Days: 1-5(mean 2.2 days)
<5 Kg, < 3months146 pts with no significant respiratory distress operated on electivelyAverage operative time 80minutesAverage length of stay post-op 1-10 days (mean 1.6)
SegmentectomyTechnique•Lateral 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
Results•45 resections completed successfully thoracoscopically•Operative time : 30 – 300 minutes (mean 120)•Chest tube duration: <24 hours: 37•Hospital stay: 1-6 days (mean 2 days) All require F/U CT 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
Bronchogenic cyst
First Thoracoscopic TEF RepairDenver 2000
Room Set up TEF repair
TEF Repair Place more prone then not!30 degree scope, more posterior looks down on instruments.
New Trocar Position Left hand moreposterior
Non Type C Esophageal AtresiaManagement•Type A & B: G- tube placed day 1 or 2•Growth 3-8 weeks: G tube bolus feeds, upper pouch suctioning•Gap study Q 2-3 weeks•Bronchoscopy to evaluate for upper pouch fistula
Results•All 32 procedures completed successfully thoracoscopically•Gaps: 4-8vertebral bodies•Operative time: 45-135 min•Avg op time type A: 95• type B: 115•3/32 had documented leaks which resolved with conservative therapy•G tube feeds resumed on day 5 in 29/32
Retained pouch
H-type
H type
Vascular RingsJanuary 2000 –July 201925 patientsAge: 3 weeks –15 years Weight: 3.6 -62 KGW/U : ECHO, CT Angio, MRA 4 patients had a double arch and TEF15 Patients Right Arch with Diverticulum of Kommerelli5 patients right dominant arch and aberrant left subclavian and atretic left arch1 right arch and suspected ringSlater BJ, Rothenberg SS. The management of patent ductus arteriosus and vascular rings in infants and children. J Laparoendosc Adv Surg Tech 2015
Results•24/25 completed thoracoscopically•1 conversion for complete double arch•Average Hospital stay: 1.2 days Left arch Ligamentum
CDHHow Best to Approach?Open/Laparoscopic/Thoracoscopic
When to Operate MIS•Fi02 < 50%•Off ECMO•NO ?•Minimal Inatropic Support•HFOV vs Conventional ?•Left vs Right
CDH & Eventration: Room Set-up Laparoscopic Supine HeadMonitor MonitorSurgeonAssist Nurse
CDH Thoracoscopic repair – Patient positioning •Lateral decubitus•On stack of towels•Back to edge of table to allow left hand freedom to move•Head on small pad - lower than shoulder
CDH Thoracoscopic repair – room setup
Laparoscopic Inguinal Herniotomy Dissection & Ligation Technique Specially designed herniotomy hook dissectorSet-up
Large Lateral Defect
CDH Thoracoscopic repair – patch “pearls”
CDH Thoracoscopic repair – cosmetic results
Post-op day 1Post-op day 60 CDH Thoracoscopic repair – post - op radiographs
Scoliosis
Tips and TricksUse gravityUse InsufflationBribe anesthesia!Patience!Beta Blockers (for the surgeon)Maintain anatomic dissection: Don’t take short cuts!!!First do no harm!
Thoracotomy
Victor Hugo HISTOIRE D’UN CRIME 1852
It’s hard but it’s worth it!
•: Atlas of Pediatric Laparoscopy and Thoracoscopy -9780323694346 (elsevierhealth.com)
Hang in there!