Supine Positioning for Bilateral VATS: Pediatric Surgery Difficult...

Lateral decubous positioning has been adopted from the transition from open thoracotomy to vats. It provides ease of exposure and rapid conversion to open thoracotomy. With advancements in vats, this no longer applies. Lateral positioning may add unnecessary morbidity, including brachial plexus injury and decubitous ulcers. The following is a case presentation exemplifying the use of supine positioning in bilateral vats. The patient is a 17 year old male with a history of asthma who presents with shortness of breath and chest tightness when running. He was found to have bilateral apical blebs and a large right spontaneous pneumothorax. This was treated with a chest tube. He later developed a small left spontaneous pneumothoraxa resolved with observation. Several months later, bilateral vats with bilateral apical bled resections and mechanical pleurodesis was performed. Due to the routine nature of the procedure, it was performed in the supine position. A single sterile preparation was done, providing simplicity and reducing operative time. The right side was approached first. The patient was positioned on the edge of the right side of the bed. 25 millimeter ports were placed at the seventh intercostal space at the midclavicular line and the sixth intercostal space at the mid axillary line. A 12 millimeter port was placed at the 4th intercostal space at the mid axillary line to accommodate the GIA stapler. Note both surgeons have adequate working space with their hands unencumbered. Upon entry, several adhesions were identified at the apex. These were taken down to reveal multiple large blabs. A GIA stapler was used for the resection. Sharp dissection and cautery were used to take down final attachments. Note the excellent visualization and minimal interference between the instruments. Mechanical pleurodesis was performed. A 24 French chest tube was placed in the apex, and the lung was reinflated. The incisions were closed with vicro and monochrol suture. The patient was then transferred to the left edge of the table, and access to the left thorax was obtained with similar port placement. There was no need for re-draping or prepping. The left bats was performed in a similar fashion to the right. A GIA stapler was fired multiple times to resect the blabs. The specimen was removed through the 12 millimeter port, and mechanical pleurodesis was performed. A 24 French chest tube was placed in the apex, and the lung was reinflated. The incisions were closed with vicro and monochrol suture. Post-operative chest X-ray shows complete resolution. Bilateral vats was safely completed in the supine position. This provides simplicity, convenience, decreased operative time, and decreased positioning-related morbidity. Is that it? Yeah. All right, so, Let's talk about this. Um, I guess, let me ask first, um, does, does, does anyone else or does everyone else here do, if they're gonna be doing bilateral procedures, would they do this as a supine, uh, positioning or would you do lateral decubitus? Let me start it off with you, Jack. Um, I haven't done this, but I think it's great. But what my, I have two questions. One is for what other condition would you be doing bilateral vats other than spontaneous pneumothorax. Right. And the second question is, do you always do this operation after the first pneumothorax? Cause they only had one on each side here. So, let me, let's address, I don't know if Nick, if you want to answer, and then we, I can give an answer to this and, And Mark McCollum as well. So, Nick, any other, um, situations that you can think of for bilateral vats? So I don't, I don't have any other specific examples of pathology, but the patient selection is pretty important. So if there's a procedure that, uh, requires bilateral vats with low morbidity and a very well-defined pathology such that you won't, um, you know, encounter. Any surprises, I think this is the sort of case that you should consider supine. I do, uh, I do it for hyperhidrosis. So when I do bilateral thoracic sympathectomies, uh, I will do that at one sitting and I will have the patient supine. The arm positioning is a little different, I think, perhaps than what you described. I missed the very beginning of your video, so I'm going to challenge you, Jose. I'm going to challenge you. Because, um, I thought about that too, the, uh, supine position for bilateral hyper, uh, hydrosis, um, uh, but the problem is when you put them supine in that position, you want the lung to fall away so you don't have to use an instrument to hold the lung away. And you can still then use two hands to do your sympathectomy. So I think that it was easier to do a lateral position. Now you've done it, so I want to hear your comments, but you really need that lung really fallen away so you can see that spine when you're doing a sympathectomy. Yeah, I, um, I have not seen it be a problem, you know, the lung falls away plenty. You, you, you tip the table to, uh, really to give you a little extra help, uh, and, uh, and use CO2 compression, uh, of the lung to help with your exposure. And I don't typically do it with a single port, so I do usually have a second, and if needed, a third hand if I thought the lung was really in my way, and all of the incisions come in through the from the axillary region basically. All right, before we go to Sharif, Mark, did you want to make any comments? This is your video. Uh, we're having a hard time hearing Doctor McCollum. I don't know if his, uh, phone is on. Can you hear me now? Yeah, we can hear you. Yeah, I would just underscore what Nick said, and, and this is a procedure that's useful in a, in a low risk to conversion thoracoscopic case, and, and, uh, that's is the perfect case for it. Any other, uh, low risk pleural based, uh, lesion case, if you were looking for a biopsy or something superficial, superficial. Uh wedge resection, I think it would be applicable as well. But again, uh, if there's a high risk of conversion or a difficulty with exposure, I would probably go with the traditional decubitus position. And, and so, and, and I'm going to turn it to Sharif in a second, but the point is supine vats, whether it's bilateral or unilateral for emyema, for whatever, you really don't necessarily need to be putting all these patients into lateral decubitus. It's, it's probably safer for the patient. You know, we always, we always keep, we say position the patient for laparoscopy, not as if I were to open. I mean, the incidence is so low that you could quickly convert if you needed. Yeah. I think it's the same, the bang on the head kind of thing. We just do something because it's what we did in a prior iteration of it, it's like we all were taking whenever you people were doing spleens because everyone did it through a trauma midline. You were like, no, the spleen's over here. Do it over, you just, we all, these are the why these things are great, reload, you know, think, do you have to have them. It's with a new procedure, new approach, Sharif. Yeah, I, I really like this, um, I really like this presentation, the whole idea. I'm just going to mention that another procedure that works, that is a good candidate for this, it comes up maybe once every 2 or 3 years. It's rare, but I recently did one last month, is putting bilateral phrenic nerve, um, stimulators for patients with central, uh, hyperventilation syndrome. And because the phrenic nerve is quite anterior, the spine position is actually perfect for this, and you can just prep the whole thing at once and, and do both sides. But I guess the question, which you just alluded to, Todd, is even if it's unilateral, I mean, these patients are all tall, thin, and they have these huge prominent, uh, ASIS's and all this, and I, I find it's really kind of a hassle to put them in lateral positions. So just looking at this, even if I was doing unilateral, I think I would go ahead and do it in supine, because it seems like the Exposure was really good. So I just had two questions. One is, uh, were you using a double lumen tube because it looked like you had a pretty good lung collapse, and then did you collapse each side, uh, subsequently? And were your pleurodesis, was it just an apical pleurodesis, or were you able to get all around the chest with the supine position? I'm so glad you brought that up, Mark. Why don't you start off, uh, answering some of those technical questions, and then we'll get into techniques of pleurodesis. Not that anyone's going to have any opinion on that. Yeah, that's going to be a whole webinar, but in this case, we did, we were able to do mechanically pleurodesis from about the 5th rib intercostal space up, and we're able to get a, actually it was as easy and has been as easy as the standard approach with the decubitus, but circumferentially from about the 5th intercostal space up to the apex we're able to pleurise and you cut out for the first portion. The question, I'm sorry. Double lumen tube. We did use that. This kiddo had a double lumen tube and with a little bit of positive pressure in the chest that you're working on, the exposure was great, and I want to point out a technical thing that I don't know if that the video did show, but the patient was, was moved so they were off to the on the very side edge of the bed. Then you had full mobility of your hands. So Mark, this was really well done. Uh, Nick, great presentation. Let's talk about the pleurodesis technique. I'm just curious. Um, Jeff, go ahead. Do you have a comment? Yeah, Mark, I like this. I'm gonna use it. Um, and good for you. Um, about the pleurodesis, um, I do a, a parietal pleurectomy fairly aggressively, and it's a, it's really, really easy. You just get into that, that space underneath the parietal pleura and just have fun stripping it off, and I think it's a far more effective way to, to seal that pleural cavity. Than than rubbing it with what effectively is sandpaper. I've seen some recurrences after mechanical pleurodesis, and, uh, knock on wood, I haven't had any recurrences after a pleurectomy, but, um, I mean, if you're in there. Might as well go the distance is, is my thinking and do a pleurectomy, which is really, really easy thoracoscopically. I would agree with Doctor Blair, and the other thing you don't want to do is you don't want to suck out any blood because the blood patch technique is also very effective for, um, for pleurodesis. Um, there was a question that somebody, uh, somebody wondered what was being used in the video for the pleurodesis, and I, I think it looked to me like it was the, uh, cautery, um, scratch pad. That's what I think that's what I use. That's what most people use, but I, I, I would like to just take the opposite approach. I, I'm not sure whether pleurodesis is actually necessary in these cases. The, the cause of the problem are, is blebs in the apex of the lung. You remove the blebs. You shouldn't have a recurrent pneumothorax, and I don't really think, I think we all do pleurodesis and I do it as well, but I question whether it's really necessary. Great question. But Jack, the blebs are, the blebs are not just a one point in time thing. I think they have to do with the anatomy of the lung and and kind of an overstretch. So I think if you take out one bleb, nothing is to say that another bleb is not going to form in a few months. I think these are congenital blebs. I don't think that they're, I don't think they form over time at the age of 16. Sharif, the preteens then what's that? Oh, preteens, just probably because of growth, then it becomes a problem when they're older. But Sharif, I think this goes along the lines of the epigastric hernia. I don't think we know. I think, uh, a lot of what we're doing is guessing, uh, like everything we do in pediatric surgery. Cathy, you're gonna make a comment. Yeah, I mean there are certain congenital. Problems that you go in there and there are blebs all over the place and you see the largest ones at the apex, you assume those are the ones that, that burst, but really, you can have blebs that you either can't see, can't identify how many times have you gone in there to take out a bleb and then you can't exactly see where the bleb is and you staple off the apex. I tend to strip the. The cupola of the pleura and then use the abrading technique for the lower aspects of the chest where the where the stripping of the pleura becomes harder. So, uh, I think, by the way, let me comment on both of those. I think we can answer this question. Uh, with the help of 10 or 15 centers, we could do a prospective randomized trial of lebectomy with pleurodesis and blebectomy without pleurodesis and see over many years with a lot of centers if there's really a higher incidence of recurrence without the pleurodesis. Um, I, I used to do pleurectomies as well, and I found that it was incredibly painful. Um, so, I stopped doing it. Um, and I may be wrong, and I, I'm willing, I wanna hear what everyone says here and this will probably direct my plan. Um, I was introduced to aerosolized talc, and I know that people have a heart attack when they hear that, but I'm curious, uh, like, Jack, are you OK? OK. Um, but I, I'm curious if anyone else here uses, uh, uh, any kind of chemical, uh, pleurodesis or talc powder. Well, um, uh, Todd, I mean, I used to use that routinely, and I would just insufflate through the, you know, the insufflator for the laparoscopy, um, and I actually just changed a couple of years ago when I got here to Montreal because everybody else was doing mechanical pleodesis, and it's anecdotal, and I don't have data to support it, but it seemed to me like the patients who were getting talc had a lot more pain post-op, um, and that's, that's why I changed. I agree with the, uh, the pleurectomy and the talc, um, are, are very painful postoperatively, and if you've ever had to re-operate in a chest that's had talc in it, you'll never do it again, uh, and I don't want the whole lung frozen, uh, and that's why the mechanical pleurodesis works effectively. I just need the apex of that lung to stick up. And if you notice in that video, when we started on the right side, just the area where the previous bleb had spontaneously erupted was well adhered to the apex of the chest. Yeah, it's kind of funny. It's like, yeah, go ahead. I think your point, the question is, do you really want to freeze the chest, or you're just trying to prevent almost like a tension in which the whole thing collapses down? And if you have a couple bits of scar that are doing that to hold it up, maybe you, you've done the job. That's a great point. But who knows? But then again, no pain, no gain. I mean. I think the more painful it is, probably the more effective pleurodesis you're gonna get. I'm curious from, um, Jeff and Kathy, how much your chest, how much pleurodesis do they, do you do, or pleurectomy do you do? Just do you do an apex or do you do a lot? And Jeff, you said it was super easy, so is it easy? It's once you get started, it's hard to stop. Uh, it's strips away, and yeah, it's painful, but, um, you know, with modern analgesics, uh, you know, it's, it's it seems to be manageable. I'm a tall lanky guy. I've probably got blebs and I'll probably suffer by, by having a traumatic or a spontaneous pneumothorax at the end of this webinar, but, uh, Jeff, I hate to tell you this, but you're out of the age group. Oh, Jeff, if you come down here to Akron Children's, we'll do it in a supine position and it'll have a good outcome. Let, let's, uh,