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Ann Thorac Surg 1996;61:1066-1069
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Complications of Thoracoscopy

Section of General Thoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The revolution in video technology has led to the acceptance of thoracoscopy as an important tool in thoracic surgery.

Methods. A review of all patients undergoing thoracoscopy at the University of Maryland between November 1991 and March 1995 was performed to identify the incidence of intraoperative and postoperative complications. In addition, the role of computed tomography for predicting intraoperative complications was analyzed.

Results. Three hundred forty-eight procedures were performed in 321 patients. Twenty-seven patients required conversion to thoracotomy for various indications. In 12 patients further resection was required after frozen section diagnosis confirmed lung carcinoma. Six patients were opened due to adhesions. Two patients were opened due to inability to find the lesion (this represents 1.6% of all solitary pulmonary nodules). Three cases were converted to thoracotomy for lesions that were too large to remove (representing 2.5% of all solitary pulmonary nodules resected). Two patients required conversion to thoracotomy because of inability to obtain one-lung ventilation. One case required a limited thoracotomy for a lost needle used for needle localization of a solitary intraparenchymal nodule, and 1 patient had emergent exploration for bleeding. Early postoperative complications developed in 10 patients. There were two explorations in the immediate postoperative period for bleeding. Prolonged air leak occurred in 3 patients, empyema in 2, and recurrent pneumothorax, pulmonary edema, and pneumonia in 1 patient each. Computed tomography failed to diagnose adhesions in the majority of patients requiring conversion to thoracotomy.

Conclusions. Thoracoscopy is a safe and effective procedure with low intraoperative and postoperative complication rates.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1069.

Since the introduction of thoracoscopy by Jacobeus in 1910 [1], many exciting advances have been made in thoracic surgery. The fiberoptic telescopes now available provide excellent intrathoracic visual acuity and large, well-illuminated fields of vision. In addition, recently developed endoscopic thoracic instruments, including dissectors, retractors, and stapling devices, have allowed us to apply a thoracoscopic approach to many standard procedures. The anesthetic management of patients with thoracic disease has also improved dramatically. These advances have helped foster the revolution of minimally invasive thoracic surgical techniques [2].

The efficacy and safety of this technique is therefore under strict scrutiny in the surgical community to assure its proper application. Although most of the postoperative complications are similar to open procedures [3], intraoperative complications of video-assisted thoracic surgery (VATS) may differ significantly from those of thoracotomy [4]. We studied the complications associated with thoracoscopy in our series of thoracoscopy patients to determine the incidence of morbidity and mortality and assess the ability of preoperative imaging studies to predict complications.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Three hundred forty-eight procedures were performed in 321 patients at the University of Maryland Medical System and the Baltimore Veterans Affairs Medical Center between July 1990 and March 1995. A variety of thoracoscopic procedures for different indications were performed: solitary pulmonary nodules, 121; pulmonary infiltrates, 25; lung cancer staging, 16; esophagus cancer staging, 49; pleural diseases, 57; emphysema, bullae, and blebs, 41; biopsy of mediastinal mass and nodes, 13; sympathectomy and splanchinectomy, 7; and others (eg, implantable cardioverter-defibrillator, Heller myotomy, thymectomy, spine), 19. Records were reviewed for the incidence of conversion to open thoracotomy and the occurrence of intraoperative or postoperative complications. Hospital morbidity and mortality were defined as occurring within 30 days of the procedure or during the same hospitalization.

Radiographic findings, obtained from review of chest roentgenograms and computed tomographic (CT) scans, were correlated with the clinical data to determine the contribution of radiologic imaging and were analyzed retrospectively.

All patients were anesthetized with a double-lumen tube except 2 ventilator-dependent patients who could not tolerate one-lung anesthesia. Patients were placed in the lateral decubitus position, and the table was flexed maximally to widen the intercostal spaces. A 12-mm incision was made in the sixth or seventh intercostal space in the midaxillary line, and the pleural cavity was entered with a blunt hemostat. A finger was placed through the incision into the pleural space to check for pleural symphysis that might block entry. If pleural adhesions were found, blunt dissection with the finger was often successful in creating a large enough space to insert the first trocar. Alternatively, a second incision was made over a different area, in a similar fashion, to identify an area with a free pleural space. Carbon dioxide insufflation was begun through the first port to expedite the lung collapse when no significant adhesions or lung injury was noted. Insufflation pressures up to 8 to 10 mm Hg were used for the initial collapse [5]. An operating scope with a 5-mm viewing aperture and a 5-mm working port was used for lysis of extensive adhesions if these were present. This thoracoscope was usually sufficient for simple pleural procedures. Additional ports were placed under direct vision as necessary for more extensive procedures [6].

Computed tomography-guided needle/wire localization of small deep parenchymal nodules was performed using a previously described technique [7]. The patient was taken to the operating suite and the wire was cut at the subcutaneous tissue layer. The intrathoracic part of the wire that protruded from the lung was then used to locate the nodule after the thoracoscope was inserted [8]. Specimens were generally retrieved with an endoscopic plastic bag.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Twenty-seven patients (8%) required conversion to open thoracotomy for various indications. There were no deaths attributed to the thoracoscopic procedures in this series. Postoperative complications developed in 14 patients (4%).

In 12 patients (3.5%) further resection was required for primary carcinoma of the lung after a frozen section diagnosis was made. Six patients (1.8%) required conversion to thoracotomy due to extensive adhesions precluding the completion of the planned procedure. In 2 patients (0.5%) the lesion was not found at thoracoscopy and the procedure was therefore converted to open thoracotomy. The lesion was too big to remove through the 12-mm port in 3 patients (0.8%), which required a minithoracotomy (<4-cm incision) to remove the specimen. Two patients required conversion to open procedure because of anesthesia's inability to correctly achieve adequate one-lung ventilation.

One patient, undergoing a pericardiectomy, underwent urgent open exploration for presumed bleeding. No specific bleeding was found by the time he was reexplored. Preoperative computed tomography-guided needle localization was performed in 8 patients. In 1 patient (12%) the needle used for localization was not identified, requiring limited local exploration to retrieve the lost needle from the soft tissue.

Early Postoperative Complications
Of the 10 postoperative complications, exploration in the immediate postoperative period for excessive intercostal drainage occurred in 2 patients. Three patients had prolonged air leak (greater than 7 days); 2 patients had a postoperative empyema. One patient had a recurrent pneumothorax 10 days after VATS blebectomy (this was the first thoracoscopic blebectomy early in our series), which required limited thoracotomy. One patient had postoperative pulmonary edema with acute myocardial infarction, and pneumonia developed in 1 patient.

In both of the patients with excessive intercostal drainage, exploration failed to detect any specific bleeding. One of these was reexplored thoracoscopically, the other required limited thoracotomy. Two of the 3 patients with prolonged air leaks and the 1 patient with a recurrent pneumothorax had undergone stapling of apical blebs for multiple spontaneous pneumothoraces. The third patient with a postoperative air leak had severe emphysema and was receiving corticosteroids preoperatively. Two of these patients were managed conservatively and 1 required repeat thoracoscopy. The two postoperative empyemas were caused by methicillin-resistant strains of Staphylococcus aureus and were attributed to contamination of operating room instruments from other cases. Pulmonary edema developed in one 78-year-old patient due to an acute myocardial infarction in the postoperative period. Postoperative pneumonia occurred in 1 patient who had undergone pericardiectomy and pleurodesis for malignant disease.

Delayed Postoperative Complications
There were 4 patients in whom late postoperative complications developed (1.2%). Two patients had tumor recurrence after thoracoscopy. This may have been related to the use of the VATS technique and therefore is included as a late complication in this series. In 1 patient a malignant pleural effusion developed 6 months after a thoracoscopic wedge resection to diagnose a solitary pulmonary nodule that turned out to be metastatic melanoma. At that time, we were not using endoscopic plastic bags routinely. In 1 patient a large parenchymal recurrence developed 6 months after a wedge resection for solitary pulmonary nodule was performed. Pathologic examination showed metastatic leiomyosarcoma from the uterus. This patient eventually required a pneumonectomy to control the intrathoracic disease.

Two female patients had chronic postoperative pain syndrome, which required consultation by the pain service. One patient had undergone lung biopsy for the diagnosis of interstitial lung disease and 1 patient had undergone thoracoscopic sympathectomy for hyperhidrosis.

The overall incidence of complications, including early and late complications, was 14/348 patients (4%). The incidence of perioperative complications including conversion to thoracotomy was 41/348 patients (12%). Excluding patients with lung carcinoma requiring further resection or patients requiring extension of the port incision to remove lung tumors, there were 26 of 348 patients (7.5%) who required conversion to thoracotomy or had a postoperative complication.

The impact of preoperative imaging studies and their ability to predict adhesions was also analyzed. Computed tomographic scan correctly showed evidence of pleural disease in 6 of 9 cases of dense pleural adhesions found at thoracoscopy (66%). The remaining 3 cases of dense adhesions had normal preoperative scans. Imaging studies thus failed to detect adhesions in 33% of patients.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The development of improved video technology over the last 5 years has permitted minimally invasive thoracic surgery to replace open thoracotomy for a large number of surgical indications. Video-assisted thoracic surgery allows complete visualization of the pleural space with evaluation of both the parietal and visceral pleural surfaces. Video-assisted thoracic surgery has therefore become the surgical procedure of choice in the diagnosis and treatment of most pleural and some pulmonary, pericardial, and mediastinal diseases [9]. Video-assisted thoracic surgery is now widely used for resection of small peripheral pulmonary nodules [10] and biopsy of interstitial lung disease [11]. Video-assisted thoracic surgery is also useful for treating patients with spontaneous pneumothorax [12] or giant bullae [13], and recently was used in performing volume reduction for patients with diffuse emphysema [14].

Although there have been numerous reports regarding the utility and technical refinements of VATS [2, 9, 15, 16], there has been relatively little emphasis on the occurrence and management of complications of this new thoracic surgical procedure. Most surgical series have indicated a lower incidence of complications for VATS than for open thoracic procedures. Lewis and colleagues [9] noted ten complications in 100 consecutive thoracoscopies performed for a wide range of indications, and Kaiser and Bavaria [3] reported a 10% incidence of complications in 200 patients. Krasna and colleagues [11] reported 2 complications (6.5%) in 36 patients undergoing lung biopsy for interstitial lung disease. A recent report by Bensard and associates [17], which was a direct comparison of VATS versus open lung biopsy for interstitial lung disease, showed fewer perioperative complications.

Many of the postoperative complications seen after thoracoscopy are similar to those that occur after open thoracotomy. Typical postsurgical complications such as pulmonary embolus and minor wound infections seen after general thoracic procedures are also observed. Only 1 case of significant pleural adhesions was reported by Kaiser and Bavaria [3]. In contrast, we experienced 6 cases of significant pleural adhesions (1.8%) requiring conversion to thoracotomy. As demonstrated in previous reports of VATS procedures, persistent air leak was the most common postoperative complication. Risk factors include emphysema or apical bleb disease, which occurred in all 3 of our cases. As in 1 of our patients, persistent air leak has also been associated with the use of steroids in patients with giant bullous disease treated by thoracoscopic methods [13]. Prolonged air leak was seen in 3 patients in our series; only 1 patient required control with repeat thoracoscopy.

No patient with pleural pathology suffered a thoracoscopy-related complication in this series. The negligible rate of complications in pleural pathologies demonstrates the relative safety of VATS in these patients. Patients with solitary pulmonary nodules, pulmonary infiltrates, and emphysema giant bullous disease had the maximum number of complications. This emphasizes the need for adequate training and careful attention to the details of thoracoscopic techniques in managing pulmonary parenchymal pathologies.

Percutaneous CT-guided hook-wire localization of pulmonary nodules remains a useful technique for identifying small lesions deep to the visceral pleura or away from the fissures. As demonstrated in other series, hook-wire dislodgment may occur [18]. We encountered this complication in 1 of 8 cases. The delay between CT localization and subsequent thoracoscopy was the main reason for dislodgment and subsequent need for local exploration in this patient.

The very low incidence of postoperative pneumonia and lobar atelectasis in our series was presumably due to reduced postoperative pain and subsequent less compromise of respiratory function after VATS as compared with thoracotomy. We have not compared the infectious complications of VATS with open thoracotomy in our institution as the indications for both have varied substantially. We routinely use perioperative antibiotics for three doses in all thoracoscopic procedures.

We recently described the radiographic findings used to predict adhesions. Using preoperative CT scans and correlating these predictions with findings at thoracoscopy, we found that when CT scans were positive there was a 66% correlation with thoracoscopic findings of adhesions, but when negative there was no correlation [19].

In summary, this study demonstrates that VATS, a new and increasingly popular, minimally invasive thoracic surgical technique, is associated with an acceptable low complication rate. Preoperative imaging studies appear to have low specificity in predicting pleural adhesions but when positive should be used to target areas free of adhesions at the time of thoracoscopy. The contribution of imaging studies is most important in the postoperative period for the diagnosis and management of postoperative complications. In general, VATS can be used as a safe alternative approach in certain indications for thoracic surgery.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the forty-second Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–11, 1995.

Address reprint requests to Dr Krasna, Rm N4W94, 22 S Greene St, Baltimore, MD 21201.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Jacobeus HC. Possibility of the use of cystoscope for the investigation of the serous cavities. Munch Med Wochenschr 1910;57:2090–2.
2. Mack MJ, Arnoff RJ, Acuff TE, et al. Present role of thoracoscopy in the diagnosis and treatment of diseases of the chest. Ann Thorac Surg 1992;54:403–9.[Abstract]
3. Kaiser LR, Bavaria JE. Complications of thoracoscopy. Ann Thorac Surg 1993;56:796–8.[Abstract]
4. Krasna MJ. Complications of thoracoscopy. In: Bailey R, Flowers J, eds. Complications in laparoscopic surgery. St. Louis: Quality Medical Publishers, 1994.
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6. Landreneau RJ, Mack MJ, Keenan RJ, Hazelrigg SR, Dowling RD, Ferson PF. Strategic planning for video-assisted thoracic surgery. Ann Thorac Surg 1993;56:615–9.[Abstract]
7. Templeton PA, Krasna MJ. Localization of pulmonary nodules for thoracoscopic resection: use of needle/wire breast biopsy system. AJR 1993;160:761–2.[Free Full Text]
8. Shah RM, Spirn PW, Salazar AM, et al. Localization of pulmonary nodules for thoracoscopic excision: value of CT-guided wire placement. AJR 1993;161:279–83.[Abstract/Free Full Text]
9. Lewis RJ, Caccavale RJ, Sisler GL, Mackenzie JW. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 1992;54:421–6.[Abstract]
10. Landreneau RJ, Hazelrigg SR, Ferson PF, et al. Thoracoscopic resection of 85 pulmonary lesions. Ann Thorac Surg 1992;54:415–20.[Abstract]
11. Krasna MJ, White CS, Aisner SC, Templeton PA, McLaughlin JS. The role of thoracoscopy in the diagnosis of interstitial lung disease. Ann Thorac Surg 1995;59:348–51.[Abstract/Free Full Text]
12. Melvin WS, Krasna MJ, McLaughlin JS. Thoracoscopic management of spontaneous pneumothorax. Chest 1992;102:1875–6.[Free Full Text]
13. Wakabayashi A. Thoracoscopic technique for management of giant bullous lung disease. Ann Thorac Surg 1993;56: 708–12.[Abstract]
14. McKenna RJ, Brenner M, Mullin MJ, Singh N, Berns, M. Surgical treatment of diffuse emphysema. A randomized, prospective trial of laser bullectomy versus lung reduction surgery with staples and bovine pericardium. Abstract presented at the 75th Annual Meeting of The American Association for Thoracic Surgery, Boston, MA, April 23–26, 1995.
15. Miller JI Jr. The present role and future consideration of video-assisted thoracoscopy in general thoracic surgery. Ann Thorac Surg 1993;56:804–6.[Abstract]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark J. Krasna Joseph S. McLaughlin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Krasna, M. J. Articles by McLaughlin, J. S. Search for Related Content PubMed PubMed Citation Articles by Krasna, M. J. Articles by McLaughlin, J. S. Related Collections Related Article