Ann Thorac Surg 1996;61:1267-1268
© 1996 The Society of Thoracic Surgeons
How To Do It
Thoracoscopic Exposure of Intervertebral Discs
Robert W. Ikard, MD,
David H. McCord, MD
Centennial Medical Center, Nashville, Tennessee
Accepted for publication November 6, 1995.
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Abstract
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Video-assisted thoracic surgical techniques provide access to the anterior thoracic spine without the morbidity of open thoracotomy. Improved diagnostic methods now give better awareness of the incidence and clinical significance of thoracic herniated nucleus pulposus. We present video-assisted thoracic surgical exposure techniques that have been used successfully to treat thoracic disc disease from T-2 to T-12.
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Introduction
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Improved techniques, including selective nerve blocks, computed tomographic myelography, and magnetic resonance imaging, have resulted in better diagnosis of thoracic spinal disc disease and understanding of its incidence. In contrast to the cervical and lumbar areas, surgeons have hesitated to operate on thoracic discs because of the morbidity of thoracotomy.
Video-assisted thoracic surgical techniques can provide better-tolerated access to the thoracic spine. Endoscopic discectomy and placement of fusion cages provide safe, well-tolerated treatment for thoracic herniated nucleus pulposus without the pain and longer hospitalization associated with lateral thoracotomy.
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Technique
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The operation is usually done through the right side of the thorax to avoid retraction on the heart and aorta. A double-lumen endotracheal tube is used so the lung can be collapsed. After the patient has been positioned for lateral thoracotomy, the diagnosed disease level is estimated by topographic examination. Lead bead markers are placed in longitudinal rows through this site over the spine and posterior axillary interspaces. Lateral and anterioposterior radiographs are made to check location. The incision site is marked in the posterior axillary line directly over the correct interspace.
The surgeon stands at the patient's front, the camera operator and assistant at the back. A thoracoscope with a 30-degree lens is placed through the initial incision, and the thorax is inspected. Retracting and camera ports are usually put two to three interspaces from the operating port. They are near the posterior axillary line but may be more anterior on the chest wall and enter the chest at an acute angle.
After the other ports are inserted, the camera is moved, and the original port becomes the operating access. Interference with the operator from levering the camera or retractor must be avoided. An additional retractor can be placed if exposure is inadequate.
The operating port is oriented vertical to the spine. If necessary, it is better to make another incision than operate at an acute angle. Operation on an adjacent disc also requires another incision. Examples of typical instrument arrangements are presented:
Upper Thorax
At this level, both retractor and camera ports are caudad to the operating port. Unless there are apical adhesions, the collapsed lung readily falls away. The camera can be placed well out of the surgeon's way (Fig 1
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Fig 1. . Instrument placement for access to the T2-3 disc. The lung is collapsed. Note the vertical orientation of the operating instrument. (CP = camera port; OP = operating port; RP = retracting port.)
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Middle Thorax
Because there is more space in the mid-chest, there can be more variation in placement of camera and retracting ports. A second retracting port may be needed to move aside a bullous or stiff lung (Fig 2).
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Fig 2. . Instrument placement for access to the T7-8 interspace. (CP = camera port; OP = operating port; RP = retracting port.)
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Lower Thorax
Unless well retracted, the diaphragm obscures the operating field. Care must be taken to avoid placing a trocar into the abdomen. As at the other extreme of the chest, lung retraction is usually easy (Fig 3).
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Fig 3. . Instrument placement for access to the T11-12 interspace. (CP = camera port; OP = operating port; RP = retracting port.)
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Comment
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Other spine diseases than thoracic herniated nucleus pulposus can be managed by video-assisted thoracic surgery [1]. Improved instrumentation and expansion of thoracic, orthopedic, and neurologic surgical methods will likely expand its use.
We have operated on 22 patients with thoracic herniated nucleus pulposus from levels T2-3 through T11-12. Six required treatment at two levels. Due to excessive pleurodesis, one procedure was converted to open thoracotomy. One patient with chronic obstructive pulmonary disease required brief readmission for pulmonary insufficiency. Other than transient, mild port wound pain, there was no morbidity.
Accurate, unimpeded exposure is necessary for success. The preferred perpendicular orientation to discs is reliable and safe. The illustrated approaches to all levels of the thoracic spine are considered guidelines, and surgical ingenuity will doubtless result in other incision placements.
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Footnotes
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Address reprint requests to Dr Ikard, 2400 Patterson St, Suite 516, Nashville, TN 37203.
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Reference
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- Mack MJ, Regan JJ, McAfee PC, Picetti G, Ben-Yishay A, Acuff TE. Video-assisted thoracic surgery for the anterior approach to the thoracic spine. Ann Thorac Surg 1995;59:1100–6.[Abstract/Free Full Text]
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[Abstract]
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Abstract
Introduction
