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Ann Thorac Surg 1998;65:328-330
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Thoracoscopic Operations on Reoperated Chests

Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong;
Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan;
Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA

Accepted for publication August 15, 1997.

Dr Yim, Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, New Territories, Hong Kong (e-mail: yimap@cuhk.edu.hk).

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. A previous operation is generally considered to be a relative contraindication to the minimal access approach. We reviewed our combined experience from three centers with video-assisted thoracic surgery on reoperated chests.

Methods. From September 1992 to December 1996, 2,477 patients underwent video-assisted thoracic surgery of whom 40 patients (33 men; age range, 9 to 78 years) had prior operations on the ipsilateral side of the chest: 23 after prior open procedures (22 thoracotomies, 1 median sternotomy) and 17 after video-assisted thoracic surgery. The second procedures consisted of bullectomy or bulla ligation (8), mediastinal and hilar mass biopsy (8), wedge lung resection (6), pericardial window (5), lung volume reduction (4), redo thoracodorsal sympathectomy (3), talc insufflation alone (3), decortication (2), and suturing of a pleural rent (1).

Results. Adhesions were noted in all patients ranging from minimal to strong fibrous adhesions. However, in only 2 patients (5%) were the procedures abandoned because of adhesions. Video-assisted thoracic surgery was safely completed in all other patients. There was no mortality or intraoperative complications and mean hospital stay was 5.1 ± 3.2 days (range, 0 to 17 days).

Conclusions. Video-assisted thoracic surgery on reoperated chests is feasible and does not carry a higher morbidity or mortality compared with first-time operations, even though it may be technically more difficult. Experience and clinical judgment, however, are required to select these patients for reoperation with video-assisted thoracic surgery.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Video-assisted thoracic surgery (VATS) presents a new approach to the surgical management of a wide variety of chest conditions [1]. However, like any form of minimal access surgical procedure, there are concerns about using this approach on patients with a previous operation in the same body cavity. These concerns are primarily focused on adhesions, which could lead to poor visualization, bleeding, and lung and vascular trauma. As a result, many surgeons avoid VATS on reoperated chests. We reviewed our combined experience from three centers (Chang Gung Memorial Hospital, Taipei, Taiwan; Southern Illinois University School of Medicine, Springfield, Illinois; and Prince of Wales Hospital, Shatin, Hong Kong) to determine the feasibility and results of VATS on reoperated chests.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Patients
From September 1992 to December 1996, a total of 2,477 patients underwent VATS of whom 40 patients (33 men; age range, 9 to 78 years) had prior operations on the ipsilateral chests: 23 after prior open procedures (22 thoracotomies, 1 median sternotomy) and 17 after prior VATS. The average time interval between the two operations was 14.3 ± 8.3 months. Tube thoracostomy alone was not considered a prior operation for this study.

Operative Technique
With general anesthesia and selective one-lung ventilation, patients were positioned in the full lateral decubitus position with the operating table flexed to open up the upper intercostal spaces [2]. The thoracoscope was placed according to the usual intercostal approach strategy for the procedure [3]. Old port sites were deliberately avoided as they were likely to have adhesions underneath. Pleura was entered using a "clamp and finger" technique as in placement of a chest drain. In the presence of adhesions, it was pertinent that a pleural space was created by gentle blunt finger dissection before insertion of the port and thoracoscope. Instrument ports were similarly created under direct thoracoscopic vision if possible. An operating scope is occasionally useful in the initial adhesiolysis.

The second procedures consisted of bullectomy or bulla ligation (8), mediastinal and hilar mass biopsy (8), wedge lung resection (6), pericardial window (5), lung volume reduction (4), redo thoracodorsal sympathectomy (3), talc insufflation alone (3), decortication (2), and suturing of a pleural rent (1). These procedures were tabulated separately after prior open procedures (Table 1) or VATS (Table 2).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

There was no mortality or intraoperative complications. One patient (after decortication) required blood transfusion (2 units) in the postoperative period but no further intervention was needed. Mean hospital stay for the entire group was 5.1 ± 3.2 days (range, 0 to 17 days).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
A previous chest surgical procedure is generally taken as a relative contraindication to VATS, even though this subject has been inadequately examined. Although some adhesions existed in all the patients in our study, there were only two procedures out of 40 (5%) that we could not complete using VATS. There was a general impression that the adhesions were more dense after thoracotomy compared with VATS, and both operations that required conversion had prior open procedures (one thoracotomy and one median sternotomy). Although these numbers are too small to draw definitive conclusions, it has been our experience that prior ipsilateral chest surgery is not a contraindication to VATS.

Some surgeons in Europe routinely create a pneumothorax by injecting 300 mL of air into the pleural cavity, then take a radiograph to plan for the optimal entry sites for ports [4]. We have no experience with this technique but it is doubtful that this practice would facilitate management in our case as the "clamp and finger" technique, when properly applied, is very safe. On the other hand, it is possible that carbon dioxide insufflation could facilitate adhesiotomy by collapsing the lung.

Experience of the surgeon and the nature of the surgical procedure are important factors in deciding whether VATS should be used in reoperated chests. Adhesions exist in a continuum with dense fibrous union of tissue at one end and loose fibrinous connections at the other end of the spectrum. Although the nature of the first operation may be suggestive of the degree and extent of adhesions encountered in a subsequent procedure, this is not always predictive. Pleuropulmonary tuberculosis is still prevalent in Asia and adhesions as a result of prior tuberculosis are not uncommon even in chests that have not been previously entered [5].

Thoracoscopic exploration of a reoperated chest is generally safe if attention is paid to details. Once a clear space is created connecting the camera and instruments ports (which may require initial blunt finger dissection), adhesiolysis can proceed in the usual manner. In most circumstances, we have not found adhesiolysis in a closed chest to be more difficult compared with an open chest, and in fact, for adhesiolysis, VATS often provides an excellent view. Pleural symphysis, which precludes VATS, in our experience is uncommon. We have not found any preoperative imaging technique to be useful in discriminating patients for VATS in the reoperative setting. On the other hand, adhesiolysis over the lung hilum requires extreme caution. We have no experience of VATS major lung resection in a reoperated chest but do not consider it advisable.

In conclusion, VATS on a reoperated chest is technically feasible and does not carry a higher morbidity or mortality compared with first-time operations in carefully selected patients.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Supported by Earmarked Research Grant 1996 (CUHK 280/96M)

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Yim APC, Liu HP Complications and failure of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996;61:538-541.[Abstract/Free Full Text]
2. Yim APC Minimizing chest wall trauma in video assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:1255-1256.
3. Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Video assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800-807.[Abstract]
4. Viallat JR, Rey R, Astoul P, Boutin C Thoracoscopic talc poudrage pleurodesis for malignant effusions. Chest 1996;110:1387-1393.[Abstract/Free Full Text]
5. Yim APC The role of video assisted thoracoscopic surgery in the management of pulmonary tuberculosis. Chest 1996;110:829-832.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Anthony P. C. Yim Hui-Ping Liu Stephen R. Hazelrigg Mitchell J. Magee Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yim, A. P. C. Articles by Magee, M. J. Search for Related Content PubMed PubMed Citation Articles by Yim, A. P. C. Articles by Magee, M. J.