Ann Thorac Surg 1998;66:590-591
© 1998 The Society of Thoracic Surgeons
How to Do It
Axillary thoracoscopy
Michael W. Frank, MDa,
Carl L. Backer, MDb,
Constantine Mavroudis, MDa,
Axel W. Joob, MDa
a Division of Cardiothoracic Surgery, Northwestern University Medical School, Chicago, Illinois, USA
b Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, Chicago, Illinois, USA
Accepted for publication May 1, 1998.
Address reprint requests to Dr Frank, Division of Cardiothoracic Surgery, Loyola University Medical School, 2160 S 1st Ave, Maywood, IL 60153
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Abstract
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Thoracoscopy can be done safely and effectively through working ports placed in the axilla in patients whose pathology is in the upper half of the thorax. We have used this technique successfully in 37 patients with no complications. Advantages include superior cosmesis, optimal access to the apex of the chest, and, if necessary, easy conversion to axillary thoracotomy.
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Introduction
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Thoracoscopic surgery has become a routine part of the practice of thoracic surgery. Most reports of thoracoscopic procedures report positioning the patient in preparation for a posterolateral thoracotomy. Ports are typically placed to facilitate conversion to a limited posterolateral thoracotomy, if needed [1]. We have been using an axillary thoracotomy for many routine thoracic open cases such as upper lobectomy. We find it provides excellent exposure while minimally insulting the chest wall [2]. Our experience and success with axillary thoracotomy has led us to perform axillary thoracoscopy. We place two working ports in the fourth intercostal space that can be connected if conversion to axillary thoracotomy is necessary. We have found that axillary thoracoscopy safely and effectively provides access to the upper lobes, superior segment of the lower lobes, pleural surfaces of the upper half of the hemithorax, upper mediastinum, and upper thoracic spine.
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Technique
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Careful patient position is of paramount importance (Fig 1). We place the patient in the lateral decubitus position with the bed flexed at the waist. A roll is placed between the patient’s contralateral axilla and the bed. Flexing the bed lowers the iliac crest and prevents the iliac crest from interfering with the camera. The arm is elevated so that the humerus is perpendicular to the plane of the floor. The elbow is bent at a right angle. The forearm is padded and either securely suspended from the ether screen or placed on a mechanical arm rest. A continuous pulse oximetry probe on the finger of the elevated arm assures that positioning has not significantly impeded arterial perfusion to that arm. By elevating the arm as described, the latissimus dorsi muscle is reflected posteriorly and the axilla is exposed.
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Fig 1. Patient position and thoracoscopic port sites. (© 1997 by Rachid F. Idriss. Reprinted with permission.)
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The anterior border of the latissimus, the posterior border of the pectoralis, the areola, and the intercostal spaces provide the landmarks for the placement of the ports (see Fig 1). The first port (a working port) is placed posterior to the border of the pectoralis (and posterior to the breast border) in the fourth intercostal space. The second port (the camera port) is placed in the midaxillary line in the seventh or eighth intercostal space. This port is placed under thoracoscopic visualization. The third and final port is placed anterior to the border of the latissimus dorsi in the fourth intercostal space. This working port is placed bluntly without cautery because of the proximity of the first branch of the long thoracic nerve. It has been proposed that transection of this nerve at this level does not produce any significant postoperative motion impairment [3]. Nevertheless, we avoid injury to this nerve. The chest tube exits through the camera port at the conclusion of the procedure.
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Results
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Over the past 18 months we have used this approach in 37 patients (age range, 15 to 81 years). The indications included indeterminate lung parenchymal mass (20), spontaneous pneumothorax and apical bleb resection (5), lung biopsy (3), bilateral sympathectomy (3), mediastinal mass (2), upper mediastinal and aortopulmonary lymph node sampling (2), parietal pleural mass (1), and spine exposure (1). None of the patients sustained complications. Seven procedures were electively converted to axillary thoracotomies by connecting the two working ports into a thoracotomy. In 6 patients indeterminate coin lesions were found to be primary lung cancer on frozen section. Elective conversion to axillary thoracotomy was done to perform open lobectomy and complete lymph node staging. In the seventh patient an indeterminate upper lobe coin lesion was successfully excised thoracoscopically, but the frozen section revealed metastatic colon cancer. Conversion to axillary thoracotomy was done to explore for other metastatic lesions (no additional metastatic lesions were found). In each procedure that was converted to an axillary thoracotomy, the axillary thoracotomy provided excellent exposure.
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Comment
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The differences between the axillary and posterolateral thoracoscopic approaches provide for advantages and disadvantages. The distance between the working ports using the axillary approach is a little less than with the posterolateral approach. Theoretically this could yield technical difficulty with "fencing." We have not had significant problems with this, seemingly because both instruments are pointed cephalad and not toward each other. When using endostaplers it is occasionally useful to move the camera to one of the "working ports" and use the endostapler through the more inferior "camera port." We have not seen clinical evidence of an injury to the first branch of the long thoracic nerve. The abducted arm will interfere with thoracoscopic work directed toward the inferior portion of the hemithorax. Therefore, positioning in this fashion limits the use of axillary thoracoscopy to pathology of the upper chest.
Our experience indicates that there are many advantages of the axillary approach. Cosmetically, the working ports are well hidden in the axilla. Typically none of the ports go through the latissimus dorsi. We have found that this approach provides optimal exposure to the apex of the chest. Finally, using the axillary thoracoscopic approach connecting the working ports allows easy and fast conversion to an axillary thoracotomy, which we consider to be less morbid than posterolateral approaches.
We conclude that axillary thoracoscopy is useful for resection of indeterminate upper lobe and superior segment lower lobe lesions, treatment of spontaneous pneumothorax and apical bleb resection, parenchymal lung biopsy, sympathectomy, resection of upper mediastinal masses, sampling of aortopulmonary window and upper mediastinal lymph nodes, exposure of the upper thoracic spine, and biopsy or resection of upper thoracic pleural-based lesions. Advantages include excellent cosmesis and easy conversion to axillary thoracotomy if needed.
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References
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- Landreneau R.J., Mack M.J., Hazelrigg S.R., et al. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800-807.[Abstract/Free Full Text]
- Ginsberg R.J. Alternative (muscle-sparing) incisions in thoracic surgery. Ann Thorac Surg 1993;56:752-754.[Abstract/Free Full Text]
- Fry W.A. Thoracic incisions. Chest Surg Clin North Am 1995;5:177-188.[Medline]
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