Ann Thorac Surg 1999;67:1181-1183
© 1999 The Society of Thoracic Surgeons
How To Do It
Thoracoscopic resection of the lung with the ultrasonic scalpel
Teruhiro Aoki, MDa,
Shizuka Kaseda, MDa
a Department of Thoracic Surgery, Saiseikai Kanagawaken Hospital, Yokohama, Japan
Accepted for publication September 23, 1998.
Address reprint requests to Dr Kaseda, Department of Thoracic Surgery, Saiseikai Kanagawaken Hospital, 6-6 Tomiya-cho, Kanagawa-ku, Yokohama 221-0821, Japan
e-mail: kaseda{at}ra2.so-net.ne.jp
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Abstract
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We used an ultrasonic scalpel, the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH), for limited thoracoscopic resection of the lung in 30 consecutive patients. There were no problems with bleeding in any of the 30 patients. After resection with Harmonic Scalpel the lung was closed with absorbable sutures. In 10 patients the operation was converted to lobectomy, and lymph node dissection was done because intraoperative histopathologic examination revealed lung cancer. Postoperative complications were not observed in the remaining 20 patients who had limited resection only. The Harmonic Scalpel is a useful tool for partial lung resection procedures.
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Introduction
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Partial resection of the lung is a surgical procedure widely used for diagnosis of lung nodules and diffuse processes and for treatment of primary and metastatic lung neoplasms. In video-assisted thoracic operations, the surgical approach might be limited and it is difficult to get enough of a surgical margin using staplers alone, especially in deeply located pulmonary lesions. We devised a technique using a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) to facilitate this procedure. The Harmonic Scalpel functions with ultrasonic energy, vibrating longitudinally at up to 55,000 Hz, and produces less smoke than regular electrocautery. This device allows coagulation and division of the tissue at comparatively low temperatures (less than 100°C), producing a minimal amount of vaporization plume [1]. The Harmonic Scalpel has been used in other video-assisted procedures, such as cholecystectomy, internal mammary artery harvest, and pericardial resection [1–4]. Because it has been reported that the Harmonic Scalpel can coagulate well with good hemostasis, for example, a branch of the internal mammary artery was completely resected and coagulated [3], we therefore introduced it in limited lung resection [5].
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Technique
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Patients were all placed in the lateral position after establishment of general anesthesia with a double-lumen tube. A 10-mm port was sited in the seventh intercostal space at the midaxillary line to introduce a rigid thoracoscope (30 degrees). A 5-mm port was sited in the seventh intercostal space at the posterior axillary line for the grasper or dissector. An 11-mm port was sited in the fifth intercostal space at the midclavicular line for the Harmonic Scalpel. When the tumor was too large to remove through the 11-mm port, the fifth intercostal space incision was extended to facilitate the operation. In video-assisted thoracic operations, the first stage involves collapsing the lung to ensure a good field of vision through the thoracoscope. After the resection line was carefully identified, the lung was retracted and resected with the Harmonic Scalpel. During resection of lung parenchyma the Harmonic Scalpel laparoscopic coagulation shears were used with the power level set at 3 and the blunt blades selected (Fig 1). Bleeding from the resected margin was controlled well at these settings. After resection of the lung, a sealing test revealed air leaks by using an airway pressure of 5 to 10 cm H2O. Major air leakage was stopped with suturing. After resection of the lung with the Harmonic Scalpel, the resected surfaces of lung parenchyma tended to be well coagulated and were thus comparatively hard. As the lung is reexpanded, the resected surfaces are less flexible than the surrounding lung tissue and tend to invaginate into the lung. Finally the resected surface is closed and sutured normally (Fig 2). In some cases in which air leakage persisted along the suture line, fibrin glue or gelatin-resorcinol-formaldehyde-glutaraldehyde glue [6, 7] coating was used along the suture line.
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Fig 1. Photograph of our Harmonic Scalpel with laparoscopic coagulation shears. During resection of lung parenchyma the blunt blade was used.
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Fig 2. Schema of limited lung resection with the Harmonic Scalpel. The top left diagram shows lung and nodule. During the video-assisted thoracic operation the lung was resected in the collapsed condition (top right). When the lung was reexpanded, the resected surfaces were comparatively inflexible compared to the surrounding tissue, so that they invaginated slightly into the lung (bottom right). The resected surface was sutured (bottom left).
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We used this technique in 30 cases (ten lung cancers, ten spontaneous pneumothoraces, five metastatic lung tumors, three giant bullae, and two lung tuberculomas). In our hospital all patients with solitary lung nodules undergo preoperative examinations for pathologic diagnosis, including bronchoscopy, transbronchial lung biopsy, or needle biopsy. In the present patients, however, a preoperative cytologic or pathologic diagnosis could not be made because of difficult location of the nodule or no definitive finding from the specimens. We thus performed partial resection first and took frozen sections. In the 10 patients with lung cancer the resected specimen was examined by frozen section. Where diagnosis of lung cancer was confirmed, which it was in all 10 cases, lobectomy was done on the residual lobe of the lung, and mediastinal lymph node dissection was performed. In the remaining 20 cases of partial resection only, there was one case with prolonged air leakage (10 days). However there were no other operation-related complications, and in all 30 resected surfaces no major bleeding was observed.
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Comment
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The Harmonic Scalpel is not electrically but ultrasonically activated [1]. In an operating field with bleeding, the Harmonic Scalpel can both cut and coagulate tissue with good hemostasis. The blade tip can be selected from a range of different tips, which include a ball coagulator, a hook spatula, and laparoscopic coagulation shears that use vibrating blades with sharp, blunt, or flat edges. Helal and colleagues [8] reported that, among these tips, the laparoscopic coagulation shears were best at coagulating vessels. Thus we used the laparoscopic coagulation shears for lung resection. Bleeding from the lung parenchyma was controlled best when the blunt edge was used. There are other nonstaple methods for lung parenchyma resection, such as standard cautery and the neodymium:yttrium-aluminum-garnet laser. We have used these methods previously many times for lung operations, and the most significant difference between these two methods and the Harmonic Scalpel is coagulative ability. Standard cautery and the neodymium:yttrium-aluminum-garnet laser are capable of cutting lung parenchyma well, but neither method can control bleeding from medium-sized to large vessels. Conversely, the Harmonic Scalpel is capable of complete coagulation of a branch of the internal mammary artery [3], thus in lung resection we can get a clean operative field. Because the Harmonic Scalpel is ultrasonically activated, in an operating field with bleeding the Harmonic Scalpel can both cut and coagulate tissue with minimal secondary thermal damage. Concerning air leakage, none of these three methods can control this problem on their own and all require additional suturing.
In 1996 we introduced the Harmonic Scalpel in lung resection. At first we attempted to preserve the resected surface as it was, covering the surface with fibrin glue and Dexon mesh (Davis & Geck, Inc, Pearl River, NY) [9], because we thought that preserving the resected surface would be better for lung expansion. Our experience, however, showed that the resected surface of the collapsed lung was well coagulated after using the Harmonic Scalpel, with associated shrinkage of the tissue architecture. Consequently, as the lung was reexpanded the somewhat hard and inflexible resected surfaces failed to expand at the same rate as the rest of the lung tissue and did not always close naturally. We therefore changed our method from attempting to preserve the surface with fibrin glue and mesh to direct closure following the slight invagination of the resected surfaces during reexpansion. At present we are not sure whether this direct closure is good for lung function or not, but we can at least report that in our patients there have been no operation-related complications to date. We certainly need a longer follow-up time for these patients before we can make a definitive statement regarding the efficacy of this method, but we have tentatively concluded that the Harmonic Scalpel is a useful method for partial lung resection especially in video-assisted thoracic operations and in open thoracotomy.
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References
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Amaral H.F. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc 1994;4:92-99.[Medline]
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Amaral H.F. Laparoscopic cholecystectomy in 200 consecutive patients using an ultrasonically activated scalpel. Surg Laparosc Endosc 1995;5:255-262.[Medline]
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Ohtsuka T., Wolf R.K., Hiratzka L.F., Wurnig P., Flege J.B.J. Thoracoscopic internal mammary artery harvest for MICABG using the Harmonic Scalpel. Ann Thorac Surg 1997;63:S107-S109.
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Ohtsuka T., Wolf R.K., Wurnig P., Park S.E. Thoracoscopic limited pericardial resection with an ultrasonic scalpel. Ann Thorac Surg 1998;65:855-856.[Abstract/Free Full Text]
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Kaseda S., Aoki T., Kitano M., Yamamoto S. Preliminary experience using Harmonic Scalpel under thoracoscopic guidance (in Japanese). Nihon Naishikyo Geka Gakkai zasshi (J Jpn Soc Endosc Surg) 1997;2:254-258.
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Bachet J, Goudot B, Dreyfus G, et al. The proper use of glue: a 20-year experience with the GRF glue in acute aortic dissection. J Cardiac Surg 1997;12(2 Suppl):243–53.
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Nomori H., Horio H. Gelatin-resorcinol-formaldehyde glutaraldehyde glue-spread stapler prevents air leakage from the lung. Ann Thorac Surg 1997;63:352-355.[Abstract/Free Full Text]
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Helal M., Albertini J., Lockhart J., Albrrink M. Laparoscopic nephrectomy using the Harmonic Scalpel. J Endourol 1997;11:267-268.[Medline]
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Kaseda S., Aoki T., Hangai N., Yamamoto S., Sugiura H. Treating bullous lung disease with holmium YAG laser in conjunction with fibrin glue and Dexon mesh. Lasers Surg Med 1998;22:219-222.[Medline]
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Abstract
Introduction
