Ann Thorac Surg 2003;75:599-601
© 2003 The Society of Thoracic Surgeons
How to do it
Needlescopic operation for partial lung resection
Yasunori Ikeda, MDa*,
Shinichiro Miyoshi, MDa,
Norio Seki, MDa,
Satoru Kobayashi, MDa,
Hideo Umezu, MDa,
Motohiko Tamura, MDa
a Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, Tochigi, Japan
Accepted for publication August 2, 2002.
* Address reprint requests to Dr Ikeda, Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, 880 Kitakobayashi Mibucho, Shimotugagun, Tochigi 321-0293, Japan.
e-mail: ikeda{at}dokkyo.med
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Abstract
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Needlescopic operation using instruments with a diameter of 2 mm has not been applied to partial lung resection because of the difficulty in grasping the lung firmly or the possibility of injuring the lung easily with 2-mm forceps. We have developed a technique using a mini-loop retractor and successfully performed partial lung resection in 35 patients with pneumothorax, small lung tumor, or interstitial pneumonia.
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Introduction
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Needlescopic operation using instruments with a diameter of less than 3 mm has been applied mainly to cholecystectomy [1, 2] and sporadically to urologic operations [3, 4]. In thoracic procedures, however, its use has been limited to diagnostic thoracoscopy [5], laser ablation for spontaneous pneumothorax [6], or thoracic sympathectomy for palmar hyperhidrosis [7]. More recently, this technique has been applied to lung biopsy for diffuse pulmonary disease, using 2-mm and standard thoracoscopic equipment [8]. However, this technique using 2-mm forceps has disadvantages such as difficulty in grasping the lung firmly and easily injuring the lung. We describe a more developed needlescopic surgical procedure using a mini-loop retractor.
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Technique
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Minimally invasive thoracoscopic surgery using 2-mm and standard thoracoscopic equipment was performed on 35 patients between July 2000 and October 2001. These patients consist of 20 with spontaneous pneumothorax, 10 with interstitial pneumonia, 3 with an indetermined pulmonary nodule, and 2 with a metastatic tumor in the peripheral lung field. Biopsy was done for interstitial pneumonia and indetermined pulmonary nodule. Those with indetermined pulmonary nodule or metastatic lung tumor underwent preoperatively computed tomographic-guided hookwire marking.
The patients were placed in the lateral decubitus position and induced with general anesthesia using a double-lumen endotracheal tube. Instruments used were a routine 10-mm thoracoscope, a 2-mm minithoracoscope, their introducers, a directly puncturable 2-mm port, a 2-mm miniforceps (U.S. Surgical Corporation, Norwalk, CT), and a Mini Loop Retractor II (Tyco Healthcare, Tokyo, Japan) with a diameter of 2 mm.
An incision of about 1.5 to 2 cm in length was usually made in the sixth or seventh intercostal space on the midaxillary line and a 12-mm thoracoport was inserted through the incision. In patients with spontaneous pneumothorax who had already had a drain in place, the drainage hole served for the thoracoport.
The thoracic cavity was carefully observed through the 12-mm thoracoport with a routine 10-mm thoracoscope, which produces a clear view. Two 2-mm ports for forceps, thoracoscope, or the Mini Loop Retractor II were inserted by puncture into the fourth or fifth intercostal space on the anterior and posterior axillary lines (Fig 1).
In the case of spontaneous pneumothorax, the posterior or mediastinal side of the lung apex, which is difficult to visualize, was examined with the 10-mm thoracoscope by trapping and retracting the entire apex with a loop of Mini Loop Retractor II. Once a bulla was found, it was strangulated at its base by the loop of the Mini Loop Retractor II and fixed. The 10-mm thoracoscope was then replaced by the 2-mm scope. Resection of the bulla was done with an endostapler inserted through the 12-mm port under the guidance of the 2-mm thoracoscope. The procedure of partial lung resection for indetermined pulmonary nodule and metastatic lung tumor was similar to that for pneumothorax (Fig 2).
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Fig 1. Typical positioning of thoracoscopic instruments and thoracoscope for an approach to a lesion. (A = 10-mm thoracoscope; B = 2-mm miniforceps; C = Mini-Loop Retractor II; D = 2-mm thoracoscope; and E = 10-mm endostapler.)
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Fig 2. (A) After preoperative computed tomographic-guided hookwire marking, the lung, including indetermined pulmonary nodule, is looped by the Mini Loop Retractor II. (B) The 2-mm needlescopic view shows that the target lung fixed by the Mini Loop Retractor II is resected.
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The resected tissue was then transferred from the Mini Loop Retractor II to an endoscopic holding forceps inserted through the 12-mm port and was taken out of the thoracic cavity. When the specimen was large or including a malignant nodule, an endocatch was used to facilitate its extraction or avoid dissemination of malignant cells.
Upon completion of the operation, a drain was inserted through the hole for the 12-mm port, followed by a one-stitch suture of the internal layer and a one-stitch suture of the skin. The holes for the 2-mm ports were closed only with a surgical tape without any suture.
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Comment
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Standard thoracoscopic operation is widely accepted to be less invasive than open chest procedures. Needlescopic operation using instruments with a diameter of 2 mm is considered even less invasive than standard thoracoscopic operations using 10-mm instruments. However, partial lung resection needs at least one 12-mm port for the stapler. Therefore, we have developed a technique of standard thoracoscopic operation by partly incorporating 2-mm instrumentation, which is almost the same as the technique used by Yamada and colleagues [8].
We initially used a 2-mm forceps to grasp the lung. However, it was very difficult to grasp the lung firmly with the mini-forceps because of its short jaws and poor holding strength. This problem has been solved using the Mini Loop Retractor II. This is inserted into the pleural cavity through a skin puncture and a loop at its distal end is easily and freely adjustable in dimensions so that it can act as a retractor or holding forceps.
The position of insertion could be altered according to the operating field. No bleeding was observed at the puncture site after operation. The puncture wound was closed without sutures or scar formation (Fig 3).
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Fig 3. The 2-mm port-site skin wounds at 2 weeks postoperatively are barely visible. Arrows indicate the wounds of the 2-mm mini–port-site.
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We have successfully performed partial lung resection using this technique in 35 patients. No procedure was converted to standard thoracoscopic or open operation. The mean duration of the operation was 59.2 minutes, the mean bleeding volume was 7.5 mL, and the mean duration of drainage was 1.2 days. Postoperative analgesic medication was required in 3 of the 35 patients (8.6%), which is less frequent than after standard thoracoscopic operation. The patients were satisfied with the appearance of the wound from a cosmetic viewpoint.
In conclusion, needlescopic partial lung resection seems to have resulted in less postoperative pain and a smaller scar than conventional thoracoscopic operation. When used appropriately, 2-mm instrumentation has the potential to enhance patient satisfaction by minimizing incision-related morbidity and improving cosmesis.
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References
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- Gagner M., Garcia-Ruiz A. Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc 1998;8:171-173.[Medline]
- Cheah W.K., Lenzi J.E., So J.B., et al. Randomized trial of needlescopic versus laparoscopic cholecystectomy. Br J Surg 2001;88:45-47.[Medline]
- Inderbir S.G., Jon J.S., Gyung T.S., et al. Needlescopic adrenalectomy—the initial series: comparison with conventional laparoscopic aderenalectomy. Urology 1998;52:180-186.[Medline]
- Jon J.S., Inderbir S.G. Needlescopic urology: incorporating 2 mm instruments in laparoscopic surgery. Urology 1998;52:187-194.[Medline]
- d’Alessandro A. Microthoracoscopy. At the cutting edge of thoracic surgery. J Laparoendosc Adv Surgl Tech 1997;7:313-318.
- Hazama K, Akashi A, Maehata Y, et al. Minimally invasive thoracoscopic laser ablation for spontaneous pneumothorax. J Jpn Soc Endosc Surg 2001;6:179–82
- Yamamoto H., Kanehira A., Kawamura M., et al. Needlescopic surgery for palmar hyperhidrosis. J Thorac Cardiovasc Surg 2000;120:276-279.[Abstract/Free Full Text]
- Yamada S., Kosaka A., Masuda M., Toyoshima M. Minimally invasive lung and pleural biopsies using 2-mm and standard thoracoscopic equipment. Jpn J Thorac Cardiovasc Surg 2000;48:700-702.[Medline]
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Abstract
Introduction
