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Ann Thorac Surg 2003;75:1665-1667
© 2003 The Society of Thoracic Surgeons

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How to do it

Hand-assisted thoracoscopic surgery

^a St Vincent’s Hospital, Melbourne, Australia
^b Austin and Repatriation Medical Centre, Victoria, Australia

Accepted for publication October 8, 2002.

^* Address reprint requests to Dr Wright, 55 Victoria Parade, Fitzroy VIC 3065, Australia
e-mail: gmwright{at}ausdoctors.net

	Abstract

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Hand-assisted thoracoscopic surgery is a novel minimally invasive approach for performing techniques conventionally performed by posterolateral thoracotomy. Hand-assisted thoracoscopic surgery overcomes one of the major drawbacks of minimally invasive thoracic surgery in allowing full manual palpation of the lungs through a subcostal incision under video guidance, while avoiding a thoracotomy when the indication is pulmonary metastasectomy with curative intent or resection of undiagnosed lung nodules. The technique may result in improved quality of life outcomes compared with a thoracotomy.

	Introduction

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It is recognized that video-assisted thoracic surgery (VATS) is not just less invasive by virtue of incision size and early postoperative pain compared with thoracotomy, but also by many other indicators including length of hospital stay, convalescence, and pulmonary function [1–3]. However when VATS is used for the excision of some lung nodules, limitations emerge. Nodules that are not subpleural, or not large and firm enough to palpate with an instrument, are difficult to identify by VATS. Finger palpation through an enlarged port site may localize some nodules, but this is unreliable, uncomfortable, and unhelpful in estimating tissue margins. When the indication for an operation is metastasectomy with curative intent, VATS has been clearly shown to be inadequate in localization and clearance of all nodules [4], because of the inability to palpate the lung. This necessitates further operation for missed lesions and has the potential to lose control of the disease. Some lesions are in awkward positions, and others require the removal of unnecessarily large amounts of normal tissue to effect an excision with VATS.

Many of these problems are solved by hand-assisted thoracoscopic surgery (HATS), which uses the advantages of VATS while allowing the surgeon to introduce one hand into the pleural cavity through a subcostal-transdiaphragmatic route. We originally used a subxiphoid-retrosternal technique similar to that described by Mineo [5]; however, we found this technique to have disadvantages of pain from xiphisternectomy and discomfort for the surgeon. Technically, access is very difficult if the costal margin angle is very narrow, and particularly for posterior, left lower lobe lesions, compression of the right ventricle may occur. In addition, a single case of temporary right phrenic nerve palsy occurred using the subxiphoid approach, which most likely was an indirect traction injury [6]. We describe our technique in which the lung can be fully palpated and all lesions (especially deep ones) can be localized.

	Technique

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The anesthesia protocol is the same as for a standard thoracotomy, which is delivered by a specialist thoracic anesthetist. An epidural catheter is optional, and the patient is intubated with a double-lumen endotracheal tube to allow for single lung ventilation. Hospital stay is determined by the timing of drain tube removal.

Preparation
The patient is positioned by rotating the affected side up to a half-lateral or full lateral position and protecting all bony pressure points. Preparation and draping are applied to allow access to the ipsilateral hypochondrial region, in addition to usual thoracotomy draping.

Hand-assisted incision
A 7-cm to 8-cm incision (cm equal to glove size) is made 2 cm below and roughly parallel to the costal margin and the rectus muscle divided (modified Kocher’s incision). Simultaneously, a port site is established in the seventh intercostal space at the anterior axillary line to allow introduction of a video-telescope as with VATS (Fig 1).

View larger version (83K): [in this window] [in a new window]   Fig 1. Hand in chest palpating the lung through the subcostal-transdiaphragmatic incision.

View larger version (73K): [in this window] [in a new window]   Fig 2. Access into the pleural cavity through the spilt in the anterior diaphragmatic fibers.

View larger version (49K): [in this window] [in a new window]   Fig 3. Application of an endoscopic stapler for the excision of a lesion pinched up in hand.

Closure
The anterior port site is used to place an intercostal chest drain, which is connected to an underwater seal. The other port site is closed with a deep suture and the skin is closed with a subcuticular suture. The rectus muscle or linea alba, or both, in the abdominal incision is reapproximated with a heavy running suture as with a standard Kocher’s incision. The skin is closed with a fine subcuticular suture.

Chest drains are removed 1 or 2 days after the operation. The patient is usually discharged on oral analgesics the following day.

	Comment

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Forty-six HATS procedures (12 subxiphoid, 34 subcostal) have been performed at the authors’ institutions. Two subxiphoid cases were converted to open thoracotomy because lesions were too large and central and required lobectomy. One subcostal case was converted due to pleural symphysis. A randomized prospective trial is currently underway at St Vincent’s Hospital, Melbourne, comparing HATS with thoracotomy for pain and early postoperative quality of life. In the trial, an epidural catheter is routinely placed to mirror thoracotomy management. However, off-trial cases (and trial cases where the epidural catheter has failed) have not required this form of analgesia.

A number of patients have also had thoracotomy. Those having had subcostal HATS claimed that this was markedly less painful than a thoracotomy. One patient who underwent a subxiphoid approach stated that the thoracotomy was less painful. Of patients requiring later thoracotomy, adhesions were minimal.

The advantages of the HATS procedure currently include detection of lesions missed on preoperative imaging, identification of lesions not found on VATS, and complete resection of deep lesions [4, 6]. There is potential for better early postoperative quality of life and reduced morbidity compared with an open thoracotomy [6]. Disadvantages of HATS include the need for two skilled surgeons practiced in the procedure and preferably a small hand for the access incision. The procedure may be technically difficult in obese patients and for posterior lesions. There is the potential for phrenic nerve damage through the access incision, but not borne out in early studies [7].

	Acknowledgments

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The authors acknowledge Tyco Healthcare for funding the medical illustrations.

	References

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1. Nagahiro I., Andou A., Aoe M., Sano Y., Date H., Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362-365.[Abstract/Free Full Text]
2. Landreneau R.J., Hazelrigg S.R., Mack M.J., et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285-1289.[Abstract]
3. Santambrogio L., Nosotti M., Bellaviti N., Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59:868-870.[Abstract/Free Full Text]
4. McCormack P.M., Bains M.S., Begg C.B., Burt M.E. Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg 1996;62:213-216.[Abstract/Free Full Text]
5. Mineo T.C., Pompeo E., Ambrogi V., Pistolese C. Video-assisted approach for transxiphoid bilateral lung metastasectomy. Ann Thorac Surg 1999;67:1808-1810.[Abstract/Free Full Text]
6. Wright G.M., Long H. Hand-assist minimum invasion–maximum return. Aust NZ. J Surg 2001;71(Suppl):A17.
7. Clarke C.P., Ali A., Moshinsky R., Seevanayagam S., Raman J. The effect of hand-assisted thoracoscopic surgery (HATS) for pulmonary secondaries does not compromize diaphragmatic function. Heart Lung Circ 2001;10:A39.

This article has been cited by other articles:

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				T. C. Mineo, V. Ambrogi, and E. Pompeo Transxiphoid Hand-Assisted Thoracoscopic Surgery: An Approach Included in the Armamentarium Ann. Thorac. Surg., November 1, 2005; 80(5): 1982 - 1982. [Full Text] [PDF]

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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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wright, G. M. Articles by Paiva, J. M. Search for Related Content PubMed PubMed Citation Articles by Wright, G. M. Articles by Paiva, J. M. Related Collections Lung - other