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Ann Thorac Surg 2009;87:224-228. doi:10.1016/j.athoracsur.2008.08.069
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Thoracoscopy Versus Thoracotomy Improves Midterm Musculoskeletal Status and Cosmesis in Infants and Children

Taiwo A. Lawal, MBBS*, Jan-H. Gosemann, Joachim F. Kuebler, MD, Sylvia Glüer, MD, PhD, Benno M. Ure, MD, PhD

Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany

Accepted for publication August 29, 2008.

* Address correspondence to Dr Lawal, c/o Prof Benno Ure, Department of Pediatric Surgery, Hannover Medical School Germany, 1 Carl-Neuberg Str., Hannover, 30625, Germany (Email: lawaltaiwosurgery{at}yahoo.com).


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   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: It has been postulated that video-assisted thoracoscopic surgery (VATS) achieves a better biometric and aesthetic outcome than conventional thoracic surgery (CTS), but data are lacking. We aimed to compare the midterm effects of both approaches in children.

Methods: Sixty-two infants and children, who underwent VATS (34; 55%) or CTS (28; 45%) for benign thoracic conditions, were evaluated at follow-up after a mean of 3.8 years (1 to 7 years). The patients underwent standardized clinical assessment of the skeletal system and function. The intercostal spaces were investigated for rib fusion by ultrasound. Patients (± parents) themselves, as well as clinicians, subsequently assessed the scars.

Results: Comparing the operated versus nonoperated sides, chest asymmetry was significantly less frequent after VATS versus CTS in the horizontal plane (mean relative difference 0.996 ± 0.003 vs 0.964 ± 0.008, p < 0.001) and in nipple location (mean relative difference 0.985 ± 0.008 vs 0.949 ± 0.013, p = 0.047). The ranges of motion of the shoulder joints did not differ significantly. However, the incidence of scoliosis was lower in VATS patients (9% vs 54%, p < 0.001) and the intercostal spaces of the operated hemithoraces were narrower after CTS (p < 0.001). The Manchester scar assessment scores were in favor of VATS (mean 7.5 vs 13.1, p < 0.001). The visual analog scale scores recorded by patients-parents and independent observers were also significantly better after VATS. Patient satisfaction was less with CTS as 10% wanted to have the scar revised, compared with none in the VATS group.

Conclusions: The thoracoscopic versus conventional approach to the thoracic cavity in children is associated with significantly less midterm musculoskeletal sequelae and a better cosmetic outcome.

Thoracic incisions are associated with potential shoulder and musculoskeletal dysfunction that can impair daily life activities [1]. Conventional thoracotomy used to be performed by the posterolateral approach and more recently with the muscle sparing technique. Notable complications after conventional thoracic surgery (CTS) include musculoskeletal deformities, scoliosis, winged scapula, and shoulder dysfunction [2, 3]. Others include aesthetic problems and breast and pectoral muscle maldevelopment in particular in children [4, 5].

In the last few decades, video-assisted thoracoscopic surgery (VATS) has become a major approach for thoracic surgical procedures performed by pediatric surgeons [6–8]. The safety and efficacy has been demonstrated by numerous studies [9–11]. Potential advantages of VATS over CTS include decreased postoperative pain, a shorter hospital stay, better cosmetic results, and a decreased incidence of chest wall deformities, including scoliosis and breast deformity. However, these advantages are largely undocumented [12]. Various reviews have been done on the effects of posterolateral thoracotomy and VATS on shoulder function in adults [13, 14], but not in children. There is a paucity of data on the biometric and aesthetic outcome after such operations [12].

The long-term follow-up of children who underwent thoracic surgical procedures has been shown to be of paramount importance in view of the consequences of early physiologic alterations or developmental changes of the thorax. These can result in impairment of musculoskeletal and respiratory functions and advance with aging [15, 16]. This study was thus designed to review musculoskeletal outcomes, shoulder function, and cosmetic results in the midterm after VATS versus conventional thoracotomy in children.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patients
The operative records of all patients who had intrathoracic surgery at our university clinic between January 2000 and December 2006 were reviewed. One hundred and six patients met the inclusion criteria of VATS or CTS for benign thoracic conditions. Patients with sternotomy incisions, cervical incisions, minithoracotomy, and pectus excavatum repair were excluded. Also excluded were patients who had multiple surgery, bilateral operations, and those who had a previous thoracoscopy or conventional thoracotomy. The study was approved by the Ethics Committee of the University. Parents gave informed consent for the study. When the children were older than 12 years, they also gave a double consent.

Methods of VATS
Reusable Storz (Karl Storz, Tuttlingen, Germany) instruments were used for the thoracoscopies. The first trocar was placed at the tip of the scapula; 2 to 3 additional trocars (3.5 to 5 mm) were inserted depending on the procedure.

Methods of CTS
With left or right lateral positioning, incisions were made in the fourth or fifth intercostal spaces. Generous subcutaneous dissections were done for adequate mobilization of the latissimus dorsi and serratus anterior muscles, and muscle sparring techniques were used. The intercostal muscles were incised tangential to the ribs. Adequate visualization enhanced with the use of retractors. After the surgical procedures, the ribs were approximated and the muscle layers, subcutaneous tissue, and skin wound were closed.

Methods of Follow-Up
All patients were seen and interviewed by two of the authors (TAL and JG). The follow-up was done at the out-patient department and consisted of assessing shoulder function and musculoskeletal status as well as evaluating the cosmetic appearance of the scars created by the surgical procedures.

Shoulder Function and Musculoskeletal Status
The hemithorax on the operated side was compared to the nonoperated side in relation to anatomic parameters. Measurements included the nipple to xiphisternum distance, distance from the nipple to the midpoint of the clavicle, scapular spine to the midline, inferior border of the scapular to the midline, vertical chest (midclavicular point to the midpoint of the costal margin), and transverse chest diameters. The relative differences between the operated and nonoperated sides were taken in relation to the nonoperated side; ie, distance on operated side ÷ distance on nonoperated side.

The ranges of motion of the shoulder joints were measured during flexion, extension, abduction, and internal and external rotation using a goniometer. Each patient stood upright or on the mother's laps and moved each limb to the end of active range of shoulder motion [17]. The mean differences between measurements in each plane on both sides were then recorded. The children were examined for the presence of scoliosis using the forward-bending test and goniometry [18] and classified as mild (<20 degrees, grade I), moderate (20 to 40 degrees, grade II), and severe (>40 degrees, grade III).

Ultrasound scanning was done with an ATL Ultramark 9 HDI Ultrasound System (Philips ATL, Bothell, WA) to obtain the width of the intercostal space of entry (CTS) or average (VATS) and compared with corresponding spaces on the nonoperated side to detect the presence of rib fusion, and the relative difference calculated.

Cosmesis
The patients (± their parents) were asked about satisfaction with the scars and they graded their satisfaction using a visual analog scale with scores from 1 (excellent) to 10 (very poor) [19]. The scars were thereafter assessed with the Manchester scar scoring system [20]. This involved a visual analog scale component, as well as scores for the color match, texture, contour, and presence or absence of distortions. Scores were allocated for each parameter and totaled with a minimum score of 5 for the ideal scar and a maximum of 28. Likewise, two research fellows not involved in surgery reviewed photographs of the scars taken and allocated scores on a visual analog scale [21].

Statistical Analysis
Data were collated and statistical analysis performed using Microsoft Excel (Microsoft Corp, Redmond, WA) and SPSS (SPSS Inc, Chicago, IL) software. Data were expressed as means ± standard error of the mean. Comparison of the parameters and tests of significance were done with the Fischer exact test and Mann-Whitney rank sum test and a p value was set at 95% confidence interval.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Sixty-two patients (58.5%) presented in the clinic for the study; two declined participation and twenty-three (22%) were interested, but could not come to the hospital as they lived far away. The remaining patients (19%) could not be followed up. There were no significant differences in the mean age at surgery and gender distribution of patients who had VATS versus CTS (Table 1), but the mean follow-up period differed significantly (3.1 ± 0.28 vs 4.6 ± 0.39 years, p < 0.001).


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  		Table 1 Patients Characteristics
 
Shoulder Function and Musculoskeletal Status
The relative differences between chest wall measurements comparing the operated and nonoperated sides were done in both vertical and horizontal planes and tabulated (Table 2). The nipple to xiphisternal distance on the operated side was 0.985 ± 0.008, relative to the length on the nonoperated side in the VATS group, compared with 0.949 ± 0.013 in the CTS group (p = 0.047). The transverse chest diameter (hemithorax) on the operated side was 0.996 ± 0.003, relative to the same diameter on the nonoperated side in the VATS group, versus 0.964 ± 0.008 in the CTS group (p < 0.001). The measurements of the other parameters were not significantly different. The mean differences in the upper arm and lower arm circumferences in the VATS group were 0.25 ± 0.05 cm and 0.26 ± 0.06 cm, and corresponding values in the CTS group were 0.34 ± 0.08 cm and 0.38 ± 0.08 cm (p = 0.65 and 0.432, respectively).


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  		Table 2 Relative Values of Chest Wall Measurements Recorded as Values on the Operative Side Divided by the Measurements on the Nonoperated Side
 
Three patients who had VATS (9.7%) had scoliosis grade I versus 14 (53.8%) who had CTS (p < 0.001) (Fig 1). None of the patients had grade II (moderate) or III (severe) scoliosis. The mean differences between the maximum range of motion in the shoulder joint between the operated and nonoperated sides in the VATS versus CTS groups were not significant in all the movements assessed.


Figure 1
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  		Fig 1. Incidence of scoliosis, grade I in children, who had VATS (n = 34) versus CTS (n = 28) at follow-up. (CTS = conventional thoracic surgery; VATS = video-assisted thoracoscopic surgery.)

 
In patients who had VATS the mean width of the intercostal space of entry into the thoracic cavity was 0.97 ± 0.007, relative to the corresponding intercostal space width on the nonoperated side. Similar measurement in the CTS group resulted in 0.83 ± 0.041 (p < 0.001). No case of complete rib fusion was seen.

Cosmesis
The mean Manchester scar score was 7.5 ± 0.2 in the VATS group and 13.1 ± 0.8 in the CTS group (p < 0.001) (Fig 2A). The scars were scored by two independent assessors using the visual analog scale, with mean values recorded for patients who had VATS being 2.4 ± 0.2 versus 3.9 ± 0.2 for those in the CTS group (p = 0.004) (Fig 2B). The mean visual analog scale score for the scar recorded by the patients (± parents) was 2.6 ± 0.4 in the VATS group versus 4.3 ± 0.5 in the CTS group (p = 0.014) (Fig 2C). Thirty-one of 32 patients who had VATS (97.1%) were satisfied with their scars compared with 25 of the 28 (89.3%) in the CTS group (p = 0.341). None of the patients in the VATS group wanted a revision of the scar as against 3 of 28 of the CTS group (p = 0.087).


Figure 2
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  		Fig 2. (A) Manchester scar scores, (B) patient measured, and (C) clinician assessed visual analog scale scores after VATS versus CTS; mean 7.5 ± 0.2; 2.6 ± 0.4, 2.3 ± 0.2 vs 13.1 ± 0.8, 4.3 ± 0.5, 3.9 ± 0.2, respectively. (AU = assessment unit; CTS = conventional thoracic surgery; VATS = video-assisted thoracoscopic surgery.)

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
In our study, chest asymmetry was significantly lower after VATS compared with CTS, especially in relation to the transverse chest diameter. The outcome after CTS is similar to the findings of Bal and colleagues [3], who investigated 49 children after thoracotomy for congenital cardiac malformations. Those authors found thoracic wall asymmetry in 14% and chest wall deformity in 18% of their children. The nipples were asymmetric in 63%. A significant difference regarding the location of the nipples was also noted in our study. However, whether this would result in gross nipple asymmetry is not known and would require follow-up till completion of puberty.

The ranges of motion in the shoulder joints between the operated and nonoperated sides were not significantly different in either of our groups at follow-up. In another prospective evaluation of 30 adult patients randomly selected to have either a posterolateral or muscle sparing approach, the shoulder range of flexion in the sagittal plane was significantly reduced at 14 days after the latter [2]. There were no differences in the other ranges of motion. Conversely, in a prospective evaluation of 60 patients who were randomly selected to undergo either procedure, the range of motion for flexion, abduction, and adduction were significantly higher in the muscle sparing group at 1 month postoperation [13].

The absence of a significant difference in our study may be attributable to the lower incidence of shoulder dysfunction after muscle sparing conventional thoracotomy, which our patients had, and the possible compensatory improvement in shoulder function in young children. In the study by Li and colleagues [14], comparing early shoulder function after VATS with posterolateral thoracotomy in adults, differences in shoulder strength were significant at 1 week, being higher after VATS. Forward elevation was also higher in the same group at 3 months postoperatively. Similarly, a retrospective analysis of 90 children under the age of 8 years who had a muscle sparing or posterolateral thoracotomy showed that shoulder girdle movements are regained earlier in the former group [22].

Fifty-four percent of our patients who had CTS had scoliosis compared with 10% of those who had a minimally invasive procedure. This significantly high incidence of scoliosis compares with similar reports in the literature. Bal and colleagues [3] found an incidence of scoliosis of 31% after conventional cardiothoracic surgery. Durning and colleagues [23] reported an incidence of scoliosis of 50% at ten years follow-up in children who had thoracotomy for the treatment of esophageal atresia. Eight out of fourteen patients who were reoperated because of esophageal anastomotic dehiscence after thoracotomy for esophageal atresia developed scoliosis, in a review done by Gilsanz and colleagues [24]. Twenty of 61 patients who had lateral thoracotomy for esophageal atresia in childhood, and were followed up until completion of growth, had scoliosis exceeding 10 degrees [25].

Thoracic deformity has been implicated as preceding spinal deformity in the pathogenesis of idiopathic scoliosis [26, 27]. All the cases of scoliosis in our study were, however, mild, showed less than 20 degrees of curvature, and were unlikely to need treatment in childhood.

Ultrasound confirmed that the intercostal spaces on the operated side were significantly narrower than on the other side in patients who had CTS compared with those who had VATS. This may be due to the approximation of the ribs above and below the intercostal space during a thoracotomy wound closure. An association between rib fusion and development of scoliosis in patients who had previously undergone thoracotomy has been suggested [28].

Comparison and scoring of scars resulting from surgical operations has received attention in recent years [29]. It has been suggested to use a reproducible, reliable, valid, and accurate system [19]. The visual analog scale scar scoring and Manchester scar scoring system have been shown to be consistent, reliable, valid, and feasible in the objective analyses of scars [20]. Crowe and colleagues [21] also demonstrated the validity of photographic analysis in scoring scars with substantial interrater and single rater reliability.

In our study, the scar assessment scores of the patients who had VATS were significantly lower than those of the patients who had conventional thoracic surgery, and the scores on the visual analog scales were significantly better. Additionally, the acceptability of the scar was 100% in patients who had VATS compared with a wish to revise the scar in 10% of the patients who had CTS. We conclude that VATS achieves a significantly better cosmetic outcome.

Limitations of the present study include the nonusage of radiologic studies to confirm the diagnosis of scoliosis, as well as a statistically significant difference in the mean follow-up period of 3.1 versus 4.6 years. In conclusion, the thoracoscopic versus conventional approach to the thoracic cavity in children is associated with significantly less midterm musculoskeletal sequelae and a better cosmetic outcome.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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