Ann Thorac Surg 1996;61:1069
© 1996 The Society of Thoracic Surgeons
Discussion
Discussion
See also page 1066.
DR NORMAN J. SNOW (Cleveland, OH): I have a question for you. Of the 12 patients in whom you converted to a thoracotomy, how many had standard clinical indicators that this lesion was most likely malignant and therefore you might have obviated the time and expense of thoracoscopy to begin with by proceding directly to thoracotomy?
DR KRASNA: I cannot give you an exact number, but all of these patients had lesions that were smaller than 2 cm. At our institution we routinely perform preoperative percutaneous needle biopsy to obtain a tissue diagnosis by cytologic examination before attempted resection. In all the patients who underwent thoracoscopy, the percutaneous needle biopsy result was negative. I should point out that at Maryland we have approximately a 93% success rate with percutaneous needle biopsy. These were all cytologic-negative specimens, and only those patients were taken for thoracoscopic diagnosis.
DR MARK S. ALLEN (Rochester, MN): Doctor Krasna, I enjoyed your presentation. I do not think that we should call converting to an open procedure a complication; I think we should call that good judgment.
I have two questions. Have you had any complications from using CO2 to collapse the lung, such as hypotension from a tension pneumothorax or CO2 emboli from intravascular injec-tion? Also, have any of your patients had long-term pain caused by damage to the intercostal nerves from the trocars you use?
DR KRASNA: Thank you, Dr Allen. I think that we really did not see any complications with CO2 insufflation. We have presented here in the past a clinical trial to study its clinical applicability and have found it useful. Just as an example, recently we have been performing thoracoscopic spine surgery, rather than doing this with four or five trocars, we do the entire five- or six-level diskectomy using two trocars. We take advantage of the CO2 insufflation, however, to retract the lung anteriorly by rotating the table and by pushing the diaphragm inferiorly. In none of these cases have we had any problems with the CO2 insufflation pressures.
I think that in general this can be done safely. I do think that we use trocars not only because we are using CO2, but using trocars allows you to put instruments in and out of the chest without damaging the underlying muscle. I have been impressed by many series, including your own, where trocars are not used routinely except to hold the telescope. I have found that by putting instruments in and out of the chest and frequently moving them around, if you do not have a trocar, there is going to be more damage either to the intercostal nerves or to the muscles. In terms of the chronic pain, we did see this in 2 patients, and it could be attributable, obviously, to the use of trocars, but those were the only patients who had this type of problem.
Related Article
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Complications of Thoracoscopy
- Mark J. Krasna, Sanjay Deshmukh, and Joseph S. McLaughlin
Ann. Thorac. Surg. 1996 61: 1066-1069.
[Abstract]
[Full Text]
