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Original Articles: General Thoracic

Invited Commentary

Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY 14263

(Email: todd.demmy{at}roswellpark.org).

Kim and colleagues [1] present their experience with an incrementally less invasive procedure (ie, needlescopic thoracic surgery). Their work was not the first report of small thoracoscopes, in fact terms like "microthoracoscopy" using 2-mm instruments date back to 1997, as they cite. Because needlescopy is gaining popularity for common operations like laparoscopic cholecystectomy that "kick-started" video-assisted thoracoscopic surgery, thoracic surgeons should take heed. In fact, thoracic surgeons now report many cases using needlescopic instruments for thoracic sympathectomy.

Thoracic sympathectomy is a logical choice for this technology for several reasons: the target area is relatively small; tissue manipulation, dissection, and hemostasis requirements are fewer; and chest tubes are usually not required afterward. The latter is important because chest tubes cause pain, limit patient mobility, and prolong hospital stay.

Avoidance of rib spreading seems to be the difference for the quantum advantage of thoracoscopy in comparison with open or minimal access operations that allow intercostal retraction. When it comes to smaller or fewer ports, benefits are more nuanced. Especially with narrow posterior interspaces, smaller cameras or instruments that apply less torque or wound healing effects to the intercostal nerve are desirable. However, apart from the cosmetic benefits, advantages of 3-mm ports are uncertain so long as larger ports are needed to extract specimens or place larger instruments such as surgical staplers. In fact, investigators have not always found benefits for port size or port number reductions. Accordingly, methods that reduce postoperative pleural inflammation or consolidate ports to the same interspace may have similar importance.

As technology advances, low-profile cameras will likely capture high-definition images with less light or supplemental luminescence delivered through separate needle holes. Instruments that angle will also reduce leverage-related rib trauma. However, a holistic approach that eliminates air leaks, pleural irritation, chest tubes, thick instrumentation, and large access incisions may be needed to achieve a dramatic incremental clinical advantage for needlescopic operations in comparison with thoracoscopic operations.

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1. Kim HK, Jo W-M, Jung JH, et al. Needlescopic lung biopsy for interstitial lung disease and indeterminate pulmonary nodules: a report on 65 cases Ann Thorac Surg 2008;86:1098-1103.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Todd L. Demmy Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Demmy, T. L. Search for Related Content PubMed PubMed Citation Articles by Demmy, T. L. Related Collections Lung - cancer Related Article