7. Children’s Mercy Experience
• Jan 2000 – June 2007
• 230 patients = 231
thoracoscopic operations
• Age = 9.6 ± 6.1 years
• Weight = 36.6 ± 24.1 kg
• 115 boys : 115 girls
JJLLAASSTT 1188::113311--113355,, 22000088
8. Thoracoscopic Operations
Children’s Mercy Experience (2000-2007)
Diagnostic No. of Patients
Wedge biopsy of solitary lung lesions 37
Biopsy and excision of mediastinal masses 26
Wedge biopsy of diffuse parenchymal disease 15
Evaluation of penetrating thoracic trauma
1
Total 79
Therapeutic
Pleural decortication for empyema 79
Exposure for scoliosis 26
Bullae resection for pneumothorax 25
Lobectomy 9
Repair of esophageal atresia and fistula 8
Evacuation of hemothorax and pleural effusion 3
Repair of bronchopleural fistula 1
Total JJLLAASSTT 1188::111335111--113355,, 22000088
9. Complications
• No intra-operative complications
• 3 conversions to open during lobectomy
• 2 right upper lobectomies (visualization)
• 1 left lower lobectomy
(infection/inflammation)
• 1 persistent pneumothorax after bleb resection
JJLLAASSTT 1188::113311--113355,, 22000088
10. Results
Length of stay = 3.8 ± 4.0 days
• Excluding esophageal atresia
and scoliosis
Chest tubes in 211 patients (91%)
• 2.9 ± 2.0 days
(excluding esophageal atresia and
scoliosis)
• 93 traditional chest tubes
• 118 soft drains
• 20 patients without post-operative
chest tubes
(JLAST 19: S23-S25, 2009)
11. Conclusion
• Safe and effective
• Primary diagnostic and therapeutic
application for most thoracic conditions
12. Thoracoscopy - Empyema
Technique
• Three 10 mm incisions
(triangle)
• Initial incision 4th or 5th
ICS, AAL
• Use telescope to compress
lung and create working
space
• 2nd incision opposite 1st one,
PAL
• 10 mm cannulas,
insufflation to 6-8 torr
10 mm angled
telescope
13. Thoracoscopy - Empyema
Technique
• 3rd incision (10 mm),
9th or 10th ICS, MAL
• Site for chest tube
exteriorization
14. Thoracoscopy - Empyema
Technique
• Rotate instruments
among the three
incisions
• Can remove
canula, insert
curved ring
forceps
19. London Prospective Trial
VVAATTSS vv FFiibbrriinnoollyyssiiss ww//UUrrookkiinnaassee
• No difference in LOS (6 v 6 days)
• No difference in 6 month CXR
• VATS more expensive ($11.3K v $9.1K)
• 16 % failure rate for fibrinolysis
AAmm JJ RReessppiirr CCrriitt CCaarree MMeedd 11744::222211--22227,,
22000066
20.
21. Current Management
2008 - 2011
• Fibrinolysis has been our initial therapy
• 4 mg tPA in 40 cc saline for 3 days through a 12 Fr chest
tube
• 102 consecutive patients
• 15.7% failure rate
• Mean hospitalization after initiation of fibrinolysis –
6.1 d +/- 2.5
• Mean O.R. time after failed fibrinolysis – 65 min
• Mean hospitalization after thoracoscopy – 5.9 d +/- 3.7
25. Principles
• Single lung ventilation
• Double lumen ETT
• Contralateral
mainstem intubation
• Bronchial blocker
26. Principles
• Lateral patient position
• Monitor over patient’s
shoulder
• Surgeon/assistant on
anterior side of patient
• Work medial to lateral;
do not flip lung over
• Do not hesitate to convert
35. Thoracoscopic Repair EA/TEF
Fistula Ligation
• Metal clip
• Weck clip
• Tie (x2 ?)
• Suture ligature (x2 ?)
• Suture closure – tracheal side
36. Tips/Tricks
• Surgisis placed b/w
esophagus & tracheal
suture line to help
prevent recurrent TEF
JJ LLAASSTT 1177::338800--338822,, 22000077
37. How To Get Started
Not The Ideal Case
• 2 - 2.5 kg
• Very high upper pouch
• Complex single
ventricle physiology
• Prostaglandin
dependent
38. How To Get Started
Ideal Case
• Baby – 2.5-3 kg; no other
anomalies
• Esophageal segments close
together (CXR,
Bronchoscopy)
• Start thoracoscopically –
Go as far as comfortable
• Try it again
39. Summary
• Thoracoscopy can
be done safely and
effectively in infants
and children
• Patient selection
always important
• Distinct advantages,
esp avoidance of
musculoskeletal
sequelae