Minimal invasive cardiothoracic surgery2

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Minimal invasive cardiothoracic surgery2

  1. 1. Video Assisted Thoracoscopic Surgery “A mode of entry into the chest” Prof Dr Samieh Amer Professor of cardiothoracic surgery
  2. 2. History 1853 Dr A. J. Desormeaux used the term “Endoscope” for the first time 1865 Sir Francis Richard Cruise advanced the endoscope by improving the light source and the first to use it for the thoracic cavity 1910 Hans Christian Jacobaeus first published physician to use Thoracoscopy 1990 introduction of the fibroptic camera, USA
  3. 3. Era of enthusiasm Era of neglect Era of rapid development 1910-1950 1950-1990 1990-Present
  4. 4. Indications Diagnosis  exploration, biopsy and staging of malignancies Decortication of empyema Pleurodesis Management of spontaneous pneumothorax Resection of lung, mediastinal, pleural and esophageal masses and cysts Thoracic sympathectomy Surgical intervention for diaphragm Management of thoracic trauma Cardiac surgery
  5. 5. Advantages Minimally invasive, no more thoracotomy or sternotomy incisions thus avoidance of muscle division and bone fractures Reduces blood loss and transfusion consequently reduces risk of hepatitis & HIV Less post-operative effects on pulmonary function (FEV1) Reduces post-operative inflammatory reaction (reduced pro- and anti-inflammatory cytokines e.g. IL-6, IL-8 & IL-10)
  6. 6. Continue….. Reduces incidence of infection Faster recovery Decreased post-operative pain Shorter hospital stays Reduced usage of narcotics Smaller post-operative scars  more cosmetic Better wound healing Reduces morbidity
  7. 7. Disadvantages Loss of tactile sensation?? Lengthier procedures?? Surgical assistance limited Limitations  Absolute:  Obliterated pleural space due to adhesions  Anatomical difficulties  Relative:  Intolerable lung anaesthesia  Lack of experience  Mechanical ventilation  Intolerable hypoxemia  Bleeding diathesis  Unstable cardiovascular status
  8. 8. Popularity 100% of patients with spontaneous pneumothorax management, worldwide 75% of the total Lung resections in Ireland 69% of mediastinal tumours and cysts resection in UK 25% of the total thoracic operations in USA 16% of lobectomies in USA
  9. 9. Invasive staging Fiber-optic Mediastinoscopy Transbronchial needle aspiration Transthoracic needle aspiration Esophageal endoscopic ultrasound needle aspiration Chamberlain procedure (anterior mediastinatomy) VATS Direct comparison among the tests is not possible, the issue is to define which procedure is most useful for a particular lesion (sensitivity, specificity, false positive rate, false negative rate)
  10. 10. Examples Fiber-optic Mediastinoscopy; gold standard among staging tests of mediastinal lymph nodes stations: 2&4R, 2&4L, 3 and anterior subcarinal (7) sensitivity: 82-85% specificity: 100% false-negative: 10% VATS; used to assess stations not accessible by Mediastinoscopy stations: 5,6,7,8, 9 and allows inspection of the pleura sensitivity: 90% specificity: 100% false-negative: <10%
  11. 11. Continue…. Transbronchial needle aspiration stations: subcarinal (7) sensitivity: 75% false-negative: 50% Transthoracic needle aspiration; tumours larger than 1.5 cm and bulky mediastinal tumours sensitivity: 90% false-negative: 50% Chamberlain procedure stations: 5 (aorta-pulmonary window) sensitivity: 87% false-negative: 10%
  12. 12. Recent developments Cost reduction compared to the past Advanced diagnostic imaging techniques  64-slice helical CT scan with IV-contrast  Integrated FDG-PET scan Advanced instrumentation 3D cameras Increased experience Shorter learning curve Anastomotic technology
  13. 13. Continue..... Introduction of the thoracoscope (deflectable) Auto-fluorescence Thoracoscopy for more accurate mesothelioma staging and early stage pleural malignancies Fluorescein-enhanced Autofluorescence Thoracoscopy (FEAT) Narrow Band Imaging (NBI) technique which enhances vascular architecture of tissues, aids in biopsy site selection as it clearly demarcates tumour margins Total development Video  Robot
  14. 14. Auto-fluorescence Thoracoscopy VS White light thoracoscopy view Auto-fluorescence thoracoscopy of breast cancer metastasis to view of breast cancer metastasis parietal pleura to parietal pleura
  15. 15. Fluorescein-enhancedAutofluorescence Thoracoscopy White Light view Bleu Light view
  16. 16. Narrow Band Imaging New alternative light wavelength capture system VS Pleural cavity of patient X with Pleural cavity of patient X with metastatic adenocarcinoma, metastatic adenocarcinoma, white light NBI
  17. 17. Deflectable tip thoracoscope
  18. 18. Robotic applications in cardiac surgery Pericardiectomy Implantation of automatic cardiac defibrillator Mitral Valve repair or replacement Harvesting of Internal Mammary Artery Coronary Artery Bypass Grafting Closure of PDA PA banding Management of cardiac injuries Atrial Ablation
  19. 19. Who and Where?When and How?
  20. 20. Knowing it does not mean that we should do it!Knowing it means that we should do it!

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