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Indications for Thoracoscopy in Children

Indications for Thoracoscopy in Children. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri. Lung Biopsy Lobectomy Sequestration resection Excision bronchogenic cyst Foregut duplication resection Esophageal myotomy Anterior spine fusion

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Indications for Thoracoscopy in Children

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  1. Indications for Thoracoscopy in Children George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri

  2. Lung Biopsy Lobectomy Sequestration resection Excision bronchogenic cyst Foregut duplication resection Esophageal myotomy Anterior spine fusion Debridement/decortication Diaphragmatic hernia/plication - ? Spontaneous ptx PDA ligation Thoracic duct ligation Esophageal atresia repair Aortopexy Mediastinal mass exc/bx Thymectomy Sympathectomy Pericardial window Division of vascular ring Nuss operation Anterior spinal operations Indications for Thoracoscopic Procedures in Children

  3. Musculoskeletal Sequelae From Thoracotomy • Shoulder elevation • Limitation shoulder movement • Scoliosis • Respiratory dysfunction • Mammary maldevelopment • Atrophy chest wall muscles

  4. Post Thoracotomy Sequelae • Durning RP, et al: J Bone Joint Am 62, 1980 • Gilsanz V, et al: AJR Am J Roentgenol 1983 • Jaureguizar E, et al: J Pediatr Surg 1985 • Chetcuti P, et al: J Pediatr Surg 1989 • Goodman P, et al: J Comput Assist Tomogr 1993 • Frola C, et al: AJR Am J Roentgenol 1995

  5. ThoracoscopyPatient Positioning

  6. Data Points • Age • Weight • Gender • Type of operation • Indication for operation • Final diagnosis • Chest tube • Complications • Length of stay

  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 JLAST 18:131-135, 2008

  8. Thoracoscopic Operations Children’s Mercy Experience (2000-2007) JLAST 18:131-135, 2008

  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 JLAST 18:131-135, 2008

  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 at CMH

  12. Thoracoscopy - EmpyemaTechnique • 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 - EmpyemaTechnique • 3rd incision (10 mm), 9th or 10th ICS, MAL • Site for chest tube exteriorization

  14. Thoracoscopy - EmpyemaTechnique • Rotate instruments among the three incisions • Can remove canula, insert curved ring forceps

  15. Thoracoscopy - Empyema Please use this link if you experience problems viewing the video above.

  16. Thoracoscopy - Duplication Please use this link if you experience problems viewing the video above.

  17. Thoracoscopy – Lymph Node Bx Please use this link if you experience problems viewing the video above.

  18. Thoracoscopy – Left Lower Lobectomy Please use this link if you experience problems viewing the video above.

  19. Diagnosis of Malignancy via Thoracoscopy • Alveolar Soft-part Sarcoma • Ewing’s Sarcoma • Ganglioneuroma • Lymphoma • Neuroblastoma • Rhabdomyosarcoma • Schwannoma • Wilms’ Tumor • Yolk Sac Tumor

  20. Thoracoscopic RepairEA/TEF

  21. EA/TEFPreoperative Evaluation • Echocardiogram – assess cardiac anomalies • Renal US – assess kidneys • CXR/spine films – assess vertebral anomalies • PE – assess limb, anorectal anomalies • US great vessels – assess location of aortic arch

  22. Thoracoscopic Repair EA/TEF

  23. Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula: A Multi-Institutional Analysis George W. Holcomb III, Steven S. Rothenberg, Klaas MA Bax, Marcelo Martinez-Ferro, Craig T. Albanese, Daniel J. Ostlie, David C. van der Zee, C K Yeung American Surgical Association, 2005 Ann Surg 242:422-430, 2005

  24. Thoracoscopic Repair EA/TEF104 Patients Waterston A: > 5.5 lb with no significant associated problems Waterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomaly Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

  25. Preoperative Bronchoscopy Please use this link if you experience problems viewing the video above.

  26. Port/Instrument Positions

  27. EA/TEF Why Thoracoscopy? 89 pts/16 yrs • shoulder elevation: 24% • chest deformity: 20% • abduction limited: 100% • spine deformities: 18% • breast deformities: 27% (3/11) Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985

  28. Thoracoscopic Repair EA/TEFFistula Ligation • Metal clip • Weck clip • Tie (x2 ?) • Suture ligature (x2 ?) • Suture closure – tracheal side

  29. Tips/Tricks • Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF J LAST 17:380-382, 2007

  30. Tips/Tricks • Oscillating ventilator • U-clips anterior anastomosis JLAST 21: 877-879, 2011 Please use this link if you experience problems viewing the video above.

  31. How To Get StartedNot The Ideal Case • 2 - 2.5 kg • Very high upper pouch • Complex single ventricle physiology • Prostaglandin dependent

  32. How To Get StartedIdeal 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

  33. QUESTIONS www.cmhmis.com

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