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Video-assisted thoracic surgery( VATS) has been utilized worldwide for treatment of thoracic disease in recent years. Then, in most VATS, the thoracoscope was handled by young surgeons consequently. In VATS, a role of the scopist is very important, because if there is no consensus of verticality and horizontality on the monitor among operator, assistant and scopist, it is difficult to perform the surgery smoothly. Therefore, it is important for young surgeons to improve their skills as scopist. However, there are few models of verticality and horizontality on the monitor and thoracoscope techniques of VATS. We present our consensus of verticality and horizontality on the monitor in the standard 3-ports VATS by right upper lobectomy and left upper lobectomy.

Thoracoscopic esophagectomy in the prone position (ThE-PP) is usually performed with four ports, which makes the operation almost solo surgery. We now perform ThE-PP with five ports, with the advantage of having the assistant able to provide additional help. The aim of this study was to elucidate the benefits of ThE with five ports over ThE with four ports.We retrospectively reviewed the clinical charts of 47 patients with esophageal cancer who underwent ThE-PP. A total of 14 patients underwent ThE-PP with four ports and 33 with five ports. We compared the number of dissected lymph nodes (LNs)--total; upper left, middle, and lower mediastinum--between the four-port and five-port groups.The number of LNs dissected, including the total, the upper left and middle mediastinum, were not significantly different between the two operations. The number of LNs dissected from the lower mediastinum, however, was significantly higher in the five-port group (median number and interquartile range: 5 and 2-7, respectively) than in the four-port group (0.5 and 0-3, respectively) (P0.01).ThE-PP performed with five ports has an advantage over the same operation done with four ports in terms of lymphadenectomy in the lower mediastinum.

Objective: We have recently reported our isolated and working swine heart model that examines the valve motion precisely by a high-speed digital video camera system. Using this modality, the present study aimed (1) to delineate the motion of the mitral leaflets, chords and annulus throughout the cardiac cycle, and (2) to elucidate the influence of alterations in loading conditions on leaflet excursion. Methods: The valve motion of five isolated and working swine hearts was observed by an endoscope recording the images at 250 frames per second. Modified Krebs— Ringersolutionwas usedas the sole perfusate. Theimages wereobtained inhearts30 min after reperfusion,changingtheleft atrialpressureas 4, 8, and 12 mmHg. Results: The motion of the mitral valve in the vicinity of diastole was considered to be well understood by dividing the entire sequence into five stages: ‘decoaptation,’ ‘E excursion,’ ‘diastasis,’ ‘A excursion,’ and ‘coaptation.’ Initial separation occurred at both sides of the central tips of the leaflets. The leading edges always followed the mid-portion of the rough zone during opening and closing. The ‘strut’ second-order chords retained their tension throughout the cardiac cycle and played the role as rotary shafts of the other branching chords. The first-order chords lost their tension during opening, suggesting they mainly are involved in valve competence. Annular constriction occurred coincident with atrial contraction. An increase in preload made the isovolumic relaxation and contraction times shorter. The leaflets opened faster in the rapid-filling phase, whereas they required more time for opening and closing in the atrial-filling phase. Conclusions: The present study revealed the integrated movement of the mitral leaflets, chords and annulus, as well as the impact of altered preload.

Objective: To review our experience of indications, technique, and complications as they relate to video-assisted thoracoscopic surgery (VATS) in the diagnosis and management of intrathoracic diseases. Subjects and Methods: One hundred and fifty consecutive VATS procedures, which were performed over a 3-year period, were retrospectively evaluated. Indications included recurrent or persistent primary spontaneous pneumothorax (n = 73 patients), lung biopsies for diagnosis of diffuse lung disease (n = 33), pleural biopsies (n = 18), wedge resections of pulmonary nodules (n = 8), bilateral thoracic sympathectomy (n = 6), decortication (n = 5), mediastinal tumor biopsies (n = 5), excision of bullous emphysema (n = 1), and removal of a foreign body from the pleural cavity (n = 1). An alternative method of manipulating thoracoscopic instruments without using a trocar is described. Results: Of the 150 VATS procedures, 127 (85%) were successfully performed, 6 (4%) were converted to thoracotomy and 17 (11%) had complications. The most common complication was prolonged air leak, which occurred in 9 patients. The average postoperative hospital stay was 4 days (range: 2–17). Diagnostic procedures were considered successful in 32 out of 33 lung biopsies and in all 18 patients with pleural diseases, 8 lung nodules, or 5 mediastinal tumor biopsies. The other 86 therapeutic VATS procedures were effective in 82 (95%) patients. Four (5%) patients had a recurrence of the pneumothorax after VATS. Conclusion: Thoracoscopy and the use of a nontrocar technique is a safe and effective method for the diagnosis and treatment of intrathoracic diseases.

From the Division of Pediatric Surgery, UCSF Benioff Children’s Hospitals, Oakland, Calif; the Department of Surgery, University of California, San Francisco–East Bay, Oakland, Calif; and the Department of Cardiothoracic Surgery, Regional Medical Center, San Jose, Calif. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 15, 2015; revisions received Sept 17, 2015; accepted for publication Sept 27, 2015. Address for reprints: Sang H. Lee, MD, Department of Cardiothoracic Surgery, Regional Medical Center, 455 O’Connor Dr, Suite 280, San Jose, CA 95128 (E-mail: sangleemd@hotmail.com). J Thorac Cardiovasc Surg 2016;151:887-8 0022-5223/$36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.09.110

Study objectives To test a novel semirigid pleuroscope to be used by pulmonologists for the diagnosis and treatment of pleural diseases. Design Prospective study. Setting Three tertiary referral centers for pulmonary diseases. Patients Thirty-four patients who were referred for medical thoracoscopy between September 2000 and April 2001. Measurements and results Thirty-six procedures were performed. The most common indications were for pleurodesis of a malignant pleural effusion (53%) or for evaluation of an exudative effusion of unknown etiology (44%). All operators found the instrument easy to use. In all but one case, the images were thought to be adequate, despite the presence of adhesions in 12 patients and loculations in 8 patients. Pleural biopsies were performed in 13 patients, and talc pleurodesis procedures were performed in 25 patients. Mean (ŷ SD) duration of chest tube drainage was 2.9 ŷ 1.8 days postprocedure. There were no complications. Conclusions The prototype semirigid pleuroscope is a useful instrument in the diagnosis and management of pleural diseases. It is similar in design to a standard flexible bronchoscope, so the skills involved in operating the instrument should already be familiar to the practicing pulmonologist. It is compatible with existing video processors and light sources, so little additional equipment must be added to the endoscopy suite. The semirigid pleuroscope may allow for an increase in the performance of medical thoracoscopy by pulmonologists.

OBJECTIVE To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis. METHODS Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires. RESULTS Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax. CONCLUSION Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.

In minimally invasive surgery, the white-light thoracoscope as a standard imaging tool is facing challenges of the low contrast between important anatomical or pathological regions and surrounding tissues. Recently, the near-infrared (NIR) fluorescence imaging shows superior advantages over the conventional white-light observation, which inspires researchers to develop imaging systems to improve overall outcomes of endoscopic imaging. We developed an NIR and white-light dual-channel thoracoscope system, which achieved high-fluorescent signal acquisition efficiency and the simultaneously optimal visualization of the NIR and color dual-channel signals. The system was designed to have fast and accurate image registration and high signal-to-background ratio by optimizing both software algorithms and optical hardware components for better performance in the NIR spectrum band. The system evaluation demonstrated that the minimally detectable concentration of indocyanine green (ICG) was 0.01 ?? ? M , and the spatial resolution was 35 ?? ? m . The in vivo feasibility of our system was verified by the preclinical experiments using six porcine models with the intravenous injection of ICG. Furthermore, the system was successfully applied for guiding the minimally invasive segmentectomy in three lung cancer patients, which revealed that our system held great promise for the clinical translation in lung cancer surgeries.

Thoracic sympathectomy is a commonly performed surgical procedure for the treatment of palmar hyperhidrosis. However, one major complication of such a procedure is compensatory truncal hyperhidrosis. We describe an extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke. Bilateral reoperative needlescopic video-assisted thoracic surgery was performed for the reversal of thoracic sympathectomy with an interposition intercostal nerve graft. The patient's truncal hyperhidrosis resolved gradually over 1 month following the reversal procedure.

This report introduces a hilar side approach for posterior basal segmentectomies by the process of specific vision thoracoscopic surgery, which has been used extensively for peripheral small lung cancer by the author. Although it requires a deeper understanding of hilar anatomy and fine control, it is safer and less invasive to the thoracic wall and results in less postoperative pain than the thoracotomy counterpart and as a hilar side approach allows for less deformation. The necessary order of processes involves specific vision, inflation-deflation and blunt dissection from the hilum.

Infrared thoracoscopy with indocyanine green (ICG) is a new method of evaluating lung perfusion. We succeeded in visualizing lung emphysematous lesions and intersegmental borders using infrared thoracoscopy with ICG in animals, and within clinical investigations. There are 2 methods in infrared thoracoscopy. One is the 2-wavelength method, and the other is the 1-wavelength method. The 2- wavelength method is based on ICG absorption, and the 1-wavelength method is based on ICG fluorescence. The 2-wavelength method is superior for the clarity of images. On the other hand, the 1-wavelength method is superior for the duration of staining and the dose of ICG. Commonly, the inflation and deflation line has been used to identify the intersegmental border, but lung reinflation narrows the surgical view and can lead to prolongation of operation time, particularly in the context of video-assisted thoracic surgery (VATS). Infrared thoracoscopy with ICG is based on blood flow rather than on ventilation and can thus achieve anatomical segmentectomy without lung reinflation. This article closely reviews the principle and usefulness of infrared thoracoscopy, and difference between 2- and 1- wavelength method.

Thoracoscope is very important in thoracoscopic surgery (TS). There are many types of telescope and monitor. Also the placement of access port and location of the monitor image often differ between each institutions. Thoracic surgeons need to know these features to perform good TS. In our department, 2,375 patients (98% of all operation) were underwent 3-ports TS for 5 years. Operator always stands by patient's right side and camera assistant stands by patient's left side. Using 2 monitors, left side of monitors image sets to patient's head side and camera assistant see the inverted image monitor. Regardless of the localization of the lesion, three ports are always placed in same intercostal space. One of the advantages of TS is the ability of obtaining close and magnified operative image which can be possible to be shared with assistant and other surgical staff. The other advantages is that surgeons can review the recorded surgical digital versatile disc(DVD).

Primary spontaneous pneumothorax (PSP) is one of the most frequent diseases that thoracic surgeons handle, but the aetiology is not really known. We prospectively examined intraoperative images and collected the data of PSP patients who received bullectomy and mechanical pleurodesis with the thoracoscope at the Department of Thoracic Surgery at our hospital. Vascular-penetration defects (VPDs) were 2-6 mm vessel-converged holes that we found on the apex of the parietal pleura of PSP patients exclusively. The VPDs were solely located in the apex of the parietal pleura on the chest wall above the first rib. As many as up to four in number could be present. The VPDs were sometimes complementary to blebs and were not found in any of the other thoracoscopic surgeries for diseases other than PSP. We postulate that the presence of VPDs may be a contributing factor to the formation of a subgroup of emphysematous-like changes and the recurrence of PSP.

BACKGROUND: To assess the diagnostic accuracy and the safety of medical thoracoscopy (MT) performed with the semirigid thoracoscope.METHODS: We retrospectively evaluated patients who underwent MT with semirigid thoracoscope under local anesthesia for unexplained exudative pleural effusion from March 1, 2009 to September 1, 2013 in Denmark.RESULTS: Sixty-nine patients were retrospectively studied. In 13 patients it was not possible to perform the scheduled MT, in 9 cases due to an insufficient pneumothorax, in 3 due to an insufficient pleural effusion, and in 1 due to a purulent pleuritis. In 56 patients in whom MT was completed, the procedure was diagnostic in 44 cases: malignancy was reported in 26 patients and a benign diagnosis in 18. In the remaining 12 patients a definite diagnosis was not reached, and further testing was required.In an "intention-to-treat analysis" (69 patients in total), the diagnostic accuracy of MT was 63%, the sensitivity for malignancy was 59% [95% confidence interval (CI)=43%-73%], the specificity was 100% (95% CI=86%-100%), and the negative likelihood ratio was 0.41 (95% CI=0.29-0.58). Considering the 56 patients in whom it was possible to complete the procedure, the diagnostic accuracy was 78%, the sensitivity for malignancy was 74% (95% CI=54%-87%), the specificity was 100% (95% CI=83.75%-100%), and the negative likelihood ratio was 0.27 (95% CI=0.15%-0.45%). No mortality was reported.CONCLUSIONS: MT performed under local anesthesia with a semirigid scope is a simple and safe procedure with an acceptable sensitivity for malignancy.

Background The practice of tube thoracostomy entails high risk as it is a closed technique. Open thoracostomy and closed minithoracostomy techniques have been approved worldwide as safe modalities. Applying the concept of a new closed thoracostomy technique with high safety and simplicity is a major advancement in this regard. Materials and methods This was a case series pilot study introducing a new technique for closed-tube thoracostomy. Thirty-one patients with primary unilateral pneumothorax were selected for the study. All patients coming to the Emergency Department at Security Forces Hospital, Dammam City, Kingdom of Saudi Arabia, between January and August 2012, matching the study criteria were recruited to undergo the new technique. The surgical set required for the technique was defined and prepared sterile. Preinsertion and postinsertion chest x-ray and chest computed tomography scans were obtained for the entire study sample. Results We recruited the first 31 patients requiring tube thoracostomy who visited the Emergency Department. All procedures were performed by the author, assisted by on-call registrars. No complications were observed with the new technique. Moreover, advantages of the technique were demonstrated and documented. Conclusions The new technique provides safe tube introduction and precise tube positioning, saves time, and involves no technical precautions. The technique has been applied on selected simple cases as the first trial and requires further testing in cases of hemothorax, empyema thoracis, traumatic chest injuries, and complicated pulmonary diseases that require drainage. Further evaluation of the technique by randomized studies is required.

Background . Telemanipulation systems have enabled coronary revascularization on the arrested heart. The purpose of this study was to develop a technique for computer-enhanced endoscopic coronary artery bypass grafting on the beating heart. Methods . The operation was performed using the daVinci telemanipulation system. Through three ports, the left internal thoracic artery was harvested in 10 mongrel dogs (30 to 35 kg) using single right-lung ventilation and CO 2 insufflation. Through a fourth port an articulating stabilizer, manipulated from a second surgical console, was inserted to stabilize the heart. The left anterior descending artery was snared using silicone elastomer slings anchored in the stabilizer cleats and the graft to coronary artery anastomosis was performed. Results . In 7of 10 dogs, total endoscopic beating heart bypass grafting, cardiac stabilization, arteriotomy, and arterial anastomosis were performed using computer-enhanced technology. Endoscopic stabilization and temporary left anterior descending artery occlusion were well tolerated. All grafts were patent although minor strictures were found in 2. In 3 dogs, the procedure could not be completed (1 ventricular arrhythmia, 1 left atrial laceration, and 1 right ventricular outflow tract compression). Conclusions . Endoscopic beating heart coronary artery bypass grafting is possible in a canine model using a computer-enhanced instrumentation system and articulating stabilization.

Complications of tube thoracostomy, e.g., organ lesions and malpositioned tubes, are not uncommon. To date, techniques for tube placement have been nonvisualized. The authors believe that a fully visualized penetration of the thoracic wall layers should help to avoid not only perforations and organ lesions but also functionally malpositioned tubes. This article describes a modified endoscopic device, allowing fully visualized and optically controlled access to the pleural cavity for routine chest tube placement. The results of the technical feasibility study for 28 human cadavers showed that it was possible to place the tube as desired. No organ lesions were present. The results suggest that this device and the technique could reduce the risk of complications. The handling of the device is easy and safe. The technique is minimally invasive. The authors' next goal is to prove the results in a clinical study.

This pilot study was conducted to estimate the use of the thoracoscopic surgery as a new approach for the internal mammary nodes (IMN) in breast cancer.For this study, 21 women with breast cancer who underwent the approach for nodes IMN were enrolled. All the women had suspicious IMN metastasis and no distant metastasis.Thoracoscopic IMN dissection was performed safely for 20 of the women, with an average operative time of 44 min. One woman was excluded from the procedure because of pleural adhesion. The patients were restricted from walking for 1.3 days because of chest drainage, but no patients had severe complication or chest wall deformity after the operation. Six patients had positive IMN outcomes. After surgery, 10 of the 20 patients had a lower tumor node metastases (TNM) staging. Two patients who tested positive for IMN and three who tested negative experienced a relapse, but none had pleural dissemination in a median follow-up period of 24 months.Thoracoscopic surgery may be useful in managing patients with IMN.

Equine surgery continues to benefit from advances in endoscopic surgical techniques. Much of what we have learned in equine endoscopy comes from techniques used in humans. Descriptions of the normal anatomy of the standing horse and advances in instrumentation have improved our ability to perform laparoscopic surgery in standing and dorsally recumbent horses. This article describes the history of laparoscopy and available instrumentation.

With the recent development of video-assisted thoracic surgery, visual inspection of the thoracic cavity has been used to provide a more accurate diagnosis and prognosis of thoracic diseases and to better manage these diseases. Equipment, techniques, and complications for standing thoracoscopy in horses are described.

Objective Recently, the efficacy of video-assisted mitral valve surgery has been demonstrated. The evolution of this technology has been relatively rapid. In this article we review this development and predict the future of endoscopic and robotic-enabling technology for cardiac valve operations. Methods A new video-assisted mitral valve operation is described and results discussed. The majority of each valve operation was done through assisted vision and near endoscopically. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest induced using a new percutaneous, transthoracic cross-clamp. A 5 to 6-cm minithoracotomy was used in each patient. Videoscopy was helpful for suture placement, chord reconstruction, leaflet resection, knot tying, and valve ring or prosthesis positioning. A voice-activated robotic arm was used to direct the camera in many instances. Results Thus far a total of 110 patients have undergone this operation successfully with a 0.9% operative mortality. Our early series (N = 31), published with cost data, is reviewed in detail. Cardiopulmonary perfusion and cross-clamp times for all 100 patients were longer than for conventional sternotomy patients at 158 +/- 3.9 and 110 +/- 3.6 minutes, respectively, versus 121 +/- 4.6 and 90 +/- 4.6 (N = 105); however, there have been less complications. Operative, perfusion, and arrest times have fallen progressively to 144 +/- 4.5 and 90 +/- 4.5, respectively (N = 55 Aesop 3000 cases). Complex repairs and replacements have become routine with anterior leaflet pathology addressed. Bleeding, ventilatory times, blood transfusions, and hospital stay have been reduced. One patient required reoperation for a technically failed repair and two renal patients had late endocarditis. We have used voice-activated, robotic (Aesop 3000) assistance for camera control in 51 of these patients. This addition has decreased camera motion artifact and lens cleaning, while providing direct "cerebral-eye" tracking of instruments for the surgeon. We were the first in the United States to apply the DaVinci articulated wrist robot to do a complete mitral repair and have done multiple repair with this articulated wrist device. Conclusions From this and other work reviewed, we conclude that video-assisted and computer-assisted robotic techniques are safe and may be the pathway to truly endoscopic mitral valve operations. We are encouraged regarding the use of this new technology for mitral valve operations.

Right thoracotomy is an alternative to mid-sternotomy for left atrium access. The Port-Access approach is an option that reduces the skin incision and obviates rib spreading. Patients and methods: From February 1997 until November 1999, 121 patients underwent mitral valve surgery through a right antero-lateral thoracotomy using the Heartport cardiopulmonary bypass (CPB) system. Mean age was 60 years (31–84). Most patients had normal ejection fractions and were in NYHA Class II or III. Seventy-five patients had valve repair (62%) and 46 (38%) had valve replacement. Pathologies were myxoid (n = 80), rheumatic (n = 30), chronic endocarditis (n = 5), annular dilatation (n = 3), sclerotic (n = 1), ingrowing myxoma (n = 1), and one closure of a paravalvular leak. Results. Two patients had conversion to sternotomy for aortic dissection (one died) with the Endo-Aortic Clamp, and two others for peripheral vascular problems. One patient died at postoperative day 1 after reoperation for failed repair, another with double valve surgery on postoperative day 4 after two revisions for bleeding. Twelve underwent revision for bleeding (10%). Three had prolonged ICU stay for respiratory insufficiency. Two late valve replacements for endocarditis occurred. Echographic control revealed residual insufficiencies (grade 1–2) in two valvular repairs. There were neither paravalvular leaks nor myocardial infarcts. There were no cerebrovascular accidents due to embolic phenomena. Mean ICU and hospital stay were 2.1 and 8.7 days, with a major difference between the first 30 patients and those who followed. Conclusion: Port-Access mitral valve surgery can be a valid alternative to conventional sternotomy and seems to be an important improvement in minimally invasive cardiac surgery.

For a long time it has been known that sympathectomy is an effective treatment for hyperhidrosis and other conditions. The surgical options available until recently usually have required thoracotomy or large posterior incisions, and physicians generally have been reluctant to recommend surgery for most patients with "benign" disorders. Recently, thoracoscopic techniques have allowed surgeons to offer these patients a permanent solution with minimal surgical trauma.In 20 patients, 30 endoscopic thoracic sympathectomies (ETS) were performed for several indications. Nine patients had bilateral sympathectomies. The procedures were performed on the day of admission, with the patient under general anesthesia using double lumen endotracheal intubation and hand temperature monitoring. Each lung was reinflated on completion of the sympathectomy, and residual pneumothorax aspirated before closure of the incisions. No placement of chest tubes was performed in the operating room.All sympathectomies were completed thoracoscopically. There were no major complications, and 90% of the patients were discharged within 24 hours of admission. The average operative time was 69 min.Findings from this study show that ETS is a safe and effective procedure that can be performed routinely on an outpatient basis. The use of miniendoscopic (2-mm) instrumentation is safe and effective in most patients and a helpful adjunct in providing these patients with minimally traumatic surgery. Long-term results should be evaluated on the basis of specific indications for sympathectomy.

Since Jacobaeus performed the first thoracoscopy to explore pleural space and mechanically broke pleural adhesions to facilitate the collapse therapy for pulmonary tuberculosis in 1910, numerous thoracic surgeons have been attempting this technique as a means of accomplishing many intrathoracic procedures previously done through open thoracotomy. As the refinement of video technology has advanced, thoracoscopic surgery has played a very important role in thoracic surgery especially since the early 1990s. Because the advantages of video-assisted thoracoscopic surgery for patients include low post-thoracotomy-related morbidity, cosmetic considerations, low pain, earlier post-operative mobilization, and a shorter operation time in some indications, surgeons have been demonstrating its increasing utility in the diagnosis and treatment of the pleura, lung, mediastinum, great vessels, pericardium, and oesophagus. The most common application of the thoracoscopic approach still remains in the management of pleuropulmonary disease. The indications for the thoracoscopic technique are very broad, but its role in the management of primary lung and oesophageal cancer has yet to be confirmed. Thus, the surgeon who uses the technique in these cancerous diseases should be prudent. In conclusion, these thoracoscopic procedures will play more important roles in the practice of thoracic surgery in the future.

Summary Thirty-two thoracoscopies were performed in 28 horses. Sixteen horses were affected with pleuropneumonia whereas 12 were affected with various other thoracic conditions. The indications for thoracoscopy was diagnostic in 19 cases, therapeutic in 11 cases and both diagnostic and therapeutic in 2 cases. Twenty-six thoracoscopies were done standing whereas 6 were performed under general anaesthesia. The specific procedures performed during thoracoscopy were exploratory only (7), biopsy of the lung and lymph nodes (10), drain placement into pleural effusions (2) and abscesses (5), exploration prior to thoracotomy (2), transection of pleural adhesions and decortication (1) and window pericardectomy (2). Diaphragmatic hernia repair (2) and partial pneumonectomy (1) were initiated thoracoscopically but conversion to thoracotomy was necessary for completion. Standing thoracoscopy was well tolerated in most horses. Transient exacerbation of pulmonary compromise evidenced by tachypnoea was readily alleviated by reinflation of the lung. Standing thoracoscopy provided good visualisation of the dorsal and lateral structures of the thorax. The ventral thoracic structures and the cranial ventral diaphragmatic surfaces of the lungs were best visualised in dorsal or lateral recumbency under general anaesthesia. Thoracoscopy is a safe and useful diagnostic and therapeutic tool in horses with thoracic diseases.

The application of video-assisted thoracic surgery (VATS) for major lung resection is controversial. We review our combined experience from three centers in Asia. From June 1993 through June 1997, 214 patients underwent VATS major resections (2 segmentectomies, 203 lobectomies, 6 bilobectomies, 3 pneumonectomies), mostly for primary malignancy. Stringent selection criteria were used to choose patients for this approach. We prefer a technique of not spreading ribs, using conventional thoracic instrument for dissection and routine use of wound protector for specimen retrieval. There was one postoperative surgical death and 47 non-fatal complications, which compare favorably with published series on open technique. Of the primary lung cancer patients, 93% are still alive after a mean follow-up of 26 months. We conclude that VATS major lung resection is technically feasible in selected patients and associated with favorable intermediate-term results.

Background: This study was performed to evaluate the technical feasability and validity of videoassisted pulmonary lobectomy using simultaneous stapling of the hilar structures. Methods: Between December 1995 and July 1997, 30 video-assisted thoracic non-rib spread simultaneously stapled lobectomies (VATS(n)SSL) were performed. Results: Fourteen males and 16 females underwent 9 right upper, 4 right middle, 5 right lower, 4 left upper, and 8 left lower lobectomies for 15 adenocarcinomas, 7 squamous cell carcinomas, 4 benign and 2 metastatic lesions, 1 carcinoid and 1 mucosa-associated lymphoid tissue-lymphoma. All patients with primary lung carcinoma had peripheral lesions, 13 were T1 and 9 were T2 lesions. Lesions ranged from 1.0 cm to 4.0 cm, averaging 2.2 cm. Results of 10 cervical mediastinoscopies were negative. Two patients had positive nodes at postoperative examination. Operating time for the series averaged 128 minutes, for the first 10 patients 146 minutes, and for the last 10 patients 106 minutes. There was no surgical mortality and no transfusion. Perioperative bleeding averaged 185 mL. Two procedures were converted to open thoracotomy. Hospitalization averaged 4.4 days for the entire group. Conclusion: Video-assisted thoracic surgical non-rib spread simultaneosly stapled lobectomy is a technically feasible and safe procedure. Therapeutic outcomes for resected neoplasms need to be evaluated in long-term follow-up studies.

This article describes the techniques for performing a video-assisted thoracic surgery (VATS) lobectomy. Each lobe can be approached from anteriorly, posteriorly, or intralobarly. Each method is described and the advantages of each technique are discussed. The surgical results in 105 cases are presented. The VATS technique has decreased operative trauma and has shortened hospital stay with a concomitant reduction in cost to the patient and health-care provider. These advantages make VATS lobectomy an excellent alternative for excision of well localized peripheral lung cancer.

One hundred fifty video-assisted thoracic surgery (VATS) endoscopic hilar dissection lobectomy procedures are presented. Median blood loss was 65 mL and correlated with operative time (P.0001) which averaged 144 minutes. Conversion to open thoracotomy was required in a further 20 patients (11.8%). One VATS patient (0.67%) died at 4 days from a catastrophic pulmonary embolus and 2 patients died within 30 days of surgery from pulmonary embolism and adrenal failure (overall 30-day mortality, 2%). Serious complications occurred in 3 cases: bronchopleural fistula (1) and requirement for ventilation (2). Air leakage (4 days) occurred in 17 patients, correlated (P.0003) with the presence of either adhesions or fissural fusion (11.3%), and resulted in prolonged hospitalization compared with patients without air leakage (11.1 vs 6.7 days; P.0004). Open thoracotomy patients required 42% more morphine (P.001) and 25% more nerve blocks than VATS patients (P.001) who were 33% more likely to sleep following surgery (P0.01). Follow-up of 97 patients with non-small cell lung cancer (2,634 months total: mean 27) revealed 14 recurrences: 10 systemic and 4 (28.6%) within the thorax. No port site or pleural recurrences occurred. Stage analysis showed survival free of lung cancer-related death of 94% at 36 months for Stage I, 57% for Stage II, and 25% for Stage III.

Study objectives Recently, pulmonologists have performed thoracoscopy under local anesthesia using rigid thoracoscopes or flexible bronchoscopes. The latter allow greater access within the pleural cavity but are difficult to manipulate. The Olympus LTF semiflexible fiberoptic thoracoscope combines features of both instruments, having a solid body and a flexible terminal section. In the first study with this instrument, we evaluated ease of use and compared diagnostic yield with closed needle biopsy. Patients Twenty-four patients with pleural effusion were investigated. Setting Scottish University Hospital. Design Thoracoscopy was performed in the bronchoscopy suite after premedication with atropine and papaveretum. Following a standard Abram's needle biopsy, the LTF thoracoscope was inserted through a flexible introducer (Olympus Optical Co Ltd; Tokyo, Japan). The pleura was inspected and biopsy specimens were taken of suspicious areas. Results The final diagnosis was malignant pleural effusion in 16 of 24 patients. Ten of 16 were positive by Abram's biopsy, giving a sensitivity of 62%. Thirteen of 16 were positive by fiberoptic thoracoscopy, giving an improved sensitivity of 81%. The LTF thoracoscope was easy to use for pulmonologists experienced in rigid thoracoscopy and flexible bronchoscopy. Excellent views of the pleura were obtained from a single entry point. The procedure was well tolerated and no complications were encountered. Conclusion The LTF thoracoscope allows excellent pleural access but a larger biopsy channel (currently 2 mm) might increase the accuracy of diagnosis.

Endoscopic transthoracic sympathectomy (ETS) is a minimally invasive method, causing only small injuries and few complications, and requires only a short period of hospitalization. Therefore, this method has been applied to patients with palmar hyperhidrosis to whom the conventional transthoracic sympathectomy, which is much more invasive, or thoracic sympathetic blockade, which often causes complications, cannot be applied. Conventional thoracoscopes, such as a resectoscope 8 mm in diameter for urological operations, or a thoracoscope 5 mm in diameter, were usually used for this purpose, but they cause operative injuries. We performed ETS using a thoracoscope 2 mm in diameter (MiniSite 2 mm 0 degrees, USSC171303). Its visual field and handling were not inferior to those of conventional thoracoscopes, and the operative injuries were only 2 mm in size. For the patient, a small scar of this size means virtually no scar.

Purpose: This study was undertaken to determine whether videoendoscopic thoracic aorta-to-femoral artery bypass is a technically feasible operation. Methods: An acute canine study involving five mongrel dogs was carried out. After the dogs had been given a general anesthetic, the femoral arteries were exposed in the traditional fashion. On the left side, a retroperitoneal, retrorenal tunnel was extended from the common femoral artery to the diaphragm. Under videoendoscopic control, the tunnel was opened through the posterior thoracic attachments of the diaphragm into the thoracic cavity. A Dacron graft was tunneled from the thoracic cavity on the left to the left groin. The thoracic aorta was controlled with a side-biting clamp, and an endoscopically performed end graft-to-side thoracic aortic anastomosis was created. After completion of the thoracic anastomosis, the left femoral anastomosis was created in a traditional manner. A left-to-right femoral bypass completed the lower extremity vascular procedure. An open thoracotomy was avoided. Results: Videoendoscopic thoracic aorta-to-femoral artery bypass was successfully performed in all five animals. All components of the thoracic procedure, including exposure, dissection, vessel control, cross-clamping, and anastomosis, were performed through the thoracic ports with conventional laparoscopic instruments. Blood loss was minimal. All animals survived the procedure before being killed. Conclusion: Videoendoscopic thoracic aorta-to-femoral artery bypass is a technically feasible operation in a canine model. Advantages of this unique approach over the experimental laparoscopic and the traditional transperitoneal open aortofemoral bypass include ease of aortic exposure, ability to control a segment of disease-free aorta, and anastomosis in a disease-free segment of aorta. Potential advantages include decreased perioperative morbidity rates with the videoendoscopic approach. Before there is clinical consideration of this surgical approach, long-term experiments are required to demonstrate the safety of the procedure. (J Vasc Surg 1998;27:948-54.)

To explore the safety and the effectiveness of laparoscopic and thoracoscopic spinal surgery, an acute/non-survival animal trial was performed in 5 pigs using rigid and flexible endoscopes, flouroscopy, a holmium-YAG laser, and prototype instruments and implants. Our study aimed to approach the intervertebral disc space and spinal canal using laparoscopic and thoracoscopic techniques and to explore the potential and limits for endoscopic anterior spinal decompression and fusion. In a lateral recumbency access was provided to the anterolateral aspect of the lumbar spine from L1/2 to L7/S1, the thoracic spine was accessible from T2/3 to the diaphragmatic insertion. Complete disc space emptying with penetration into the spinal canal could be performed, epidural bleeding could be controlled by a hemostatic sponge, however bleeding restricted visualization for further endoscopic manipulation in the spinal canal. Intervertebral fusion was accomplished at T6/7, L4/5 and L7/S1 using small fragment plates with 3.5 mm screws and iliac bone grafts or prototype carbon fiber cages. On post mortem examination we found no dural tears and no nerve root damage, all animals had stabilized fusion sites and good implant position. We conclude that minimally invasive thoracoscopic and laparoscopic approaches to the spine are feasible and safe to perform disc decompression and implant placement for spinal fusion. In addition to currently performed laparoscopic interbody fusion, also plate fixation to reestablish lordosis of the lumbar spine is feasible at least in the porcine model. Careful disc decompression must be performed prior to implant introduction to prevent iatrogenic disc protrusion and spinal cord or nerve root compression. However, further surgical exploration of the spinal canal using these techniques does not provide adequate visualization of epidural spaces and therefore must be regarded as unsafe.

It is estimated that approximately 25% of cardiac surgery will be performed through minimal access by the year 2000. While original efforts focused on performing minimally invasive cardiac surgery totally thoracoscopic, and with cardiopulmonary bypass, more recent realistic approaches rely on small targeted incisions and video assisted techniques on the beating heart. Current instrumentations which provide segmental stabilization of the heart eliminate the need for cardioplegic arrest and cardiopulmonary bypass. While early results are encouraging, intermediate and long term clinical outcome and graft patency remain to be determined.

We present the case of a 69 yr old, white male, suffering from diffuse interstitial lung disease, finally diagnosed as paracoccidioidomycosis or South American blastomycosis. During the course of his disease, antineutrophil cytoplasmic antibodies (c-ANCAs) became positive, suggesting the possibility of a Wegener's granulomatosis. Transbronchial biopsies and a video-assisted thoracoscopic lung biopsy revealed only the pulmonary yeast infection, without other co-existing pathology. During treatment with itraconazole, the patient improved clinically and functionally, and c-ANCAs became negative. Serological monitoring confirmed the diagnosis. To our knowledge, this is the first report describing positive c-ANCAs in a patient with paracoccidioidomycosis. It re-emphasizes the fact that cautious interpretation of c-ANCAs in patients without convincing clinical signs or pathological evidence of a granulomatous vasculitis is absolutely necessary. In this era of increased mobility, a thorough medical history, including documentation of travel, remains an inexpensive tool in making a diagnosis and is still the cornerstone of good medical practice.

Endoscopically sutured vascular anastomoses are complex, time consuming, and require great dexterity. We decided to evaluate performance enhancement using a robotic device to create sutured coronary artery bypass anastomoses with endoscopic techniques in a plastic model.Seven coronary artery bypass anastomoses were endoscopically created in a plastic model using a robotic enhancement technology (Computer Motion, Goleta, CA). Anastomoses were created with a single running suture (7-0 monofilament). Our endpoints were operative time, intraoperative incidents, stability and dexterity of the robotic system, surgeon's fatigue, and anastomotic patency.Operative time was 46+/-12 min (mean+/-SD). There were no intraoperative incidents. Patency was confirmed in all anastomoses. The system's stability and dexterity were high. Surgeon's fatigue was mild.The use of robotic enhancement technology leads to an efficient performance of sutured coronary artery bypass anastomoses in a plastic model. The robotic device enhances dexterity, precision, and reduces surgeon's fatigue while preserving the quality of hand suturing.

Objective: To evaluate the role of video-assisted thoracoscopy (VAT) in the staging of non-small cell lung cancer (NSCLC). Methods: In 30 patients (18 male, 12 female, median age 62 (50‐78) years) VAT was used to assess the operability of NSCLC in cases where doubt existed after conventional staging investigations had been performed. Results: VAT was used to assess direct tumour invasion of adjacent organs in 17 patients (mediastinal invasion in 14 and chest wall invasion in 3 patients). In 4 patients with limited respiratory reserve, VAT confirmed the need only for lobectomy prior to thoracotomy. Mediastinal lymph node biopsy was performed in 5 patients with significant (\1.5 cm) lymphadenopathy on CT scan. VAT was also used to assess bilateral lesions in 4 patients with suspected synchronous tumours. Conversion to thoracotomy was necessary in 4 patients for technical reasons. Successful resection was possible in 17 of the remaining 26 cases, while unnecessary thoracotomy was avoided in 9 patients (30%) with unresectable or benign disease. In 4 patients deemed inoperable on CT scan, VAT staging enabled subsequent resection. Conclusions: Video-assisted thoracoscopy appears to have a complementary role in staging NSCLC when other methods are equivocal. It has the potential for increased sensitivity over conventional staging methods. © 1997 Elsevier Science B.V.