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Resume On distingue les traumatismes thoraciques fermes (deuxieme cause de mortalite chez les polytraumatises), et les traumatismes thoraciques ouverts (survenant le plus souvent dans un contexte d’homicide ou d’accident, il s’agit de la premiere cause de mortalite chez les 15 a 34 ans). Ils se traduisent par des tableaux cliniques multiples avec des structures touchees variees : pulmonaires (plevre, cotes, parenchyme pulmonaire), vasculaires (isthme aortique, cœur, vaisseaux cervico-thoraciques), neurologiques (rachis thoracique) ou diaphragmatiques. Dans tous les cas, leur prise en charge en urgence est pluridisciplinaire, associant urgentistes, pneumologues, chirurgiens et reanimateurs, et peut aller de la simple surveillance a la thoracotomie en urgence. Le bilan lesionnel doit etre realise en urgence, avec un role majeur de la TDM thoracique. Chez le traumatise thoracique ferme stable, une surveillance est toujours necessaire car la survenue d’un hemothorax secondaire est frequent.

Resume La pathologie tumorale mediastinale est tres variee, avec des pronostics et des therapeutiques differents. L’examen anatomopathologique est un acte essentiel tant sur le plan etiologique, que pronostique. La mediastinoscopie est communement utilisee dans la confirmation de metastases ganglionnaires, d’un carcinome bronchopulmonaire, mais aussi, a un moindre degre, pour l’exploration d’adenopathie mediastinale isolee. Enfin, cette technique permet l’approche diagnostique d’une tumeur mediastinale. L’examen extemporane a sa place, dans la premiere indication, permettant de prescrire une chimiotherapie neoadjuvante, et dans les autres situations, pour s’assurer que la quantite de materiel prelevee est suffisante, voire pour realiser des techniques complementaires.

Solitary fibrous tumour is unusual, arising most commonly in the pleura and can also occur in a large number of other sites. We report the case of a 34-year-old man with a retroperitoneal solitary-fibrous tumour, revealed by abdominal pain and hypoglycaemia. We describe the histopathological and immunohistochemical features. Solitary-fibrous tumour should be included in the differential diagnosis of spindle cell tumours in this location. Despite complete local excision, local recurrence and metastasis are seen. The behaviour of theses tumours is unpredictable and patients with solitary fibrous tumour require careful and long-term follow-up.

Resume La prise en charge d’un polytraumatise en situation precaire doit s’adapter au manque de moyens en personnel, materiel et possibilite d’evacuation. Elle necessite une strategie chirurgicale en plusieurs temps, fondee sur les donnees de l’examen clinique et d’examens radiologiques simples. Les polytraumatises instables doivent etre conduits au bloc operatoire sans delai pour realisation des interventions de sauvetage, ce sont des « Extremes Urgences ». Les polytraumatises stabilises par la reanimation peuvent beneficier d’un bilan lesionnel plus complet, avant realisation des interventions urgentes dans un delai de 6 heures, ce sont des « Premieres Urgences ». Apres mise en condition d’evacuation, les blesses doivent etre transferes vers des structures mieux adaptees pour la realisation des interventions differees.

Resume L’hyperhidrose est une pathologie benigne, fonctionnelle, mais pourtant extremement handicapante, necessitant une prise en charge therapeutique active. Les alternatives, en particulier medicales, sont nombreuses mais souvent inefficaces. Le systeme sympathique thoracique joue un role fondamental dans la propagation des stimuli de la secretion sudorale. La sympathectomie thoracique par voie endoscopique represente un traitement radical et sur des hyperhidroses palmaires et axillaires severes. Nous exposons la technique realisee dans le service, ses complications eventuelles et ses resultats. Cette intervention est realisee par de nombreuses equipes chirurgicales, depuis plusieurs annees. Malgre quelques differences techniques notables, les diverses series de la litterature confirment le large benefice apporte a ces patients. Les phenomenes de transfert de sudation frequents ne sont pas souvent invalidants, mais necessitent une information prealable, car le plus souvent irreversibles.

Resume La videothoracoscopie represente a l'heure actuelle un outil diagnostique et therapeutique incontournable chez les patients presentant une plaie ou un traumatisme ferme du thorax, en pratique civile. Cette approche a ete validee pour l'evacuation d'hemothorax caillotes ou d'empyemes post-traumatiques, pour le diagnostic des plaies diaphragmatiques, pour le traitement des chylothorax traumatiques, pour le traitement de certains pneumothorax traumatiques, pour l'ablation des projectiles intrathoraciques. Cette technique, bien que non validee, pourrait aussi presenter un interet dans l'evaluation de patients en etat de stabilite hemodynamique et presentant un hemothorax continu ou une plaie de l'aire cardiaque. Les abords classiques par thoracotomie (s) ou sternotomie mediane conservent leur place chez les patients instables sur le plan hemodynamique ou ne pouvant supporter le decubitus lateral ou l'exclusion pulmonaire unilaterale. Une formation solide ainsi qu'une bonne connaissance de la videochirurgie et de la traumatologie thoracique constituent selon nous un prerequis indispensable a la pratique de ces techniques lors de traumatismes fermes ou de plaies du thorax. Les contre-indications a la realisation d'une videothoracoscopie et les indications de conversion en thoracotomie doivent etre connues de tous, afin de ne faire courir aucun danger aux patients.

Since a few years, the medical thoracoscopy has already been used specially for the diagnostic and therapeutic taking up of the pleural pathology. Behind it, the video-assisted thoracic surgery has been improved since 1990. As a surgical technology, it proved its interest refering to the classical thoracotomy by lessening operative morbidity and mortality. The authors discuss its main indications about seven cases, recruted in the internal medicine service and operated in the thoracic surgery service of the Val-de-Grâce hospital. Some of these indications are now admited by most of the authors: 1) diagnostic aims: pulmonary biopsy in case of interstitial pathology, of pulmonary peripheral under-pleural nodule and sometimes of solid tumors of the mediastinum, specially of some lymph-nodes. 2) Therapeutic aims: the spontaneous pneumothorax treatment of the adult remains the most classical indication; the thoracic sympathectomy, the creation of pleuropericardial windows and the resection of benign tumors of the mediastinum are now well acknowledged indications.

INTRODUCTION Penetrating thoracic aorta wounds are rare but responsible for a high mortality when medical and surgical management is delayed. OBSERVATION We report the case of a 71 year-old patient with malignant lymphoma who sustained an accidental penetrating injury of the ascending thoracic aorta while undergoing trephine biopsy of the sternum. He was successfully treated with emergency sternotomy and aortic suture-repair. CONCLUSION This case report highlights the limits of sternal trephine biopsy, notably in patients whose bones are weakened by a malignant haematological process, and proposes preventive measures in order to avoid accidents.

Tumoral pathology of the mediastinum is extremely varied, with different prognoses and treatments. The pathological examination is essential, both etiologically and prognostically. Mediastinoscopy is generally used to check for lymph node metastases, bronchopulmonary carcinoma, but also, to a lesser degree, for the exploration of isolated mediastinal adenopathy. Finally, this technique enables a diagnostic approach to mediastinal tumours. The frozen section has its place, at the first indication, making it possible to prescribe neoadjuvant chemotherapy, and in the other situations to make sure that the quantity of material removed is sufficient or even to carry out complementary techniques.

Malignant melanoma most commonly presents as a primary neoplasm of the skin, but has been described in other mucosal sites. Rarely, malignant melanomas have been reported as primary visceral neoplasms, including the lung. Most such lesions have been dismissed as metastases from undocumented or regressed primary cutaneous or ocular melanomas.We report an original observation of an 82-year-old man with a pulmonary nodule presenting with chest pain. The diagnosis of melanoma was established on biopsies carried out under computerized tomography scanning and confirmed after right upper lobectomy two months later.Melanomas of the respiratory tract are usually metastatic in origin and a primary melanoma in very rare. Strict criteria must be applied before a diagnosis of primary malignant melanoma of lower respiratory tract can be accepted. Melanoma may be confused with more conventional types of lung cancer and other pigmented tumours.

The authors reviewed their experience in the management of "open abdomen" using the vacuum-assisted closure device (VAC), in order to assess its morbidity particularly in terms of fistula, and the outcome of abdominal wall integrity.Between January 2003 and October 2006, 22 patients required management with an "open abdomen" technique (18 patients were managed with the VAC abdominal dressing device with application of a specific sheet and 4 other patients simply required a dressing with the polyurethane sponge). The mean age was 55 years, and M/F sex ratio was 2.67. Indications were abdominal compartment syndrome in 7 patients, initial "abdominal closure" after trauma in one patient, severe abdominal sepsis in 7 patients, and abdominal wound dehiscence where closure was impossible in 7 patients.There were no enteric fistulae. Two infections were seen--a chronic suppuration which resolved with antibiotic therapy and a deep abscess which was drained with radiologic guidance. Of the 18 cases of "open abdomen" managed with the VAC, 15 were alive. Six (40%) underwent a delayed primary closure at a mean interval of 9 days; the others underwent secondary healing by granulation, and 10 eventually underwent split thickness skin grafting at a mean interval of 50 days. With VAC closure of the "open abdomen", the development of ventral hernia is an anticipated outcome; in four cases, patients underwent abdominal wall reconstruction at an interval of one year.Laparostomy or "open abdomen" using the VAC dressing system should be considered an established and well-defined technique which provides temporary abdominal coverage with limited morbidity.

Solitary fibrous tumour is unusual, arising most commonly in the pleura and can also occur in a large number of other sites. We report the case of a 34-year-old man with a retroperitoneal solitary-fibrous tumour, revealed by abdominal pain and hypoglycaemia. We describe the histopathological and immunohistochemical features. Solitary-fibrous tumour should be included in the differential diagnosis of spindle cell tumours in this location. Despite complete local excision, local recurrence and metastasis are seen. The behaviour of theses tumours is unpredictable and patients with solitary fibrous tumour require careful and long-term follow-up.

We report an observation of angiosarcoma of the pulmonary artery in a 65-year-old man hospitalized for acute dyspnea revealing a left mass hilaire which arose from the pulmonary artery before the development of obstructive endobronchial extension. The therapeutic sequence associated removal of the lobar bronchus obstruction by interventional endoscopy, chemotherapy using ifosfamide-doxorubicin, complete left pneumonectomy and auxiliary chemotherapy with 2 additional cycles. The patient was free of tumor relapse at nearly 3 years follow-up.

We report the case of a 36-year-old women with Hodgkin's disease treated with polychemotherapy and bone marrow autograft. Progressive growth of a thymic mass suggested possible relapse four months after treatment withdrawal. This mass did not exhibit gallium-67 uptake but showed strong affinity for 18-FDG (SUV=6.8). Surgical biopsy ruled out recurrence of Hodgkin's disease of the thymus and led to the diagnosis of thymic rebound. The aspect of the thymic compartment returned to normal spontaneously at one year.

The management of the patient with multiple trauma in unstable condition must be adapted to the means available (or unavailable) on site, i.e., trained personnel, material means, and the possibility of evacuation to a trauma center. This may require a multi-stage surgical strategy based on clinical examination and available imaging resources. Patients with multiple trauma in unstable condition should be brought to the operating room promptly for life-saving or stabilizing interventions (Extreme Urgency). The patient may then undergo further stabilization of vascular volume, coagulation, and metabolic deficits while simultaneously undergoing a more detailed clinical and radiologic evaluation; he may then return to the operating room within six hours for more definitive repair of urgent lesions (First Urgency). Once the patient is stable enough for evacuation, he should be transferred to a trauma center for definitive surgical care.

Hyperhidrosis is a benign functional anomaly which is highly stressful for the patient. Active management is required. Several medical options are available but are often ineffective. The thoracic sympathic system plays a fundamental role in propagating stimulation of sudoral gland secretion. Endoscopic thoracic sympatecomy thus provides a radical treatment for severe palmar and axillary hyperhidrosis. We describe the technique used in our unit and present results and possible complications. This method has been used by many teams for several Years and despite some differences, most confirm major patient benefit. Phenomena of transferred sudation are frequent by are usually not invalidating. Patients should however be informed of this possibility because the effect is often irreversible.

Penetrating thoracic aorta wounds are rare but responsible for a high mortality when medical and surgical management is delayed.We report the case of a 71 year-old patient with malignant lymphoma who sustained an accidental penetrating injury of the ascending thoracic aorta while undergoing trephine biopsy of the sternum. He was successfully treated with emergency sternotomy and aortic suture-repair.This case report highlights the limits of sternal trephine biopsy, notably in patients whose bones are weakened by a malignant haematological process, and proposes preventive measures in order to avoid accidents.

The adequate care of thoracic ballistic traumatisms implies a good preliminary knowledge of wounding agents, and of the principles governing lesion-based ballistic, in particular the role played by the meeting with an obstacle which modifies the ballistic behaviour of the projectile, with worsened wounding effects. Authors describe the principal types of involved projectiles and their wound profile applied to the thorax, while stressing the need to treat systematically the wound and not the weapon, and on the importance of the choice of the surgical exploration way of these lesions, which conditions, as from the initial stage, the later choices of the parietal closure and rebuilding methods. The importance of parietal disrepair is therefore an essential decisional factor in the assumption of responsibility and the definition of the therapeutic strategy of these casualties.

In the congenital malformations of the front chest wall showing depression or protrusion, the cardiorespiratory disorders are inconstant and often not linked with the distortion. On the other hand psychoaffective repercussions are major in adolescents and young adults justifying recourse to surgery with morphological and aesthetic aiming. The authors present the technique of modelling sternochondroplasty by raising with osteosynthesis by slide fastener-handle of Martin-Borrelly, applied to the correction of congenital malformation of the front chest wall in young adult, both of protrusion (pectus carinatum), of thoraxes in funnel (pectus excavatum) types or of mixed types (pectus arcuatum). This surgical replanning intervention is carried out by under-mammary way and aims at reestablishing a normal anatomy of the front chest wall. It leads to a genuine wide sternochondrocostal volet, which is stabilised by a specific, multipurpose, adaptable and reliable osteosynthesis equipment. The results obtained on a series of 14 cases are good or excellent in 86% of the cases and stable over time in the absence of major complications. A good cooperation of the patient is essential to obtain a good result in particular via the continuation of musculation exercises after assembly consolidation, possibly associated with remote mammary plastic surgery in the event of hypoplasia or of associated mammary agenesia.

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.

We report a new case of pleomorphous adenoma of the submaxillary glands with multiple lung metastases. Histological proof was obtained on the thoracoscopic surgical specimen. Clinically, this benign tumor presents as a malignant tumor. Diagnosis has been a subject of debate; surgical resection is indicated. Diagnosis is achieved by elimination in a patient with one or several nodules occurring in a context of recurrent pleomorphous adenoma.

Inguinal hernia is a common indication for surgery in Africa. Most cases involve men and are treated in advanced stages often with complications. Until now the benchmark technique for surgical management has been the well-defined herniorrhaphy technique. Use of prosthetic implants has been rare because of high cost. Recently there has been a growing interest in video-assisted surgery throughout developing countries. However this enthusiasm should not obscure the fact that the technique is still in the developing stage and thus is more costly for the local economy. Indications for video-assisted surgery should be carefully selected in function of local conditions as well as problems specific to developing countries.

We examine the classical indications for thoracoscopy in case of pneumothorax and recall the therapeutic modalities of thoracoscopic treatment. We then discuss the long-term incidence of this approach, examining outcome in terms of post-operative pain, respiratory function, cost and complications. A comparison of these parameters after thoracoscopy with those observed after classical surgery would favor thoracoscopic management.

Hydatidosis is a ubiquitous parasitic condition observed in a pulmonary localization in 30 to 40% of cases. The hydatid cyst develops slowly and is well tolerated by the host who presents no signs for a long period. Complications include compression, fissuration, rupture, anaphylactic shock or infection after a latency phase of variable duration. Treatment of pulmonary hydatidosis is classically surgical with enucleation of the cyst by cleavage between the adventice and the anhistic membrane via thorachotomy using the Ugon and Barret procedure. Needle aspiration is also possible via thorachotomy or thoracoscopy. Finally resection of the pulmonary parenchyma can be used to excise the hydatic cyst. We describe a thoracoscopic treatment using specific material, in a man with complications due to a voluminous pulmonary hydatid cyst.

American pulmonary histoplasmosis is a deep mycosis imported from North America caused by the inhalation of Histoplasma capsulatum. It is endemic in several countries throughout the world and occasional cases have been reported in France, mainly imported from out lying French territories. The most frequent clinical forms observed in immunocompetent subjects are generally benign or silent and usually limited to a fortuitously discovered pulmonary nodule. Massive exposure may lead to an acute primary invasion producing a miliary aspect. Chronic forms simulating tuberculosis are exceptional. Inversely, opportunistic histoplasmosis in AIDS patients can produce an severe multiple organ disease. Ideally, mycelium should be isolated for diagnosis, a task which is easier in disseminated or operated nodular forms. More often, the epidemiological context, clinical and radiological features, the elimination of differential diagnoses and, retrospectively, serology are sufficient for diagnosis. The clinical course is usually favorable. Itraconazole is the treatment of choice for symptomatic or complicated forms.

In 9 out of 10 cases, lymphangiomas are observed during the first years of life, generally located in the neck. Rare lymphangiomas have been reported in adults, usually in an intrathoracic localization, raising the hypothesis of an acquired origin.A retrospective analysis of patients undergoing surgery for lymphanioma of the neck or mediastinum was conducted. Pathology reports, clinical data and medical imaging (CT) were reviewed and operative and post-operative findings were analyzed in order to determine whether the cases could be divided into congenital and non-congenital forms.Data were obtained on 37 patients (23 men and 14 women, mean age 45 years, range 8-77). Four lesions (11%) were located in the neck: 3 in children and one in an elderly subject (77 yrs). Thirty-three tumors (89%) were located in the mediastinum. In 5 cases, the tumor was located in the phrenic nodes of the anterior mediastinum. These lymphangiomas occurred in young adults, had a CT density less than liquid with enhancement after contrast injection, and had a malformative vascular component proven anatomically and histologically (hemolymphangioma). These elements favored a congenital orgin. In 28 cases (76.6%) the tumor involved nodes in the posterior or middle mediastinum. They occurred in older adults and were purely liquid with no vascular component. These lymphangiomas were undoubtedly acquired.In children, adolescents and young adults, lymphagiomas are found in the neck or anterior mediastinum and have a tissular component. These tumors should be considered as congenital lymphangiomas. In older adults, lymphangiomas are found in the posterior or middle mediastinum and are purely liquid cysts suggesting an acquired origin.

We report a case of giant cell tumor of the manubrium with radiological evidence of aggressiveness. Few cases of giant cell tumor of the sternum have been published. Extensive surgery offers the best hopes of recovery. Cytogenetic studies evidenced several clonal abnormalities including a 17q isochromosome. The TP53 suppressor gene is located at 17q13.1. Whether loss of one of the TP53 alleles may have contributed to the aggressive behavior of our patient's tumor is discussed.

The use of video-guides surgery for major pulmonary resections in cancer patients raises a problem of safety and oncological quality. The aim of this prospective study was to demonstrate the oncological contribution of systematic thoracotomy in suspected stage I cancer patients. Between February 1993 and December 1996, we operated 34 consecutive patients with a solitary primary neoplastic lung nodule using normal fibroscopy and preoperative CT scan to detect mediastinal nodes. The nodules measured a mean 18.5 mm. Diagnosis was confirmed at peroperative pathology examination of the video-guided surgical resection, generally leading to thoracotomy for lobectomy-dissection. The final tumoral stage affirmed the initial diagnosis (stage I) in only 19 cases (56%). Peroperative findings showed that the other patients had more advance disease: 2 stage II (T1N1) (6%), 11 stage IIa (T1N2) (32%) and 2 stage IIIb (satellite nodule in the remaining lobe measuring 6 and 7 cm) (6%). These findings emphasize the importance of complete node dissection as well as the need to carefully palpate the entire lung. Thoracotomy remains the most reliable and reproducible method for safely fulfilling the oncological requirements.

A 58-year-old car driver suffered a road accident responsible for severe blunt thoraco-abdominal trauma. Transoephageal echocardiography, performed following the secondary development of a diastolic murmur, confirmed the presence of aortic incompetence due to commissural avulsion and guided the surgical treatment, which consisted of commissural suspension under cardiopulmonary bypass via a mini transverse trans-sternal incision. The rarity of acute aortic valve incompetence following non-penetrating thoracic trauma is illustrated by the data of the literature. This lesion is due to either avulsion of a sigmoid cusp or commissure, or laceration of the valvular tissue. Transthoracic echocardiography confirms the reality of aortic incompetence suggested clinically by appearance of a diastolic murmur, but confirmation of the mechanism of the lesions is based on transoesophageal echocardiography which allows perfectly safe and rapid visualization of the mechanism of the valvular lesion, investigation of associated lesions and guidance of therapeutic management.

We report the case of a scuba accident which provoked a pneumatocele. Initially hemorrhagic leakage filled the pseudocyst. The long term outcome was spontaneously favorable.

We report a case of malignant schwannoma of left phrenic nerve in a 65-year-old man. This uncommon diagnosis was suggested by radiological features and confirmed by histological findings on a needle biopsy and surgery specimens. We discuss management, follow-up and prognosis of malignant schwannomas.

A schwannoma of the phrenic nerve is a rare disorder which presents as a tumour of the anterior mediastinum. It is seen in adults and is usually latent. We report two cases in elderly subjects in whom the phrenic nerve tumour had achieved a significant size. One of these schwannomas had degenerated into sarcomatous change which is the first case reported to the present time.

Thoracic and abdominal wounds are characterized by their diversity, their possible danger and the necessity of a successful diagnosis and therapy strategy. Management of thoracic wounds and indications of surgical treatment are conditioned by airway and hemodynamic states, paraclinical exams and chest drainage. The approach of abdominal wounds is based upon their possible penetrating character. Surgical indications, even if very discussed, are still wider. Thoraco-abdominal wounds could concern the diaphragm and are remarkable for their surgical strategy.

To outline the most appropriate treatment of descending necrotizing mediastinitis.Three adult patients had mediastinitis occurring from a descending odontogenic infection in one case and oropharynx infection in two cases. All patients underwent extensive surgical debridement and a cervicomediastinal drainage through a cervical incision. All patients survived.Soft-tissue infections of the neck with mediastinitis demand early diagnosis aided by CT scan in order to decrease their threat to life. Extensive surgical debridement and a cervico mediastinal drainage through a cervical incision is adequate when mediastinitis is limited to the upper mediastinum. Thoracotomy has to be performed when the process spread below the carina. Patients must be treated initially aggressively with the aid of multidisciplinary support team (intensive care physicians, thoracic and head and neck surgeons). Early surgery must treat both neck and mediastin. While usually associated with greater than 40% mortality, all the patients in this series survived.

Perineo-genital wounds involving the anterior perineum or the urogenital perineum are uncommon; 1-4% of all war wounds. We report 18 cases observed in war situations. Isolated uretrogenital wounds are rarely life-threatening, but the functional prognosis is always compromised in these men whose mean age is under 30 years. Debridements should be limited and all isolated lesions should be repaired early with tight suture of the cavernous body albuginea, preservation of viable testicular and adnexal tissue (but the rate of orchidectomy is greater than 50%), and immediate suture of any wound to the urethra rather than simple alignment. In war situations, these wounds are usually caused by perforating or blast trauma. The wounds are complex, with damage to the soft tissues, sometimes involving lesions to the anal sphincter, the gluteal masses or the abdomino-pelvic structures. Laparostomy for hemostasis is justified. The risk of sepsis is high, requiring triple antibiotics, cystostomy, careful debridement, discharge drainage or possibly colostomy. Treatment of urogenital lesions is a secondary operation in these cases but must not be neglected if the mictional and sexual functions are to be preserved.

Superior vena cava gunshot wounds are rare and usually associated with high mortality before patients reach the hospital. We present an exceptional case with a 16 hour preoperative delay and a final recovery.

Since a few years, the medical thoracoscopy has already been used specially for the diagnostic and therapeutic taking up of the pleural pathology. Behind it, the video-assisted thoracic surgery has been improved since 1990. As a surgical technology, it proved its interest refering to the classical thoracotomy by lessening operative morbidity and mortality. The authors discuss its main indications about seven cases, recruted in the internal medicine service and operated in the thoracic surgery service of the Val-de-Grâce hospital. Some of these indications are now admited by most of the authors: 1) diagnostic aims: pulmonary biopsy in case of interstitial pathology, of pulmonary peripheral under-pleural nodule and sometimes of solid tumors of the mediastinum, specially of some lymph-nodes. 2) Therapeutic aims: the spontaneous pneumothorax treatment of the adult remains the most classical indication; the thoracic sympathectomy, the creation of pleuropericardial windows and the resection of benign tumors of the mediastinum are now well acknowledged indications.

An otherwise healthy 21-year-old man with no evidence or family history of Von Recklinghausen's neurofibromatosis presented a posterior mediastinal mass detected on routine chest radiographs. The findings of standard light microscopy, ultrastructural examination and immunohistochemical studies suggested the working hypothesis of an unusual malignant "Triton" tumour: -arising in a pre-existing de novo ganglioneuroma; -fortuitously detected; -predominantly made of multinucleated spindle cells with only ultrastructural and immunohistochemical rhabdomyoblastic differentiation.

Two cases of pulmonary alveolar proteinosis are reported. Emphasis is placed on imaging techniques for diagnosis with bronchofibroscopy and bronchoalveolar lavage. Treatment of symptomatic forms is based on classical alveolar lavage with a rigid bronchoscope or currently with the fibroscope.

A tumour of the posterior mediastinum was removed via thoracoscopy. The histology report was a triton tumour. This is a rare (less than 80 cases reported in the literature) malignant tumour of the nervous system: malignant schwannoma with rhabdomyoblastic differentiation. The characteristics of this rare tumour and the consequences of videoassisted surgery in this specific case are discussed: a second access is required to widen the thoracotomy and complementary radiotherapy is needed.

Operative risk is encountered daily in thoracic surgery. Preoperatively, the risk can be evaluated by the pneumologist as well as the intensive care-surgery team. The parenchymal function and the patients respiratory capacity during the post-operative period should be evaluated. It is fundamental to evaluate heart function and vascular capacity. We discuss operative risk of dissection. The risk of bronchial fistulization is estimated at 5% (pneumonectomy) and 1% (lobectomy). Immediate complications include air leaks, rhythm disorders and post-operative bleeding. Thoracic drainage is a determining factor in thoracic surgery. The main problem remains post-operative respiratory failure especially since carcinological exeresis is usually carried out in patients with bronchopathies.

Since the team at the Laennec hospital first performed an extra-pleural thoracoscopy in 1990, a certain number of thoracic surgery units have started using this new technique. Video-assisted thoracoscopy is an absolutely revolutionary technique allowing an intrapleural approach to the mediastinum and to the pulmonary parenchyma without a thoracotomy. It requires a sophisticated technical set up including a video camera, direct or angular optics, and a video screen. The patient is placed in the same position as for a thoracotomy. For the pneumothorax and dystropic bullae, Video assisted thoracoscopic surgery has been largely shown to be the superior technique. The pleura is treated by avivement or sometimes by pleurectomy. Pulmonary biopsies are often taken. Preoperative computed tomography with methylene blue injection is often required for the exeresis of peripheral parenchymatous sub-pleural nodules and sometimes a small fishhook has to be placed within the tumour. Inversely, segmentectomies or lobectomies are rarely performed. There is a certain amount of risk involved in closed chest vascular dissections, and the question of carcinologic rigour has to be raised. Tumours of the mediastinum, both cystic and solid tumours, are relatively easy to approach by dissection using video assisted thoracoscopy. Finally, this technique offers new possibilities for staging bronchial cancers, the treatment of broncho-pleural fistulas, and more recently for non operated chest trauma. This new technique is of great importance for the thoracic surgeon, although an evaluation of long-term results are still required.