Thoracic Surgical Techniques

By Francis C. Wells and Aman S. Coonar

This heavily revised second edition of this book provides a comprehensive overview of both common and rarely performed thoracic surgical techniques. Techniques covered include thymectomy, left and right lower lobectomy, rib resection for empyema, median sternotomy and lung biopsies. Emphasis is focused on the practical steps necessary to successfully and reliably perform the techniques covered, while acknowledgement is also given to individual variations in how these techniques are performed.

Thoracic Surgical Techniques provides a detailed clinical illustrative guide for successfully performing a range of procedures reliably. Its large number of detailed illustrations and concise technical descriptions provides an invaluable resource for all practising and trainee thoracic surgeons.

• Language: English
• Publisher: Springer
• Release date: Aug 30, 2018
• ISBN: 9783319662701

Book preview

© Springer International Publishing AG, part of Springer Nature 2018

Francis C. Wells and Aman S. CoonarThoracic Surgical Techniqueshttps://doi.org/10.1007/978-3-319-66270-1_1

1. Principles of Thoracic Surgery and Enhanced Recovery

Francis C. Wells¹  and Aman S. Coonar¹

(1)

Cardiothoracic surgery, Royal Papworth Hospital, Cambridge University Health Partners, Cambridge, UK

1.1 Introduction

This book is about open and minimally invasive thoracic surgery for the practicing surgeon. In thoracic surgery minimally invasive surgery is usually described as video assisted thoracic surgery or VATS , and has become part of the work of all specialist thoracic surgeons. This development has taken place because of benefits to patients, advantages for surgeons and the overall health-economic advantages related to improved health outcomes.

As VATS has developed there has been a simultaneous change in work-up and peri-operative care, with an appreciation that consistent application of enhanced recovery protocols and empowerment of the patient in their personal recovery leads to better outcomes. There have also been developments in anaesthesia with an increasing number of specialist thoracic anaesthetists who are able to achieve lung isolation and use regimes that promote faster recovery.

1.2 Patient Engagement and Expectations

For example, if we tell a patient that they will go home with a chest tube within a very few days of surgery and they and their family are prepared for that in advance, it makes earlier discharge possible. By allowing the patient to be more active in their own recovery we can change their expectation of the surgical process to one in which they were a relatively passive participant to a more active and responsible role. Successful earlier discharge is very important when health care costs are increasing. If we are to treat as many people as possible, to the highest standard, those costs need to be contained whenever possible.

1.3 Enhanced Recovery

Our approach to enhanced recovery is evidence based and includes the following steps.

1.

An explicit explanation to the patient of their recovery pathway and agreement on mutual expectations. This would mean that they have the facility and support to go home with a drain in and realize that their recovery will take place much more at home in their own environment than in-hospital.

2.

Pre-operative exercises, physiotherapy, pulmonary rehabilitation and whenever possible same day admission with maintained mobilization of the patients including, for example, walking up to the operating theatre holding area.

3.

No pre-medication other than usual drugs. Continued oral hydration and carbohydrate loaded drink to 4 h preoperatively.

4.

Minimal intra-operative use of indwelling lines and catheters at the time of surgery.

5.

Mobilisation on the day of surgery including sitting out of bed and walking. Day of surgery post-op physiotherapy.

6.

Post operative prophylactic anticoagulation and rapid mobilization.

7.

Standard post-operative medications to include oral analgesia , laxatives, antiemetic, proton pump inhibitor and minimal use of post operative antibiotics. Avoiding opiates as much as possible. Remove lines and catheter as soon as possible.

8.

Use of ambulatory drainage systems whenever possible including new generation metered devices that improve accuracy of recorded measurements.

9.

Culture change such that constipation, urinary catheter or drains being in situ are not seen as contraindications to discharge.

10.

Early post-operative (on ward or treatment room) review if necessary for removal of drains or trial without urinary catheter.

11.

Early post-discharge clinic review for reassurance, identifying complications and planning next-stage treatments.

12.

Telephone, internet and outreach or district nurse support to patients in early post-operative period.

13.

Earlier pain specialist review if symptoms not significantly settling at early reviews.

1.4 Anaesthetic Considerations

Open thoracic surgery and VATS have common requirements. There needs to be fast, reliable and effective lung isolation. If an anaesthetist does not have the relevant skills or experience the results are likely to be poor. VATS is extremely difficult if the patient starts to cough during general anesthesia. The anaesthetist who forcefully overinflates the lung when not taking precautions risks barotrauma and pneumothorax . The dialogue between surgeon and anesthetist needs to be excellent, in particular when checking the airway. There has been a move away from to epidurals to extrapleural analgesia . This has led to reduced need for central lines, less infusion of postoperative vasoconstrictor and more rapid mobilization. Recently thoracic surgery including lung resection has been performed on non-intubated patients who are breathing spontaneously under general anaesthesia. This requires very close monitoring of the patient who will not be on muscle relaxants. Newer regimes avoid opiates. Such strategies may have benefits in terms of speed of recovery.

Recently complex thoracic surgery is being performed on the sedated but still spontaneously breathing patient. This requires particular skills in thoracic anaesthesia. Possible benefits are earlier mobilization of the patient.

From the surgeon’s perspective a consultant anaesthetist who is skilled, interested and available during the case is an essential part of the effective partnership that contributes to excellent outcomes.

© Springer International Publishing AG, part of Springer Nature 2018

Francis C. Wells and Aman S. CoonarThoracic Surgical Techniqueshttps://doi.org/10.1007/978-3-319-66270-1_2

2. Fundamentals of Thoracic Surgical Techniques

Francis C. Wells¹  and Aman S. Coonar¹

(1)

Cardiothoracic surgery, Royal Papworth Hospital, Cambridge University Health Partners, Cambridge, UK

All the techniques described in this book require varying degrees of experience by the surgeon and their team. Our descriptions and pictures are a guide and reflect our experience.

2.1 Open Surgery

Open surgery generally provides excellent exposure, good illumination, complete tactile feedback, fast dissection times and usually no difficulties in removing a tumour. Disadvantages can be larger incisions , more pain and slower recovery. When the differences are quantified in the context of an enhanced recovery programme, differences in pain score and recovery time can be fairly small (for example, approximately 1 day extra in hospital with open surgery). The costophrenic recess and the apex of the lung are not always well visualized at thoracotomy and VATS may be helpful as part of a hybrid operation.

The approaches in open surgery are varied and some surgeons prefer a more posterior and some a more anterior approach. These are discussed in later chapters.

As stated in the preface, open surgery offers the opportunity to often avoid stapling and use suturing. These methods are skills that should be retained by thoracic surgeons so that when needed they can be confidently applied.

VATS can be included as part of open surgery to allow teaching.

2.2 VATS

The techniques of VATs continue to evolve. Early proponents of VATS lobectomy advocated a surgeon posterior approach akin to much of open thoracic surgery. Increasingly a surgeon anterior approach is employed. The use of fixed and robotic retractors are reducing the need for an assistant. The use of so-called ‘VATS -assisted’ and ‘minimal rib-spreading’ techniques is being abandoned in favour for true VATS surgery (no rib-spreading at all and the operation visualised almost exclusively on screen). The size and number of ports being used is reduced. Discussions now focus not on if VATS should be done but how? Uniportal surgery (single larger incision ) advocates debate if their technique is better than microportal (multiple stab incisions ) advocates. Meanwhile robot assisted thoracic surgery, unfortunately named by some as RATS, is pushing forward. Robotic systems vary from the low cost small footprint telescope holder from Freehand (Figs. 2.1 and 2.2) to the expensive large footprint full robotic system (such as the Da Vinci system from Intuitive surgical Fig. 2.3).

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Fig. 2.1

Freehand robot telescope holder. This simple scope holder is under surgeon control. The surgeon wears a lightweight head mounted emitter. The detector is on the VATS screen. Movements of the head are converted into movement in six planes (up, down, left, right, in, out). Movement occurs when a foot pedal is pressed

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Fig. 2.2

The small size robot is attached to the side of the operating table behind the patient

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Fig. 2.3

Example of a Da Vinci robotics system from Intuitive Surgical

For the thoracic surgeon this is challenging and exciting. This book describes both VATS and open surgery . A new generation of surgeons is emerging who have done far more minimally invasive surgery than open. For them, this book with its repertoire and recipes of open surgery is useful for when open options are the best technique.

With respect to VATS the main operations are simplified and summarized.

2.3 Technology for Minimally Invasive Surgery

There is a continued evolution in technology. Originally VATS surgeons had to use the tools of open surgery or instruments taken from other surgical specialties that have made faster inroad into minimally invasive surgery. The instruments of VATS include surgical telescopes, instruments for dissection, energy devices and staplers . Different companies have their own products and the selection of the equipment is a clinical-commercial decision. The similarities between different manufacturers devices tend to be smaller than the differences. When there is a technological step forward competitors seek to produce their own version as quickly as possible. With new products frequently emerging, practitioners should be confident in the indications for those devices and also in their safe use. In all situations, protocols and procedures for urgent conversion for complications in particular bleeding should be in place. As surgical teams become more skilled urgent conversions become less frequent so the need for periodic drills in emergency procedures becomes more important.

2.4 Surgical Telescopes

The latest generation of telescopes are high definition, may have 3D capability and have angulated and flexible tips. Sizes vary from 1 to 10 mm with 5 or 10 mm scopes most frequently used. Thirty degree angulation rather than 0° (or ‘straight’) has become more commonly used.

2.5 Instruments for Dissection

Dissectors, forceps, graspers, suckers and scissors are the common instruments. These are mostly stainless steel which provides tactile feedback and sufficient rigidity for probing. When articulated the angle point is inside the chest. The head size is generally less than 1 cm to allow easy entry to the chest. The VATS instruments include scissors, forceps of the Roberts, Rampley and Duval type. Short angled blunt dissecting forceps for close dissection round vessels and the bronchus. Straight VATS forceps can be used in similar fashion to standard forceps. Small gauze swabs and pledgets mounted on VATS instruments provide the equivalent of peanut dissectors and sponge-sticks.

2.6 Energy Devices

These include conventional diathermy with only a small region at the tip exposed so as to avoid injury to other structures and bipolar coagulation systems. Currently we also use the Ligasure device™ and find that it to be effective in dissection of tissues. The heat generated from the bipolar energy delivery causes fusion of collagen and elastin tissue. The system detects the thickness of tissue to be coagulated and automatically defines the amount of energy required and the delivering time. An acoustic signal informs the surgeon when the tissue obliteration is complete and its division is possible. This sealing system has a relatively less thermal effect on the tissues surrounding the sealing line. Generally, we do not use it for controlling vessels without additional clipping.

2.7 Stapling Devices

There is a proliferation of sizes, lengths and tip morphology. Recently motorized devices have become available. Currently we use either a two or three row staple for vascular structures, a two or three row staple for bronchi, sometimes with additional oversewing and even soft- tissue coverage if it is a right pneumonectomy stump. For lung parenchyma we usually use a three row device in VATS surgery and sometimes use this in open surgery or oversew with a double-layered continuous 3/0 prolene suture incorporating both an over and over and a horizontal mattress layer. At the time of writing we increasingly use powered devices with a sensor to apply a consistent pressure.

2.8 Reinforcement of Staple Lines

For some time reinforcement materials have been made available with staples. A disadvantage was that they were rather time-consuming requiring a preparation period and had a tendency to fall off the staples. Different materials used included treated pericardium and synthetic materials. New staple cartridges with preloaded reinforcement have become available. These markedly reduce load times and have improved reliability.

2.9 Steps in VATS Surgery

2.9.1 Preparation

The patient is usually positioned with the to-be operated on side upward, and is secured with either a suction bean-bag or posts and appropriate padding. The table may be broken and some surgeons like to use a sideroll too. The patient is central on the table rather than at the edge. The arm is elevated beyond 90°. A sterile field is then prepared.

During this period the ipsilateral lung is isolated and a suction catheter passed to clear secretions and assist with deflation in cases of emphysema .

Precautions against venous thromboembolism are required.

2.9.2 Position

The surgeon and assistant are usually anterior . The scrub nurse is posterior (Fig. 2.4). Two screens are used. One in front of the surgeon behind the patient, and the second in front of nurse and in front of the patient. An alternative is a single screen over the head of the patient. For certain cases the positions are reversed (for example lower lobe superior segmentectomy is often easier from a posterior approach.

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Fig. 2.4

Position of the nurse in VATS surgery. In this case the robot holding the telescope if situated behind the patient. The surgeon is anterior and is looking at a screen beside the nurse. The surgeon has a large space in which to stand

2.9.3 Telescope Holders

It is not a good use of an assistant or consultant surgeon to use them to hold telescopes for prolonged periods. We regularly use a telescope holder with a surgeon controlled robotic system (Figs. 2.1, 2.2, and 2.4) which results in a more stable image, fewer clashes or scope changes and more space for the surgeon.

2.9.4 Ports

If there is a pre-existing port or drain site this may be cleaned and re-used with enlargement if needed.

Generous amounts of local anaesthetic are used a few minutes before the incision (0.25% bupivicaine). Typically we will use 30–40 ml with a similar volume at the end of the case. Alternatives include a serratus anterior plane block and intercostal nerve blocks.

In all cases the incision is as haemostatic as possible and chest wall muscles are split rather than cut. The intercostal muscle is cut with diathermy off the superior border of the rib.

In a uniportal case a 2.5–8 cm utility incision is made in approximately the fifth interspace, centred just anterior to the anterior axillary line but not cutting into breast tissue.

In a 2–3 port procedure a 2–5 cm utility incision is made (as above) and a second incision of just about 1 cm in about the eighth interspace just posterior to the anterior axillary line. This is the camera port . If a third port is required it is of similar size approximately the same level in the midscapular line. This is the retraction port . The ports can be inter-changed.

Increasingly a sub-xiphoid utility incision is made. This may be associated with less pain .

In either approach we often use a soft tissue flexible retraction ring to hold soft tissues out of the way. This is helpful particularly if part of the operation is to be done looking through the utility incision .

2.9.5 Common Steps

1.

The first step is to check the adequacy of lung deflation. It may be necessary to press down on the lung with a VATS sponge-stick and this may take a few minutes to achieve.

2.

If there are adhesions these are taken down. Without this the assessment of the lung and dissection can be difficult. The remaining lung may not be able to fully inflate leading to later problems with the pleural space.

3.

The lung and intrathoracic space are then assessed and the operative plan confirmed.

4.

If this is a simple wedge resection the target piece of lung is grasped with a VATS Rampley forcep and the stapler is introduced with an appropriate cartridge. In the case of a peripheral lung nodule it is wise to remember that the application of the stapler will draw in the tissue from both sides. The simple application of a vascular clamp below the level of the nodule will ensure that it is not drawn excessively toward the staple cartridge. The stapler is then fired with new cartridges as needed to completely excise the wedge. If there is concern of malignancy the specimen should be placed into an extraction bag and removed from the chest to prevent any seeding of the chest wall.

5.

VATS approach to air-leaks.

At the end of the case a washout with 1l of warm sterile water is performed. During this time a check for a leak from lung parenchyma and bronchial stump is performed. Most mild air leaks will cease within a few hours but if there is a greater airleak there should be consideration of re-stapling possibly with a reinforced staple or with the use of a tissue sealants.

2.10 Tissue Sealants for VATS Surgery

A number of sealants are available. The greater the air leak the less successful they are likely to be. Other methods include the installation of sterile talc or lowering a tent of parietal pleura . Sterile talc promotes pleurodesis providing the lung remains inflated. A pleural tent has the dual effect of bringing pleura into contact with the stapled surfaces and putting some blood into the chest which also helps to close leaks and form adhesions.

2.11 General Approach to VATS Anatomical Lung Resection

In part VATS is successful because of improved visualization and although individual steps sometimes take a little longer than in open surgery the reduced opening and closure time means that the overall operation time takes a similar or shorter length of time.

Once the chest is entered steps 1–3 (above) are followed. The specific anatomy , operative steps and tips are in the individual sections (later) are followed, but all VATS lobectomies have common features which are mentioned below. These include good lymph node dissection, protection of the phrenic nerve , awareness of the anatomy particularly variations in venous anatomy , ensuring the target is in the volume to be removed and with a good enough margin, taking the precaution of checking the patency of remaining structures before stapling and the approach to an incomplete fissure . These are discussed in turn.

2.12 Lymph Node Dissection

An early lymph node dissection will reveal key structures and ensure that this is not skimmed over at the end of the case. It also allows more time to check that haemostasis has been adequate.

Our standard approach is to dissect stations 2, 4, 7, 8, 9 and 10 for right-sided tumours and 5, 6, 7, 8, 9 and 10 for left-sided tumours. In left pneumonectomy which we do not perform by VATS , station 4L (and sometimes 2L as well) are accessible.

Because of improved visualization VATS allows for very good lymph node dissection. Because of the angles often the surgeon is working from under (medial to) the lung rather than above (lateral to).

Stations 4R and 2R can be approached from under (medial to the mediastinal pleura by laterally elevating the azygous vein).

2.13 Protection of the Phrenic Nerve

An early step in lobectomy is to open the pleura at the base of the pulmonary vein and to push the phrenic nerve anteriorly. Small ligaclips are used to control bleeding rather than diathermy.

2.14 Awareness of the Anatomy Particularly Variations in Venous Anatomy

Careful review of the contrast enhanced CT will allow identification of anatomical variations.

It is essential to check the venous anatomy prior to surgery and wise to do this again during the case. Damage to venous drainage may lead to infarction of the remaining lung. The middle lobe is usually the lobe at risk.

2.15 Ensuring the Target is in the Volume to Be Removed and with a Margin

Even experienced surgeons may make errors. This can be prevented by palpating the tumour whenever possible and by continually reviewing the anatomy as the case progresses. It is essential to palpate the excised specimen to confirm the target is there and if there is doubt it should be checked with the pathologist.

2.16 Checking the Patency of Remaining Structures Before Stapling and the Approach to an Incomplete Fissure

Infamous errors have included dividing a left main bronchus instead of the upper lobe bronchus and injuring the middle lobe venous drainage. The former error can be avoided by observing a few simple steps. These are for the anaesthetist to suction the airway prior to clamping. Then to test ventilate, checking for ease of inflation AND speed of deflation. If there is doubt the staple line can be adjusted and re-checked with a flexible bronchoscope .

2.17 The Incomplete Fissure

The open operation was built around dividing the vein, then dissection in the fissure and dealing with as many pulmonary arterial branches as possible. VATS lobectomy is sometimes described as being a fissureless or fissure-last dissection. The VATS approach of vein, easily accessible pulmonary artery branches , bronchus, remaining pulmonary artery branches , fissure means that the problems of finding the pulmonary artery in the fissure are overcome. This also reduces dissection in the fissure and hence air-leak.

© Springer International Publishing AG, part of Springer Nature 2018

Francis C. Wells and Aman S. CoonarThoracic Surgical Techniqueshttps://doi.org/10.1007/978-3-319-66270-1_3

3. Bronchoscopy

Francis C. Wells¹  and Aman S. Coonar¹

(1)

Cardiothoracic surgery, Royal Papworth Hospital, Cambridge University Health Partners, Cambridge, UK

Bronchoscopy , in combination with cross-sectional imaging is fundamental to the management of patients with disease involving the lung and major airways. Two basic instruments are available: the fibre-optic bronchoscope and the rigid bronchoscope . Each has its own merits and indications .

The rigid instrument is more suitable for the removal of foreign bodies and the aspiration of thicker secretions. It allows safer biopsy of vascular tumours because it is easier to control bleeding. This can be accomplished by direct application