Surg Endosc (1999) 13: 123–126
© Springer-Verlag New York Inc. 1999
Video-assisted thoracoscopic surgery to the upper thoracic spine T.-J. Huang,1 R. W.-W. Hsu,1 H.-P. Liu,2 H.-N. Shih,1 Y.-S. Liao,1 K.-Y. Hsu,1 Y.-J. Chen1 1
Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China
2
Received: 19 September 1997/Accepted: 3 December 1997
Abstract Background: The standard open technique for exposure of the upper thoracic spine, T1–T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically. Methods: A new approach, the so-called ‘‘extended manipulating channel method,’’ was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients’ ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy. Results: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients. Conclusions: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5–3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior
Presented in part at the First Combined Meeting of the Leading European Spine Society, Zu¨rich, Switzerland, 16–19 October 1996; the Third Combined Meeting of Spinal and Pediatric Sections of the West Pacific Orthopaedic Association, Kochi, Japan, 5–8 November 1996; the First Asian Pacific Workshop on Minimally Invasive Thoracic Surgery, Hong Kong, 21–23 November 1996; the Second Scientific Congress of Chinese Speaking Orthopaedic Society, Shanghai, China, 28–30 March 1997; and the Fourth International Symposium on Thoracoscopy and Video-Assisted Thoracic Surgery, San Paulo, Brasil, 24–26 May 1997 Correspondence to: T.-J. Huang
procedure. Such an approach can achieve less procedurerelated trauma and has proved to be a good alternative to other treatment modalities. Key words: Video-assisted thoracoscopic surgery — Upper thoracic spine
In the upper thoracic spine (T1–T4), a decompression for cord compromise can usually be performed through a standard open thoracotomy. However, this open approach usually needs extensive soft tissue dissection and might preclude high-risk patients, especially those with respiratory compromise [3, 4, 8]. Prolonged postoperative rehabilitation, longer hospital stay, increased pain, and less cosmetic satisfaction were reported with formal open thoracotomy [3–5, 7, 8]. Recently, with the growing experiences and success of video-assisted thoracoscopic surgery (VATS), a number of spinal procedures including spinal biopsy, debridement, discectomy, decompressive corpectomy and interbody fusions, and internal fixations have been performed with this technique [1, 5–7, 9, 10]. We report our experience with the VATS technique by the so-called ‘‘extended manipulating channel method’’ [2] to treat eight patients endoscopically. With the aid of the video-assisted thoracoscope, the upper thoracic spine is easily approached and magnified. In this series, the thoracoscopic portals were made larger (usually 2.5–3.5 cm) than those in the standard VATS technique (Figs. 1 and 2). This allows a thoracoscope and conventional spinal instruments to enter the chest cavity and be manipulated in much the same way as with techniques used for the standard open technique. This article evaluates the feasibility of such an approach and the benefit to all patients from such a minimally invasive approach. Materials and methods From November 1, 1995 to June 30, 1997, eight patients underwent the VATS technique to treat upper thoracic vertebral lesions (Table 1). There were seven men and one woman, with ages ranging from 44 to 89 years
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Fig. 1. Video-assisted thoracoscopic spinal approach to the upper thoracic spine. Three incisional wounds, usually 2.5–3.5 cm, allow the combined use of thoracoscopy and conventional spine instruments and can be manipulated in much the same way as with an open technique.
Fig. 2. Case 4. Photo of a 56-year-old man with pyogenic spondylitis involving the T4–T5 levels 18 months after surgery. Three incisions (arrowheads) were sufficient for the procedure.
Operative technique (average, 60 years). Definitive diagnoses included two pyogenic spondylitis (one Staphylococcus aureus and one Enterococcus faecalis infection), and six spinal metastases (three with lung origins, one melanoma, and two with unknown primary origins). Five patients (cases 1–3, 6, and 7) presented initially with myelopathy. All the patients were prospectively studied. In this series, the so-called ‘‘extended manipulating channel method’’ (see Fig. 2) was used to perform VATS spinal procedures for upper thoracic vertebral lesions. The manipulating (or working) channels were made slightly larger (2.5–3.5 cm) than usual to allow the combined use of videoassisted thoracoscopy and conventional spinal instruments to perform a variety of spinal procedures endoscopically [2]. Usually, a strategy with a three-portal approach was sufficient for the procedures. Before the operation, the patient and the family were well informed that a conversion to an open thoracotomy might be necessary if the patient could not tolerate one-lung ventilation or a severe pleurodesis within the chest cavity. The surgical approach can be on the right or left side depending on the location of the abnormalities seen on computed tomography (CT) or magnetic resonance imaging (MRI) scan or depending on which side the patient is experiencing symptoms. The surgical procedure is described in the following discussion. A 45-year-old man (case 6) experienced severe upper back pain and spastic gait for 1 month. He had been diagnosed with a right orbital melanoma 11 years ago. He was admitted to the oncology ward in March 1996, and was noted as having a T3 spinal metastasis. On the second hospital day, we were consulted urgently due to the patient’s complaint of developing motor weakness. Decreased pin-prick sensation was noted below the nipple line, and the muscle strength was grade 4/5 in both legs. An MRI showed destruction of the third thoracic vertebra, and the cord was compressed anteriorly and posteriorly (Fig. 3). A same-day operation with VATS anterior corpectomy was performed, followed by posterior decompression and Luque rod fixation (Fig. 4).
The entire procedure was carried out under general anesthesia, with a double-lumen endotracheal tube (Broncho-Cath™, Mallinckrodt Medical, Athlone, Ireland) in place. The patient was put in the left lateral decubitus position. The right upper extremity was secured over the head to facilitate exposing the whole axillary region. The skin was prepped and draped for a standard posterolateral thoracotomy so that in the event of intraoperative complications, poor tolerance of one-lung ventilation, or a finding of severe pleural adhesions, the procedure could be converted to an open one. With selective collapse of the right lung and hemodynamic monitoring with an arterial line, the chest was entered through a stab incision (usually 2.5 cm). The initial trocar incision was made at the fourth intercostal space (ICS) along the anterior axillary line. An 11-mm metal trocar (Stryker, San Jose, CA, USA) was used to introduce the operating thoracoscope (0°, 10 mm, Stryker, San Jose, CA, USA). The lesion site was identified and displayed on the video monitor. The other two manipulating channels, (usually 3–4 cm in length) were made under the guidance of a scope and positioned at the posterior axillary line at the T2–T3 and T3–T4 ICS. The intercostal veins draining into the azygos arch could then be identified. The correct lesion site was ascertained by counting the ribs above with a blunt instrument or located by a guide pin under a C-arm intensifier. Using monopolar electrocautery with the aid of a Yankauer suction tube (11⬙, Edward Weck, Triangle Park, NC, USA), the parietal pleura overlying the lesion was divided longitudinally. The intercostal arteries and veins were ligated with hemoclips and divided. Decompressive corpectomy of the involved body was performed using conventional pituitary rongeurs (8⬙, Cushing type, Lawton, Tuttlingen, Germany) and elongated curettes (15⬙, Howmedica, Rutherford, NJ, USA). The decompressive procedure was done down to the epidural space and guided with video assistance. The portal for tumor or infected tissue retrieval was protected by a flexible thoracoport (Flexipath, Ethicon Endosurgery, Cincinnati, Ohio, USA). The
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Fig. 4. Lateral roentgenogram after a same-day operation with a decompressive corpectomy (T3) anteriorly, posterior decompression, and Luque rod instrumentation (from T1 to T6). The anterior edges of T2 and T4 touching each other (arrow) produced a stable situation. The patient died 9 months after surgery due to cancer dissemination.
Fig. 3. Case 6. A metastatic melanoma of T3. MRI demonstrating destruction of the third thoracic vertebra with cord compression anteriorly and posteriorly.
Table 1. Patient data for video-assisted thoracoscopic spinal surgery to the upper thoracic spine Case no.
Sex
Age
1 2
M M
67 89
3 4 5
M M M
52 55 44
6 7
M M
45 60
8
F
64
Operating time (h)
Total blood loss (ml)
Chest tube retention (days)
Presented with myelopathy
Risk factors
1 1
2.9 4.0
2,150 850
3 4
(+) (+)
COPDb Aged
R R L
1+2 1+2 3+4
4.0 3.5 3.0
400 1,200 700
4 2 3
(+) (−) (−)
R R
1+5 1+2
2.8 2.6
2,200 500
3 3
(+) (+)
R
1
2.0
300
4
(−)
Diagnosis (Level)
Side of approach
Procedures
Metastatic lung ca (T3) Metastatic ca (T3, unknown origin) Metastatic lung ca (T4) Pyogenic spondylitis (T4-5) Pyogenic spondylitis (T3-4)
R R
Metastatic melanoma (T3) Metastatic ca (T3, unknown origin) Metastatic squamous ca (T4)
a
Pleural adhesion Previous right lung pneumonia and effusion
COPDb Pleural adhesion
a
Procedures: 1, decompressive corpectomy; 2, interbody fusion; 3, biopsy; 4, curettage and debridement; 5, posterior decompression and Luque rod fixation. b COPD, chronic obstructive pulmonary disease. interbody fusion technique was then initiated by using a tricortical iliac autograft (or allograft) applied between the vertebrae by means of a conventional bone impactor (12⬙, Trauma-fix, AST, San Leandro, CA, USA). Hemostasis was ensured. A 32 French chest tube was inserted through the first incision wound and directed to the apex of the chest. On completion of the procedure, the muscle layers were closed with absorbable sutures, and the skin with a 3-0 nylon suture. A chest x-ray was taken immediately after the operation to ensure a fully inflated lung. The chest tube was removed on the third postoperative day (the usual time) when the drainage amount was less than 50 ml.
Results The surgical time ranged from 2.0 to 4.0 h (mean, 3.1 h), and the total blood loss ranged from 300 to 2,200 ml (mean, 1,038 ml). Two patients (cases 1 and 6) had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw bone surfaces. There were no injuries to the great
vessels or visceral organs and no neurologic deterioration as a result of the procedures. No patient needed postoperative intensive care. The mean duration of retention of chest tubes was 3.3 days (range, 2–4 days). The follow-up durations for the two pyogenic spondylitis patients (cases 4 and 5) were 18 months and 12 months, respectively, and both enjoyed a full clinical recovery. Of the six patients with metastatic spinal lesions, one (case 2) died of postoperative pneumonia 3 weeks after the operation. Two (cases 1 and 6) died of cancer dissemination, respectively, 1 year and 9 months after the operation. Complications included one superficial wound infection and one subcutaneous emphysema. Two patients had severe chronic obstructive pulmonary disease (COPD) preoperatively (cases 1 and 8). Their forced expiratory volume at 1 s (FEV1) and functional vital capacity (FVC) were lower than one-third the capacities of the normal control. However, both of them could tolerate one lung
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ventilation well and maintained a good arterial oxygen saturation throughout the operation. Although in two patients (cases 4 and 8) mild pleurodesis was noted intraoperatively, it could be lysed successfully without the need for conversion to an open thoracotomy. Seven patients had their surgical approaches via the right side of the chest, and one (case 5) had a left-sided approach due to a previous right lung pneumonia with pleural effusion. Discussion In the upper thoracic spine (T1–T4), where the vertebral bodies are smaller and the normal anatomy may be much distorted, an anterior surgical approach poses a great challenge to the surgeon. Standard thoracotomy usually requires removal of the third rib with a wide spreading of the intercostal space. In addition, mobilize the scapula to facilitate good surgical exposure, muscles including the trapezius, latissimus dorsi, rhomboid major, and the serratus posterior must be partially sectioned. Theoretically, an endoscopic approach to this area would cause less disturbance to the chest wall mechanics, resulting in less soft tissue trauma. The VATS technique can offer excellent visualization and magnification of the lesion sites and is suitable for tissue sampling and cord decompression without the need for an open thoracotomy. Only recently has VATS been applied in many spinal procedures including biopsy, discectomy, decompressive corpectomy, interbody fusion, and internal fixation [1, 5–7, 9]. Despite growing experience and the improvement of video optics and instrumentation, the majority of surgeons still have limited experience with this procedure. Mastering the VATS technique reportedly involves a steep learning curve [9], and this procedure is not widely accepted thus far as a routine procedure, even though it is minimally invasive. In this series, the so-called ‘‘extended manipulating channel method’’ [2] was used to perform VATS spinal procedures. Usually, a three-portal approach was sufficient for the procedure (see Figs. 1 and 2). Throughout the operation, only one metal trocar was used for introducing the scope. The extended manipulating (or working) channels and the 2.5to 3.5-cm incisional wound allow the combined use of video-assisted thoracoscopy and conventional spinal instruments that enter the chest cavity freely and can be manipulated in much the same way as with the open technique. Therefore, our approach was thought to be more user friendly than the standard VATS technique. In this series, less expensive, disposable endo-material was used for the procedures, and the total cost to the patients was less. In this series, the risk factors for patients with the VATS spinal technique included old age (case 2), severe COPD (cases 1 and 8), and pleural adhesions around the lesion sites (cases 4 and 8). Patients 1 and 8 had severe COPD. Their FEV1 and FVC were one-third that of the normal control preoperatively. However, they could tolerate one-lung ventilation well throughout the operation. The success of onelung ventilation of these two patients probably can be explained by the compensation for a preexisting ventilation– perfusion mismatch in patients with significant COPD [5].
Throughout our procedures, there was no mortality. One subcutaneous emphysema (case 2) and one wound infection (case 1) were noted postoperatively. A matter of concern involved two patients (cases 1 and 6) whose blood loss exceeded 2,000 ml due to bleeding from epidural veins or raw bone surfaces. In this series, three patients (cases 1, 2, and 8) underwent decompressive corpectomy without fusions or posterior stabilization. However, at the 1-year follow-up examination of patients 1 and 8, no increasing pain, further increased deformity, or neurologic deficit was noted. In the upper thoracic spine, the site of the decompression without fusion can produce some kyphosis until the anterior edges of the neighboring vertebral bodies touch each other and produce a stable situation. An increasing pain or significant deformity are not always encountered clinically. A posterior stabilization procedure was performed in case 6, in which a posterior decompression procedure was also needed (see Figs. 3 and 4). In this series, all patients could tolerate one-lung ventilation well throughout the operation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. In conclusion, a modification of the standard endoscopic approach method—the so-called ‘‘extended manipulating channel method’’—can make VATS spinal surgery simpler and easier. It avoids excessive procedure-related soft tissue trauma without using many expensive endo-materials. It has proved to be a good alternative to other treatment modalities.
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