Ebook Operative thoracic surgery (6/E): Part 1

Operative
Thoracic Surgery



Operative
Thoracic Surgery
SIXTH EDITION

Edited by
Larry R. Kaiser, MD, FACS

The Lewis Katz Dean
The Lewis Katz School of Medicine at Temple University
Philadelphia, Pennsylvania, United States

Sarah K. Thompson, MD, PhD, FRCSC, FRACS
Discipline of Surgery
University of Adelaide
and
Royal Adelaide Hospital
Adelaide, Australia

Glyn G. Jamieson, MS, MD, FRACS, FRCS, FACS
Discipline of Surgery
University of Adelaide
Royal Adelaide Hospital
Adelaide, Australia

First published in 1956 by Butterworths Heinemann
Second edition 1968
Third edition 1976
Fourth edition 1982
Fifth edition published in 2006 by Hodder Arnold, an imprint of Hodder Education
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Library of Congress Cataloging‑in‑Publication Data
Names: Kaiser, Larry R., editor. | Jamieson, Glyn G., editor. | Thompson, Sarah K., editor.
Title: Operative thoracic surgery / [edited by] Larry R. Kaiser, Glyn Jamieson, Sarah K. Thompson.
Other titles: Separated from (work): Rob & Smith’s operative surgery. | Rob & Smith’s operative surgery series.
Description: Sixth edition. | Boca Raton : CRC Press, [2016] | Series: Rob & Smith’s operative surgery series | Separated from Rob & Smith’s operative surgery.
5th ed. 1993-[2006] | Includes bibliographical references.
Identifiers: LCCN 2016042751| ISBN 9781482299571 (hardcover bundle : alk. paper) | ISBN 9781482299595 (eBook VitalSource) | ISBN 9781482299588
(ebook pdf).
Subjects: | MESH: Thoracic Surgical Procedures.
Classification: LCC RD536 | NLM WO 500 | DDC 617.5/4059--dc23
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and the CRC Press Web site at



“For Lindy: who after all these years still is trying to figure out how I do these books”
LK
“For Amelia: my most enthusiastic supporter”
ST
“For Elizabeth (1942-2010)”
GJ

Contents

Contributorsix
Illustratorsxv
Prefacexvii
SECTION I THORACIC SURGERY
1

Modern thoracic approaches: minimally invasive thoracic surgery
M. Blair Marshall
2
Pectus deformities
Antonio Messineo and Marco Ghionzoli
Thoracic trauma
3
Scott M. Moore, Frederic M. Pieracci, and Gregory J. Jurkovich
4
Chest wall masses and chest wall resection
Anna Maria Ciccone, Camilla Vanni, Federico Venuta, and Erino Angelo Rendina
5
Thoracic outlet syndromes
Hugh A. Gelabert and Erdog˘an Atasoy
6Tracheostomy
Abbas E. Abbas
7
Tracheal resection
Peter Goldstraw
8

Mediastinoscopy and mediastinotomy
Jennifer L. Wilson and Eric Vallières
9
Anterior mediastinal lesions
Antonio D’Andrilli, Erino Angelo Rendina, and Federico Venuta
10 Resection of posterior mediastinal lesions
Joseph B. Shrager
11Thymectomy
Larry R. Kaiser
12 Right-sided pulmonary resections
Larry R. Kaiser
13 Left-sided pulmonary resections
Reza Mehran and Jean Deslauriers
14 Extrapleural pneumonectomy
Yifan Zheng, William G. Richards, Julianne S. Barlow, Adrienne Camp, and Raphael Bueno
15 Biportal fissureless video-assisted thoracoscopic lobectomy
Alessandro Brunelli
16 Robotic approach to lobectomy
Benjamin Wei and Robert James Cerfolio
17 Uniportal video-assisted thoracoscopic surgery (VATS)
Gaetano Rocco
18Segmentectomy
Wentao Fang, Chenxi Zhong, and Zhigang Li
19 Combined bronchial and pulmonary artery sleeve resections
Abel Gómez-Caro and Laureano Molins

3
13
23
37

49
87
95
107
117
127
135
141
155
171
181
193
205
213
219


viii  Contents
20
21
22
23
24
25
26

Superior sulcus tumors
Valerie W. Rusch
Lung volume reduction surgery
Claudio Caviezel and Walter Weder

Pleural space problems
Konrad Hoetzenecker and Walter Klepetko
Video-assisted thoracoscopic surgery (VATS) sympathectomy
Young K. Hong and M. Blair Marshall
Lung transplantation
Paula Moreno
Management of postoperative chylothorax
Maxim Itkin and John C. Kucharczuk
Outpatient thoracic surgery
Laureano Molins, Juan J. Fibla, and Jorge Hernández

231
239
245
259
265
279
285

SECTION II ESOPHAGEAL SURGERY
27Endoscopy
Ewen A. Griffiths and Derek Alderson
28 Esophageal stents
Nabil P. Rizk and Sarah K. Thompson
29 Esophageal anastomoses: sutured and stapled
Jon Shenfine and Glyn G. Jamieson
30 Use of the stomach as an esophageal substitute
Arnulf H. Hölscher and J. Rüdiger Siewert
31 Use of the colon as an esophageal substitute
Benjamin Knight and Glyn G. Jamieson

32 Abdominal and right thoracic esophagectomy
S. Michael Griffin and Shajahan Wahed
33 Left thoracic subtotal esophagectomy
Jun-Feng Liu
34 Transhiatal esophagectomy
Brechtje A. Grotenhuis, Bas P. L. Wijnhoven, and J. Jan B. van Lanschot
35 Thoracoscopic and laparoscopic esophagectomy
B. Mark Smithers, Iain Thomson, and Andrew Barbour
36 Thoracoscopic removal of benign esophageal tumors
David Ian Watson
37 Perforation of the esophagus
Aaron M. Cheng, Douglas E. Wood, and Carlos A. Pellegrini
38 Laparoscopic antireflux surgery
Sarah K. Thompson and Glyn G. Jamieson
39 Laparoscopic large hiatus hernia repair
Alex Nagle, Geoffrey S. Chow, and Nathaniel J. Soper
40 Revisional antireflex surgery
Peter G. Devitt , Aravind Suppiah, and Sarah K. Thompson
41 Laparoscopic cardiomyotomy for achalasia
Sheraz Markar and Giovanni Zaninotto
42 Per oral endoscopic myotomy (POEM) for achalasia
Amber L. Shada and Lee L. Swanström
43 Left thoracic approach to esophageal diverticula
André Duranceau
44 Thoracoscopic management of esophageal diverticula
Thomas J. Watson and Christian G. Peyre
45 Laparoscopic management of epiphrenic diverticula
Fernando Mier and John G. Hunter

295

Index

453

309
315
325
337
345
355
369
377
387
393
405
411
419
425
431
437
443
449


Contributors

Abbas E. Abbas, MD, FACS
Division of Thoracic Surgery
Department of Thoracic Medicine and Surgery

Temple University School of Medicine
Philadelphia, Pennsylvania, United States

Adrienne Camp, BSc
International Mesothelioma Program
Division of Thoracic Surgery
Brigham and Women’s Hospital
Boston, Massachusetts, United States

Derek Alderson, MD, FRCS
Emeritus Professor of Surgery
University of Birmingham
and
Honorary Consultant Surgeon
University Hospitals NHS Trust
Queen Elizabeth Hospital
Birmingham, United Kingdom

Claudio Caviezel, MD
Department of Thoracic Surgery
University Hospital Zurich
Zurich, Switzerland

Erdog˘an Atasoy, MD
Department of Surgery
University of Louisville School of Medicine
and
Affiliated Surgeon
Kleinert Kutz and Associates Hand Care Center
Christine M. Kleinert Institute

Louisville, Kentucky, United States

Aaron M. Cheng, MD, FACS
Division of Cardiothoracic Surgery
Department of Surgery
University of Washington
Seattle, Washington, United States

Andrew Barbour, PhD, FRACS
Surgical Oncology Group
University of Queensland
and
Upper Gastro-Intestinal and Soft Tissue Unit
Princess Alexandra Hospital
Brisbane, Australia
Julianne S. Barlow, BSc
Division of Thoracic Surgery
Brigham and Women’s Hospital
Boston, Massachusetts, United States
Alessandro Brunelli, MD
Department of Thoracic Surgery
St. James’s University Hospital
Leeds, United Kingdom
Raphael Bueno, MD
Division of Thoracic Surgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts, United States

Robert James Cerfolio, MD, FACS, FCCP

Division of Cardiothoracic Surgery
University of Alabama at Birmingham
Birmingham, Alabama, United States

Geoffrey S. Chow, MD
Department of Surgery
Northwestern Medicine
Chicago, Illinois, United States
Anna Maria Ciccone, MD, PhD
Department of Thoracic Surgery
“Sapienza” University of Rome
Sant’Andrea Hospital
Rome, Italy
Antonio D’Andrilli, MD
Department of Thoracic Surgery
“Sapienza” University of Rome
Sant’Andrea Hospital
Rome, Italy
Jean Deslauriers, MD, FRCS(C)
Department of Thoracic Surgery
Centre Hospitalier Laval
Québec City, Canada
Peter G. Devitt, MBBS, MS, FRCS, FRACS
Discipline of Surgery
University of Adelaide
Royal Adelaide Hospital
Adelaide, Australia


x  Contributors

André Duranceau, MD
Department of Surgery
Université de Montreal
and
Department of Surgery
Division of Thoracic Surgery
Centre Hospitalier
Universitaire de Montreal
Montreal, Québec, Canada
Wentao Fang, MD
Department of Thoracic Surgery
Shanghai Chest Hospital
Jiaotong University Medical School
Shanghai, People’s Republic of China
Juan J. Fibla, MD, PhD
Thoracic Surgery Department
University of Barcelona Hospital Idc Salud Sagrat Cor
Barcelona, Spain
Hugh A. Gelabert, MD
Division of Vascular and Endovascular Surgery
David Geffen UCLA School of Medicine
Los Angeles, California, United States
Marco Ghionzoli, MD, PhD
Pediatric Surgery Department
Meyer Childrens’ Hospital and University of Florence
Florence, Italy
Peter Goldstraw, FRCS
Department of Thoracic Surgery
Royal Brompton Hospital
and

Thoracic Surgery
Imperial College, London, United Kingdom
Abel Gómez-Caro, MD, PhD
Department of General Thoracic Surgery
University Hospital Clínic de Barcelona
Barcelona, Spain
S. Michael Griffin, MD, FRCS
Northern Oesophago-Gastric Cancer Unit
Royal Victoria Infirmary
Newcastle upon Tyne, United Kingdom
Ewen A. Griffiths, MD, FRCS
Department of Upper Gastrointestinal Surgery
University Hospitals Birmingham NHS Foundation Trust
and
Department of Surgery
Queen Elizabeth Hospital
Birmingham, United Kingdom
Brechtje A. Grotenhuis, MD, PhD
Department of Surgery
Erasmus University Medical Center
Rotterdam, Netherlands

Jorge Hernández, MD
Thoracic Surgery Department
University of Barcelona Hospital Idc Salud Sagrat Cor
Barcelona, Spain
Konrad Hoetzenecker, MD, PhD
Department of Thoracic Surgery
Medical University of Vienna
Vienna, Austria

Arnulf H. Hölscher, MD, FACS, FRCS
Department of Visceral and Vascular Surgery
University of Cologne Medical School
Cologne, Germany
Young K. Hong, MD
Department of Surgery
Division of Surgical Oncology
University of Louisville Hospital
Louisville, Kentucky, United States
John G. Hunter, MD, FACS
Division of General and Gastrointestinal Surgery
Department of Surgery
Oregon Health and Science University
and
Digestive Health Center
Oregon Health and Science University
Portland, Oregon, United States
Maxim Itkin, MD, FSIR
Radiology Department
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania, United States
Glyn G. Jamieson, MS, MD, FRACS, FRCS, FACS
Discipline of Surgery
University of Adelaide
Royal Adelaide Hospital
Adelaide, Australia
Gregory J. Jurkovich, MD, FACS
Department of Surgery
UC Davis Health System University of California
Sacramento, California, United States

Larry R. Kaiser, MD, FACS
The Lewis Katz Dean
The Lewis Katz School of Medicine at Temple University
Philadelphia, Pennsylvania, United States
Walter Klepetko, MD
Department of Thoracic Surgery
Medical University of Vienna
Vienna, Austria
Benjamin Knight, MbChB, FRCS
Oesophago-gastric and Bariatric Surgery
Queen Alexandra Hospital
Portsmouth, United Kingdom


Contributors  xi
John C. Kucharczuk, MD
Division of Thoracic Surgery
Department of Surgery
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania, United States
Zhigang Li, MD
Department of Thoracic Surgery
Shanghai Chest Hospital
Jiaotong University Medical School
Shanghai, People’s Republic of China
Jun-Feng Liu, PhD
Department of Thoracic Surgery
Fourth Hospital of Hebei Medical University
Shijiazhuang, People’s Republic of China
Sheraz Markar, PhD, MRCS, MSc, MA

Department of Academic Surgery
St. Mary’s Hospital
Imperial College
London, United Kingdom
M. Blair Marshall, MD
Division of Thoracic Surgery
MedStar Georgetown University Hospital
and
Georgetown University School of Medicine
Washington DC, United States
Reza Mehran, MD, FRCS(C), FACS
Department of Thoracic and Cardiovascular Surgery
University of Texas M. D. Anderson Cancer Center
Houston, Texas, United States
Antonio Messineo, MD
Pediatric Surgery Department
Meyer Childrens’ Hospital and University of Florence
Florence, Italy
Fernando Mier, MD
Division of General and Gastrointestinal Surgery
Department of Surgery
Oregon Health and Science University
and
Digestive Health Center
Oregon Health and Science University
Portland, Oregon, United States
Laureano Molins, MD, PhD
Thoracic Surgery Department
University of Barcelona Hospital Idc Salud Sagrat Cor
and

Thoracic Surgery Department
University Hospital Clínic de Barcelona
Barcelona, Spain
Scott M. Moore, MD
Trauma and Acute Care Surgery
Denver Health Medical Center
and
University of Colorado Denver School of Medicine
Denver, Colorado, United States

Paula Moreno, MD, FETCS
Thoracic Surgery and Lung Transplantation Unit
University Hospital Reina Sofia
Cordoba, Spain
Alex Nagle, MD, FACS
Division of Gastrointestinal & Oncologic Surgery
Northwestern University Feinberg School of Medicine
Chicago, Illinois, United States
Carlos A. Pellegrini, MD, FACS, FRCSI (Hon.)
Department of Surgery
University of Washington
Seattle, Washington, United States
Christian G. Peyre, MD
Division of Thoracic and Foregut Surgery
Department of Surgery
University of Rochester School of Medicine and Dentistry
Rochester, New York, United States
Frederic M. Pieracci, MD, MPH, FACS
Trauma Center
Denver Health Medical Center

and
University of Colorado Denver School of Medicine
Denver, Colorado, United States
Erino Angelo Rendina, MD
Department of Thoracic Surgery
“Sapienza” University of Rome
Sant’Andrea Hospital
Rome, Italy
William G. Richards, PhD
Division of Thoracic Surgery
Brigham and Women’s Hospital
Boston, Massachusetts, United States
Nabil P. Rizk, MD, MPH, MS
Division of Thoracic Surgery
Hackensack University Medical Center
Hackensack, New Jersey, United States
Gaetano Rocco, MD, FRCSEd, FEBTS, FCCP
Department of Thoracic Surgical and Medical Oncology
Division of Thoracic Surgery
Istituto Nazionale Tumori
Fondazione Pascale
Istituto di Ricerca e Cura a Carattere Scientifico
Naples, Italy
Valerie W. Rusch, MD
Thoracic Surgery Service
Department of Surgery
Memorial Sloan Kettering Cancer Center
New York, New York, United States
Amber L. Shada, MD
General Surgery/MIS Division

University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin, United States


xii  Contributors
Jon Shenfine, PhD, FRCS, FRACS
Discipline of Surgery
University of Adelaide
Royal Adelaide Hospital
Adelaide, Australia
Joseph B. Shrager, MD
Department of Cardiothoracic Surgery
Division of Thoracic Surgery
Stanford University School of Medicine
Stanford, California, United States
J. Rüdiger Siewert, MD
Department of Surgery
Technical University of Munich
Munich, Germany
B. Mark Smithers, FRACS, FRCSEng, FRCSEd
University of Queensland
and
Upper Gastro-Intestinal and Soft Tissue Unit
Princess Alexandra Hospital
Brisbane, Australia
Nathaniel J. Soper, MD
Department of Surgery
Northwestern Medicine
Chicago, Illinois, United States
Aravind Suppiah, MD, FRCS

Discipline of Surgery
Royal Adelaide Hospital
Adelaide, Australia
Lee L. Swanström, MD, FACS, FASGE, FRCSEng (Hon.)
GI/MIS Division
The Oregon Clinic
Portland, Oregon, United States
and
Institute of Image Guided Surgery
IHU-Strasbourg
Strasbourg, France
Sarah K. Thompson, MD, PhD, FRCSC, FRACS
Discipline of Surgery
University of Adelaide
and
Royal Adelaide Hospital
Adelaide, Australia
Iain Thomson, FRACS
University of Queensland
and
Upper Gastro-Intestinal and Soft Tissue Unit
Princess Alexandra Hospital
Brisbane, Australia
Eric Vallières, MD, FRCSC
Division of Thoracic Surgery
Swedish Cancer Institute
Seattle, Washington, United States

J. Jan B. van Lanschot, MD, PhD
Department of Surgery

Erasmus University Medical Center
Rotterdam, Netherlands
Camilla Vanni, MD
Department of Thoracic Surgery
“Sapienza” University of Rome
Sant’Andrea Hospital
Rome, Italy
Federico Venuta, MD
Division of Thoracic Surgery
“Sapienza” University of Rome
Policlinico Umberto I
Rome, Italy
Shajahan Wahed, MD, FRCS
Northern Oesophago-Gastric Cancer Unit
Royal Victoria Infirmary
Newcastle upon Tyne, United Kingdom
David Ian Watson, MBBS, MD, PhD, FRACS, FAHMS
Department of Surgery
Flinders University
and
Oesophago-Gastric Surgery Unit
Flinders Medical Centre
Adelaide, Australia
Thomas J. Watson, MD, FACS
Division of Thoracic and Esophageal Surgery
Department of Surgery
Medstar Washington
Georgetown University School of Medicine
Washington DC, United States
Walter Weder, MD

Department of Thoracic Surgery
University Hospital Zurich
Zurich, Switzerland
Benjamin Wei, MD
Division of Cardiothoracic Surgery
University of Alabama at Birmingham
Birmingham, Alabama, United States
Bas P. L. Wijnhoven, MD, PhD
Department of Surgery
Erasmus University Medical Center
Rotterdam, Netherlands
Jennifer L. Wilson, MD
Department of Thoracic Surgery
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts, United States
Douglas E. Wood, MD
Division of Cardiothoracic Surgery
Department of Surgery
University of Washington
Seattle, Washington, United States


Contributors  xiii
Giovanni Zaninotto, MD, FACS
Department of Academic Surgery
St. Mary’s Hospital
Imperial College
London, United Kingdom
Yifan Zheng, MD

Division of Thoracic Surgery
Brigham and Women’s Hospital
Boston, Massachusetts, United States

Chenxi Zhong, MD
Department of Thoracic Surgery
Shanghai Chest Hospital
Jiaotong University Medical School
Shanghai, People’s Republic of China



Illustrators

Kelly Casssidy, BA (Hon.), MMAA 
Angela V. Christie,
Francesca Corra,
Peter Cox,

FMAA

MMAA

NDD, MMAA

Gillian Lee,

FMAA, Hon. FIMI

Gillian Oliver,

FMAA

Amanda Williams,

BA (Hon.), FMAA



Preface

It would not be unreasonable to ask why another book, when
so much information may be accessed online. Indeed, videos
of almost any operative procedure are now easily available.
So, the question is begged, why a Sixth Edition of this venerable text, Operative Thoracic Surgery? The difference lies in the
expertise embedded in each chapter of this book, provided
by internationally known, widely geographically dispersed
surgeons who literally reveal at least some of their tricks and,
in some cases, their secrets. Once you read a chapter you may
very well wish to access online videos of a particular procedure, but you will do so armed with the insights provided by
the world experts who have contributed to this book. This
Sixth Edition is much more than a text since each expert
author provides specific technical details of an operative
procedure, accompanied by accurate and beautifully drawn
illustrations. Much has changed in our field since publication
of the Fifth Edition in 2006, evidenced by the addition of new
chapters. Minimally invasive approaches have matured and,
in many cases, surpassed traditional open approaches. Take,
for example, the first chapter formerly entitled, Thoracic incisions, which now carries the title, Modern thoracic approaches:
minimally invasive thoracic surgery. New chapters on robotic

approaches to lobectomy and uniportal video-assisted thoracoscopic surgery have been added, in addition to a chapter
on outpatient thoracic surgery. The section on esophageal
surgery has been entirely revised with many new authors and
a new editor, Sarah Thompson, working with us. New chapters on laparoscopic antireflux surgery and laparoscopic large
hiatus hernia repair join other chapters detailing new and
improved minimally invasive techniques. We are especially
pleased to include a chapter on per oral endoscopic myotomy
(POEM) for achalasia, a procedure that has the potential to
render obsolete the open or laparoscopic Heller myotomy.
This new edition is timely, accurate and up-to-date and
should be a welcome addition to the library of both trainees
and senior surgeons. Once again our publisher, and in particular Miranda Bromage, has been more than just helpful
(indispensable, is the word which comes readily to mind!),
and the drawings of Gillian Lee and her team continue to add
immeasurably to the written content.
Larry R. Kaiser, MD, FACS
Sarah K. Thompson, MD, PhD, FRCSC, FRACS
Glyn G. Jamieson, MS, MD, FRACS, FRCS, FACS



SECTION
Thoracic surgery

I



1

Modern thoracic approaches: minimally invasive
thoracic surgery
M. BLAIR MARSHALL

INTRODUCTION
Chapters written on thoracic incisions have historically
dealt with the traditional approaches used in the practice of
thoracic surgery. These are standard incisions that provide
exposure to the common thoracic pathologies. These have
changed relatively little in the previous decades and have
been written about in previous versions of this text and others; I will not review these approaches here but refer you to
the previous versions of this text.
Modern approaches, strategies for less invasive means of
managing thoracic pathology have continued to grow over
the past two decades, and these ongoing developments will
be addressed by this chapter. These will be broken down by
anatomic location: pulmonary resections; wedge excision
and hilar dissections; and mediastinal approaches, anterior
and posterior, including the intraoperative strategies to facilitate working through these smaller incisions. The reasoning
for this is that given the limited access through small incisions, operative planning for these less invasive approaches
must take into account the location of the pathology; hindrances to access; hindrances for instrumentation; strategies
for resection; and reconstruction, when needed. When compared with an open approach, a minimally invasive approach
itself may be considered a hindrance; however, the magnified
view, ability to use angled cameras to change perspective, as
well as the markedly decreased pain and recovery time commonly associated with these approaches more than justify
their use.

THORACOSCOPY VERSUS LAPAROSCOPY
Although those who pioneered the field of minimally
invasive thoracic surgery did not have general surgical experience in minimally invasive surgery, that is not true of

today’s trainees. In transitioning from minimally invasive

1.1 

Baseball diamond concept for orientation of minimally
invasive ports and camera location in relation to pathology.


4   Modern thoracic approaches: minimally invasive thoracic surgery

intra-abdominal surgery to thoracic surgery, there are some
important differences.
Minimally invasive approaches are typically taught with
the baseball diamond concept in mind (see Figure 1.1).
This is where the camera typically resides at the base of the
diamond and the surgeon operates with two instruments
on either side, through ports placed at points B and D. The
pathology is typically located at point C. This approach is
kept in mind when planning thoracoscopic and laparoscopic
procedures; however, important adjustments are made due
to location within the chest, limitations of the bony fixed
chest wall, and span of operative pathology. For example,
complete intrathoracic dissection of the esophagus requires
much more movement than a laparoscopic cholecystectomy
where the operative field is fairly small. Also, unlike most
abdominal approaches, as the complexity of the intrathoracic procedures performed increases, we add extra ports
and frequently move the camera from one area to another
to maximize visualization. Lastly, as many thoracic procedures are performed with the patient in the lateral decubitus
position, visuospatial challenges are created when working
under camera guidance, in particular when surgeons are on

opposite sides of the table.

INSTRUMENTS AND ACCESSORIES
Instruments
Given the limits of the size of the incisions currently being
used for video-assisted thoracoscopic surgery (VATS), traditional open instruments have limited functionality within
these small incisions. Traditional instruments need to be
oriented along the intercostal space to function. Those who
use them in these situations quickly learn of their limitations
as the sizes of their incisions become progressively smaller.
Additional instruments have been developed specifically for
VATS. These differ from laparoscopic instruments, as early
VATS procedures often did not use insufflation of carbon
dioxide (CO2), thus maintenance of an airtight seal was not
required. VATS instruments are similar to open instruments
with alterations to the hinge points to facilitate use between
the intercostal spaces (see Figure 1.2). In addition, they are
available with a variety of curvatures allowing access to all
of the spaces of the chest, in particular to the chest wall.
Access to certain areas of the parietal pleura and chest wall
is limited with the use of straight laparoscopic instruments.
VATS-specific instruments are provided through a variety of
vendors and some are more cumbersome than others—one
should try out these instruments prior to committing to
purchasing.
After many years of performing minimally invasive thoracic surgery, we have incorporated standard laparoscopic
instruments into all of our procedures, having found they
provide a number of advantages. Specifically, their hinge
point is always at the end closest to the operator’s hand
when the instrument is within the thoracic cavity; they

(a)

(b)

1.2a–b  (a) Photograph of standard ring forceps (A) and

minimally invasive ring forceps (B). Note the long, narrow shaft
that can work easily within the intercostal spaces. (b) Additional
VATS instruments with similar mechanisms including the ring
(A), 5 mm ring forceps (B), scissors (C), vascular clamp (D), and
thorascopic needle driver (E).

work through the 5 mm ports; and they come in a variety
of lengths, from 20 to 45 cm. Additionally, most hospitals
already have several sets of these instruments, so they do
not require an additional capital purchase. When working
with both hands from the posterior and anterior aspect of
the chest, or for hilar work when the patient is in the lateral
decubitus position, we have found the standard laparoscopic
length does not work particularly well. However, we have
found pediatric laparoscopic instruments to be of use when
working at the hilum, as that length is ideally suited for most
adult patients (see Figure 1.3a and b).
When working in the anterior or posterior mediastinum, the length of the standard laparoscopic instruments
works well. In particular, for video-assisted thymectomy
or minimally invasive esophagectomy, the length of these
instruments tends to be advantageous allowing one to work
superiorly to dissect the cervical horns of the thymus gland
or, for an esophageal resection, to dissect the entire length

of the intrathoracic esophagus, from diaphragm to thoracic
outlet.

Ports
For port access, we use a metal trocar with a collar we have
modified so that it does not interfere with the trocar angularity (see mediastinal resections below). When using CO2


Instruments and accessories   5

interfere with the operative procedure, so we have not yet
found this technology useful. This is particularly true for the
smaller patient. As well, operation of this initial prototype
is not intuitive. Future improvements will probably address
these limitations.

CO2 insufflation
(a)

(b)

1.3a–b  (a) Standard laparoscopic instruments above and

the smaller pediatric length below with the 3 mm, 5 mm, and
10 mm ports. (b) Variety of shorter 3 mm laparoscopic instruments,
including a hook cautery at the bottom.

insufflation, one must use either metal ports with an adapter
for insufflation, as with the3 mm ports (see Figure 1.3a
and b), or disposable laparoscopic trocars. Although the

latter add to the expense of the procedure, they can be particularly useful in the obese patient where metal trocars are
often too short to completely traverse the chest wall. For the
utility incision, which is larger than a typical port, we use
a soft-tissue retractor such as the Alexis wound protector
(Applied Medical Resources Corporation, Rancho Santa
Margarita, California, United States). Although purists argue
that this is not “true” VATS, and may not be necessary in
the thin older individual, it is particularly useful in larger
patients.

The use of CO2 insufflation in chest surgery has become
progressively more popular. We use it frequently and find
that it facilitates a number of maneuvers when working
within the confines of the chest. In contrast to an intraabdominal procedure, where the insufflated pressure limit
is set at 15 mmHg, for intrathoracic procedures, we go no
higher than 10 mmHg, as any higher pressure often results
in hypotension due to restriction of venous return to the
right atrium.
When performing thoracic surgery without single lung
ventilation, CO2 insufflation creates a large enough pneumothorax to provide a working space. This is particularly
useful for bilateral VATS sympathectomy, where the patient
is positioned supine.
When performing thymectomy, the addition of insufflation remarkably improves visualization of the anterior
mediastinum. When working on the left side, the intrathoracic pressure obtained with insufflation is enough to push
the heart toward the right to create sufficient working space.
As well, it allows visibility of the inferior aspect of the neck
beneath the heads of the clavicles (see Figure 1.4). With the
use of CO2 insufflation, we perform VATS thymectomy without lung isolation but feel that, for those without experience,
using CO2 in the chest it is more safely performed with lung
isolation.

Insufflation of CO2 during VATS diaphragmatic plication
allows for increased intrathoracic space, as the CO2 displaces
the diaphragm inferiorly allowing for better visualization.
For other mediastinal procedures, we also use a continuous flow of CO2 to assist in the evacuation of smoke from the
chest during cautery dissection. Lastly, when lung isolation
proves to be difficult and the anesthesiologist is working on

Camera
We use a 30-degree 5 mm endoscope with a high-definition
camera, as the current optics are so good we have found little use for the 10 mm camera. The 30-degree angle allows
for improved visualization through rotation of the lens.
Today, additional endoscopes are available that strategically
address challenges associated with the camera view, such as
the EndoEYE (Olympus New Zealand Ltd., Auckland, New
Zealand) and three-dimensional viewing VITOM 3D Karl
Storz GmbH and Co. KG, Tuttlingen, Germany). In our
experience, although conceptually attractive, the location
of the articulation joint for the EndoEYE endoscope can

1.4 

View into cervical region during thymectomy; (r) right
superior and (l) left superior horns of the thymus.