Objective To investigate the method, feasibility and safety of thoracoscopic surgery for the removal of esophageal smooth muscle tumors. METHODS We retrospectively analyzed and compared 10 cases of Video-assisted Thoracic Surgery (VATS) (Group A) and 10 cases of Standard posterolateral thoracotomy (SPT) between 2005 and 2009. Both groups had smooth muscle tumors in the middle and lower esophagus. The incision length, bleeding volume, actual operation time, chest closure time, overall operation time, postoperative drainage volume, postoperative feeding and ventilating time, time to get out of bed, time with tube, postoperative dulcolax use, postoperative hospitalization days, hospitalization cost, postoperative shoulder dysfunction, prevention and management of postoperative pulmonary complications, and postoperative followup were compared between the two methods of thoracotomy. Results In the thoracoscopic group, two cases of smooth muscle tumors were slightly larger and adhered to the mucosa, and were operated by thoracoscopic-assisted minithoracomoty (VAMT). Under the condition that the preoperative gender, age, height, weight, BMI, FVC, FEV/FVC% were basically the same in both groups, the analysis of age, gender, height, weight, BMI, preoperative pulmonary function (FVC , FEV/FVC%), tumor size, postoperative feeding and ventilating time, and the overall surgical time were not statistically significant between the two groups (P0.05). Chest opening time, chest closure time, actual operation time, bleeding volume of open chest, postoperative drainage volume, chest tube removal time, dulcolax use, postoperative hospitalization days, hospitalization cost, and postoperative shoulder dysfunction between the two groups were statistically significant (P0.05) when group A was compared to group B. Postoperative follow-up was not statistically significant between the two groups (P0.05). The incidence of postoperative pulmonary complications was similar between the two groups without statistical significance. Conclusion According to the literature and their own experience, proficiency in television thoracoscopic surgical operation techniques is suitable for minimally invasive surgical treatment of some esophageal smooth muscle tumors. Television thoracoscopic surgery has very impressive clinical results, with easy operation, complete exposure, less body damage, less blood loss and pain, faster functional recovery and cosmetic results. Methods (I) Surgical methods 1. All cases in group A were treated with intravenous general anesthesia with double-lumen tracheal intubation, and single-lung ventilation was performed on the healthy side. The body position was determined according to the lesion site, and the smooth muscle tumor in the middle and upper esophagus was treated in the left lateral position with an anterior tilt of about 15 degrees and a right thoracic approach. For smooth muscle tumors in the lower esophagus, both right and left sides are possible; right thoracic approach is customary in our hospital. For patients with tumors located in the upper and middle esophagus, two television monitors were placed on each side of the operating bed, close to the patient’s head. For lower esophageal lesions, two TV monitors are placed on either side of the operating table at the patient’s feet. Procedure: Four trocars are usually placed. For upper and middle esophageal lesions, the trocars are placed below the lesion, and the first trocar is usually placed in the mid-axillary line at the 7th or 8th intercostal space for placement of the thoracoscope. The second trocar is placed slightly anterior to the mid-axillary line in the 6th or 7th intercostal space for placement of a suction device. The other 2 trocars are placed in the anterior and posterior axillary line between the 4th and 5th ribs, respectively [4]. For lower esophageal lesions, the first trocar is placed in the anterior axillary line of the 4th intercostal space, the second is placed slightly posterior to the posterior axillary line of the 5th intercostal space, and the remaining 2 are placed in the 6th intercostal space between the midclavicular line and the midaxillary line. After placing the trocars, a thoracoscope was inserted to explore the entire pleural cavity and use an electrosurgical knife to separate the pleural adhesions present; a pulling hook was inserted from the 4th intercostal space to pull the lung forward and downward to expose the posterior mediastinal esophageal bed, and the L-shaped electrosurgical knife from the other two trocars was used to longitudinally incise the posterior mediastinal pleura on the surface of the esophageal tumor, and extend it up and down by 3 to 5 cm each. Freeing the esophagus usually involves freeing only the lateral esophagus, and the full circumference of the esophagus is usually not required [5]. Depending on the location of the tumor, it is sometimes necessary to cut the umbilical vein. Care is taken not to damage the vagus nerve; if localization is unclear, an esophagoscope is immediately placed transorally to assist in localization. After the tumor was found, the tumor was grasped with invasive forceps or sutures to pull the tumor, in order to expose the tumor and mucosa clearly; when separating the tumor, a combination of blunt and sharp methods can be used, and our hospital is accustomed to using blunt separation, at this time, esophagoscopy is very important, firstly, it is to indicate the scope of the separation of the tumor; secondly, it is to suggest to the operator the depth of separation in order to prevent injury to the mucosa; thirdly, it is possible to lift up the tumor, which is beneficial to the removal of the tumor. After complete removal of the tumor, the operative field was washed and inflated through the esophagoscope to check whether there was any mucosal injury, and if there was any injury, it was repaired with 4-0 absorbable thread. The muscular layer of the esophagus was closed with non-absorbable sutures (some literature [6] suggests that the muscular layer of the esophagus can also be closed without sutures). Finally, a gastric tube was placed under direct vision, a closed chest drain was placed in the port of the lowermost trocar, the other trocars were withdrawn, checked for active bleeding, sutured the incision, and the operation was completed. 2, Group B cases g-lumen or double-lumen intubation, intravenous complex anesthesia. Position was decided according to the lesion whether left or right lateral recumbency. The standard posterior lateral incision was about 20-30 cm long, and the middle and lower lesions were entered into the chest at the left 6th or 7th intercostal space, while the upper lesions could be entered into the chest at the right 5th or 6th intercostal space. Intraoperatively, the latissimus dorsi and serratus anterior muscle groups were routinely cut, and the chest was routinely entered via the intercostal space. (II) Statistical analysis SPSS11.5 statistical software was applied, and the measurement data were expressed in ± s. The t test was used for rate comparison of means, and the χ2 test was used for rate comparison. Results Group A (TV thoracoscopy) 10 cases, 2 patients underwent thoracoscopy-assisted small incision surgery because of partial adhesion of the tumor and mucosa. Tumor size was 3.10±0.69 cm, chest opening time was 9.90±1.10 min, chest opening bleeding was 11.90±2.47 ml, chest closure time was 9.20±1.03 min, actual operative time was 75±10.54 min, and the overall operative time was 94.40±11.69 min. The postoperative drainage flow was 313±57.74 ml, and the gastric tube was removed at 3.8±0.63 days after surgery. 0.63 days after the removal of the gastric tube to start eating, with a tube time of 3.5 ± 0.71 days, dulcolax use of 40 ± 51.63 mg, postoperative hospitalization days of 6.4 ± 0.84 days, hospitalization costs of 22,300 ± 0.08 million yuan, postoperative follow-up of 11.1 ± 0.99 months, 1 case of pulmonary complications, 1 case of impaired mobility of the shoulder joints, postoperative pathology diagnosed as esophageal smooth muscle tumors. Group B (standard dissection incision to open the chest) 10 cases, tumor size 3.51±0.84cm, opening time 18.40±2.17min opening bleeding 18.60±3.13ml, closing time 21.20±2.94min, the actual operation time 52±13.69min, the overall operation time 91.50±12.70min, postoperative drainage flow 453±67.50ml, 3.6±0.52days after operation, the gastric tube was removed to start eating, the time with tube was 4.4±0.70days, the amount of dulcolax used was 100±66.67mg, the hospitalization day after operation was 12.2±0.63days, the hospitalization cost was 177±0.13million dollars, the follow-up after operation was 11.7±0.48months, the pulmonary complications were 3 cases of shoulder joint mobility disorder was 4cases, and the postoperative period was 11.7±0.48months. All of them were diagnosed as esophageal smooth muscle tumor by pathology. of postoperative drainage, time with tube, dulcolax use, postoperative hospitalization days, postoperative shoulder dysfunction, and hospitalization cost were compared with statistical significance (P0.05). Overall operative time, postoperative feeding time, postoperative follow-up comparison between the two groups, and pulmonary complications, were not statistically significant (P0.05). DISCUSSION I. Advantages and disadvantages of TV thoracoscopic resection of smooth muscle tumor Conventional open thoracotomy mostly uses standard posterior lateral incision, which has an open surgical field and is convenient to operate, but the incision is long, bleeding and traumatic, which increases the burden on the cardiorespiratory function, and even results in postoperative chest wall deformity. Compared with standard cesarean incision, TV thoracoscopic surgery has the advantages of mild postoperative pain, little effect on shoulder movement, and complete preservation of chest wall muscles which is favorable to the improvement of postoperative lung function. However, television thoracoscopy also has shortcomings: firstly, television thoracoscopy operation field is narrow, the operation lacks of realism, and it is difficult to deal with accidents such as large blood vessel injuries during the operation, and most of the time, it needs a small axillary incision or even a standard open thoracotomy incision to assist the operation. Secondly, if the application of TV thoracoscopy is not skillful, there is no advantage of operation time compared with conventional open thoracic surgery, and the skillful application of TV thoracoscopy requires a large number of cases and a long time of learning and exercising. Finally, the application of TV thoracoscopy has higher hospitalization cost than conventional open heart surgery. Second, the indications and contraindications of thoracoscopic surgery Indications: thoracoscopic surgery is suitable for single or multiple smooth muscle tumors in all parts of the esophagus of the thoracic segment with tumor diameters of more than 2 cm, the tumor morphology is dominated by round and oval shapes, and irregular shapes of tumors, such as spirals, are prone to injury of the mucosa during surgery, and smooth muscle tumors with diameters of greater than 5 cm or more often require auxiliary axillary mini-incision, so the most suitable for smooth muscle tumors between 2 and 5 cm [ 7]. Contraindications: severe dense adhesions in the pleural cavity; cardiopulmonary function or physical condition that cannot tolerate general anesthesia or open thoracotomy; those who have had mucosal biopsy in the recent past (especially within 2 weeks); those who have concomitant esophageal malignant tumors; huge esophageal smooth muscle tumors esophageal muscularis atrophic and thin or have been destroyed, and the range of muscularis defects is large and unrepairable after the tumor resection, which often requires esophagectomy [8]. Thoracoscopic resection of esophageal smooth muscle tumor preoperative and intraoperative precautions Esophageal smooth muscle tumor preoperative diagnosis is very important, often need to be identified with mediastinal lymph node tuberculosis, preoperative gastroscopy, Dllow et al. once pointed out that, in order to clarify the nature of the lesion to exclude the tumor, for any esophageal smooth muscle tumor symptoms and X manifestations of cases must be carried out endoscopic examination [9], but do not blindly carry out a biopsy of the local tissues, so as to avoid However, local tissue biopsy should not be performed blindly, so as not to damage the mucosa and affect further surgical treatment, while barium esophageal film, chest CT, and esophageal ultrasonography are all necessary. Intraoperative gastroscopy plays a very big role in assisting the operation, which can not only help to free the tumor, but also check whether there is mucosal damage. Fourth, the comparison of the time and intraoperative bleeding of the two surgical modalities The thoracoscopic group group was statistically significant (P0.05) due to the small incision, less muscle damage, and no damage to the ribs in the time of opening the chest and the time of closing the chest was shorter than that in the group of the standard dissecting thoracotomy incision. Due to the increased difficulty of operation, the actual operation time of thoracoscopic surgery was longer than that of normal posterior lateral incision. While the overall operative time was not statistically significant between the two groups because the reduction in thoracoscopic opening and closing time compensated for the actual operative time. Surgical bleeding is a very important indicator of good or bad surgical outcome, which is related to the intraoperative blow to the patient’s cardiopulmonary function and the decision of whether or not the patient needs a blood transfusion to complete the surgery, the status of the patient’s postoperative recovery, and the cost of hospitalization. As can be seen from Table 3, the thoracoscopic group had less bleeding than the conventional open-chest group in both open-chest bleeding and postoperative drainage, which was statistically significant (P0.05). The main reasons for more bleeding in the conventional open chest group: ① large incision, along the way need to cut off 2-3 layers of chest wall muscle, and damage to the dorsal thoracic artery, lateral thoracic artery, if necessary, cut off a rib, and the intercostal blood vessels; ② opening and closing the chest for a longer time, so that the trauma is exposed too long; ③ the presence of postoperative rib breaks and larger trauma and other easy to ooze blood factors. Postoperative pain is the most common surgical pain, open heart surgery due to damage to the muscles and ribs, so the postoperative pain is more obvious and persistent. Conventional posterior lateral incision postoperative pain is mainly caused by the pulling and injury of the intercostal nerve, the transection of the intercostal nerve dermal branch, and the trauma caused by the cutting of the muscle and the opening of the ribs or the fracture of the ribs of individual patients. In the thoracoscopic group, there was little muscle damage, no cutting of the ribs and no need to prop open the intercostals, so postoperative pain was mild. Comparing Table 3, it can be seen that the postoperative dulcolax use in the thoracoscopic group (40±51.63 mg) was significantly less than that in the conventional open chest group (100±56.67 mg), and the comparison between the two groups was statistically significant (P0.01). Sixth, the comparison of common chest complications Thoracoscopic surgery and conventional open heart surgery both require tracheal intubation anesthesia, intraoperative compression and damage to the lungs, postoperative pain in the chest, so that the thoracic movement is limited, while affecting the effective coughing and coughing up sputum, which often leads to the patient’s pulmonary atelectasis or inflammation of the lungs. As can be seen from Table 4, the incidence of postoperative complications in the two surgical modalities is roughly the same, with no statistical significance. However, some foreign scholars believe that the incidence of postoperative complications in the standard cesarean incision group is high [10], because: ① large traumatic surface, postoperative patients have severe pain, fear of coughing, which leads to sputum storage; ② chest wall muscle damage and rib cutting destroys the integrity of the thorax, affecting normal respiratory movements and cough reflex, making ventilation of the lungs impaired and sputum removal difficult. In the thoracoscopic group, the incision is small, the damage is light, the chest wall muscles are preserved intact, and the postoperative pain is light, so it is favorable for the improvement of postoperative lung function. Basically, it does not affect breathing, coughing and sputum, so there are fewer pulmonary complications. VII. Relationship between the functional status of shoulder joint and the two surgical styles Because of the damage to the shoulder girdle muscle in the conventional thoracoscopic group, and because of the need to use a spreader to spread the scapula during the operation, most of the patients had limited shoulder joint activities for a long time after the operation, and it even triggered periarthritis. In the thoracoscopic group, most of the patients had normal shoulder joint activities after surgery because the scapula did not need to be opened. In this paper, there was one case of postoperative shoulder joint activity disorder in group A, while there were three cases in group B, both of which were statistically significant (P0.05). Eight, the comparison of closed chest drainage time and the degree of healing of surgical incision trauma Postoperative closed chest drainage time in this statistics also have also have statistical significance, thoracoscopic surgery to be shorter than the conventional open heart surgery with tube time, which is also the performance of the surgical trauma is small. The quality and speed of wound healing directly affects the patient’s quality of life and the course of the disease. Standard cesarean incision, due to the need to cut off multiple layers of muscle, and the incision against the back, the patient supine pressure, resulting in local blood flow obstacles to the wound, affecting the healing of the incision, this paper, conventional open chest group 2 cases due to incision infection and cracking. group A, due to the damage is small, incision is small, the patient is supine, the incision is not compressed, so most of the patients with the incision healing and fast and good. Nowadays, with the development of society and the improvement of people’s quality of life, more and more patients, especially female patients, have requirements for the size of postoperative scar, and the smaller, less obvious, and more obscurely located surgical scar is welcomed by the majority of patients [11]. The difference in the size and aesthetics of the above two types of surgical incisional scars is obvious to all, so thoracoscopy has a great advantage in this regard as well. IX. Comparison of hospitalization cost Due to the application of disposable instruments and other conditions in thoracoscopic surgery, the hospitalization cost of thoracoscopic surgery is now slightly more than that of conventional open thoracic surgery, and the comparison of the hospitalization cost of these 20 patients can be clearly seen in icon 3 is statistically significant, and this disparity will be completely resolved with the development of science and technology and the prosperity of the economic construction of the society. CONCLUSION By summarizing the experience of the 10 cases of surgery, we believe that it is beneficial to pay attention to the following points: ① the patient lying on the left side, with the chest elevated; ② the esophagus is lifted from the esophageal bed with a gastroscope during the operation to reveal the lesion and to play a supportive role [12]; ③ when encountering the cord-like structure when freeing the esophagus or the tumor, use titanium clips to close the clips or electrocoagulation to stop the hemorrhage. According to the review of relevant literature [13] and our experience, thoracoscopic esophageal smooth muscle tumor resection is a safe and reliable minimally invasive procedure, which has the advantages of conventional open-heart surgery, and its weaknesses will be gradually improved or eliminated with the development of thoracoscopic technology and society.