Thoracoscopic Surgery
Thoracoscopic surgery is the abbreviation of Video-Assisted Thoracic Surgery (VATS). Thoracoscopic surgery is considered a revolutionary breakthrough in thoracic surgery at the end of the twentieth century and is the most widely used thoracoscopic procedure in minimally invasive thoracic surgery.
Features of thoracoscopic surgery
From a technical point of view, thoracoscopic surgery (VATS) is performed through two or three “keyholes” with the aid of video-assisted surveillance, which used to be performed by traditional open-heart surgery. It is essentially a “lumpectomy” operation (or lumpectomy surgery), which is less traumatic, faster recovery and shorter hospital stay than traditional open surgery. direct visual observation to transendoscopic observation). Minimally invasive techniques include all diagnostic and therapeutic techniques performed under direct imaging (internal) or indirect imaging (ultrasound, x-ray, MRI, etc.).
Traditional thoracic surgery has a large traumatic area, bleeding, more pronounced postoperative pain, potential complications, and significant surgical incision healing scars. From the perspective of human mechanics, it also destabilizes the human thorax, causing a certain degree of physiological and psychological burden to the patient. Thoracoscopic surgery solves all these defects, and its biggest advantage is that it is less invasive and the patient heals faster. Complete thoracoscopic surgery is the perfect embodiment of thoracoscopic surgery, with only one to four small holes in the chest wall, a small surgical incision and an aesthetically pleasing appearance. Usually, patients can get out of bed the day after thoracoscopic surgery and can be discharged within a short period of time.
Television (video-assisted) thoracoscopic surgery (VATS) was introduced in the 1980s and 1990s as a minimally invasive surgery using television images in combination with thoracoscopy. It is a new modality rather than a new surgical technique, and was initially used for the treatment and diagnosis of cribriform disease. With advances in instrumentation and technology, it is widely used in many different thoracic diseases.
Mediastinal cavity tumor biopsy
Therapeutic
1.Crib membrane disease: pneumothorax removal Hemothorax examination and removal Crib membrane staining Crib membrane release Crib membrane peeling
2.Pulmonary diseases: Pneumothorax surgery Pulmonary abscess excision Lung tumor wedge resection Lung lobectomy
3.Mediastinal cavity disease: thymus and other mediastinal cavity tumor resection
4.Pericardial and minimally invasive cardiac surgery: pericardial fluid drainage pericardiotomy open arterial duct ligation internal mammary artery dissection
5.Autonomic nervous system: sympathectomy or amputation (hand, axillary hyperhidrosis), large visceral nerve resection or amputation (abdominal pain relief) Vagus nerve resection or amputation
6.Esophageal diseases: diverticulectomy esophageal myotomy esophageal tumor resection
7.Diaphragmatic surgery and other intrathoracic explorations
Television thoracoscopic surgery is a new technology that is less invasive to patients, but it is still necessary to choose the most favorable surgical method according to the indications of the patients themselves. With the continuous development of newer equipment, mature techniques and the accumulation of clinical experience, the indications and development of TV thoracoscopic surgery will continue to increase for the benefit of more patients.
Specific operation of thoracoscopic surgery
Abstract: Completely thoracoscopic surgery is a new minimally invasive thoracic surgery technique using modern camera technology and corresponding surgical instruments and equipment to complete complex surgery in the chest through small holes in the chest wall. Complete thoracoscopy has changed the concept of treatment of thoracic diseases and gradually become the main surgical modality in thoracic surgery.
Completely thoracoscopic surgery is a new minimally invasive thoracic surgery technique that uses modern camera technology and corresponding surgical instruments and equipment to perform complex thoracic surgery through small holes in the chest wall. Complete thoracoscopy has changed the treatment concept of thoracic surgery and gradually become the main surgical modality of thoracic surgery, which is the development direction of thoracic surgery in the 21st century.
Complete thoracoscopic surgery requires only one to three small 1.5-4 cm holes in the chest wall. A tiny medical camera projects the situation inside the chest cavity onto a large display screen, which is equivalent to putting the surgeon’s eyes inside the patient’s chest cavity for surgery. The surgical field of view can be enlarged as needed to show subtle structures, which is clearer and more flexible than under direct visualization by the naked eye. Therefore, the exposure of the surgical field, the appearance of the subtle structures of the lesion, the judgment of the scope of surgical resection and the safety are better than those of ordinary open-heart surgery.
Thoracoscopic surgery requires higher and more stringent requirements from the surgeon, who must undergo rigorous training in thoracoscopic techniques in order to truly master the operation of complex surgery under full thoracoscopy.
Thoracoscopy is laparoscopy without the need to purchase additional instruments.
Advantages of thoracoscopy compared to traditional open-heart surgery.
Less surgical trauma: ordinary open-chest surgery is very traumatic, with very long incisions and serious thoracic injuries, requiring cutting off all layers of muscles in the chest, as well as forcibly propping open the intercostal space for 10-20 cm, or even propping off the ribs or splitting the sternum with a chainsaw. In complete thoracoscopic surgery, only one to three small holes are made in the chest wall, and it is not necessary to prop open the intercostal space. Patients can get out of bed the same day after thoracoscopic surgery.
Ordinary open-heart surgery is a big blow to the immunity of the muscles: the immunity of the muscles is crucial, especially for cancer patients, and the immunity can fight against cancer cells. The huge trauma of ordinary open-heart surgery severely weakens the immunity. Completely thoracoscopic surgery is less traumatic and has less impact on the muscles.
Rational understanding of thoracoscopic surgery
I. Correct understanding of thoracoscopic surgery
To realize that TV thoracoscopic surgery is the inevitable development of history: In recent years, with the rapid development of electronic and information technology, human beings have been able to freely manipulate the Mars rover on the earth, and in the military has also achieved long-distance (hundreds of kilometers) precision strikes; obviously, our traditional thoracic surgery method that has remained unchanged for 50 years is as far behind the times as a pilot setting up a plane for visual bombing; society and Patients are asking us to stand at the operating bedside of the contemporary surgeons, can timely use high-tech means to provide patients with both safe and reliable removal of lesions, but also to minimize trauma surgical methods; TV thoracoscopic surgery is in such a large environment was born, it is the inevitable development of science and technology and social development.
2, to recognize the advanced nature of TV thoracoscopic surgery: the advantages of small trauma, light pain, good efficacy, fast recovery, incision in line with the cosmetic requirements are typical of its advanced performance; it is a representative surgery of minimally invasive thoracic surgery, its clinical application has changed the treatment concept of some thoracic surgical diseases, especially in redefining the surgical indications, contraindications and surgical access to certain diseases has made great progress; in Domestic and foreign many advanced medical centers, it has accounted for a third or even more than half of the total number of thoracic surgery cases; its application ratio and application range also reflects the technical level of a hospital thoracic surgery to a certain extent, because the current measure of a doctor or a department’s surgical level is nothing more than: whether you do better than others or you carry out the surgery others will not.
3, to objectively evaluate the status of television thoracoscopic surgery: it is a representative of modern surgery, providing a new treatment means for clinical work, bringing a piece of life to the field of thoracic surgery which has been dull. At present, it can be used for the treatment of various diseases in thoracic surgery and has achieved the same efficacy, becoming one of the common surgical methods in thoracic surgery. However, TV thoracoscopic surgery cannot completely replace traditional surgery, and it is currently mainly applicable to relatively simple thoracic surgery; given that there is a great difference in the scope of surgery that can be carried out by doctors of different technical levels, its indications are still in the process of further improvement. In practice, thoracoscopic surgery must be carried out in a gradual manner, not for the sake of doing thoracoscopy, keeping in mind that the interests of patients come first. In addition, television thoracoscopic surgery is still far from the apex of surgical technology, it is only an excessive stage or a bridge between the traditional and the future, just as it is built on the foundation of traditional thoracic surgery, it is also the foundation of future surgery; in the applied robotic surgery and the more advanced remote control surgery that can be foreseen in the future, the thoracoscope is still one of the important components of the surgical operating system, without the thoracoscope display and guidance, these more advanced surgeries would not be possible. It can be seen that it is very necessary and urgent for today’s thoracic surgeons, especially young doctors, to actively learn and master thoracoscopic surgical techniques as early as possible.
Second, the rational face of thoracoscopic surgery
In the face of such a completely new technology and the difficulties that may be encountered, it is usually very confusing – where to start? How to do it? How can we do it well? This requires that we must consider our personal conditions comprehensively and face this challenge rationally. Just as any career requires specific qualities, as a thoracoscopist also needs to have certain professional qualities.
1, to have solid basic skills: some years ago, I often encountered such embarrassing things: a respiratory physician bought a TV thoracoscope and asked me to help carry out lung resection surgery; a dean or director selected a resident who had just graduated with a bachelor’s degree to learn thoracoscopic surgery in our department, ready to go back to work. In their imagination, TV thoracoscopy, like fiberoptic bronchoscopy or gastroscopy, is a technique that can be mastered by anyone with training. They do not know that they cannot understand the thoracic anatomy under the direct view of the open chest, so how can doctors who cannot perform open-chest surgery complete the resection or reconstruction of thoracic lesions under the fluorescent screen; how can they face possible intraoperative accidents such as hemorrhage; where do they have the confidence and courage to explore and carry out difficult and new thoracoscopic surgery! Therefore, as a thoracoscopic surgeon, the primary and necessary condition is: to have solid basic skills in open-heart surgery, a qualified thoracic surgeon who can independently carry out conventional thoracic surgery.
2, to have patience, toughness, collapse style: compared with open-chest surgery, which requires direct vision (direct contact) operation by eye to hand, thoracoscopic surgery is a semi-virtual operation by eye to monitor hand outside the chest cavity, using special instruments for non-direct contact operation. For a thoracic surgeon who is used to open-heart surgery, it is indeed very awkward to do and it seems that everything has to be learned from scratch. In fact, it is the necessity to retrain our eyes (to adapt to two-dimensional operation), hands (to adapt to the long-distance operation of special long-handled instruments) and microscopic anatomy (anatomical knowledge of local magnification), which requires a lot of time to train and empathize, as well as enough patience and perseverance. One of my division chiefs was very interested in thoracoscopic surgery, but he was already an accomplished thoracic surgeon and was very busy, so he did not have the time or patience to train in basic thoracoscopic techniques. He gave up. As a young surgeon, there are no too many rules and regulations, there is no a lot of business work, as long as you quietly and patiently, adhere to the step by step training can quickly master this technology. This is probably the reason why most of the successful thoracoscopists and other endoscopists at home and abroad are of the young and middle generation. However, to become an outstanding thoracoscopist, you need to have a solid work style, starting from simple surgery, and going step by step solidly, not to be overly ambitious and eager to get immediate success, which will easily go wrong or deviate from the direction. There are individual doctors in China who, in order to become famous as soon as possible, have just learned thoracoscopic surgery for less than a year and claimed or reported to have done many complicated thoracoscopic surgeries such as lobectomy or/and esophageal cancer resection. Only later did we understand the “secret” of their rapid progress: they all added a small incision in the chest wall or abdomen, and some of the “small incisions” were as long as about 15 CM, and the surgery was basically done under direct vision, with the thoracoscope only equivalent to a light. This is not really thoracoscopic surgery, but thoracoscopic-assisted small incision surgery; what is more worrying is that, because these doctors rely on small incisions at the beginning, lacking rigorous and systematic exercise, they can’t do any surgery without this “crutch”, so they deviate from the track of thoracoscopic surgery.
3, to constantly update knowledge, and seriously summarize experience: a colleague told me that in the past, their provincial thoracic surgery society to promote the development of thoracoscopic technology, has repeatedly invited more local doctors to do thoracoscopic surgery demonstration, but because the performance is not very successful, many originally very enthusiastic colleagues after observing but lost confidence. This shows how important it is for beginners to be able to receive a standardized education early on. Indeed, to become a qualified thoracoscopic surgeon, a good start is essential; one must learn the basic knowledge and basic skills of thoracoscopic surgery seriously from the beginning, find a formal training center for training, and observe more surgical demonstrations by well-known thoracoscopic surgeons, only then can one grasp the essence of thoracoscopic surgery as early as possible. However, this is just the beginning, but later persistent study, practice and summary are more important. Two years ago, I was invited to an eastern hospital to perform thoracoscopic esophagectomy for esophageal cancer, and after the operation, the local doctors exclaimed that the surgical method was much better than what I had written in my own book and what they had learned. After learning about it, I realized that they were trained by one of my students who had not attended our academic activities for a long time due to his busy schedule, and although he had done a lot of work in esophageal cancer surgery, he still followed the same method I adopted 8 years ago; in fact, I had made great improvements in patient position, trocar placement, and esophageal resection method long ago. As a new technology still in the process of improvement, thoracoscopic indications and surgical methods are in the process of constant updating and development, which requires us to attend high-level thoracoscopic classes and exchange meetings at the right time and observe more high-level surgical demonstrations to keep our knowledge and concepts updated, so that we can keep pace with the development of the discipline. At the same time, because thoracoscopic surgery is an emerging discipline, the current surgical instruments are far from meeting the clinical requirements, the surgical methods need to be further improved, and the surgical experience needs to be accumulated and enriched; this is a challenge and an opportunity for contemporary thoracic surgeons.
Television thoracoscopic surgery
Video-assisted Thoracoscopic Surgery
Indications
1.Pleural diseases: spontaneous pneumothorax, hemothorax, abscess thorax, celiac thorax, pleural effusion due to pleural tumor, etc.
2.Pulmonary diseases: pulmonary cystectomy, peripheral intrapulmonary nodules, stage I lung cancer, etc.
3.Esophageal diseases: esophageal smooth muscle tumor, esophageal cancer, pancreatic dyscrasia, etc.
4.Mediastinal diseases: thymectomy for severe myasthenia gravis, mediastinal tumor and cyst removal, etc.
5.Other: foreign body removal, intercostal nerve severance, partial excision of sympathetic nerve chain, biopsy, etc.
Anesthesia
1.Intertracheal double-lumen intubation general anesthesia: applicable to most thoracoscopic procedures.
2.Unilateral endotracheal intubation general anesthesia: applicable to some emergency situations where the tracheal intubation can be rapidly inserted directly into the main bronchus on the non-operative side in order to collapse the lung on the operative side.
Position
Position selection is made according to the site and nature of the lesion and the surgical approach. Principles of incision design: ① the first incision should not be too low to avoid injury to intra-abdominal organs; ② the incisions should not be too close to each other to avoid collision of instruments; ③ the three incisions are arranged in a triangle with the lesion in an inverted triangle.
1. Lateral position: the most commonly used position. Appropriate adjustments can be made as needed during the operation. Generally, three small incisions of 1.5-4 cm in length are made, and the incision for placing the thoracoscope is chosen between the 6th and 7th ribs from the mid-axillary line to the posterior axillary line, and the location of the other two incisions is determined after the lesion site is clearly identified, and the incisions are spaced 10-15 cm apart and should be triangularly distributed.
2. Supine position: the same as the median sternal incision position. It is suitable for anterior mediastinal lesion surgery and second-stage surgery of bilateral intrathoracic lesions. The incision for placing the thoracoscope is chosen in the 4th or 5th intercostal space in the anterior axillary line, and the rest of the incisions are arranged according to the above principles.
3.Half-sided position: After lying on the back, raise the back of one side by 30°~45° or rotate the operating table to achieve the required position. It is suitable for anterior mediastinum surgery.
Surgical steps
(I) Lung lobectomy
1. Lateral lying position. The skin exposure at the incision should be appropriately large to reveal the preset incision.
2.Placement of thoracoscope: make a skin incision of 1~1.5cm in length at the selected site, separate the muscles and intercostal muscles with vascular forceps and puncture the wall pleura to enter the pleural cavity, enter the finger probe, no adhesions can be directly punctured into the pleural cavity with the trocar puncture needle, put in the open trocar, place the thoracoscope from the trocar and examine the intrathoracic structures comprehensively. Then, according to the need of surgery, the second and third trocar incision will be made in the same way, and surgical instruments such as non-invasive grasping forceps, electrocautery strippers and flushing suction tubes will be placed under the surveillance of the thoracoscope.
3.Separation of interlobar fissures: cut the adhesion zone and pleura with electrocautery separation; for incomplete interlobar fissures, scissors with electrocoagulation can be used for proper separation, and then cut and suture with endoscopic suture incisor (GIA) after finding the appropriate level.
4. Treatment of the pulmonary artery: ① Separate and ligate the interlobular artery with ordinary long vascular forceps through a small incision. ②Treat the artery with GIA cut-off suture. ③Pulmonary hilar vessels and bronchi are treated together. ④Metal clip treatment method.
5.Pulmonary vein treatment: same as pulmonary artery treatment.
6.Bronchial tube treatment: cut and suture with GIA.
7.End of surgery. After the operating instrument withdraws from the pleural cavity, the incision is sutured, and then the chest drainage tube is led out via an original trocar and fixed on the skin to receive the water-sealed bottle for drainage and lung reopening.
(B) Esophageal myotomy
1. Position: right lateral recumbent position slightly tilted forward.
2, incision: the first incision is chosen in the left posterior axillary line between the 8th or 9th ribs, and the 2nd, 3rd and 4th incisions are chosen in the 6th intercostal anterior axillary line, posterior axillary line and 2 cm after the scapula. each 10, 10, 5 and 10 cm long.
3.Surgical operation: After entering the mirror, the lower lobe of the left lung was retracted with a trefoil claw pulling hook, and the mediastinal pleura was cut between the aorta and the pericardium; the esophageal muscular layer was revealed; the esophagus was freed with an all-angle forceps and a band was set to tract the esophagus; the esophageal muscular layer was cut; until the submucosa of the esophagus was seen, and the esophageal myotomy was completed.
(C) Mediastinal tumor resection (take thymoma surgery as an example)
1. Position: semi-lateral or lateral recumbent position is acceptable.
2.Incision: 3~4.
3.Surgical operation: After entering the mirror, the normal thymic tissue near the tumor is clamped with endoscopic forceps, the envelope is cut, the thymic artery is treated with metal clips, the whole tumor is separated by endoscopic instruments with sharp and blunt, and all the adhesion bands are cut off after being clamped closed with metal clips until the tumor is removed.
(IV) Pleural tumor resection
1. Position: healthy side lying position. During the operation, the position can be changed by shaking the operating table according to different tumor sites.
2.Incision: conventional thoracoscopic incision is adopted.
3.Surgical operation: After entering the mirror, use electric knife to cut the pleura along the edge of the tumor, use endoscopic grasping forceps to pull and lift the tumor, gradually peel off and remove the tumor, and end the operation with electrocautery to stop bleeding.
Postoperative treatment
Closely observe the vital signs. Pay attention to the amount, color and gas condition of chest drainage fluid.