Thoracoscopic Surgery - Indications, Evaluation, and Complications

Introduction:

Thoracoscopic surgery is the process of the treatment of chest (lungs) and heart diseases. Thoracoscopic examination of the pleura was done under local anesthesia and was first executed by Swedish physician Jacobus. Video-assisted thoracoscopic surgery was done to assess and manage the pleural effusions in cases of pulmonary tuberculosis.

Before this process, the classic technique of thoracic disease was thoracotomy. Minimum access was the main drawback of this procedure. Thus, the invention of fiber-optic light brought more outcomes. Video-assisted thoracoscopic surgery has considerable benefits over conventional thoracotomy, which involves reduced postoperative pain, reduced hospital lengths of stay, and quicker recovery of respiratory function, particularly in chronic obstructive pulmonary disease (COPD) and the old and smaller cost.

What Are Anatomy and Physiology to Be Considered in Thoracoscopic Surgery?

The adult trachea is an average of fifteen centimeters in length. It expands from the down end of the cricoid cartilage, that is, at the C6 level, and splits into two significant bronchi into both sides at the level of T5. The bronchus on the right side is more comprehensive and better in line with the trachea. It splits into the top, middle, and inferior lobe branches. The bronchus on the left side is flat and divides into the top and low branches.

The lobes of the lungs are again split into bronchopulmonary parts. Each provided blood supply by a segmental artery and a segmental bronchus. The veins are present in the center of these elements. It is necessary to be knowledgeable about these surgical branches of the lung. Therefore, the surgeon should know the anatomy before the procedure. Incisions do the surgery in the intercostal space. The incisions are made so that they correspond to the long axis of the intercostal area. The surgeon must ensure that these incisions are in the middle of the space to prevent intercostal nerve injury, which drives at the lower border of the ribs groove.

What Are the Indications of Thoracoscopic Surgery?

The indications of thoracoscopic surgery are divided into diagnostic signs and therapeutic signals.

Diagnostic Indications - Thus, this thoracoscopic procedure is used for diagnosis purposes, which includes,

• Biopsy of mediastinal lymph nodes.

• Pleuroscopy or biopsy of the pleura.

• Tissue biopsy or lymph node biopsy is to diagnose cancer in the lungs.

• Biopsy of the wall of the chest.

• Cancer staging.

Therapeutic Indications- This procedure is used for treatment purposes like,

• Pulmonary resection is done in cases of lung cancer.

• Pulmonary bleb resection or resection of the bullae.

• Drainage of the pleura is done in cases of pneumothorax, hemothorax, and empyema.

• Drainage of pericardial effusion.

• Mechanical or chemical pleurodesis.

• Excision or biopsy of mediastinal bulges and nodules.

• Excision of esophageal diverticulum or esophagectomy.

• Ligation of the thoracic duct.

• Sympathectomy.

• Resection of the chest wall tumor.

• Thoracoscopic laminectomy.

• Drainage of the spinal abscess.

What Are the Contraindications of Thoracoscopic Surgery?

• Incapable of accepting isolation of the lung or their dependence on bilateral ventilation.

• If it is not possible to keep intraluminal airway mass placement.

• Severe adhesions in the pleural cavity.

• Coagulopathy.

• Instability in the hemodynamic mechanism.

• Hypoxia.

• Cardio obstructive pulmonary disease.

• Pulmonary hypertension.

How Is Pre-evaluation Done For Thoracoscopic Surgery?

• The selection of patients has an important role in deciding the postoperative outcome. A thorough examination of the patient is mandatory, beginning with the patient selection. These examinations are mainly done on the cardiac and respiratory functions to confirm the patient can endure one-lung ventilation. Preoperative ASA assessment for physical status, spirometry usage, measuring the lungs' diffusing capacity for carbon monoxide, computed tomography, and cardiopulmonary exercise testing.

• The preoperative examination mainly evaluates lung mechanics, parenchymal process, and cardiopulmonary budget.

• A standard indicator for assessing the pulmonary reserve is the diffusing capacity of the lung for carbon monoxide. It estimates the pace of diffusion of carbon monoxide substances to the alveolar membrane. It is suitable for adequate postoperative pulmonary resources if it is higher than forty percent.

• For patients in which these values are borderline, cardiopulmonary exercise testing is done to indicate the reserve of the cardiopulmonary axis. Then, maximal oxygen consumption is estimated. If it is higher than ten milliliters per minute per kilogram is required for the procedure.

• A complete blood count indicates polycythemia. It may be because of pulmonary diseases or a raised white cell count representing infection or inflammation. Chest X-rays and computed tomography scans provide the necessary points for the process. Arterial blood gasses support recognizing patients who are at high risk of complications postoperatively. In cases with PaCO2 more elevated than 50 mm Hg or in cases where PaO2 is reduced than 60 mm Hg, are at risk during surgery. Preoperative evaluation of patients undergoing video-assisted thoracoscopic surgery may contain smoking termination, underlying disease management, and pulmonary restoration.

What Are the Complications of Thoracoscopic Surgery?

The complications of thoracoscopic surgery include,

• In selected cases, patients may experience air leakage postoperatively.

• Pain and tenderness are occurring postoperatively. This condition is common and can be managed by analgesics.

• Hypoxemia occurs as a result of the reduction of oxygen in patients.

• Bleeding.

• Wound infection.

How is Postoperative Care Done in Thoracoscopic Surgery?

Postoperative care in this procedure is mainly done for the management and reduction of pain and respiratory maintenance, and chest tube treatment. Restrictive fluid treatment is done to enhance effects postoperatively. The administration of sufficient analgesia achieves pain management, which is effective in quicker recovery and preventing respiratory difficulties. Thoracotomy has been characterized as the most distressing of operative techniques. It commences intraoperatively and persists postoperatively. It is executed by a mixture of intravenous and regional methods. Intravenous analgesia is given as systemic opioids and patient-controlled analgesia. NSAIDs (non-steroid anti-inflammatory drugs)have opioid-sparing usefulness and also do not create respiratory depression. Epidural and intercostal blocks can also augment the analgesic regimen. Increased analgesia is associated with more acceptable respiratory action postoperatively.

Conclusion:

Bleeding due to vascular damage is a complication during thoracoscopic surgery for major pulmonary resection and is the cause of emergent transformation to open thoracotomy. The surgeon, anesthesiologist, and operating room groups should be trained to transform into an open thoracotomy. Acceptable intravenous entrances are done prior to this process. This procedure with transformation and open thoracotomy was linked with morbidity and mortality rates. It should be selected for thoracotomy, even when transforming into an open procedure.