JJournournaall ooff MMinimalinimal AccessAccess SurgerySurgery OOfficialfficial PublicationPublication ofof IndianIndian AssociationAssociation ofof GastrointestinalGastrointestinal Endo-SuEndo-Surrgeonsgeons

October-December 2007 - Volume 3 - Issue 4

CONTENTS Editorial Thoracoscopic surgery: H. S. Bhanushali ...... 121 Original Article Thoracoscopic excision of mediastinal cysts in children: Prashant Jain, Beejal Sanghvi, Hemanshi Shah, S V Parelkar, S S Borwankar ...... 123

CME Articles Anesthesia for thoracoscopic surgery: I D Conacher ...... 127 Endoscopic thoracic sympathectomy for hyperhidrosis: Technique and results: C S Cinà, M M Cinà, C M Clase ...... 132 Thoracoscopic management of empyema thoracis: Michael A Wait, Daniel L Beckles, Michelle Paul, Margaret Hotze, Michael J DiMaio ...... 141 Thoracoscopic resection for esophageal cancer: A review of literature: Joris J G Scheepers, Donald L van der Peet, Alexander A F A Veenhof, Miguel A Cuesta ...... 149 Video assisted thoracic surgery in children: Rasik Shah, A Suyodhan Reddy, Nitin P Dhende ...... 161

How I do it Technique of the transcervical-subxiphoid-videothoracoscopic maximal thymectomy: Marcin Zielinski, Lukasz Hauer, Jaroslaw Kuzdzal, Witold Sosnicki, Maria Harazda, Juliusz Pankowski, Tomasz Nabialek, Artur Szlubowski ...... 168

Personal Viewpoint (Video Assisted) thoracoscopic surgery: Getting started: Tamas F Molnar ...... 173 Letters to Editor Empyema gall bladder and laparoscopic cholecystectomy: Iqbal Saleem Mir ...... 178 Authors’ reply...... 178

Forthcoming Events ...... 180

Author Index, 2007 ...... 181

Title Index, 2007 ...... 182

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184 CMYK CME Article

Anesthesia for thoracoscopic surgery

I D Conacher Department of Thoracic Anesthesia, Freeman Hospital, Newcastle Upon Tyne Nhs Hospital Trust, Freeman Road, Newcastle Upon Tyne, NE7 7DN, England

Address for correspondence: Dr I. D. Conacher MB, FRCP (Ed), MD, FFARCS. Consultant Anaesthetist: Freeman Hospital, Newcastle upon Tyne, NE7 7DN. England. Email: [email protected]

Abstract consequence of a pneumothorax. The mechanism was the phenomenon named ‘pendelluft’ - pendulum Anesthesia for thoracoscopy is based on one air. This described shunting of the physiological dead ventilation. Lung separators in the airway are essential tools. An anatomical shunt as a result of the space between the two during self-ventilation, continued of a non-ventilated lung is the resulting in a build-up of carbon dioxide and respiratory principal intraoperative concern. The combination acidosis; and often was accelerated because of the poor of equipment, technique and process increase health of patients suffering from infective conditions, risks of and dynamic hyperinß ation, in turn, notably tuberculosis. Today much of this history still potential factors in the development of an unusual form of pulmonary edema. Analgesia management influences the role of anesthesia: pain relief, facilitating is modelled on that shown effective and therapeutic instrument access, ensuring and dealing for thoracotomy. Perioperative management with the effects of co-morbidities. needs to reß ect the concern for these complex, and complicating, processes to the morbidity of In the background lies a perception, often pressing, that thoracoscopic surgery. the less apparently invasive the surgery, the more ill

Key words: Analgesia for thoracotomy, lung separators, the patients who are considered operable. There is no one lung ventilation lessening in the complexity of the anesthetic process, the degree of ‘physiological trespass’ or the need for resources to cope with the pain experience. All benefits being, as for surgery, in reduced blood loss, wound pain INTRODUCTION and hospital stay.

Thoracoscopy nearly has a century long history (1912). It Almost uniquely in surgical practice, anesthetist and is only now that technological advance has enabled move surgeon are very much rivals for the same anatomy. beyond diagnostic and experimental to the therapeutic Given the proximity of the anesthetist and surgeon and even the norm. Most operations, considered as part in the field, there are pinch points: almost inevitably, of the repertoire of the thoracic surgeon and requiring conjunction of anesthetic imperative - to oxygenate - access through a sternotomy or thoracotomy, are within will occur with that of surgery not being possible in the the range of alternative and putatively less destructive presence of lung employed to perform its function. thoracoscopic techniques. Initially, operations were conducted with local anesthetic blockade at the Dynamic hyperinflation (‘breath-stacking’) during point of access, either local anesthetic infiltration or operation and non-cardiogenic pulmonary edema some form of single or extended intercostal nerve afterwards, rare in other surgical fields, are common blockade (e.g. paravertebral space injection). Hypoxia enough to be high in the differential of any untoward and accumulation of carbon dioxide occurred as a situations developing perioperatively.

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CMYK127 Conacher: Anesthesia for thoracoscopic surgery

TRANSITION FROM THE OPEN SURGERY ACHIEVING OLV PARADIGM Lung separators are inserted into the airway and A certain amount of interdisciplinary re-balancing is stabilized in one or other bronchus. There are three necessary as the surgical operative paradigm shifts from categories of lung separator: the double-lumen tube, open to endoscopic methods. For instance, vascular the bronchus blocker and, increasingly difficult to and gastro-enterological surgeons have to get familiar acquire, the endobronchial tube [Figure 1]. For each, with new directions of approach to the mediastinum, there are positives and negatives, which are beyond the oesophagus and the lung apex. They and their the brief here. Given the trends in materials and anesthetic partners, have to familiarise themselves technology and an increasing reliance of the anesthetic with the culture, protocol, processes and problems of corpus on fibreoptic devices to help secure the airway, one lung ventilation (OLV). In turn, the practised need there is little doubt that the new generation bronchus to anticipate that the basket of morbid conditions will blockers such as the Univent, Arndt or Cohen cater to expand. perceived modern needs.[6] Logic, that older generation devices (transferable and perfectly adequate) as in An example is the change in surgical management many medical consumerist situations, is stifled by the of myasthenia gravis. Intervention is passing from weaknesses for imperatives of commerce and fashion. the traditional sternotomy for thymectomy to a Modern systems are dependent for safe operation suprasternal mediastinotomy or right video-assisted on fibreoptic technology: something of a case of a thoracoscopy.[1] Although the routine of OLV is necessity becoming a virtue. For those resistant to for muscle relaxants, there is no requirement in these compelling ideas, it is worth remembering myasthenics. Rarely, if ever, is there any requirement for that the double lumen tube is simple, flexible and postoperative respiratory support if all neuromuscular best sited with endobronchial portion in the left blockers, depolarising and non-depolarising, are main bronchus.[7] This gives reliably better lung eschewed. Sensitive use of deep inhalational anesthesia separating conditions and easier change for bilateral or total intravenous anesthesia and analgesia minimise and sequential procedures such as sympathectomy the hazard of these interval procedures in a life-long or the different phases of an oesophagectomy.[8] It slow mutating disease.[2] has been noted that the bronchus blockers may not give adequate support to the bronchus of the lung COMMON THEMES OF OLV being ventilated with a significant increase in risk of

It is well within conventional practice to conduct thoracoscopy without formal OLV, but operating risks are increased and less than ideal operating conditions more frequent.[3-5] A requirement for one lung to be shifted away from the operating field largely defines the anesthetic process and is most easily satisfied by deliberately withholding ventilation from one lung - for description the ‘surgical lung’. Operatively, the hemi-thorax becomes surgically more spacious by due process of lung collapse. In some situations this usual sequence may not be sufficient: carbon dioxide insufflation may be required to separate the pleura and maintain collapse.

Figure 1: Lung separators. (from L to R) Double lumen tube (right sided There are lung ventilation, postoperative management - note slot for upper lobe bronchus): Endobronchial tube (Macintosh Leatherdale - left sided): Bronchus blocker (Cohen/Cook model) and and complication issues specific to OLV. ancillary

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128 CMYK Conacher: Anesthesia for thoracoscopic surgery producing air-trapping, circulatory dysfunction and Increase in shunt fraction barotraumas.[9] This may be increasingly pertinent with Stopping ventilation to a lung increases the proportion the rise in numbers of the obese in developed societies of the cardiac output that is not oxygenated (shunt presenting for surgery. And is just one of several fraction). Normally the shunt is in the region of 20-28%, potential causes of a dangerous and confusing clinical irrespective of whether the anesthetic is volatile agent complex of dynamic hyperinflation. This may require (isoflurane, sevoflurane, desflurane) or intravenous urgent treatment and a remedial pattern of positive agent (propofol, opioid) based. Increasing the inspired pressure ventilation. The presenting syndromic of realistically does not have any effect above hypoxia and hypotension however is much more a this value. Some patients, notably the younger and common feature when there is intrinisic pulmonary fitter tend to the higher level and are harder to deal pathology; and is particularly marked in thoracoscopic with. Attendants must resist temptation to raise the lung volume reduction surgery.[10,11] level of intervention beyond the safe. Even though it usually reflects a ventilation problem, surgery should CONSEQUENCES OF OLV not continue until oxygen saturations are consistently above 90%. Attempts to improve the oxygen flux The effects of stopping the ventilation of one lung by pharmacological manipulation to produce a can be categorized by the following: some or all of ‘pneumonectomy circulation’ should be discouraged.[13] which may result in physiological trespass and can act Temporarily ‘soft’ clamping the pulmonary artery to independently or summate: stop the shunt flow is advocated by the experienced, • Open pneumothorax and the additive effect of but it too is not without risk that is difficult to justify. carbon dioxide insufflation • Increase in anatomical shunt (perfusion of a non- Adopting the lateral decubitus position ventilated lung). This increases gravitational influences by adding • Adoption of the lateral decubitus position the weight of the mediastinum to other forces that physically reduce the functional residual capacity of the Open pneumothorax dependent (ventilated) lung. However there may be a Once the intrinisic negative pleural pressure dynamic beneficial effect as pulmonary blood flow is redistributed is breached, the lung collapses and retracts toward to the ventilated zone - in effect improving ventilation/ the hilum due to intrinsic elasticity. So effective perfusion ratios and reducing the physiological shunt. usually is the effect of this passive intervention that If bronchus blockers are used, the dependent main the additional insufflation of carbon dioxide rarely bronchus is unsupported and compressed by the weight is required to separate the visceral from the parietal of the mediastinum: hypoventilation and/or dynamic pleura. A lung that does not collapse is as likely to be hyperinflation can result. due to the anchoring by pleural adhesions, as it is a fault of inadequate lung separation. But it is always worth Ventilation of the single lung checking the anesthetic side (e.g. inadequate bronchus It is essential to apply the same minute volume (to cuff seal) before seeking and treating pleural adhesions maintain normocarbia) to one lung. Given the switch to and resorting to carbon dioxide insufflation. OLV and to reduce the inflation pressure, it is achieved by reducing the calculated to a lower range Carbon dioxide creates ‘tension’. The rise in intrathoracic of 5-10 ml per kg, adjusting the ventilation frequency pressure reduces venous return, pulmonary blood flow rate to stabilize the end tidal carbon dioxide.[14] and increases right heart workload.[5,12] In general and in practice, these would appear to influence process Dispute resolution practically no more than occasional and overzealous OLV must never be assumed to be safe.[15] No operating surgical activity close to the pulmonary artery or atria should be conducted with oxygen saturations of less of the heart. then 90%. The safe position always is ventilation of

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CMYK129 Conacher: Anesthesia for thoracoscopic surgery both lungs and 100% oxygen. A saying ‘CPAP to the protect and promote healing of anastomoses, increase top (surgeon’s lung) PEEP to the bottom (anesthetist’s/ resistance to infection and the formation of venous dependent lung)’ refers to a traditional view of lateral thromboses, maintain gastro-intestinal activity and give thoracotomy practice by which some compromise a sense of well-being during a prolonged debilitating of these conflicting situations can be produced. The recovery. oxygen reservoir capacity of the surgeon’s lung can be enhanced by partial re-expansion and oxygen There is only speculation that Objective 4 realistically is insufflation without too much impedance to surgical achievable but a more proactive approach to the design, working conditions.[16] Occasionally, surgery only may number and site of ports is likely to pay dividends be possible by alternating with ventilation; and cycle in the amount of prolonged post-thoracotomy type change instituted as oxygen saturations drop into the discomfort and neuralgia.[20] low 90’s. POSTOPERATIVE MAINTENANCE INTRAVENOUS POSTOPERATIVE MANAGEMENT FLUID

Analgesia Special attention to this aspect is necessary because of Recently the objectives of pain relief have been a condition variously named postoperative pulmonary defined.[17] edema or post-pneumonectomy pulmonary edema. Characterized as a consequence of OLV and classically 1 Humanitarian unilateral, it is part of a spectrum of acute respiratory 2 Reverse the effects of surgery (in context - reduced distress syndrome and as such difficult to separate from chest wall and pulmonary compliance) more usual confounding diagnoses like pneumonia, 3 Promote healing bronchiolitis, aspiration and sepsis. Though premorbid 4 Prevent transition to chronic pain syndromes. dispositions (COPD, cardiac, liver disease), surgical (prolonged handling) and anesthetic (ventilator induced Achieving standard for Objectives 1 and 2 is all that is damage) have been identified, prevention policy and required for much thoracoscopic practice. The painful management of the condition are best viewed clinically experience relatively is short-lived; an aided ability to on the basis of a failing or failed pulmonary lymphatic take deep breaths and cough can be anticipated and a system.[21] Attendants should resort to a traditional rapid return to mobility is likely with early removal of colloid fluid restriction (1ml/kg/hour) maintenance chest drains, if present. Routine and standard patient policy if any of the specific OLV factors are suspected; controlled analgesia systems (PCAS) containing opioids and full clinical management upgrade, as for acute generally are all that are required, in combination respiratory distress syndromes, if signs develop. with oral supplementation with simple analgesics and non-steroidal anti-inflammatory drugs. Percutaneous REFERENCES paraverteral blockade is known to reduce the pressor reactions to the nociception of thoracic surgery: it is 1. Manlulu A, Lee TW, Wan I, Law CY, Chang C, Garzon JC, et al. Video-assisted thoracic surgery thymectomy for non-thymomatous feasible to prolong this form of anti-nociception by myasthenia gravis. Chest 2005;128:3454-60. inserting epidural-type catheters during surgery and 2. Della Rocca G, Coccia C, Diana L, Pompei L, Costa MG, Tomaselli E, et [18,19] al. Propofol or sevoflurane anesthesia without muscle relaxants allow infusion of local anesthetic postoperatively. Chest the early extubation of myasthenic patients. Can J Anesth 2003;50:547- drains also can be used as conduits for local anesthetics. 52. For esphagectomies, in which a more prolonged bedfast 3. Horswell JL. Anesthetic techniques for thoracoscopy. Ann Thorac Surg 1993;56:624-9. and hypercatabolic state is anticipated, resources early 4. Rozenberg B, Katz Y, Isserles SA, Baitman B. Near sitting position and should be directed to an epidural-based technique two lung ventilation for endoscopic transthoracic sympathectomy. J to function throughout the perioperative period. Cardiothorac Vasc Anesth 1996;10:210-2. 5. Olsfanger D, Jedeikin R, Fredman B, Shachor D. Tracheal anaesthesia Historical and observational evidence supports the for transthoracic sympathectomy: An alternative to endobronchial intuitive sense that Objective 3 should be sought to anaesthesia. Br J Anaesth 1995;74:141-4.

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6. Cohen H, Benumof JL. Lung separation in the patient with a difficult 16. Conacher ID. Pre-emptive analgesia and the paravertebral space: An airway. Curr Opin Anaesthesiol 1999;12:29-35. ignis fatuus. Br J Anaesth 2006;96:667-8. 7. Conacher ID. Anaesthesia for thoracoscopic surgery. Best Pract Res 17. Kaya FN, Turker G, Basagan-Mogol E, Goren S, Bayram S, Gebitekin C. Clin Anaesthesiol 2002;16:53-62. Preoperative multiple injection thoracic paravertebral blocks reduce 8. Chui PT, Mainland P, Chung SC, Chung DC. Anaesthesia for three- postoperative pain and analgesic requirements after video-assisted stage oesphagectomy: An initial experience. Anaesth Intensive Care thoracic surgery. J Cardiothorac Vasc Anesth 2006;20:639-43. 1994;22:593-6. 18. Soni AK, Conacher ID, Waller DA, Hilton CJ. Video-assisted 9. Conacher ID, Velasquez H, Morrice DJ. Endobronchial tubes - a case thoracoscopic placement of paravertebral catheters: A technique for re-evaluation. Anaesthesia 2006;61:587-90. for postoperative analgesia for bilateral thoracoscopic surgery. Br J 10. Myles PS, Ryder I. Pulse oximetry. Lancet 1995;346:850. Anaesth 1994;72:462-4. 11. Conacher ID. Dynamic hyperinflation - the anaesthetist applying a 19. Richardson J, Cheema S. Thoracic paravertebral nerve block. Br J tourniquet to the right heart. Br J Anaesth 1998;81:116-7. Anaesth 2006;96:537. 12. Wolfer RS, Krasna MJ, Hasnain JU, McLaughlin JS. Hemodynamic effects 20. Slinger PD. Acute lung injury after pulmonary resection:more pieces of carbon dioxide insufflation during thoracoscopy. Ann Thorac Surg to the puzzle. Anesth Analg 2003;97:1555-7. 1994;58:404-8. 21. Conacher ID. Postoperative pulmonary oedema - tussles with Starlings 13. Conacher ID. 2000 - Time to apply Occam’s Razor to failure of hypoxic in the death zone. Anaesthesia 2006;61:211-4. pulmonary vasoconstriction. Br J Anaesth 2000;84:434-6. 14. Management of patients undergoing oesophagectomy. In: The Report of the National Confidential Enquiry into Perioperative Deaths 1996/1997. Compiled by Gray AJ, Hoile RW, Ingram GS, Sherry KS. Cite this article as: Conacher ID. Anesthesia for thoracoscopic surgery. J Min National CEPOD: London; 1998. p. 57-61. Access Surg 2007;4:127-31. 15. Pfitzner J, Peacock MJ, Daniels BW. Ambient pressure oxygen Date of submission: 09/01/07, Date of acceptance: 12/01/07 reservoir apparatus for use during one-lung anaesthesia. Anaesthesia Source of Support: Nil, Confl ict of Interest: None declared. 1999;54:454-8.

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