Indications for Thoracoscopy in Children George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri

Indications for Thoracoscopic Procedures in Children Lung Biopsy Lobectomy Sequestration resection Excision bronchogenic cyst Foregut duplication resection Esophageal myotomy Anterior spine fusion Debridement/decortication Diaphragmatic hernia/plication - ? Spontaneous ptx PDA ligation Thoracic duct ligation Esophageal atresia repair Aortopexy Mediastinal mass exc/bx Thymectomy Sympathectomy Pericardial window Division of vascular ring Nuss operation Anterior spinal operations

Musculoskeletal Sequelae From Thoracotomy Shoulder elevation Limitation shoulder movement Scoliosis Respiratory dysfunction Mammary maldevelopment Atrophy chest wall muscles

Post Thoracotomy Sequelae 1.Durning RP, et al: J Bone Joint Am 62, Gilsanz V, et al: AJR Am J Roentgenol Jaureguizar E, et al: J Pediatr Surg Chetcuti P, et al: J Pediatr Surg Goodman P, et al: J Comput Assist Tomogr Frola C, et al: AJR Am J Roentgenol 1995

Thoracoscopy Patient Positioning

Data Points Age Weight Gender Type of operation Indication for operation Final diagnosis Chest tube Complications Length of stay

Children’s Mercy Experience Jan 2000 – June patients = 231 thoracoscopic operations Age = 9.6 ± 6.1 years Weight = 36.6 ± 24.1 kg 115 boys : 115 girls JLAST 18: , 2008

Thoracoscopic Operations Children’s Mercy Experience ( ) DiagnosticNo. of Patients Wedge biopsy of solitary lung lesions37 Biopsy and excision of mediastinal masses26 Wedge biopsy of diffuse parenchymal disease15 Evaluation of penetrating thoracic trauma1 Total79 Therapeutic Pleural decortication for empyema79 Exposure for scoliosis26 Bullae resection for pneumothorax25 Lobectomy9 Repair of esophageal atresia and fistula8 Evacuation of hemothorax and pleural effusion3 Repair of bronchopleural fistula1 Total151 JLAST 18: , 2008

Complications No intra-operative complications 3 conversions to open during lobectomy 2 right upper lobectomies (visualization) 1 left lower lobectomy (infection/inflammation) 1 persistent pneumothorax after bleb resection JLAST 18: , 2008

Results Length of stay = 3.8 ± 4.0 days –Excluding esophageal atresia and scoliosis Chest tubes in 211 patients (91%) –2.9 ± 2.0 days –Excluding esophageal atresia and scoliosis –93 traditional chest tubes –118 soft drains –20 patients without post- operative chest tubes (JLAST 19: S23-S25, 2009)

Conclusion Safe and effective Primary diagnostic and therapeutic application for most thoracic conditions at CMH

Thoracoscopy - Empyema Technique Initial incision 4 th or 5 th ICS, AAL Use telescope to compress lung and create working space 2 nd incision opposite 1 st one, PAL 10 mm cannulas, insufflation to 6-8 torr 10 mm angled telescope

Thoracoscopy - Empyema Technique 3 rd incision (10 mm), 9 th or 10 th ICS, MAL Site for chest tube exteriorization

Thoracoscopy - Empyema Technique Rotate instruments among the three incisions Can remove canula, insert curved ring forceps

Thoracoscopy - Empyema Please use this link if you experience problems viewing the video above.this link

Thoracoscopy - Duplication Please use this link if you experience problems viewing the video above.this link

Thoracoscopy – Lymph Node Bx Please use this link if you experience problems viewing the video above.this link

Thoracoscopy – Left Lower Lobectomy Please use this link if you experience problems viewing the video above.this link

Diagnosis of Malignancy via Thoracoscopy Alveolar Soft-part Sarcoma Ewing’s Sarcoma Ganglioneuroma Lymphoma Neuroblastoma Rhabdomyosarcoma Schwannoma Wilms’ Tumor Yolk Sac Tumor

Thoracoscopic Repair EA/TEF

EA/TEF Preoperative Evaluation Echocardiogram – assess cardiac anomalies Renal US – assess kidneys CXR/spine films – assess vertebral anomalies PE – assess limb, anorectal anomalies US great vessels – assess location of aortic arch

Thoracoscopic Repair EA/TEF

Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula: A Multi-Institutional Analysis George W. Holcomb III, Steven S. Rothenberg, Klaas MA Bax, Marcelo Martinez-Ferro, Craig T. Albanese, Daniel J. Ostlie, David C. van der Zee, C K Yeung American Surgical Association, 2005 Ann Surg 242: , 2005

Thoracoscopic Repair EA/TEF 104 Patients Waterston A: > 5.5 lb with no significant associated problems Waterston B: lbs. or higher weight with moderate pneumonia or congenital anomaly Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

Preoperative Bronchoscopy Please use this link if you experience problems viewing the video above.this link

Port/Instrument Positions

EA/TEF 89 pts/16 yrs shoulder elevation: 24% chest deformity: 20% abduction limited:100% spine deformities: 18% breast deformities: 27% (3/11) Why Thoracoscopy? Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy for tracheo-esophageal fistula. J Pediatr Surg 20: , 1985

Thoracoscopic Repair EA/TEF Fistula Ligation Metal clip Weck clip Tie (x2 ?) Suture ligature (x2 ?) Suture closure – tracheal side

Tips/Tricks Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF J LAST 17: , 2007

Tips/Tricks Oscillating ventilator U-clips anterior anastomosis JLAST 21: , 2011 Please use this link if you experience problems viewing the video above.this link

How To Get Started Not The Ideal Case kg Very high upper pouch Complex single ventricle physiology Prostaglandin dependent

How To Get Started Ideal Case Baby – kg; no other anomalies Esophageal segments close together (CXR, Bronchoscopy) Start thoracoscopically – Go as far as comfortable Try it again

QUESTIONS