1. Indications for Thoracoscopy in Infants and Children 50th Meeting of the Brazilian Association of Pediatric Surgeons George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. 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

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

4. Post Thoracotomy Sequelae 1.Durning RP, et al: J Bone Joint Am 62, 1980 2.Gilsanz V, et al: AJR Am J Roentgenol 1983 3.Jaureguizar E, et al: J Pediatr Surg 1985 4.Chetcuti P, et al: J Pediatr Surg 1989 5.Goodman P, et al: J Comput Assist Tomogr 1993 6.Frola C, et al: AJR Am J Roentgenol 1995

5. Thoracoscopy Patient Positioning

7. Children’s Mercy Experience Jan 2000 – June 2007 230 patients = 231 thoracoscopic operations Age = 9.6 ± 6.1 years Weight = 36.6 ± 24.1 kg 115 boys : 115 girls JLAST 18:131-135, 2008

8. Thoracoscopic Operations Children’s Mercy Experience (2000-2007) 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 18:131-135, 2008

9. 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 18:131-135, 2008

10. 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)

11. Conclusion Safe and effective Primary diagnostic and therapeutic application for most thoracic conditions

12. Thoracoscopy - Empyema Technique Three 10 mm incisions (triangle) 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

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

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

15. Thoracoscopy - Empyema Watch the full video.

17. Patient Variables at Consultation WBC 20.819.70.71 Weight (kg) 24.620.70.52 Age (Years) 4.8 5.20.77 Days of Symptoms 9.010.60.32 VATStPA P Value O2 support (L/min) 0.81 0.790.96 Study Results ER/PCP visits 2.9 2.70.69 J Pediatr Surg 44:106-111, 2009

18. Outcomes 16.6% failure rate for fibrinolysis VATStPA P Value PO Fever (Days) 3.1 3.80.46 O2 tx (Days) 2.25 2.330.89 LOS (Days) 6.89 6.830.96 Patient Charges $11,660$7,5750.01 Analgesic doses22.321.40.90 Study Results J Pediatr Surg 44:106-111, 2009

19. London Prospective Trial VATS v Fibrinolysis w/Urokinase No difference in LOS (6 v 6 days) No difference in 6 month CXR VATS more expensive ($11.3K v $9.1K) 16 % failure rate for fibrinolysis Am J Respir Crit Care Med 174:221-227, 2006

21. Current Management 2008 - 2011 Fibrinolysis has been our initial therapy 4 mg tPA in 40 cc saline for 3 days through a 12 Fr chest tube 102 consecutive patients 15.7% failure rate Mean hospitalization after initiation of fibrinolysis – 6.1 d +/- 2.5 Mean O.R. time after failed fibrinolysis – 65 min Mean hospitalization after thoracoscopy – 5.9 d +/- 3.7

22. Thoracoscopy - Duplication Watch the full video.

23. Thoracoscopy – Lymph Node Bx Watch the full video.

24. Thoracoscopic Lobectomy Intralobar sequestration CCAM Bronchiectesis Lobar emphysema Other lobar conditions

25. Principles Single lung ventilation Double lumen ETT Contralateral mainstem intubation Bronchial blocker

26. Principles Lateral patient position Monitor over patient’s shoulder Surgeon/assistant on anterior side of patient Work medial to lateral; do not flip lung over Do not hesitate to convert

27. Thoracoscopy – Left Lower Lobectomy Watch the full video.

28. Thoracoscopic Repair EA/TEF

29. 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

30. Thoracoscopic Repair EA/TEF

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

33. Preoperative Bronchoscopy Watch the full video.

34. Port/Instrument Positions

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

36. Tips/Tricks Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF J LAST 17:380-382, 2007

37. How To Get Started Not The Ideal Case 2 - 2.5 kg Very high upper pouch Complex single ventricle physiology Prostaglandin dependent

38. How To Get Started Ideal Case Baby – 2.5-3 kg; no other anomalies Esophageal segments close together (CXR, Bronchoscopy) Start thoracoscopically – Go as far as comfortable Try it again

39. Summary Thoracoscopy can be done safely and effectively in infants and children Patient selection always important Distinct advantages, esp avoidance of musculoskeletal sequelae

40. www.cmhmis.com QUESTIONS