J Thorac Cardiovasc Surg 2006;131:1424-1425
© 2006 The American Association for Thoracic Surgery
Reply to the Editor
Joshua H. Burack, MD
Department of Surgery, Division of Cardiothoracic Surgery, State University of New York–Downstate, Box 40, 450 Clarkson Ave, Brooklyn, NY 11203
Thank you for the invitation to respond to the letter written by Drs Jutley, Cooper, and Rocco. The worldwide interest in the application of minimally invasive techniques to patients who have sustained penetrating chest trauma is stimulating. The uniportal technique is a novel and innovative approach to thoracoscopic surgery, with the proposed benefit of a single incision and reduced pain. The reported technique requires small roticulated endoscopic instruments, a single incision in the fifth interspace and the posterior axillary line, and an operation performed in a sagittal plane. Furthermore, the reduction of postoperative pain has been documented in a small retrospective series of 16 patients.
1
However, the interspace is substantially smaller in the posterior rather than anterior thorax, and I suppose that the effect of instrumenting a narrow posterior interspace might cause more, and not less, pain, particularly if an endoscopic clamp, a 5-mm video camera, and an 11-mm endostapler are all placed through the same incision.
Furthermore, I anticipate technical limitations with the ability to perform an exploratory thoracoscopy for traumatic injury through a single incision in the midthorax. During the course of elective surgical intervention for bullous disease, interstitial disease, or a pulmonary nodule, a midscapular incision is recommended for lesions in the superior or apical segments, and a posterior axillary incision is recommended for lingular or middle lobe lesions.
1,2
There is no such preoperative target in the case of traumatic injury, and thoracoscopy is a true exploration. The entire pleural cavity must be inspected, and many times the video camera is moved from one port to another to obtain a comprehensive view. I suspect that in all but the most limited injury, it would be unwise to limit the exploration to a single point of view. However, the uniportal technique might be valuable as an initial diagnostic maneuver, and if the entire injury is comfortably visualized and if endoscopic stapled resection is not required, the uniportal technique might suffice.
Because of concerns regarding the anatomic constraints of the posterior approach and the potential for a less than complete trauma exploration, I would only consider the uniportal approach of potential value as an initial diagnostic maneuver, and I would continue to approach most patients with complex penetrating chest injury with a conventional 3-port approach or open thoracotomy.
 |
References
|
|---|
- Jutley RS, Khalil MW, Rocco G. Uniportal vs. Standard three-port VATS technique for spontaneous pneumothorax. comparison of post-operative pain and residual paraesthesia. Eur J Cardiothoracic Surg 2005;28:43-46.[Abstract/Free Full Text]
- Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-728.[Abstract/Free Full Text]
Top
References