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Background: It is widely believed that bilateral thoracoscopic lung volume reduction (BTLVR) yields superior results when compared with unilateral thoracoscopic lung volume reduction (UTLVR) with regard to spirometry, functional capacity, oxygenation and quality of life results., Methods: To address these issues, we compared the results of patients undergoing UTLVR (N = 338 patients) and BTLVR (N = 344 patients) from 1993 to 1998 at five institutions. Follow-up data were available on 671 patients (98.4%) between 6 and 12 months after surgery, and a patient self-assessment was obtained at a mean of 24 months., Results: It was found that BTLVR provides superior improvement in measured postoperative percent change in FEV1 (L) (UTLVR 23.3% +/- 55.3 vs BTLVR 33% +/- 41, p = 0.04), FVC(L) (10.5% +/- 31.6 vs 20.3% +/- 34.3, p = 0.002) and RV(L) (-13% +/- -22 vs -22% +/- 17.9, p = 0.015). BTLVR also provides a slight improvement over UTLVR in patient's perception regarding improved quality of life (UTLVR 79% vs BTLVR 88%, p = 0.03) and dyspnea relief (71% vs 61%, p = 0.03). There was no difference in mean changes in PO2 (mm Hg) (UTLV 4.5 +/- 12.3 vs BTLVR 4.9 +/- 13.3, p = NS), 6-minute walk (UTLVR 26% +/- 66.1 vs BTLVR 31% +/- 59.6, p = NS) or decreased oxygen utilization (UTLVR 78% vs BTLVR 74%, p = NS)., Conclusions: These data suggest that both UTLVR and BTLVR yield significant improvement, but the results of BTLVR seem to be superior with regard to spirometry, lung volumes, and quality of life.

Objective: Most reports of thoracoscopic lung volume reduction (TLVR) are relatively small and early experiences from a single institution, factors which limit both the statistical validity and the applicability to the population at large. In order to address these shortcomings we undertook an analysis of the TLVR experience at five separate institutions to assess operative morbidity and identify predictors of mortality., Methods: Questionnaires were sent to four groups of surgical investigators at five institutions actively performing TLVR. Data was requested regarding preoperative, operative and postoperative parameters. Twenty-five potential predictors of mortality were analyzed and seven proved to be at least marginally significant (P<0.10). These parameters were entered into a stepwise logistic regression analysis to identify independent predictors., Results: The 682 patients (415 males, 267 females, mean age 64.0 years) underwent unilateral (410) or bilateral (272) TLVRs. Overall, operative mortality was 6% with half of the deaths resulting from respiratory causes. The remaining patients were discharged to home (88%), a rehabilitation facility (4%) or a ventilator facility (2%). There were 25 perioperative factors chosen representing clinically important indices such as spirometry, oxygenation, functional status, clinical and demographic variables. Univariate analysis identified seven variables as predictors of mortality (P<0.10) and these were entered into a stepwise logistic regression analysis. Only age, 6-min walk, gender (male 8%, female 3% mortality) and the procedure performed (unilateral 4.6%, bilateral 8%) were independent predictors while preoperative steroid therapy, preoperative oxygen administration, and time since smoking cessation dropped out of the model. The specific institution, learning curve (early vs. late experience), type of lung disease, spirometric indices and predicted maximum VO(2) were not significant predictors., Conclusion: This experience suggests that unilateral and bilateral lung volume reduction procedure can be performed with acceptable morbidity and mortality. Although age, gender, exercise capacity and the procedure performed are all independent predictors of mortality, the risk of operative death did not appear excessive in this fragile patient subset.

Background: It has been suggested that bilateral thoracoscopic lung volume reduction (BTLVR) yields significantly better long-term survival than unilateral thoracoscopic lung volume reduction (UTLVR)., Methods: All perioperative data were collected at the time of the procedure. Follow-up data were obtained during office visits or by telephone., Results: A total of 673 patients underwent thoracoscopic LVR: 343 had either simultaneous or staged BTLVR and 330, UTLVR. As of July 1998, follow-up was available on 667 (99%) of the 673 patients with a mean follow-up of 24.3 months. The patients in the BTLVR group were significantly younger (62.6+/-8.0 years versus 65.4+/-8.1 years; p < 0.0001), had a higher preoperative arterial oxygen tension (69.7+/-12 mm Hg versus 65.3+/-11 mm Hg; p < 0.0001), and had a superior preoperative 6-minute walk performance (279.9+/-93.6 m [933+/-312 feet] versus 244.5+/-101.4 m [815+/-338 feet] p < 0.0001). There was no difference in the operative mortality rate between the two groups (UTLVR, 5.1%, and BTLVR, 7%). Actuarial survival rates for the UTLVR group at 1 year, 2 years, and 3 years were 86%, 75%, and 69%, respectively versus 90%, 81%, and 74%, respectively, for the BTLVR group (p = not significant)., Conclusions: Contrary to previous reports, survival after BTLVR was not superior to that after UTLVR even though the former group appeared to have a lower risk preoperatively because of younger age, higher arterial oxygen tension, more advantageous anatomy, and better functional status. Despite thoracoscopic LVR, the actuarial mortality rate approached 30% at 3 years, and this calls into question whether this procedure offers any survival advantage to patients with end-stage emphysema.

Background: A previous operation is generally considered to be a relative contraindication to the minimal access approach. We reviewed our combined experience from three centers with video-assisted thoracic surgery on reoperated chests., Methods: From September 1992 to December 1996, 2,477 patients underwent video-assisted thoracic surgery of whom 40 patients (33 men; age range, 9 to 78 years) had prior operations on the ipsilateral side of the chest: 23 after prior open procedures (22 thoracotomies, 1 median sternotomy) and 17 after video-assisted thoracic surgery. The second procedures consisted of bullectomy or bulla ligation (8), mediastinal and hilar mass biopsy (8), wedge lung resection (6), pericardial window (5), lung volume reduction (4), redo thoracodorsal sympathectomy (3), talc insufflation alone (3), decortication (2), and suturing of a pleural rent (1)., Results: Adhesions were noted in all patients ranging from minimal to strong fibrous adhesions. However, in only 2 patients (5%) were the procedures abandoned because of adhesions. Video-assisted thoracic surgery was safely completed in all other patients. There was no mortality or intraoperative complications and mean hospital stay was 5.1 +/- 3.2 days (range, 0 to 17 days)., Conclusions: Video-assisted thoracic surgery on reoperated chests is feasible and does not carry a higher morbidity or mortality compared with first-time operations, even though it may be technically more difficult. Experience and clinical judgment, however, are required to select these patients for reoperation with video-assisted thoracic surgery.

Video-assisted thoracic surgery (VATS) has enabled more complex procedures previously requiring thoracotomy to be accomplished in lung cancer management. VATS today can be employed in the evaluation of idiopathic (and known) malignant pleural effusions, mediastinal adenopathy, indeterminate pulmonary nodules, and compromise resection and lobectomy of peripheral stage I non-small cell lung cancer. Thus, VATS is becoming an accepted approach to a variety of intrathoracic problems, although its absolute indications for patients with lung cancer have yet to be firmly defined. This article reviews the authors' current experience with VATS procedures in the treatment of patients with lung cancer.

Video-assisted thoracic surgery or thoracoscopy has proved to be valuable in many settings in thoracic surgery. The use of video-assisted thoracic surgery in trauma has been limited, especially with respect to penetrating trauma. We report the use of thoracoscopy to remove intrathoracic fragments of glass and avert the need for a thoracotomy.

Background: Surgical procedures for emphysema have been proposed and in many settings resulted in significant improvement in dyspnea and function. The most prevalent surgical problem in all series is prolonged postoperative air leak., Methods: One hundred twenty-three patients undergoing stapled thoracoscopic unilateral lung volume reduction operation were prospectively randomized to receive either no buttressing of their staple lines or buttressing of all staple lines with bovine pericardial strips., Results: The two groups were comparable in preoperative risks and in the severity of their emphysema. Postoperative complications were identical in the two groups with respect to pneumonia, empyema, and wound infection; however, there was a significant difference in the duration of postoperative air leaks. Those having the pericardial strips used to buttress their staple lines had chest tubes removed 2.5 days sooner and were discharged from the hospital 2.8 days sooner as a result. The cost data revealed that because of the cost of the pericardial sleeves, the overall hospital charges were almost identical for the two groups ($22,108 bovine, $22,060 no bovine) in spite of the shortened hospital stay., Conclusions: The use of bovine pericardial sleeves to buttress the staple lines in thoracoscopic unilateral lung volume reduction operation results in a shorter duration of postoperative air leaks. Total hospital charges were comparable in the two groups as the 2.8 days saved in the hospital were offset by the cost of the pericardial sleeves.

One hundred forty-one patients were prospectively enrolled in a study of contact-tip laser bullectomy at four institutions. Ninety-one have had both preoperative and postoperative testing at 3 months. Nonsmoking patients with disabling dyspnea at less than 50 yards and with a forced expiratory volume in 1 second of 35% or less were enrolled. Testing included formal pulmonary function tests, arterial blood gasses, computed tomographic scans, ventilation/perfusion scans, echocardiograms, electrocardiograms, 6-minute walk testing, transdiaphragmatic pressures, and quality of life and dyspnea index questionnaires. A modest 16% improvement was noted in forced expiratory volume in 1 second (0.69 to 0.80 L), and there was a 29% improvement in 6-minute walk distances (655.2 to 846.3 feet). Oxygen use was completely discontinued in 16%. Risk factors for mortality included age, 6-minute walk distances, low diffusing capacity for carbon monoxide, high carbon dioxide tension, and high base excess. Minor improvement was judged from the dyspnea index and the Medical Outcome Study Short Form-36. Preoperative predictors of good outcome included heterogeneous disease, lack of carbon dioxide retention, and no emaciation (weight < 40 kg). Comparison of our results with those in the literature suggests that the improvement seen with the contact neodymium:yttrium-aluminum-garnet laser is not as good as that provided by the stapled techniques for volume reduction.

Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage +/- decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 +/- 2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4 +/- 7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8 +/- 0.5 days postoperatively and hospital stay averaged 4.3 +/- 1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.

Video-assisted thoracic surgery has been widely used in the treatment of spontaneous pneumothorax despite a paucity of data regarding the relative safety and long-term efficacy for this procedure. We reviewed 113 consecutive patients (68 male and 45 female patients, aged 15 to 92 years, mean 35.1) who underwent 121 video-assisted thoracic surgical procedures during 119 hospitalizations from 1991 through 1993. Recurrent ipsilateral pneumothorax was the most frequent indication for surgery and occurred in 77 patients (65%). The most common method of management was stapling of an identified bleb in the lung, which was undertaken in 105 (87%) patients. No operative deaths occurred. Complications included an air leak lasting longer than 5 days in 10 (8%) patients, two of whom required second procedures for definitive management. No episodes of postoperative bleeding or empyema occurred. The postoperative stay ranged from 1 day to 39 days (median 3 days, average 4.3 days) and 99 patients (84%) were discharged within 5 days. Mean follow-up was 13.1 months and ranged from 1 to 34 months. Eleven patients (10%) were lost to follow-up. Ipsilateral pneumothorax recurred after five of 121 procedures (4.1%). Twelve perioperative parameters (age, gender, race, smoking history, site of pneumothorax, severity of pneumothorax, operative indications, number of blebs, site of blebs, bleb ablation, method of pleurodesis, and prolonged postoperative air leak) were entered into univariate and multivariate analysis to identify significant independent predictors of recurrence. The only independent predictor of recurrence was the failure to identify and ablate a bleb at operation, which resulted in a 23% recurrence rate versus a 1.8% rate in those with ablated blebs (p < 0.001). These data suggest that video-assisted thoracic surgery is a viable alternative to thoracotomy for the treatment of recurrent spontaneous pneumothorax. It results in a short hospital stay, low morbidity, high patient acceptance, and a low rate of recurrence.

The Video Assisted Thoracic Surgery Study Group was formed to collect data on thoracoscopic procedures in an effort to define the role for this new technique. With more than 40 participating institutions, 1,820 cases have been collected through December 1992. Lung nodules and pleural effusions represent the most frequent indications, and wedge resection and operation in the pleural space were the most common procedures performed. Four hundred thirty-nine procedures (24%) were converted to a thoracotomy because of the need for more extensive resection (219), inability to find the pathology (65), too large a lesion or difficult location (62), adhesions (58), equipment failure (25), or bleeding (10). Prolonged air leak (> 5 days) was the most frequent complication. Patients undergoing video-assisted thoracic surgery and wedge resection had a mean hospital stay of 5.1 days; video-assisted thoracic surgical lobectomy was performed in 38 patients, who had a mean stay of 6.3 days. Air leaks were more prevalent in patients with poor pulmonary function (forced expiratory volume in 1 second < 1 L) and the elderly (> or = 75 years) after video-assisted thoracic surgical wedge resection. Video-assisted thoracic surgery appears safe and may be advantageous for some procedures. Further studies will be required to define its precise role in thoracic surgery.

Traditional nonoperative diagnostic approaches to the indeterminate solitary pulmonary nodule include bronchoscopy and percutaneous needle biopsy. Although both methods are minimally invasive, the diagnosis of the small, peripheral nodule may remain elusive. Open thoracotomy is often required when these methods fail to obtain a diagnosis. Between January 1991 and June 1992, 242 patients with indeterminate solitary lung nodules underwent thoracoscopic excisional biopsy as the primary diagnostic method. Wedge excisions of the nodules were all performed by thoracoscopic techniques using an endoscopic stapler alone (72%), neodymium:yttrium-aluminum garnet laser (18%), or both (10%). A definite diagnosis was obtained in all patients. Two patients required conversion to thoracotomy to locate the nodule (both malignant). A benign diagnosis was obtained in 127 patients (52%) and a malignant diagnosis in 115 (48%). Of the malignant nodules, 51 (44%) were primary lung cancer and 64 (56%) were metastases. All patients diagnosed with primary lung cancer having adequate pulmonary reserve (n = 29) underwent formal open lung resection during the same procedure. There was no mortality, and significant morbidity was limited to atelectasis in 3 patients (1.2%), pneumonia in 2 patients (0.8%), and prolonged air leak more than 7 days in 4 patients (1.6%). Average hospital stay for patients having thoracoscopy only (n = 213) was 2.4 days (range, 1 to 12 days). Thoracoscopy offers a minimally invasive approach for the diagnosis of the indeterminate solitary nodule. It has advantages over traditional diagnostic methods of being virtually 100% sensitive and 100% specific with no mortality and minimal morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)

As with any operative procedure, careful preoperative and intraoperative planning are vital to achieving a safe and effective video-assisted thoracic surgical intervention. We outline some of our basic strategies for enhancing the success of this approach in the management of thoracic surgical problems.

For its first 80 years, thoracoscopy was primarily reserved for the evaluation and treatment of pleural disease. Extension of thoracoscopic techniques to management of parenchymal lung disease remained limited until the availability of endostaplers and adaption of video-assisted techniques through minimal access incisions. The widespread acceptance of mechanical staplers in open lung resections during the previous two decades has facilitated conversion to closed methods in the past 2 years. A variety of techniques for mechanical stapling in thoracoscopy are discussed. The impact of mechanical stapling in 300 consecutive thoracoscopic pulmonary resections is presented.

Median sternotomy has been a common approach for resection of bilateral pulmonary metastases. It provides good exposure and quick accessibility to most lesions in the lung. The retrocardiac left lower lobe may at times be a problematic area for resection of metastases. We have used a simultaneous median sternotomy and left video-assisted thoracoscopic approach to remove three such lesions in two patients, with satisfactory results.

Thoracoscopic techniques were used to perform a pericardiectomy in 35 patients with purely effusive pericardial disease after medical management and pericardiocentesis had failed to be effective. There were no intraoperative complications and postoperative complications were few. Two cases of dysrhythmia and 2 cases of pneumonia occurred postoperatively. Malignancy was identified as the cause in 18 patients and there were benign causes in the remaining 17. The hospital stay in the group with benign effusions was 4.6 days. There were no recurrences of pericardial effusions and no constrictive changes developed during a mean follow-up of 9 months. Fourteen (40%) patients had pleural or pulmonary abnormalities that were managed simultaneously thoracoscopically. These abnormalities included 2 pleural masses, 2 pulmonary nodules, and 12 pleural effusions. In 8 instances, the pericardiectomy was performed from the right pleural cavity in order to address the pleural or pulmonary problem. Thoracoscopic pericardial resection has proved safe and effective. It allows a wider pericardial resection than that usually permitted by the subxiphoid route, and should lessen the pain and the number of pulmonary complications, compared with open thoracotomy. An additional advantage is that it allows the visualization and management of simultaneous pleural and pulmonary abnormalities.

Thoracoscopy would seem to have several potential advantages over open techniques in terms of the attendant postoperative pain and pulmonary complications. Although many questions exist pertaining to the use of thoracoscopy in the therapeutic management of malignancies of the mediastinum, its use for benign disorders appears desirable. Since December 1990, we have removed 9 mediastinal cysts using a thoracoscopic procedure. These included 7 bronchogenic or enteric cysts, 1 pericardial cyst, and 1 thymic cyst. The average cyst size was 4.2 cm, with 11 cm the largest diameter. Complete removal of the cysts was possible in all but 1 case, in which the cyst adhered to vital structures. A portion of the cyst wall was therefore left intact and the mucosa cauterized. The average hospital stay in these patients was 2.1 days, and there were no intraoperative or postoperative complications. All cysts were benign. The resection of mediastinal cyst using thoracoscopic procedures and based on standard surgical indications would seem to be appropriate. Thoracoscopic removal should be considered as an alternative method to resection of mediastinal cysts.

Cervical mediastinoscopy is useful for the diagnosis of paratracheal lymph node metastasis from bronchogenic carcinoma. Access to adenopathy in the aorticopulmonary window, anterior mediastinal, periazygos, and subcarinal lymph nodes is difficult with this technique. Operative visibility in these locations through anterior mediastinotomy, the Chamberlain procedure, is limited. We have used thoracoscopic mediastinal exploration in 40 patients with computed tomographic scan evidence of enlarged aorticopulmonary window (n = 30) or enlarged right periazygos or subcarinal lymph nodes (n = 10). This procedure was used primarily as an adjunct to cervical mediastinoscopy in the staging of bronchogenic carcinoma. Adjunctive thoracoscopic nodal sampling was 100% sensitive and 100% specific in diagnosing the mediastinal adenopathy. It did not significantly delay thoracotomy in cases of benign adenopathy. Visibility of the ipsilateral pleural space and mediastinum was excellent. Thoracoscopic exploration with mediastinal nodal sampling is a valuable diagnostic adjunct for assessment of adenopathy inaccessible to cervical mediastinoscopy and can overcome many of the limitations of anterior mediastinotomy.

Significant advances in surgical equipment, video monitoring, and endoscopic surgical techniques have expanded the role of thoracoscopy to include pulmonary resection. One limitation of the thoracoscopic technique is the loss of manual palpation to identify the nodule that is either too small or too deep beneath the pleural surface. We describe the techniques used in 300 thoracoscopic pulmonary resections that have aided in identification of pulmonary nodules. These techniques include careful preoperative assessment of the computed tomogram, preoperative injection of methylene blue, or a needle localizing system to identify the nodule. Intraoperative techniques include instrument palpation, digital palpation, and intraoperative ultrasonography. It should be possible to identify the majority of pulmonary nodules at the time of thoracoscopy with these localizing techniques. All nodules were successfully identified in our last 200 thoracoscopic resections.

Many thoracic surgical procedures previously performed using open thoracotomy techniques can now be accomplished using video-assisted thoracic surgical approaches. This has primarily resulted from improvements in both the video and surgical instrumentation and the development of an effective endoscopic surgical stapling device. Laser technology that has been adapted for use in endoscopic surgery has been extended to video-assisted thoracic surgical applications for the resection of pulmonary nodules difficult to manage with the endoscopic stapler alone. We present our experience with the neodymium:yttrium-aluminum garnet laser as either a primary resective tool or as an adjunct to the endoscopic stapler in 67 consecutive patients who underwent video-assisted thoracic surgical wedge resection of the lung.

Background: Patients with diffuse pulmonary infiltrates often require biopsy for a diagnosis. Standard operative therapy, open wedge resection via thoracotomy, is associated with known morbidity. We hypothesized that closed thoracoscopic wedge resection may result in reduced morbidity and decreased duration of hospital stay. This retrospective study compares open resection with thoracoscopic wedge resection in patients with diffuse pulmonary infiltrates., Methods: Seventy-five patients with diffuse pulmonary infiltrates underwent diagnostic lung biopsy. Patients requiring mechanical ventilation and high levels of pressure support before biopsy were excluded from the study. Between March 1987 and September 1991, a total of 28 patients underwent open wedge resection via lateral thoracotomy. Since April 1991, a total of 47 patients underwent thoracoscopic resection., Results: There was no difference between the groups in age, sex, presence of immunosuppression, or final pathologic diagnosis. Adequate tissue was obtained for pathologic diagnosis in all patients of both groups. All surgeons believed that thoracoscopic biopsy provided better visualization of the entire lung than did a limited thoracotomy. Mean operative time was 69 minutes for open biopsies and 93 minutes for thoracoscopic biopsies [p = 0.038]. Mean duration of chest tube drainage was not significantly different between the two groups. Duration of hospital stay was significantly less for thoracoscopic biopsy (4.9 days) than for open biopsy (12.2 days) (p = 0.018). Fourteen of 28 open biopsies resulted in complications compared with 9 of 47 closed biopsies (p = 0.009). There were 6 deaths among patients having open biopsies and 3 deaths among those having closed biopsies (p = not significant)., Conclusion: A significant decrease in hospital stay was noted with thoracoscopic biopsy when compared with lung biopsy via the standard open approaches. Thoracoscopy provided excellent visualization and allowed for wedge resection that provided adequate tissue for diagnosis in patients with diffuse pulmonary interstitial disease.

Video-assisted thoracoscopy has recently evolved as an alternative to thoracotomy for several thoracic disorders. Spontaneous pneumothorax may be ideally suited for thoracoscopic management. Stapling of apical blebs and pleurodesis or pleurectomy can now be performed thoracoscopically in a fashion identical to the standard operation done through a lateral or axillary thoracotomy. We compared our results with thoracoscopic management of spontaneous pneumothorax in 26 patients (group I) with a group of 20 patients previously subjected to axillary thoracotomy (group II). Indications for operation, sex distribution, and average age (group I, 32.3 years; group II, 33.7 years) were comparable. Hospital stay was less in group I (2.88 +/- 0.99 days versus 4.47 +/- 1.07 days; p = 0.07), as was the use of parenteral narcotics after 48 hours (2/26 = 7.7% versus 14/20 = 70%; p = 0.01). There have been no recurrences to date (mean follow-up, 8 months) in the thoracoscopic group. Video-assisted thoracoscopic management of spontaneous pneumothorax allows performance of the standard surgical procedure while avoiding the thoracotomy incision. Video-assisted thoracoscopic management is safe and offers the potential benefits of shorter hospital stays and less pain.

Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (less than 3 cm) in the outer third of the lung. Patients with preoperative histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttrium-aluminum garnet laser (31), endoscopic stapler (29), or both (25). The mean diameter of the lesions was 1.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2), bleeding requiring transfusion (1), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drainage was 3.3 +/- 3.0 days. Mean postoperative stay was 5.7 +/- 4.9 days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 15; radiation fibrosis, 1; sclerosing hemangioma, 1; rheumatoid nodules, 1; granuloma, 2; nocardia, 1; infarct, 1; hamartoma, 4; scar, 1; cytomegalovirus pneumonia, 1), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 13 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)