1. IInnddiiccaattiioonnss ffoorr TThhoorraaccoossccooppyy iinn
IInnffaannttss aanndd CChhiillddrreenn
5500tthh MMeeeettiinngg ooff tthhee BBrraazziilliiaann
AAssssoocciiaattiioonn ooff PPeeddiiaattrriicc SSuurrggeeoonnss
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
JJLLAASSTT 1188::113311--113355,, 22000088

8. Thoracoscopic Operations
Children’s Mercy Experience (2000-2007)
Diagnostic No. of Patients
Wedge biopsy of solitary lung lesions 37
Biopsy and excision of mediastinal masses 26
Wedge biopsy of diffuse parenchymal disease 15
Evaluation of penetrating thoracic trauma
1
Total 79
Therapeutic
Pleural decortication for empyema 79
Exposure for scoliosis 26
Bullae resection for pneumothorax 25
Lobectomy 9
Repair of esophageal atresia and fistula 8
Evacuation of hemothorax and pleural effusion 3
Repair of bronchopleural fistula 1
Total JJLLAASSTT 1188::111335111--113355,, 22000088

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
JJLLAASSTT 1188::113311--113355,, 22000088

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

13. Thoracoscopy - Empyema
Technique
• 3rd incision (10 mm),
9th or 10th 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

17. Study Results
PPaattiieenntt VVaarriiaabblleess aatt CCoonnssuullttaattiioonn
VVAATTSS ttPPAA PP VVaalluuee
AAggee ((YYeeaarrss)) 44..88 55..22 00..77
WWeeiigghhtt ((kkgg)) 2244..66 2200..7 00..5522
WWBBCC 2200..88 1199..7 00..711
OO22 ssuuppppoorrtt ((LL//mmiinn)) 00..8811 00..799 00..9966
DDaayyss ooff SSyymmppttoommss 99..00 1100..66 00..3322
EERR//PPCCPP vviissiittss 22..99 22..7 00..6699
JJ PPeeddiiaattrr SSuurrgg 4444::110066--111111,, 22000099

18. Study Results
OOuuttccoommeess
VVAATTSS ttPPAA PP VVaalluuee
LLOOSS ((DDaayyss)) 66..8899 66..8833 00..9966
OO22 ttxx ((DDaayyss)) 22..2255 22..3333 00..8899
PPOO FFeevveerr ((DDaayyss)) 33..11 33..88 00..4466
AAnnaallggeessiicc ddoosseess 2222..33 2211..44 00..9900
PPaattiieenntt CChhaarrggeess $$1111,,666600 $$7,,55755 00..0011
1166..66%% ffaaiilluurree rraattee ffoorr ffiibbrriinnoollyyssiiss
JJ PPeeddiiaattrr SSuurrgg 4444::110066--111111,, 22000099

19. London Prospective Trial
VVAATTSS vv FFiibbrriinnoollyyssiiss ww//UUrrookkiinnaassee
• 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
AAmm JJ RReessppiirr CCrriitt CCaarree MMeedd 11744::222211--22227,,
22000066

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

23. Thoracoscopy – Lymph Node Bx

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

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
62 Patients
Waterston B
30 Patients
Waterston C
12 Patients
Operation converted 2 2 1
Operation staged 1 - -
Esophageal anastomotic leak 2 3 3
Stricture (on initial esophagram) 3 1 -
Patients needing only 1 dilation 7 5 -
Patients needing 2 dilations 9 1 2
Patients needing 3 dilations - 3 1
Patients needing >3 dilations 3 2 -
Recurrent tracheoesophageal fistula 1 1 -
Fundoplication 19 6 1
Imperforate anus operations 4 4 2
Duodenal atresia repairs - 2 2
Aortopexy 6 1 -
Death 1 - 2
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

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
JJ LLAASSTT 1177::338800--338822,, 22000077

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. QUESTIONS
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