The purpose of this book is to document the challenges related to "potential anatomical spaces", traditionally described as "hidden" spaces. The spread of video-assisted surgery and its application in the management of diseases involving organs or anatomical structures placed in the "potential spaces" neck, mediastinum, pro-peritoneum and retro-peritoneum, subfacial space of the leg, and axilla , has rendered their surgical anatomy less abstract.
Skip to main content Skip to table of contents. Advertisement Hide. This service is more advanced with JavaScript available. Additional pericardial biopsies can be performed if required. More recently, the thoracoscopic approach has been employed to perform video-assisted pericardioscopy to assess resectability of bulky non-small-cell lung cancer with suspicion of intrapericardial invasion of the pulmonary vessels [11].
Aff ter incision of the pericardial sac Fig. If these vessels are free from neoplastic invasion Fig. Operative view of the pericardial sac being incised by hook cautery. Figure 6. Videobronchoscopic examination of the intrapericardial tract of the pulmonary vessels.
Transbronchial and CT-guided percutaneous needle biopsy can be effective in T selected cases to confirm malignant cytology metastatic to mediastinal lymphnodes. However, a surgical biopsy is still required in many instances to establish a histologic diagnosis. Because of the access and visual limitations of cervical mediastinoscopy and anterior mediastinotomy, VATS techniques have been explored as an adjunctive modality to evaluate mediastinal lymphadenopathy, particularly when these are located out of the reach of the mediastinoscope or when a more comprehensive evaluation of the mediastinum is required and multiple sites within the mediastinum require biopsy.
The focus of many of the reported experiences with VATS evaluation of mediastinal lymphadenopaty has been in the extended staging of potentially resectable lung cancer [12] and esophageal cancer [13, 14].
VATS is also useful in the evaluation of primary mediastinal lymphadenopathy associated with benign and malignant lymphoid conditions [15]. It can also easily provide sufficient tissue to establish the histologic diagnosis of benign or infectious diseases, including sarcoidosis and lymphoid hyperplasia.
VATS avoids the more extensive and cosmetically unappealing anterior mediastinotomy incision and allows for immediate use of radiation therapy without the fear of detrimental wound healing problems. We currently routinely prefer VATS to anterior mediastinotomy for lymphadenopathies contained within the aorto-pulmonary window. However, we still prefer the anterior mediastinotomy approach for the diagnosis of large anterior mediastinal masses abutting the anterior chest wall.
In these cases, a simple anterior incision is preferable to the complications 56 Endoscopic surgery of the potential anatomical surrounding double-lumen endotracheal intubation, especially when the trachea is compressed by a huge mediastinal mass. Lymphadenopaty in aortopulmonary window. The dissection and sampling L of lymphnodes and other pathologic processes in these locations have been safe, accurate and technically feasible. General anesthesia and double-lumen endotracheal intubation are required.
For this VATS approach the patient is placed in right full lateral decubitus position, with the table rotated posteriorly to better expose the anterior part of the chest.
The thoracoscope is usually introduced through the sixth ICS along the middle axillary line. Second and third ICS access sites are obtained through the fourth ICS in the auscultatory triangle and along the anterior axillary line for dissecting instruments and the endoscopic clip applier Fig. If necessary, an additional 5 mm port can be placed between the second and the third port, always through the fourth ICS so that the most posterior access can be employed to retract the lung with a fan retractor.
A Figure 8 Operative view of VATS access for biopsy in the aorto-pulmonary window respecting the ideal triangular disposition of the camera and instrumentation. Lymphnode staging in lung cancer. VATS can be employed as an alternative L to anterior mediastinotomy for the biopsy of lymphnodes in the aortopulmonary window ascending aorta nodes and Botallo ligament nodes.
In addition, it also allows access to paraesophageal and pulmonary ligament levels that are not reachable either by mediastinoscopy or by anterior medastinotomy. In selected T. On the right side, VATS allows exploration of upper and lower paratracheal lymphnodes, subcarinal nodes, paraesophageal and pulmonary ligament nodes.
An additional advantage of using VATS for mediastinal staging of lung cancer is the possibility to concomitantly assess the resectability of bulky tumours with radiologic suspicion of mediastinal invasion and to discover unsuspected pleural seedings, thus avoiding unnecessary thoracotomy. Lymph nodes staging in esophageal cancer. Since lymphnode metastasis L has been shown to represent an important prognosticator in esophageal cancer, VATS A has been employed in combination with laparoscopy for staging of biopsy-proven esophageal cancer [13, 14].
Thoracoscopic lymphnodes staging is usually performed through a right approach and a three-trocar access that allows one to reach the right paratracheal nodes, the subcarinal nodes and most of the paraesophageal nodes. On the other hand, whenever noninvasive staging shows enlargement of the aortopulmonary window lymphnodes, a left-sided approach is preferred.
They are most commonly found in the middle mediastinum, although they may also be located in the 58 Endoscopic surgery of the potential anatomical posterior mediastinal compartment. They are often asymptomatic, being discovered incidentally. However, they may cause symptoms due to compression or irritation of adjacent structures and infection from communication with the tracheobronchiale tree.
Preoperative evaluation includes a chest X-ray, which usually reveals a well circumscribed rounded density with or without signs of calcifications in the capsula.
An air fluid level may be present if a communication with the gastrointestinal or respiratory tract does exist. An esophagogram may reveal distortion of the esophagus, while a CT scan can be useful to confirm the diagnosis and provide information about connections with the tracheobronchiale tree or the esophageal wall. Complete resection is the preferred management of these lesions. After positioning of the patient as previously described for similarly located lesions, proper exposure is achieved after division of thick adhesions which are frequently found in these instances.
The cyst is than aspirated and its content is submitted for bacteria and fungi cultures. Subsequently, the cyst is grasped with a clamp and the mass is dissected away from the surrounding tissues. In most patients, the cyst can be removed in its entirety. Sometimes, however, the cyst is adherent to vascular structures, so that a small amount of its wall can be left in place to reduce risks of vascular injuries. In these cases, cauterization of the mucosal lining of the residual part of the cyst is recommended to avoid recurrence.
The pleural cavity is then irrigated with antibiotic solution and 2 chest tubes are inserted into the pleural cavity [17].
Contraindications for the thoracoscopic approach include malignant histology, size greater than 6 cm, a low costodiaphragmatixc location and the presence of a spinal artery in close proximity to the tumour [18, 19]. As for other intrathoracic pathology, optimal instrument manipulation is achieved by inserting the trocars so that the lesion can be managed from an adequate distance.
Thus, we usually approach posteriorly located lesions through a slightly anterior access site. We also rotate the operative table anteriorly to facilitate gravity assistance for the displacement of the lung. Most frequently, posterior neurogenic tumours are located in the superior costovertebral recess. A lung retractor is placed through the fifth intercostal space in the anterior axillary line, while two operating ports are placed in the fourth and third intercostal spaces through the anterior axillary line Fig.
Disposition of thoracoscopic ports for access to posterior mediastinal tumors. Filled in circle indicates the camera port. Open circles indicate ports for instrumentation.
Occasionally, it can be necessary to extend one of these incisions to facilitate tumour dissection and removal. When the tumour is excised, it is extracted from the chest through an endoscopic retrieval bag and a chest tube is placed in the posterior mediastinum. The approach to the upper and midesophagus is performed through the right pleural cavity, while that for lower thoracic esophagus and gastroesophageal junction is best accomplished from the left chest.
The camera port is placed two intercostal spaces caudad to the lesion in the midaxillary line and two to three operating ports are placed following the usual triangular or diamond disposition.
For lesions of the gastroesophageal junction, the trocar placement is reversed. Next, a fan retractor is inserted through the fifth intercostal space on the midclavicular line.
Operating ports are placed through the fourth intercostal space on the posterior and the anterior axillary lines, respectively. A hydrostatic balloon dilator is inserted under endoscopic guidance and inflated to compress the tumour and thus facilitate its identification and enucleation.
The mediastinal pleura is incised and the exposed esophagus bulges slightly into the wound. After the esophageal muscular layers are incised, the exposed tumour is separated bluntly from both the muscle and mucosal layers. Once the tumour has been excised, it is placed in an endoscopic specimen bag and removed 60 Endoscopic surgery of the potential anatomical through the most anterior port, the muscle layer is re-approximated with interrupted non-absorbable sutures to prevent pseudodiverticula formation.
A single chest tube is placed in the posterior mediastinum close to the esophageal suture [20]. Other nonmalignant lesions of the esophagus, including duplication cysts and diverticula, can be treated using a similar approach.
The preferred management of both these lesions is complete resection, which is best accomplished with an endoscopic stapler placed at the base of the lesion after incision of the esophageal muscle layers.
Once again, suturing the muscle layer over the staple line. For esophageal diverticula, a concomitant myotomy distal to the pouch is usually performed thoracoscopically, to treat the underlying motor disorder and to prevent recurrence [17].
Recently, thoracoscopy-assisted esophagomiotomy has been performed in patients with esophageal achalasia by a combined 8 to 10 cm minithoracotomy sixth or seventh intercostal space and two mm trocar ports placed through stab incisions inferior to the thoracotomy [21].
The most effective surgical option is the three-holes esophagectomy, entailing a thoracotomy, a laparotomy and a cervicotomy access. This aggressive approach, however can be associated with significant morbidity and mortality. Avoiding the consequences of thoracotomy in fragile patients might be the first step toward the goal of reducing the esophagectomy-associated morbidity. Transhiatal esophagectomy is one alternative to thoracotomy but has the disadvantage inherent to the blind dissection involved.
VATS has been proposed as a less invasive alternative aimed at allowing the dissection of the thoracic esophagus to be performed under direct vision without thoracotomy []. The operation is carried out in three stages. The first is the thoracoscopic mobilization of the esophagus. The second is the construction of the gastroplasty, which is carrried out through laparotomy incision, while the third stage is the creation of the cervical anastomosis between the esophagus and the gastric pull-through.
The patient is placed in the left lateral decubitus position, tilted forward a little to facilitate exposure of the posterior mediastinum. Using double-lumen tube intubation, five trocars are inserted in the right side of the chest, one through the sixth intercostal space, two through the fourth, and two through the eight Fig. The posterior mediastinum is entered through two longitudinal incisions in the right mediastinal pleura, along the right sympathetic chain and the right wall of the trachea, respectively.
The azygos arch is divided by endoscopic vascular stapler so that access to the T. The right vagus nerve is divided. The anterior aspect of the descending aorta is cleared up. This step requires careful identification and interruption of two or three esophageal arteries.
The esophagus is progressively dissected free either below and above the tumour level and subsequently encircled with two vascular tapes to allow gentle traction and thus facilitate the completion of the esophageal mobilization.
All periesophageal, subcarinal, and paratracheal lymphnodes are disected free either en bloc with the esophagus or separately [24]. Posteriorly, middle and upper mediastinal dissection lead to division of the left vagus nerve just below the left main bronchus. Once the dissection is completed, the esophageal bloc is eventually abandoned in the chest. The chest is drained by two chest tubes. The patient is then placed in the recumbent position for laparotomy and cervicotomy as for the standard three-holes approach.
The recent development of miniaturized instrumentation and scope can now allow one to minimize the extent of the skin incisions resulting in excellent cosmetic results. In patients with palmar hyperidrosis, we perfom a bilateral surgical ablation of the sympathetic chain between T2 and T3 associated with resection of all visible side branches under sole loco-regional anesthesia.
A percutaneous intercostals block is performed at the 62 Endoscopic surgery of the potential anatomical level of the thoracic incision for a maximum extension of 3 spaces by local injection of ropivacaine 7.
Patients maintain spontaneous breathing throughout the procedure and supplementary oxygen is administered by means of a facemask as required. The patient is placed in the semi-prone position for each side, with the ipsilateral arm abducted and mild anti-Trendelenburg inclination.
The former being used to introduce a 5 mm telescope, while dissection is performed Figure 12 Patient positioning and instrument placement for dorsal thoracic sympathectomy through the other port. The first side to be approached is always the right.
The surgical technique consists in opening the parietal pleura, identifying the T2-T3 sympathetic chain and dividing by cautery communicating branches. Subsequent dissection at T2 level is always performed by scissors to avoid possible heat injury to the stellate ganglion, while T3 section is made on cautery. Careful dissection of accessory branches and the Kuntz nerve is performed to prevent relapses.
A 10 Fr thoracic drain is inserted through the lower port and left in place in each pleural cavity for 2 to 3 hours.
Appropriate management require prompt diagnsosis and active surrgical intervention in addition to appropriate antibiotic therapy. Accepted surgical approaches include anterior cervicotomy with or without subxiphoid incision, thoracotomy or even open window thoracostomy. During the last few years, the expansion of the indications for VATS in mediastinal pathology have led to applying it to manage acute purulent mediastinitis [27].
The procedure can be performed by either a right or left approach. Under general anesthesia and with double-lumen tube intubation, the patient is placed in lateral decubitus position as for thoractomy and a two trocar access is usually employed.
In fact, VATS allows excellent visualization of the whole pleural cavity. After evacuating blood clots, pus and fibrinous debris from the pleural cavity, it is possbile to explore the mediastinum and to drain mediastinal fluid collections.
The cost-effectiveness of these minimally invasive procedures compared with the analogous open procedures still remains to be determined. In fact, despite a shortened hospital stay and an easier patient acceptance of the procedure, the equipment is more expensive and time spent in the operating room may be longer.
Nonetheless, there exists now sufficient evidence that for some disease processes, such as mediastinal biopsy in areas not reached by the mediastinoscope, nonthymomatous myasthenia, mediastinal cysts or benign posterior mediastinal tumours, VATS can undoubtedly offer some advantages over standard open approaches and could now be advocated as the technique of choice. Video-assisted thoracoscopic thymectomy for myasthenia gravis.
Chest ; Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg ; Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis. Ann Thorac Surg ; Thoracoscopic thymectomy in autoimmune myasthenia: results of the left-sided approach. Ann Thorac Surg ; 5. Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis.
Ann Thorac Surg ; 6. Thoracoscopic completion thymectomy in refractory nonthymomatous myasthenia. Ann Thorac Surg ; 7. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg ; 8. Recurrent massive hyperplasia of the thymus. Scand Cardiovasc J ; 9. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: surgical results in 23 patients. Ann Thorac Surg ; Video-assisted extended thymectomy in patients with thymoma by lifting the sternum.
Usefulness of videothoracoscopic Intrapericardial examination of pulmonary vessels to identify resectable clinical T4 lung cancer.
Video-assisted thoracic surgery: basic technical concepts and intercostals approach strategies. Thoracoscopic Lymph Node Staging for esophageal cancer. Thoracoscopic staging of esophageal cancer: A prospective multiinstitutional study.
Surgical endoscopic techniques in the diagnosis and follow-up of patients with lymphoma. Br J Surg ; Combined Video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of lung cancer.
Thoracoscopic management of posterior mediastinal tumors. Chest Surg Clin North Am ; Videothoracoscopic excision of thoracic neurogenic tumors. A comparative study of thoracoscopic vs open removal of benign neurogenic mediastinal tumors. Mafune KI, Tanaka Y. Thoracoscopic enucleation of an esophageal leiomyoma with balloon dilator assistance. Surgery Today ; Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: Results of a minimally invasive technique.
Thoracoscopic esophagectomy : technique and initial results. Ann Thorac Surg ; T. Video-assisted thoracoscopic esophagectomy and radical lymphnode dissection for esophageal cancer.
A series of 75 cases. Surg Endosc ; Minimally invasive esophagectomy. Urschel HC. Dorsal sympathectomy and management of thoracic outlet syndrome with VATS.
Video-assisted thoracoscopic T2 sympathectomy for hyperidrosis palmaris. J Am Coll Surg ; Thoracoscopic management of descending necrotizing mediastinitis. The number of involved nodes is related to breast cancer dimensions. Lymph-node status is still the most important independent prognostic parameter [1,2,3,4], although other prognostic factors have been studied in order to avoid axillary dissection.
Axillary dissection is a high morbidity rate surgical procedure: it produces pain, paresthesies, seroma, lymphoedema, infection and arm disorders, according to different authors [4]. On the above considerations, since the sentinel lymph-node technique has been adopted as the experimental procedure intended to avoid axillary dissection in selected T1 clinically negative axillary node breast cancer patients [5,6].
To date, this procedure validity has been endorsed by both clinical and oncological evidence. This also enhances the importance of immunohistochemical and genetic amplification techniques in detecting lymph-node metastasis Table 1. All other cases are to be treated by standard axillary dissection. According to the U. National Cancer Institute guidelines for breast cancer, axillary lymph nodes staging should be considered a valuable aid in indicating prognosis and therapy.
Most authors agree that axillary node dissection in case of clinically negative nodes is a necessary staging procedure. However, controversy exists as to the extent of the procedure because of the associated long-term morbidity arm discomfort and swelling. Data suggest that the lymph node involvement level I versus II versus III does not add any independent prognostic information on the total number of positive axillary nodes [1] Therefore, the standard evaluation procedure usually envisages only a I and G.
Several research groups have tried to define a population of women having such a low nodal metastasis probability as to avoid axillary node biopsy. In an effort to decrease the morbidity of axillary lymphadenectomy while maintaining accurate staging, several studies have investigated lymphatic mapping and sentinel lymph node SLN biopsy in women with invasive breast cancer. Detection compounds should be injected into the biopsy cavity or into the subareolar area or around the tumor.
These preliminary reports demonstrate a Studies have suggested the use of SLN biopsy only to T1 and T2 patients, without evidence of multifocal involvement, clinically positive lymph nodes, or prior chemotherapy neoadjuvant. Before SLN may replace total axillary lymphadenectomy, randomized trials are needed in order to confirm that both procedures yield comparable survival rates.
It is important to note that prior experience of the breast surgeon is critical to the success of sentinel node biopsy. Demand from patients for the procedure might outpace adequate physician training in some medical centers. Patients should always be assured that the physicians performing surgery and subsequent nodes analysis have adequate experience with the procedure. In , Suzanne et al. They were followed by others 70 Endoscopic surgery of the potential anatomical as Brun in [17].
The aims were: a to reduce procedure morbidity pain, arm discomfort and oedema, shoulder restriction [18; 19; 20], and b To give better aesthetic results by reducing axillary scarring while preserving the same oncologic radicality as the traditional open technique. The above aims were to be obtained through minimally invasive access, sufficient to perform adequate lymphnode dissection. So far, studies concerning sentinel node biopsy appear very promising in avoiding a complete axillary lymphadenectomy in selected patients.
Complete axillary dissection must be performed in the following cases: — Patients with pre-operative clinically positive axyllary lymph nodes; — Patients with positive sentinel node; — Patients with multifocal or large breast cancer.
On the above considerations, we think that the time has not yet come to completely abandon axillary dissection as the local treatment and the prognostic parameter, with the exception of selected cases; it is still mandatory to try and reduce the morbidity of this surgical procedure. Seroma is definitely the most frequent axillary dissection complication and its management surely affects National Health Care costs.
Many controversial solutions have been proposed to solve this problem. Some tried to act on the surgical technique; others on drains management, others again have evaluated the influence of postoperative physiotherapy timing on lymphatic complications of axillary dissection. Another issue is nowadays important: the gold standard in breast cancer surgery is to achieve the best oncologic result combined with the best cosmetic and functional result possible.
For this reason, several studies have been carried out to reduce the anti-aesthetic effects of breast surgery. A new word has been created to describe a kind of surgery that can conjugate oncologic and reconstructive surgery: oncoplastic surgery. The concept of oncoplastic surgery, first described by Audretsch [21], is based on the possibility to apply some plastic surgery techniques to breast oncological surgery. The possibility to perform breast conserving surgery without leaving anti-aesthetic scars and breast deformities is today achievable if performed by expert breast surgeons.
Apart from mastectomy cases, where the entity of breast demolition easily allows the performance of dissection cases of skin-sparing mastectomy, presently increasingly used in breast conserving surgery, still faces two situations where a complete axillary dissection is required: — Clinically positive axillary nodes and — Positive sentinel node, particularly when the sentinel node biopsy is performed in local anaesthesia before the lymphadenectomy.
In the above cases, the axillary dissection can be performed through the access way of the tumorectomy or with a separate incision in the axilla. This incision has to be three to four cm long it and needs a strong retraction of the pectoral muscles, resulting in post-operative pain and shoulder restriction.
The use of minimal invasive surgery can reduce the entity of the scar and the post-operative discomfort. Access to the axilla is necessary for lymph node sampling and excision to determine the cause, extent, and type of cancer or other diseases that affect the lymph nodes.
The axilla is the pyramidal area at the junction between the arm and the thorax. A knowledge of the neurovascular relationships within the axilla is of paramount importance to a clinician.
Boundaries of the axilla The apex of pyramid points into the neck and lies between the 1st rib, the clavicle and the superior edge of the subscapularis muscle. The major vessels of the arm pass through the apex. The anterior wall is formed by pectoralis major and minor and the clavicle. The posterior wall is composed of the subscapularis muscle on the costal surface of the scapula and more laterally, the muscles of the posterior axillary fold teres major and latissimus dorsi.
The axillary artery, the brachial plexus, and the main branches of this plexus are enclosed in an axillary sheath a sleeve of tough fascia. This sheath, the axillary vein, the groups of lymph nodes and the branches of all the major vessels and nerves are embedded in a large amount of tough fatty tissue, making anatomic and surgical dissection of the axilla challenging. Branches of the axillary artery supply the muscles and joints of the shoulder and pectoral region and also part of the breast.
The axillary vein lies on the medial side of the axillary artery and collects blood from all parts and regions of the upper limb. It is the direct upward continuation of the basilic vein of the arm at the inferior border of teres major and ends at the lateral border of 1st rib to become the subclavian vein.
The vein lies outside the axillary sheath. Figure 2 73 Axillary vessels, lymphatics and nerves The brachial plexus is an ordered network of large nerves through which sensory and motor nerve supply is distributed to all structures in the upper limb.
This plexus is formed by the union of the ventral rami of C5-C8 and T1 nerves. The cords of the plexus - medial, lateral and posterior - are named according to their relationship with the axillary artery.
The present monograph is dedicated to the surgical part of Gynecology: endoscopic reproductive surgery. This work offers a perfect balance between sedimented knowledge and new.
Potential anatomical spaces have attracted surgeons in the past and in recent years. Due to the development of modern imaging techniques and the advent of minimally invasive surgery, access to these spaces has become a real surgical option. Newell RLM. Meakins JL. Evidence-based practice: new techniques and technology. Leu H, Schreiber A. Endoscopy of the spine: minimally invasive therapy. Orthopade ; —72 PubMed Google Scholar. Laparoscopic lumbar discectomy.
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