Thoracoscopic Surgery for Thoracic Spinal Tumors

Published on 02/04/2015 by admin

Filed under Neurosurgery

Last modified 02/04/2015

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Chapter 32 Thoracoscopic Surgery for Thoracic Spinal Tumors

INTRODUCTION

For the surgery of thoracic spinal tumors, open thoracotomy is usually performed. However, morbidity associated with conventional open thoracotomy often limits the application of anterior approaches to the thoracic spine. Most of the vertebral body tumors of the thoracic spine involve the anterior column, and these tumors require rib removal and parietal pleura opening, which can cause the complications, such as post-thoracotomy syndromes and intercostal neuralgia.1 Open thoracotomy also requires extensive exposures with incisions measuring up to 20 cm. In recent years minimally invasive open microscopic approaches using special retractors have been developed that can minimize the size of the operative access to 6–10 cm. These “mini-approaches” are quite feasible in surgery on the upper and mid-thoracic spine. The limited working space available through small incisions may block the microscopic view and result in difficult manipulation of instruments. However, video assisted thoracic surgery (VATS) using four portals in the chest wall permits surgery that is as effective as the open approaches, and it provides a better view than the microscopic approach. Unlike the open approaches, the surgeon’s operative view is not obscured by hands or operative instruments, and high morbidity associated with open procedures can be avoided. Biomechanically, the VATS approach, like any other anterior approach to the spine for reconstruction, significantly increases the axial load-bearing capabilities of the spine.2

THORACOSCOPIC CORPECTOMY AND STABILIZATION

PLACEMENT OF PORTALS

Through a 1.5-cm skin incision above the intercostal space, small Langenbeck hooks are inserted (Fig. 32-3) The muscles of the thoracic wall are crossed in a blunt, muscle-splitting technique, and the intercostal space is opened by blunt dissection, thus exposing the pleura and creating an opening to enter the thoracic cavity. The 10-mm trocar is inserted and one-lung ventilation is started. The 30-degree scope is inserted at a flat angle in the direction of the second trocar. Perforation of the thoracic wall to insert the second, third, and fourth trocars is performed under visual control through the scope, and the other trocars are inserted as shown (Fig. 32-4).