AustralAs J Cardiac Thorac Surg 1993:2( 1) Video Thoracoscopy Becomes A Procedure Of Choice Peter Clarke, FRACS Austin Hospital, Heidelberg Victoria, Australia T horacoscopy was originally described by Jacobaeus in 1910 when he adopted a cytoscope for the examination and lysing of adhesions in patients with tuberculosis 1. A year later he reported the first laparoscopic examination in humans and extended the technique of thoracoscopy for biopsy of the pleura and lungs 2. The use of the thoracoscope for treatment of spontaneous pneumothorax was first suggested by Sattler in 1937 3. However, this technique did not become widely practised because of the limitations in handling the blebs that are the underlying cause of the problem. During the 1980s the development of computer-chip television led to the introduction of video-controlled endoscopes which allowed sophisticated procedures to be done via the endoscope. This and refinements in instru- mentation have created a widespread interest in thoracoscopic surgery which parallels that for laparoscopic procedures. Nathensen et al described a technique of video-thoracoscopy ligation of bullae and pleurectomy for spontaneous pneumothorax in 1991 which has become the standard technique in many centres 4. The main advantage is that there is no need to spread the ribs of divide muscles. This results in a shorter hospital stay, less morbidity, and (perhaps of most importance from the patient’s point of view) little long-term post-thoracotomy neuralgia. Therapeutic video-thoracoscopy has become the procedure of choice for lung biopsy, peripheral lung resection, pleural biopsy, pleurodesis, pericardectomy, and removal of pleural-based and mediastinal lesions. It is likely that full resections, evaluation of operability and practically all the procedures performed on the oesophagus will fall into the province of the video-thoracoscopic surgeon. The down side is the necessity for expensive equipment and the need for training in the new techniques. Some cardiac surgeons who do a small amount of thoracic surgery are finding that they will have to train in the new techniques or virtually give up the thoracic surgical part of their practice. As the benefits of video- thoracoscope surgery become more apparent, demand will be largely patient-driven, and there may be difficulty in resisting the suggestion that opening the chest is a sign of failure rather than the appropriate procedure. The College of Surgeons has wisely set up a multi- disciplinary committee to advise on standards and training in all the varieties of endosurgery, but this committee will probably have a limited life span as endosurgical procedures will ultimately become part of the mainstream of each speciality. The paper by Kwang Ho Kim in this issue shows just what can be achieved by refining simple thoracoscopy for the treatment of spontaneous pneumothorax. This technique is particularly applicable to those areas where the cost of providing video-thoracoscopic surgery is pro- hibitive. It is inevitable that as the popularity of video-controlled thoracoscopy increases, the equipment will become cheaper and more widely available, and more surgeons will seek training in the field. References 1. Jacobaeus HC. Possibility of the use of the cytoscope for investi- gation of serous cavities. Munch Med Wschr 1910;57:2090-2. 2. Jacobaeus HC. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:289-96. 3. Sattler A. The treatment of spontaneous pneumothorax with special reference to thoracoscopy. Beittr Klin Tuberk 1937;89:395-9. 4. Nathansen LK, Shigi SS, Wood RAB, Cushieri A. Video-thoracoscopic ligation of bulla and pleurectomy for spontaneous pneumothorax. Am Thorac Surg 1991;52:3 16-9. 39

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AustralAs J Cardiac Thorac Surg 1993:2( 1)

Video Thoracoscopy Becomes A Procedure Of Choice

Peter Clarke, FRACS

Austin Hospital, Heidelberg Victoria, Australia

T horacoscopy was originally described by Jacobaeus in 1910 when he adopted a cytoscope for the examination and lysing of adhesions in patients with tuberculosis 1.

A year later he reported the first laparoscopic examination in humans and extended the technique of thoracoscopy for biopsy of the pleura and lungs 2.

The use of the thoracoscope for treatment of spontaneous pneumothorax was first suggested by Sattler in 1937 3. However, this technique did not become widely practised because of the limitations in handling the blebs that are the underlying cause of the problem.

During the 1980s the development of computer-chip television led to the introduction of video-controlled endoscopes which allowed sophisticated procedures to be done via the endoscope. This and refinements in instru- mentation have created a widespread interest in thoracoscopic surgery which parallels that for laparoscopic procedures.

Nathensen et al described a technique of video-thoracoscopy ligation of bullae and pleurectomy for spontaneous pneumothorax in 1991 which has become the standard technique in many centres 4. The main advantage is that there is no need to spread the ribs of divide muscles. This results in a shorter hospital stay, less morbidity, and (perhaps of most importance from the patient’s point of view) little long-term post-thoracotomy neuralgia.

Therapeutic video-thoracoscopy has become the procedure of choice for lung biopsy, peripheral lung resection, pleural biopsy, pleurodesis, pericardectomy, and removal of pleural-based and mediastinal lesions. It is likely that full resections, evaluation of operability and practically all the procedures performed on the oesophagus will fall into the province of the video-thoracoscopic surgeon. The down side is the necessity for expensive equipment and the need for training in the new techniques.

Some cardiac surgeons who do a small amount of thoracic surgery are finding that they will have to train in the new techniques or virtually give up the thoracic surgical part of their practice. As the benefits of video- thoracoscope surgery become more apparent, demand will be largely patient-driven, and there may be difficulty in resisting the suggestion that opening the chest is a sign of failure rather than the appropriate procedure.

The College of Surgeons has wisely set up a multi- disciplinary committee to advise on standards and training in all the varieties of endosurgery, but this committee will probably have a limited life span as endosurgical procedures will ultimately become part of the mainstream of each speciality.

The paper by Kwang Ho Kim in this issue shows just what can be achieved by refining simple thoracoscopy for the treatment of spontaneous pneumothorax. This technique is particularly applicable to those areas where the cost of providing video-thoracoscopic surgery is pro- hibitive.

It is inevitable that as the popularity of video-controlled thoracoscopy increases, the equipment will become cheaper and more widely available, and more surgeons will seek training in the field.

References 1. Jacobaeus HC. Possibility of the use of the cytoscope for investi-

gation of serous cavities. Munch Med Wschr 1910;57:2090-2. 2. Jacobaeus HC. The practical importance of thoracoscopy in surgery

of the chest. Surg Gynecol Obstet 1922;34:289-96. 3. Sattler A. The treatment of spontaneous pneumothorax with special

reference to thoracoscopy. Beittr Klin Tuberk 1937;89:395-9. 4. Nathansen LK, Shigi SS, Wood RAB, Cushieri A. Video-thoraco-

scopic ligation of bulla and pleurectomy for spontaneous pneumothorax. Am Thorac Surg 1991;52:3 16-9.