Rigid endoscopy: thoracoscopy

image of Rigid endoscopy: thoracoscopy
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Thoracoscopic surgery offers a minimally invasive approach for the treatment of a variety of thoracic disease processes. This chapter covers indications, instrumentation, patient preparation, anaesthetic considerations, access and port placement, surgical procedures, and complications. The chapter also contains five video clips.

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13.1 A 30-degree angled telescope is very useful for thoracoscopy as rotation of the light post allows a great field of view and the possibility of looking around organs in the thorax.
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13.2 A Thoracoport™ (Medtronic Inc.) is a simple disposable port used for thoracoscopy that will accommodate the 12 mm endoscopic staplers sometimes used for lung lobectomy procedures.
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13.3 A variety of non-disposable thoracic cannulae are available for use in thoracoscopy. The use of threaded cannulae is encouraged to reduce cannula pull-out during instrument exchanges.
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13.4 Endoscopic staplers such as the Endo GIA™ (Medtronic Inc.) discharge six rows of staggered staples and incorporate a cutting blade between the third and fourth rows of staples. These staplers must be passed through a 12 mm or larger cannula.
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13.5 The EZ-blocker™ (Teleflex Inc.) is a newer type of endobronchial blocker that has a bifurcated tip and two balloons, each of which can be inflated in a mainstem bronchus depending on which side needs to be blocked.
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13.6 The double-lumen endobronchial tube is helpful, especially when the right lung needs to be blocked, as ventilation through the left-sided bronchial tip can allow left-sided ventilation without the need for direct obstruction of the very cranially located right mainstem bronchus.
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13.7 The initial incision into the pericardium during thoracoscopic pericardiectomy is one of the most challenging parts of the procedure and is best made by taking small bites with sharp laparoscopic scissors. (© Karl Storz SE & Co. KG)
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13.8 Once penetration into the pericardial sac has been established, forceps are used to elevate the pericardium from the epicardium to facilitate further dissection. (© Karl Storz SE & Co. KG)
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13.9 A completed pericardial window in a dog.
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13.10 During a subphrenic pericardiectomy, all the pericardium below the phrenic nerves is removed. In this image, all that remains attached is the cranial portion of the pericardium, which will be sectioned before removal of the pericardial tissue in a specimen retrieval bag.
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13.11 Placement of an endoscopic stapler at the base of a right auricular mass before resection. (Courtesy of Dr J. Brad Case)
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13.12 Lateral radiograph showing a modestly sized cranial mediastinal mass in a 12-year-old Labrador Retriever. The mass was diagnosed as a thymoma. This case is an excellent candidate for thoracoscopic thymoma resection.
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13.13 A large thymoma can be seen in the cranial mediastinum of this dog. The mass was mobile and resectable in this case.
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13.14 CT image showing a left-sided caudal lung lobe mass in a Labrador Retriever that was large but still a good candidate for lung lobectomy. CT is a valuable part of case selection for thoracoscopic lung lobectomy.
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13.15 A large mass can be seen protruding from the surface of the lung lobe.
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13.16 The Endo GIA stapler (Medtronic Inc.) can be seen having just been deployed across the hilus of a caudal lung lobe during thoracoscopic lung lobectomy. Note that the stapler has not transected the full length of the lung lobe and a second cartridge will be required to complete the resection.
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13.17 Thoracoscopic-assisted lung lobectomy. The lung lobe has been partially exteriorized through an assist incision. In this case, an endoscopic stapler is being placed across the hilus of the lung lobe through the assist incision to complete the resection.
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13.18 Reconstructed image of a CT lymphangiogram showing the lymphatic anatomy before thoracic duct ligation. These studies help greatly in preoperative planning for patients that will undergo thoracoscopic thoracic duct ligation.
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13.19 Intraoperative view of a thoracic duct ligation. The haemoclips can be seen in position on the thoracic ducts dorsal to the aorta.
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13.20 Persistent right aortic arch in a dog. The ligamentum can be seen as the white band of tissue being elevated by the right-angled forceps. The ligamentum was subsequently sectioned and released. (© Karl Storz SE & Co. KG)
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13.21 A grass awn can be seen located at the diaphragmatic reflection in the very most caudal aspect of the pleural cavity. This is a common site for grass awns that have migrated through the lung lobe out into the pleural space and become lodged there.


Resection of a cranial mediastinal mass.

Resection of a cranial mediastinal mass and removal from the thorax in a specimen retrieval bag.

Placement of an endobronchial blocker.

Demonstration of the correct bronchoscopically guided placement of an endobronchial blocker.

Optical entry using a trocarless cannula.

Optical entry using a trocarless cannula (ENDOTIP, Karl Storz Endoscopy).

Resection of a lung lobe using an endoscopic stapler.

Resection using an endoscopic stapler of a consolidated lung lobe in a dog secondary to pneumonia associated with chronic grass awn migration.

Thoracic duct ligation with haemoclips.

Thoracic duct ligation with haemoclips

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