1 Introduction

Thoracoscopy has now reached an excellent level even in neonatal and pediatric age. There are many procedures that can be performed; for many of them, thoracoscopic approach has actually proved its superiority compared to traditional surgery in terms of shorter days of hospitalization, less postoperative pain, reduction of scarring, and long-term complications (i.e., scoliosis, thoracic deformities) [1, 2]. The long-term effects (as well as laparoscopy) of the use of CO2 in the neonatal age are still to be assessed. Even more than in laparoscopy, thoracoscopy requires greater collaboration with the anesthesiologist (see Anesthesia in pediatric MIS chapter). Another limit of thoracoscopic approach concerns the mobility of trocars and surgical instruments within the small pediatric intercostal spaces.

2 Indications

Currently technological advances, more skilled and experienced surgeons, and introduction of more efficient and standardized techniques allowed to expand significantly the spectrum of indications for thoracoscopic procedures [3].

In Tables 6.1 and 6.2, the relation between difficulty level, location within the thoracic cavity, possible procedures, and suggested patient’s position is shown.

Table 6.1 Description of the possible indications described as low/moderate level of difficulty, location of the pathology, and possible positioning of the patient
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Table 6.2 Description of the possible indications described as high level of difficulty, location of the pathology, and possible positioning of the patient
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3 Contraindications

Nowadays the development of better instrumentation and improvement in surgical techniques reduced drastically the number of contraindications to perform thoracoscopy. Surgeon experience and patient clinical conditions are fundamental at the time of deciding the surgical approach [4].

Absolute. These comprehend conditions that prevent adequate visualization of the thoracic space and/or serious respiratory compromising:

  • Severe respiratory distress which requires alternative forms of ventilation: inability to tolerate single-lung ventilation, contralateral pneumonectomy, high positive-pressure ventilation

  • Giant anterior mediastinal masses that compromise respiration

  • Severe hemodynamic instability

Relative. Do not discard thoracoscopy but must be carefully planned:

  • Previous thoracic surgery

  • Pleural adhesions caused by previous widespread infections

  • Coagulopathy

  • Large tumors or extended pulmonary metastasis

4 Preoperative

  1. (a)

    Equipment

    Basic thoracoscopy equipment has no significant difference with laparoscopy instrumentation. Basic instrument set must be used in case of a thoracoscopic procedure:

    • According to the size and weight of the patients, 3–5 mm instruments must be available.

    • Trocars: valved trocars allow to insufflate low-pressure CO2 to help collapse the lungs. This is particularly useful in smaller children in whom complete lung exclusion cannot be acquired. Trocar length must be decided according to the size, age, and weight of patient, in small and thin patients 50–70 mm. Blunt-tipped trocars reduce the chance of causing lungs or tissue injury during introduction due to thin chest wall. Because of the little thickness of children’s chest walls, trocars must be fixed to it during long procedures in order to avoid them to slip during manipulation. Sometimes it could be indicated also to use instruments without trocars.

    • Optics: 2.7 or 5 mm optics depending on age and weight of patients; 10 mm optics can be used in children of 8 years or more. The most commonly used scopes are 0° or 30°, but other angles as 45° or 70° might as well be used in particular situations in order to improve visibility.

    • Basic set: grasper, curved dissectors, curved scissors, forceps, irrigator/aspirator, cautery device, needle holder, clip applier, monopolar/bipolar cautery.

    • Disposable equipment: endoloops, hemostatic clips (5–10 mm).

    Nevertheless, evolution in techniques, surgeon’s ability and experience, and procedure’s level of difficulty are just some factors that might require the use of special instruments such as harmonic scalpel (Ultracision®, Ethicon), LigaSure™ (Covidien), endoscopic ultrasound, argon beam coagulator, and endoscopic stapler (5–12 mm).

  2. (b)

    Imaging

    Preoperative imaging is essential for surgical planning since adequate imaging allows an accurate positioning of the patient, therefore better access points to the lesion area.

    Depending on the nature of the pathology, different imaging techniques might be used: MRI scans are useful in cases of vascular lesions or masses involving the spinal canal, CT scans for masses and infiltrates, US for the largest fluid collections, or even X-ray in cases of pneumothorax. If possible, 3D reconstruction imaging is extremely helpful for the surgeon.

  3. (c)

    Positioning, room set-up, and trocar placement

    Depending on the procedure that will be performed, the patient has to be positioned correctly, in order to obtain the wider field of view and the best access to the anatomical structures of interest. The unaffected lung and the other structures must be kept out of the operative field; for this purpose the patient will be positioned so that these structures are located below the area of interest. In the photos are shown the three principal positions used for thoracoscopy. In Fig. 6.1 the patient is in a standard lateral decubitus position with operative side up and the ipsilateral upper limb flexed above patient’s head. In this position the surgeon can dominate the entire pleural cavity, which makes this position the best choice for procedures such as lung biopsy and pleurodesis [5, 6]. In Fig. 6.2 the patient is in a prone modified position with affected side slightly elevated. This position allows the surgeon the best access to the posterior mediastinal structures. Finally, in Fig. 6.3, the patient is in a supine position with affected side slightly elevated. This position provides an excellent view of the anterior mediastinum. Once the patient is secured, he can be moved in the Trendelenburg or reverse Trendelenburg position and rotated in order to achieve the best operative view and ergonomics for the surgeon. It is mandatory to have a monitor on both sides of the operating table, with one of it standing in line with the surgeon and the other in line with the assistant or the scrub nurse. The surgeon and the assistant stand normally in front of the operative area, with the scrub nurse positioned on the other side. In order to obtain the best operative view and working space, it is essential to correctly position the patient and choose the right placements of ports in the intercostal spaces. In general, a camera port and two operative ports may be sufficient to perform many thoracoscopic procedures; an additional port can be placed for retraction. In Figs. 6.1, 6.2, and 6.3 the sites to place the trocars depending on patient’s position are shown: in lateral decubitus position, the camera port is placed along the midaxillary line (Fig. 6.1); if the lesion is localized in the posterior mediastinum, then the port should be placed along the anterior axillary line (Fig. 6.2). When approaching the anterior mediastinum, the camera port should stay along the posterior axillary line (Fig. 6.3). Normally, the camera port will be placed between and above the two operative ports.

    Fig. 6.1
    figure 1

    Patient in standard lateral decubitus position. PAL posterior axillary line, MAL midaxillary line, AAL anterior axillary line

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    Fig. 6.2
    figure 2

    Patient in modified prone position. PAL posterior axillary line, MAL midaxillary line, AAL anterior axillary line

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    Fig. 6.3
    figure 3

    Patient in modified supine position. PAL posterior axillary line, MAL midaxillary line, AAL anterior axillary line

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  4. (d)

    Anesthesia

    Considering the complexity of pediatric patients and the pathologies treated, knowledge of the surgical plan and surgeon’s experience alone won’t guarantee success unless they are combined with an optimal relationship with the anesthesiology team.

    Anesthetic features that comprehend double lung/single-lung ventilation will be discussed at the Anesthesia in pediatric MIS chapter.

5 Postoperative

The complexity of postoperative care depends on the difficulty of surgery. Patients who underwent biopsy, limited resection, or observation can be monitored at the surgical ward, without intensive special care. In some cases, after a 24-h time observation, these patients can be ready for discharge [7, 8]. Chest tubes can be removed in the first postoperative day once the pneumothorax resolves. Heavy nonabsorbable suture is used to secure the tube to the skin followed by application of an occlusive, adherent dressing. Thoracoscopic approach allowed to reduce muscle stretching resulting in a significant reduction in postoperative pain, allowing the patient to regain effective deep breathing; likewise, the injection of local anesthetics at trocar sites before insertion followed with an IV painkiller in the immediate postoperative period allows fast and efficient pain management. An adequate pain management and an early and aggressive pulmonary toilet help in reducing the incidence of postoperative pneumonias and other pulmonary complications. It hasn’t been proved that thoracoscopic approach may not reduce significantly hospitalization time, but it surely reduces general morbidity and postoperative pain [9, 10].

6 Complications

  1. (a)

    Intraoperative

    • Conversion to open thoracotomy: the decision of converting to an open procedure should not be considered as a complication, unless a significant technical mistake was made.

    • Tension pneumothorax during insufflation or initial air introduction.

    • Significant bleeding from a vessel or parenchymal injury, most of the times it can resolve without conversion.

    • Gas (air or CO2) embolism.

    • Diaphragmatic or subdiaphragmatic organ lesions from port or instrument insertion

    • Cardiac arrhythmias: due to use of cautery near to the heart, vagus nerve, or pericardium.

  2. (b)

    Postoperative

    • Air leak/persistent pneumothorax is one of the most common postoperative complications; luckily it can be considered a self-limited problem once a chest tube suction/drainage is positioned. Any thoracoscopic procedure, in which an air leak or accumulation of pleural fluid is anticipated, requires placement of an intercostal chest tube. Tubes sizes may range from 12 to 28 Fr, depending on the size of the patient and can be placed under direct vision (via one of the port sites) in order to evacuate pneumothorax. According to the possibility of air leak, the tube may be connected to a low-pressure suction system or a water seal. Tubes can be removed when lungs stay fully expanded for 24/48 h and fluid drainage is minimal (less than 2.5 mL/Kg per day) [11].

    • If leaks persist the possibility of a bronchopleural fistula might be considered; in this case a re-exploration, thoracoscopically, is needed.