Este estudo foi conduzido de acordo com a Declaração de Helsinque e o comitê de ética clínica local (2018/09).
1. Exame físico
NOTA: Os testes provocativos para o diagnóstico da EOT estão representados na Figura 1.
<ol><li>Para o teste de Adson (teste dos escalenos, Figura 1A), levar o ombro do paciente à rotação externa com leve abdução e um pouco de extensão e palpar o pulso radial. Estenda a cabeça do paciente para trás e gire em direção ao ombro testado. Peça ao paciente para inspirar e prender a respiração.<ol><li>Considerar o teste positivo nos casos em que a reprodução dos sintomas ou a abolição do pulso radial ocorre enquanto os sintomas se resolvem com a rotação da cabeça para o lado controlateral.</li>
	</ol></li>
	<li>Para o teste da órtese costoclavicular (Figura 1B), levar o braço do paciente para trás, deprimir e retrair a escápula do paciente no lado ipsilateral. Verifique o pulso. Se o pulso radial desaparecer ou os sintomas forem reproduzidos, o teste é considerado positivo.</li>
	<li>Para o teste de hiperabdução (Figura 1C), estender levemente o braço do paciente e palpar a artéria radial. Abduzir o braço 90-180°. Um teste positivo é uma diminuição do pulso da artéria radial da linha de base para a nova posição.</li>
	<li>Para o teste de Roos (Leste) (Figura 1D), realize o teste na posição sentada ou em pé. Leve os ombros do paciente a abdução de 90°, gire externamente e flexione os cotovelos a 90°. Os cotovelos devem estar ligeiramente atrás do plano frontal. Peça ao paciente que abra e feche as mãos por 3 minutos.<ol><li>Considere o teste positivo se o paciente apresentar peso, dor isquêmica ou fraqueza dos braços ou dormência e formigamento das mãos. A descoloração das mãos também é significativa para o teste. NOTA: O tratamento cirúrgico é a primeira opção nos casos de SVT, enquanto o tratamento cirúrgico é realizado nos casos de NTOS após 3 meses de terapia conservadora, sem qualquer melhora na vida diária, na vida profissional e na qualidade do sono.</li>
	</ol></li>
</ol>2. Avaliação clínica e eletrodiagnóstica pré-operatória
<ol><li>Para avaliação da melhora clínica com o tratamento cirúrgico, apresentar achados clínicos no exame físico, achados eletromiográficos e no questionário QuickDASH (Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) relacionados aos sintomas das atividades diárias e aos períodos pré-operatórios sociais e psicológicos.</li>
	<li>Determinar os EMGs pré-operatórios medindo o potencial de ação motor composto (CMAP), o potencial de ação do nervo sensorial (SNAP) e a velocidade de condução nervosa (NCV) e a latência da onda F. Faça gravações usando um sistema de medição EMG/NCV/EP comercial (por exemplo, Nihon Kohden Neuropack 2).</li>
</ol>3. Ressecção da primeira costela transaxilar de forma gradual
<ol><li>Realizar anestesia usando um protocolo padrão de indução anestésica que inclui 0,6 mg/kg de brometo de rocurônio, 0,05 mg/kg de midazolam e 1-2 μg/kg de fentanil.</li>
	<li>Administrar tiopenthal sódico a 6 mg/kg para manutenção.</li>
</ol>4. Posição do paciente (Figura 2)
<ol><li>Após posicionar o paciente em decúbito lateral, envolver o braço, elevar e pendurar em posição de abdução de 90°. Se necessário, reduza a tração a cada 3-5 minutos para evitar complicações pós-operatórias.</li>
	<li>Use uma solução de iodopovidona estéril a 10% para esterilização tópica. Escorra o braço, a axila e o peito. Use lençóis estéreis no resto do corpo para evitar contaminação.</li>
</ol>5. Alcançar a primeira costela
<ol><li>O uso dos instrumentos cirúrgicos é mostrado na Figura 3 e na Tabela de Materiais.</li>
	<li>Realizar uma incisão transversal abaixo da linha do cabelo axilar, estendendo-se do músculo peitoral anteriormente e do músculo grande dorsal posteriormente, com 5-7 cm de comprimento.</li>
	<li>Cruze a pele, o tecido subcutâneo e a fáscia até alcançar a parede torácica anterior.</li>
	<li>Use dissecção romba para alcançar a primeira costela.</li>
</ol>6. Liberar a primeira costela dos músculos e da fáscia
<ol><li>Perfurar a fáscia que recobre a primeira costela e dissecar o periósteo que recobre a parte superior da costela. Dissecar a borda inferior da costela dos músculos circundantes usando cautério monopolar e raspatório costal.</li>
	<li>Dividir os músculos intercostais até o ligamento costoclavicular na junção esternocostal e a costa angular na junção costovertebral posterior.</li>
	<li>Na borda superior da primeira costela, expor o músculo escaleno anterior anteriormente e o músculo escaleno médio posteriormente. Coloque a pinça curva sob os músculos escalenos anterior e médio para cortar os músculos ao nível de sua inserção sobre a primeira costela, onde estão mais distantes do feixe neurovascular.</li>
</ol>7. Remoção da primeira costela ou da costela cervical
<ol><li>Iniciar a ressecção da primeira costela na junção esternocostal anteriormente. Primeiro, gire de sua borda superior e, em seguida, da borda inferior para ressecá-la usando um cortador de costela do esterno. Garantir que as estruturas neurovasculares sejam preservadas.</li>
	<li>Em seguida, ressecar a porção posterior da costela e desarticular a parte localizada distalmente ao ângulo da costela; portanto, completar a ressecção da costela.</li>
	<li>Após liberar totalmente a costela cervical do tecido circundante, ressecção e desarticulação da costela até que a superfície articular do processo transverso seja vista.</li>
</ol>8. Pós-Operatório
<ol><li>No pós-operatório, realizar radiografia de tórax para descartar complicações, como pnomothorax.</li>
	<li>Remover o dreno torácico no 1º dia de pós-operatório em casos sem intercorrências.</li>
	<li>Use anti-inflamatórios não esteroides, analgésicos narcóticos e um relaxante muscular para dor pós-operatória.</li>
	<li>No pós-operatório imediato, examinar o movimento do braço no lado operado. Continuar a fisioterapia nos dois primeiros meses de pós-operatório.</li>
	<li>Orientar o paciente a não realizar nenhuma atividade desgastante com o lado operado.</li>
</ol>9. Avaliação clínica e eletrodiagnóstica pós-operatória
<ol><li>Para avaliação da melhora clínica com o tratamento cirúrgico, comparar os achados clínicos no exame físico, achados eletromiográficos e o questionário QuickDASH (Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) relacionados aos sintomas das atividades diárias e sociais e psicológicas pré e pós-operatórias (3 meses).</li>
	<li>Comparar a EMGs pré e pós-operatória medindo o potencial de ação motor composto (PAMC), o potencial de ação do nervo sensitivo (SNAP) e a velocidade de condução nervosa (NCV) e a latência da onda F. Faça gravações usando um sistema de medição EMG/NCV/EP comercial (por exemplo, Nihon Kohden Neuropack 2).</li>
	<li>Realizar o exame físico no pós-operatório para avaliar a dor e parestesia.</li>
</ol>

<ol>
	<li>Peet, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+evaluation+of+a+therapeutic+exercise+program.">Thoracic outlet syndrome: evaluation of a therapeutic exercise program.</a> InProc Mayo Clinic. 31, 281-287 (1956).</li><li>Han, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+in+thoracic+outlet+syndrome:+the+importance+of+resection+of+the+first-rib.">Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.</a> European Journal of Cardio-Thoracic Surgery. 24 (3), 428-433 (2003).</li><li>Yavuzer, &. #. 3. 5. 0. ;., Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach.">Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.</a> European Journal of Cardio-Thoracic Surgery. 25 (2), 173-178 (2004).</li><li>Roos, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+for+first+rib+resection+to+relieve+thoracic+outlet+syndrome.">Transaxillary approach for first rib resection to relieve thoracic outlet syndrome.</a> Annals of Surgery. 163 (3), 354 (1966).</li><li>Jubbal, K. T., Zavlin, D., Harris, J. D., Liberman, S. R., Echo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+of+First+Rib+Resection+in+the+Surgical+Repair+of+Thoracic+Outlet+Syndrome.">Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.</a> Hand. , 1558944718760037 (2018).</li><li>Likes, K. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years.">Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years.</a> Vascular and Endovascular Surgery. 49 (1-2), 8-11 (2015).</li><li>Akku&#351;, M., Ya&#287;murlu, K., &#214;zarslan, M., Kalani, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+outcomes+of+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores.">Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores.</a> Journal of Clinical Neuroscience. 58, 75-78 (2018).</li><li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Sanders, R. J., Annest, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome.">Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.</a> Journal of Vascular Surgery. 61 (3), 821-825 (2015).</li><li>Sanders, R. J., Hammond, S. L., Rao, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+a+review.">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li><li>Vos, C. G., &#220;nl&#252;, &. #. 1. 9. 9. ;., Vo&#251;te, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+First+rib+resection.">Thoracic outlet syndrome: First rib resection.</a> Shanghai Chest. 1 (1), (2017).</li><li>Desai, S. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression.">Outcomes of surgical paraclavicular thoracic outlet decompression.</a> Annals of vascular surgery. 28 (2), 457-464 (2014).</li><li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Urschel, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome.">Transaxillary first rib resection for thoracic outlet syndrome.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 10 (4), 313-317 (2005).</li><li>Sheth, R. N., Campbell, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+thoracic+outlet+syndrome:+a+randomized+trial+comparing+two+operations.">Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.</a> Journal of Neurosurgery: Spine. 3 (5), 355-363 (2005).</li><li>Urschel, H. C., Razzuk, M. 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A TFRR é a técnica cirúrgica mais utilizada para o tratamento da EOT9,10,11. A vantagem da TFRR é que ela proporciona um melhor resultado estético com uma incisão oculta na axila, sem a necessidade de corte da musculatura para atingir o campo cirúrgico. Sua desvantagem é o espaço de trabalho relativamente estreito e profundo. A abordagem supraclavicular, preferida para o tratamento arterial da EOT, coloca a artéria sub...

A compressão do plexo braquial, artéria subclávia ou veia no triângulo escaleno é clinicamente conhecida como síndrome do desfiladeiro torácico (SDT), descrita pela primeira vez por Peet et al.1. A síndrome do desfiladeiro torácico é subdividida em neurogênica (NTOS), EOT arterial e EOT venosa com base na etiologiasubjacente1. Pacientes com NTOS (93-95% dos casos de EOT) apresentam dor, dormência e fraqueza ipsilateral. Pacientes com EOT venosa (3-5%) apresentam trombose venosa, e pacientes com EOT arterial (1-2%) apresentam evento tromboembólico arterial e isquemia. O tratamento conservador da EOT inclui medicamentos e fisioterapia e é a primeira escolha para os casos de EOT. As modalidades de tratamento cirúrgico incluem procedimentos de descompressão e são realizadas após falha do manejo conservador2. As técnicas de descompressão incluem a ressecção transaxilar da primeira costela (TFRR), a escalenectomia supraclavicular da primeira costela (SFRRS), a escalenectomia (sem ressecção da primeira costela via supraclavicular ou transaxilar) e a primeira ressecção da primeira costela por abordagem posterior (PA-FRR)3. A ressecção transaxilar da primeira costela, técnica descrita por Roos et al., em 1966, é um método eficaz para o tratamento daEOT4,5. O principal objetivo da TFRR é remover completamente a última costela cervical e a primeira torácica e descomprimir o feixe neurovascular subjacente.
Os EOT vasculares (SVO) são diagnosticados com angiotomografia, USG duplex colorida e arteriografia ou venografia, enquanto o NTOS é diagnosticado com radiografia, estudos eletrodiagnósticos (eletromielografia com agulha), USG duplex Doppler colorido e RM cervical. Consultas de fisioterapeuta e psiquiatra devem ser obtidas para excluir outros distúrbios no pré-operatório. O alívio dos sintomas com a injeção de lidocaína no músculo escaleno anterior também é um bom indicador para o diagnóstico e preditor de benefício cirúrgico em pacientes com NTOS6.

<table><tbody><tr><td>Ag Debakey vascular forceps 24 cm, 3.5 mm</td><td>Lawton medizintechnik</td><td>30-0032</td><td>Check the hemorrhage</td></tr><tr><td>Bone chisels curved 13x9.1/2&#039;&#039;</td><td>Aesculap Inc.</td><td>MB-992R</td><td>Dissect the periost of the first rib</td></tr><tr><td>Doyen-stille retractor 24 cm</td><td>Lawton medizintechnik</td><td>20-0650</td><td>Skin- muscle retraction</td></tr><tr><td>Foerster sponge forceps straight</td><td>Lawton medizintechnik</td><td>07-0156</td><td>For swabbing</td></tr><tr><td>Luer stille bone rongeur curved 27 cm</td><td>Lawton medizintechnik</td><td>38-0703</td><td>Bone punches</td></tr><tr><td>Luer stille rongeur straight 22 cm</td><td>Lawton medizintechnik</td><td>38-0400</td><td>Rib cutter</td></tr><tr><td>Mayo hegar needle holder 20.5 cm</td><td>Lawton medizintechnik</td><td>08-0184</td><td>Suturing</td></tr><tr><td>Metzenbaum scissors curved delicate 23 cm</td><td>Lawton medizintechnik</td><td>05-0665</td><td>Dissection</td></tr><tr><td>Overholt curved forceps delicate 30.5 cm</td><td>Lawton medizintechnik</td><td>06-0807</td><td>Split the scalen muscles from the rib</td></tr><tr><td>Roberts art forceps straight 24 cm</td><td>Lawton medizintechnik</td><td>06-0370</td><td>For sponge and remove remain bone</td></tr><tr><td>Roux retractor medium size 15.5 cm</td><td>Lawton medizintechnik</td><td>20-0402</td><td>Wound retraction</td></tr><tr><td>Semb rasparotry 22,5 cm, 12mm</td><td>Lawton medizintechnik</td><td>39-0252</td><td>Dissect the muscle of the first rib</td></tr><tr><td>Smith peterson model curved osteotome 13x205 mm</td><td>Lawton medizintechnik</td><td>46-0783</td><td>Dissect the muscle of the first rib</td></tr><tr><td>Stille -giertz rib shears 27 cm</td><td>Lawton medizintechnik</td><td>38-0200</td><td>First rib cutting</td></tr><tr><td>Stille osteotome 8x205 mm</td><td>Lawton medizintechnik</td><td>46-0248</td><td>Dissect the periost of the first rib</td></tr><tr><td>Wagner rongeur 5.5x210 mm</td><td>Lawton medizintechnik</td><td>53-0703</td><td>Punches</td></tr></tbody></table>

transaxillary first rib resection for treatment of the thoracic outlet syndrome

A síndrome do desfiladeiro torácico (SDT) é um distúrbio comum que causa perda significativa de produtividade. O protocolo de ressecção transaxilar da primeira costela (TFRR) tem sido utilizado para a descompressão de estruturas neurovasculares aprisionadas no EOT. Dentre os demais procedimentos cirúrgicos, a vantagem da TFRR é que ela apresenta a menor taxa de recidiva e melhores resultados estéticos. A desvantagem da TFRR é que ela fornece um corredor de trabalho estreito e profundo que torna a obtenção do controle vascular um desafio.

Desfechos Clínicos Um total de 15 pacientes foi incluído neste estudo. Três pacientes (20%) eram do sexo masculino e 12 pacientes (80%) do sexo feminino. A média de idade dos pacientes foi de 30,6 ± 8,98 anos. Todos os participantes do sexo masculino e 5 do sexo feminino eram trabalhadores braçais. A queixa mais comum do grupo NTOS foi dor e dormência braço-antebraço, fraqueza de preensão e atrofia hipotenar. No seguimento clínico pós-operatório, os pacientes foram questionados sobre sua ...

Watch this Scientific Journal Video about Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome at JoVE.com

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Apresentamos um protocolo de ressecção transaxilar da primeira costela para tratamento da síndrome do desfiladeiro torácico por compressão do plexo braquial, veia subclávia e artéria.

Ressecção da Primeira Costela Transaxilar para Tratamento da Síndrome do Desfiladeiro Torácico

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

transaxillary-first-rib-resection-for-treatment-thoracic-outlet

Research

JoVE Journal

Medicine

2.7K visualizações.  Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. Apresentamos um protocolo de ressecção transaxilar da primeira costela para tratamento da síndrome do desfiladeiro torácico por compressão do plexo braquial, veia subclávia e artéria.

Vídeo: Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Técnica e critérios de seleção dos pacientes do Anterior direita mini toracotomia para substituição da valva aórtica de acesso mínimo

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

Medicina

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Dispositivo de porta única de baixo custo (LoCoSP) para uma abordagem transcerúrica em Esofagictomia Transhiatal Minimamente Invasiva

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum (TOLF) Using Ultrasonic and Conventional Osteotomes

Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. TOLF is typically treated with surgical decompression. A variety of surgical techniques, including laminoplasty, laminectomy, and lamina fenestration, are used for the effective treatment of TOLF. However, traditional methods are associated with a substantial risk of perioperative complications, including dural laceration and/or iatrogenic spinal cord injury. Therefore, it is important to develop an efficient and secure surgical technique for TOLF. Herein, we describe a method for laminectomyperformed at the thoracic spine using an ultrasonic osteotome combined with a conventional osteotome. This technique can reduce intraoperative complications. This is a relatively safe and easy-to-learn method that should be recommended for the treatment of TOLF.

Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum TOLF Using Ultrasonic and Conventional Osteotomes

We present a methodology for using an ultrasonic osteotome combined with a conventional osteotome for laminectomy in thoracic ossification of the ligamentum flavum. This is a relatively safe and easy-to-learn method that avoids the perioperative complications associated with the conventional method.

Laminectomia para a remoção da ossificação torácica do ligamento flavo (TOLF) usando osteótomos ultra-sônicos e convencionais

Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. TOLF is typically treated with surgical ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

Tireoidectomia Endoscópica Transoral Abordagem Vestibular para Lobectomia Tireoidiana

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Um Protocolo de Não Intubação para Cirurgia Toracoscópica Videoassistida com Respiração Autonômica Preservada

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Autor em destaque: Uma cirurgia toracoscópica videoassistida não intubada com analgesia multimodal e anestesia inalatória com sevoflurano 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Cirurgia Toracoscópica Videoassistida Não Intubada

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Tireoidectomia Total Robótica Transoral e Dissecção Linfonodal Regional Central Bilateral para Carcinoma Papilar de Tireoide

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

Tireoidectomia endoscópica sem gás por via transaxilar

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Removal of Subcostal Specimen After Complete Portal Robotic Lobectomy

Subcostal Specimen Removal in Completely Portal Robotic Lobectomy

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional robot-assisted lobectomy (RAL). CPRL-4 integrates a fourth robotic arm and CO2 insufflation, resulting in superior visualization within the intrathoracic cavity owing to enhanced lung deflation. While CPRL-4 effectively achieves pulmonary resection, extracting specimens typically necessitates an intercostal utility thoracotomy, which may pose risks. To address potential damage associated with this method, we introduced a subcostal trans-diaphragmatic access port during resection, later enlarging it for specimen removal post-lobectomy. This study evaluated the efficacy and feasibility of this subcostal trans-diaphragmatic specimen removal approach following CPRL-4 procedures for pulmonary malignancies, all performed by a single surgical team. The findings suggest that subcostal specimen removal post-CPRL-4 offers several advantages, including reduced risk of thoracotomy-related complications, making it a practical, feasible, and safe method. This innovation has the potential to improve outcomes and patient care in pulmonary malignancy surgeries significantly.

This protocol describes the removal of lung specimens following a completely portal robotic lobectomy. Determining the optimal location for specimen extraction is a pertinent question, as both intercostal and subcostal routes can serve as potential extraction paths following robotic or video-thoracoscopic lobectomy. We choose subcostal lung specimen removal over intercostal removal.

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional ...

Ressecção da Primeira Costela Transaxilar para Tratamento da Síndrome do Desfiladeiro Torácico

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Tireoidectomia Endoscópica Transoral Abordagem Vestibular para Lobectomia Tireoidiana

Cirurgia Toracoscópica Videoassistida Não Intubada

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Tireoidectomia Total Robótica Transoral e Dissecção Linfonodal Regional Central Bilateral para Carcinoma Papilar de Tireoide

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Subcostal Specimen Removal in Completely Portal Robotic Lobectomy