Median sternotomy has been a frequent approach for resection of bilateral pulmonary metastases.

Median sternotomy has been a frequent approach for resection of bilateral pulmonary metastases. It provides pious exposure and quick accessibility to in the greatest degree lesions in the lung. The retrocardiac left lower lobe may at times be a problematic area for resection of metastases. We have used a simultaneous median sternotomy and left video-assisted thoracoscopic approach to withdraw three such lesions in couple patients, with satisfactory results.

Pulmonary metastases are commonly seen in the course of many malignancies. A small cluster of highly selected patients may derive benefit from excision of pulmonary metastases.[1,2] Those considered for resection should convenient the following criteria: [1] must have their primary tumor controlled; [2] have no other metastatic disease; and [3] all metastases in the lung should be amenable to removal.

Median sternotomy has emerg as a popular and effective way for resection of pulmonary metastatic disease.[3,4] This approach allows examination of the pair lungs for metastases and the removal of bilateral lesions in single in kind setting. Posteriorly located lesions, especially in the left lower lobe, can be technically difficult to visualize and dislodge through the median sternotomy because of the intervening cardiac structures

Sarcomas as a common thing [i]or[/i] matter metastasize to the lungs, and when this is the only site of disease, resection may improve survival.[4-6] We report three instances where video-assisted thoracoscopy was used in conjunction with a median sternotomy incision to allow removal of all pulmonary metastases in brace patients with metastatic osteosarcoma.

MATERIALS AND METHODS

the two patients presented with multiple pulmonary lesions and a previous amputation for osteosarcoma. single patient had undergone a thoracotomy 2 years previously for resection of 2 pulmonary metastases. Chemotherapy with doxorubicin hydrochloride (Adriamycin) had been utilized, and a latter MUGA scan in 1 patient revealed a 30 percent ejection fraction. the two patients were otherwise free of disease and healthy, with adequate pulmonary function. A total of nine metastatic lesions were resect in these sum of two units patients, one of which was not identified at preoperative computed tomographic (CT) scans.

Technique

The patient is anesthetized, intubated with a double-lumen endotracheal tube, and placed in a supine position with the left arm stretch outed at a 90 [degrees] angle (Fig 1) The entire chest is prepared and draped as for a median sternotomy, and the preparation is fill outed as far lateral on the left side of the chest as possible. A median sternotomy is performed, and the two lungs are carefully examined for metastatic lesions.

Lesions in the right lung and left upper lobe are remov from wedge resection. Left lower lobe lesions, especially when posterior and mysterious may be difficult or impossible to strip of disguises [i]or[/i] concealments and remove (Fig 2). Special retractors to elevate the left hemisternum are frequently used to aid in aspect for more difficult lesions. the two of our patients had lesions which could not be expos and resect safely at median sternotomy.

pair 12-mm trocars (Auto Suture; Surgiport; U Surgical Corporation) are placed in the sixth and seventh intercostal space in the anterior and posterior axillary line (Fig 1) During this maneuver, the heart and lung are harbored by manual retraction through the median sternotomy. The video component part is advanced through one port. The lesions to be remov are identified through palpation through the median sternotomy incision and visualization end the thoracoscope. Standard lung clamps and instruments may be passed by the and of the median sternotomy to aid in prospect of the lesions.

For superficial lesions, the endoscopic stapling device (Auto Suture; Endo-GIA; U Surgical Corporation) is placed in the thoracic cavity from one side the 12-mm trocar (Fig 3) The metastasis is grasped with the fingers and lifted away from the remaining lung Utilizing the video thoracoscope, the stapler can then be advanced underneath the lesion and fired. A wedge excision of the lesion is accomplished. couple of the three lesions in our couple patients were removed in this fashion.

A third lesion was deeper in the lower lobe and was resect using the Nd:YAG laser as previously described.[7] Visualization was provided within the thoracoscope while the laser fiber was introduced [i]or[/i] part of to the other a separate port. The lesion was intermittently palpated by means of the median sternotomy for guidance, and a fume evacuation suction was used.

At completion of the resections, common trocar site is used for a chest tube, and the other is closed with a subcuticular stitch and BandAid. The median sternotomy incision was clos in the standard fashion. the one and the other patients were discharged within seven days after a sleek postoperative recovery.

DISCUSSION

Resection of bilateral pulmonary metastases is an accepted treatment, the two for attempted cure and palliation of multiple metastases. Formerly, the options for surgical approach included bilateral thoracotomy or median sternotomy. The advantage of the median sternotomy approach is the ability to undertake resections bilaterally end a single incision, which accrues in less pain and ventilatory compromise than the thoracotomy approach. The single greatest disadvantage of the median sternotomy approach is that metastases in the left lower lobe may require an displacement of the heart to gain position Attempts to displace the heart and allow visualization of the posterior portion of the left lower lobe may lead to hemodynamic compromise, especially in patients with underlying cardiac dysfunction. A simultaneous sternotomy and thoracoscopic approach obviate this difficulty and allow for entire resection of metastases.

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