| Abstract|| |
Thoracoscopic surgery and other minimally invasive approaches in children achieved marked advancement and expanded to include several disciplines in the last decade. The new armamentarium of the minimally invasive surgery including the smaller instruments and better magnification led to the application of this technology in the small infants and neonates. Currently, thoracoscopy is considered the preferred surgical approach for various conditions in neonates and infants over the standard thoracotomy, and thoracoscopic training is included in the surgical training curriculum for the residents in many institutes worldwide. Children are different from adults, and technique modifications are required when using thoracoscopy in children. Thoracoscopy showed satisfactory results in several operations including pulmonary resections, mediastinal tumors biopsies or resections, repair of the diaphragmatic hernias, decortication, and tracheoesophageal fistula. This review aims to address the unique aspects of thoracoscopic surgery in children, identify its potential technical and anatomical challenges, and the proposed solutions. A literature search for latest and relevant publications was done using the keywords (thoracoscopy; pediatric; lung biopsy; decortication; lobectomy; mediastinum; esophagus; and diaphragmatic hernia).
Keywords: Decortication, diaphragmatic hernia, esophagus, lobectomy, lung biopsy, mediastinum, pediatric, thoracoscopy
|How to cite this article:|
Bawazir OA. Thoracoscopy in pediatrics: Surgical perspectives. Ann Thorac Med 2019;14:239-47
Minimally invasive surgical (MIS) techniques have been increasingly applied in pediatric surgery, and thoracoscopy is currently considered the standard approach for several procedures ,, MIS is preferred because it is associated with reduced tissue trauma, decreased pain, reduced hospital stay, and equal or even better clinical outcomes when compared to the standard surgical approaches., Thoracoscopy is considered now the preferred approach for several surgical interventions including the lung and mediastinal biopsies, as well as decortication for empyema. Currently, several pediatric centers worldwide have adapted many advanced thoracoscopic procedures, including lobectomies, esophageal surgery, and diaphragmatic hernia repair.
Jaureguizar et al. reported significant musculoskeletal deformities postoperatively in 35% of patients who had a tracheoesophageal fistula repair through a thoracotomy, and scoliosis developed in 30% of the neonates. Better long-term muscular skeletal morbidity was reported after thoracoscopy, in addition to the superior cosmetic results. Moreover, thoracoscopy was associated with better postoperative pulmonary mechanics, and consequently lower hospital stay and wound-related complications. Shorter hospital stay following thoracoscopy is one of its main advantages, and thoracoscopic lung and mediastinal biopsies and patent ductus arteriosus (PDA) repair can be discharged within 24 h of the procedure. In addition to the direct impact on the patients and procedure outcomes, thoracoscopy provides the surgeons with higher magnification leading to better visibility of the vital structure thus avoiding their injury.
Thoracoscopy is not without risks and compared to the open approaches; thoracoscopic procedures are technically more demanding due to the smaller working field, difficult hemostasis, lack of tactile feedback, and two-dimensional vision. These factors have a direct impact on the learning curve for thoracoscopic surgery and may influence the outcomes. The question is whether the benefits of thoracoscopy outweigh its risk and steep learning curve.
The aim of this review is to address the unique aspects of thoracoscopic surgery in the pediatric population, identify its potential challenges and the proposed solutions. A literature search of several databases such as “PubMed, Ovid, and Science Direct” was performed. The keywords used were “thoracoscopy and pediatrics and lung biopsy or empyema or lobectomy or esophageal surgery or mediastinal surgery or patent ductus arteriosus ligation.” Relevant and latest publications were identified and discussed.
| Historical Background|| |
Thoracoscopy in pediatric patients was first described in 1971 by Klimkovich and coworkers who performed diagnostic procedures for mediastinal and lung lesions,, Rothenberg et al. reported the first thoracoscopic lung lobectomy in 1994–1995,, and the first thoracoscopic pure esophageal atresia repair was performed in Berlin in 1999.
| Anatomical axnd Physiological Issues|| |
Children are different from adults not only anatomically and physiologically but also emotionally. These factors may require modifications to the techniques used in adults to avoid complications. Most of the complications can be managed thoracoscopically depending on its nature and the surgeons' experience; however, the conversion to open thoracotomy is still required in up to 17% of cases. Complications can be broadly classified into complications related to the approach and procedure-specific complications. Insufflation is unique to endoscopic surgery and has its physiologic consequences and complications., Conversion to open access may increase morbidity associated with the procedure and should be considered as thoracoscopic-related complications.
The size of the infants may hinder proper exposure and increase the risk of complications. This limits the use of minimally invasive approaches including robotic surgery to specific weights. An anatomical difference in infants may affect trocar placement and limit the space to vital organs such as the heart and great vessels. In general, the children have relatively soft and cartilaginous and more pliable chest wall compared to the rigid chest wall of the adults, and the ribs run more horizontally to the vertebrae compared to the oblique course in the adult population. The trachea is short and narrow in the children compared to the adults, and the right bronchus is less angled. In addition, different upper airway anatomy may warrant different airway management during anesthetic management. All these anatomical factors should be considered when planning thoracoscopic surgery in the pediatric population.
| Common Thoracoscopic Procedures|| |
Lung biopsy is a simple procedure, and thoracoscopy became the preferred approach for it. Thoracoscope offers a tool to evaluate the entire surface of the lung and the pleura, but lacks tactile sense which may be required to evaluate deep lesions. Lung biopsy is essential in pulmonary fibrosis to identify its specific pathology, and it is required for tumor staging and evaluating the response to therapy.,
Preoperative diagnostic workup is essential before lung biopsy to precisely localize the lesion and identify the extent of the disease, and it includes chest radiographs and computed tomography (CT) or magnetic resonance imaging. Thoracoscopic lung biopsy has replaced thoracotomy due to the lower morbidity and mortality associated with it, in addition to the decreased hospital stay. It became our standard technique for biopsy, and thoracotomy is no longer performed for this purpose.
Several techniques have been proposed to guide the surgeons to localize deep lesions during a thoracoscopic lung biopsy. These techniques include CT-guided needle localization with the application of methylene blue dye or a blood patch to mark the area overlying the lesion. Other methods involve marking the lesion with a needle or microcoil labeling and intra-operative ultrasound. These localizing procedures are preferably done just before the biopsy, and a frozen section should be used to evaluate the presence of the lesion in the excised tissue.
Lung biopsy is typically performed in the lateral decubitus position, and port placement should be modified according to the patient's size and the location of the lesion. Lung parenchyma can be sealed postbiopsy using endoloops or ligature, and an endostapler can be used in older children. The biopsy can be removed within an endoscopic bag or through the port depending on its size.
Diaphragmatic hernias including Bochdalek hernia can be managed using a minimally invasive approach either through laparoscopy or thoracotomy. Thoracoscopy was used first in infants with a diaphragmatic hernia and delayed presentation, then it was used for primary repair of neonatal hernia either directly or by patch repair. The criteria for the successful thoracoscopic approach in neonates were reported. Neonates with the favorable lung-head ratio, no liver or stomach herniation, minimal ventilator settings, and absence of significant pulmonary hypertension had favorable outcomes. Preoperative extracorporeal membrane oxygenation is not considered a contraindication to the thoracoscopic repair of the hernia.
Patients with hypoplastic lung require low pressure and low carbon dioxide (CO2) insufflation to compress the lung; in addition, they have an acceptable working field offered by the small-sized lung. CO2 insufflation also aids in hernia reduction, and the hernial sac does not need excision in all patients. The defect can be closed by direct nonabsorbable sutures in most cases [Figure 1]. If no posterolateral diaphragmatic border remains, a periosteal suture can be used. In a survey conducted on 280 pediatric surgeons, MIS was the preferred approach for the primary repair of a diaphragmatic hernia in ≥50% of them and half of them preferred thoracoscopy for the recurrent hernia.
|Figure 1: A case of diaphragmatic hernia repaired thoracoscopically by direct suture technique. (a) preoperative chest X-ray, (b) thoracoscopic view of the small intestine herniating to the chest cavity, (c) reduction of the intestinal content, (d) direct suture repair of the diaphragm|
Click here to view
Thoracoscopic repair of the neonatal hernia has several drawbacks, namely longer operative time compared to open repair, conversion to open repair which ranges from 3% to 14%,, and recurrence of hernia (from 14% to 21%).
| Ligation Of The Patent Ductus Arteriosus|| |
In a randomized trial comparing medical therapy versus ligation for the management of PDA, indomethacin therapy was associated with significant complications, and PDA ligation was the preferred approach, especially in infants with very low birth weight. The thoracoscopic technique for PDA ligation was developed by Burke et al. in Boston and Laborde et al. in Paris in the early 1990s. The thoracoscopic approach gains popularity in many centers for PDA ligation, and it can be safely used in low weight babies, and it has the advantages of better magnification compared to the standard approach. Better magnification has a role in decreasing operative times which is vital in criterial ill patients. In addition, thoracoscopic ligation offers cosmetic benefits which may have a psychological effect over the long-term follow-up, and it avoids chest tube insertion in ≥95% of the patients and consequently will lead to a shorter hospital stay.,
| Esophageal Surgery|| |
Repair of tracheoesophageal fistula and esophageal atresia can be performed thoracoscopically. Esophageal atresia repair using thoracoscopy was first performed live during the International Pediatric Endosurgery Group Meeting in 1999 in Berlin and is considered a technical breakthrough for thoracoscopic surgery. Several series have followed and reported the outcomes of esophageal atresia repair associated with distal fistula. Thoracoscopic repair of esophageal atresia is not suitable for all neonates, and hemodynamic instability, low body weight (<2 kg), and the inability to tolerate single-lung ventilation are considered contraindications for the procedure.
In a comparison between the thoracoscopic repair and open repair of esophageal atresia; a multinational and multiinstitutional retrospective analysis of 104 patients was performed. The results of the study showed comparable outcomes and complications rate between both techniques. A meta-analysis of five large series comparing open versus thoracoscopic repair showed no statistically significant difference in the complications or outcomes between thoracoscopic and the open repair.
The patient is placed in the prone position with 45° tilt of the right side. Usually, the use of bronchial blockers or right mainstem bronchus intubation is not necessary. Low flow CO2 insufflation is used to create pneumothorax which is preferred over mechanical retraction due to better pulmonary mechanics. Azygos vein division is not required in all patients, but it can be cut with diathermy. A tracheoesophageal fistula may be ligated using titanium clip, but suture ligation is preferable.
| Lobectomy|| |
Thoracoscopy lobectomy is a challenging procedure and technically demanding compared to adult lobectomy which could be attributed to the small working place or the complex nature of the lung pathology with the risk of bleeding.
The indications of lobectomy for congenital lesions such as congenital lobar emphysema [Figure 2], congenital cystic adenomatoid malformations, lobar sequestration predominate in pediatric age, and lobectomy for a malignant tumor is rarely performed. Nonanatomical lung resection can be performed for several lesions [Figure 3]. Prenatal ultrasound examinations have a major role in diagnosing congenital lung lesions intra-uterine. Most of these lesions are asymptomatic at birth and the question of whether they need surgery and when still debatable. Clearly symptomatic lesions necessitate surgery., The possibility of malignant transformation and infectious complications in these lesions may argue early operation. Several surgeons suggest surgery at mid-infancy., While thoracoscopic surgery for congenital lung malformation is done in numerous centers, a study which compared the thoracoscopic versus the open surgery is limited. In a case-matched study, no significant difference between thoracoscopic versus open lobectomy as regard to the length of hospital stay, chest tube duration, and opioid requirement. The feasibility and effectiveness of thoracoscopic lobectomy have been demonstrated in several studies.,,,,, The outcomes of open and thoracoscopic lobectomies are comparable in small children. The benefits of the thoracoscopic approach must be weighed against the surgeons' experience to avoid the complications of thoracoscopy in this special subset of patients.
|Figure 2: Congenital lobar emphysema (a) preoperative chest X-ray, (b) preoperative computed tomography scan, (c) thoracoscopic view of the distended lobe, (d and e) thoracoscopic lobectomy, (f) postoperative chest X-ray|
Click here to view
|Figure 3: Thoracoscopic excision of Wilms' tumor metastasis to the right upper lobe. (a) preoperative computed tomography scan sagittal section, (b) thoracoscopic view of the tumor, (c) excision of the tumor thoracoscopically, (d) the tumor after excision|
Click here to view
Double-lumen endotracheal tube is preferable for single-lung ventilation during the procedure. Alternatively, this can be achieved by the use of bronchial blocker or mainstem intubation of the contralateral lung, and in neonate insufflation of low flow CO2 may be enough. In infants with a cyst that occupy a large space, it is always helpful to decompress this cyst to free more working space. Thoracoscopic surgery usually starts with anterior hilar dissection then the structures are identified and ligated in a stepwise fashion from posterior to anterior or from below upward depends on which lobe to resect. Small endoscopic stapler and sealing devices are now available for vascular control. For smaller infant and neonate clips or endoloop can be used to control the bronchus.
| Mediastinal Tumors and Cysts|| |
Thoracoscopy can be used safely to resect both anterior and posterior mediastinal lesions in children with better access compared to the open approach. Posterior lesions are mainly neurogenic tumors, and they are relatively easy to excise, but the risk of bleeding is viable. Teratoma and lymphoma are commonly found in the anterior mediastinum. Preoperative imaging is essential for proper localization of the lesion and to identify its nature, and intraoperative sonography may be helpful. Several inflammatory lesions mimicking malignant lesions have been found in the mediastinum. A thoracoscopic biopsy is a preferred approach for benign mediastinal lesions in infants; however, more experience and longer follow-up are required before promoting this approach with malignant tumors.
Proper positioning is essential to provide adequate exposure. The position should allow the lung to drop away from the lesions by gravity.
| Empyema|| |
Empyema is classified by the American Thoracic Society into three stages, exudative, fibrinopurulent, and organizing stage. The exudative stage usually lasts 24–72 h, and fluid is thin and can be managed with chest drainage. Pus is formed in the fibrinopurulent stage, and the lung becomes less expandable. This stage usually lasts for 7–10 days up to for several weeks. The organizing stage is characterized by the formation of a membranous “peel” with fibrosis, and the lung becomes entrapped. Early intervention in empyema is essential to prevent the development of the chronic stage. Drainage if adequate in the exudative stage, it is not enough to manage the fibrinopurulent stage, and thoracoscopy is recommended. Thoracoscopy determines the stage of the disease, breaks the loculi, and completely evacuate the infected material. In addition, thoracoscopy provides a visual diagnostic tool for the disease of the underlying lung and the presence of bronchopleural fistula. The intercostal tube is required after thoracoscopic decortication, but usually for a shorter duration than open decortication. The main disadvantages of thoracoscopic decortication are the requirement of general anesthesia and surgical expertise.
Thoracoscopy can be performed either primarily or after the failure of conventional management with intercostal drainage and antibiotics. Timing for thoracoscopic decortication is controversial, and recent results advocate early decortication before the development of a chronic stage. We recommend conservative management for patients presenting in stage I and if the disease persists ≥7 days or in case of loculations, thoracoscopic intervention is recommended [Figure 4]. Thoracoscopic decortication achieved good outcomes when it is performed within 7 days of the presentation. In a systematic review of 44 studies including 1369 patients, early intervention for empyema either through an open or thoracoscopic approach was associated with a shorter length of stay, but no difference between thoracoscopic and conventional decortication. The current practice integrates both thoracotomy and thoracoscopy for the management of empyema in children.
|Figure 4: Thoracoscopic decortication. (a and b) preoperative computed tomography scan, (c) preoperative chest X-ray, (d) thoracoscopic view of the thickened pleura, (e) thoracoscopic cutting of the adhesions, (f) chest X-ray 3 months after decortication|
Click here to view
| Points To Consider For Thoracoscopy|| |
Cosmetic aspects are very essential in thoracoscopic surgery. Single-lung ventilation using a double-lumen endotracheal tube should be considered for thoracoscopic lobectomies in older children, and bronchial blockers are alternatives. However, in small children low pressure CO2 insufflation should be sufficiently provided no desaturation occurs.
Pain is less frequently reported after thoracoscopy compared to thoracotomy, and usually, it is related to port incisions. Local infiltrating anesthesia at the site of trocar insertion before the closure is helpful to control postoperative pain. An intercostal nerve block can also be done under direct visualization at the conclusion of the procedure.
The recommended CO2 insufflation pressure is 5 mmHg which has minimal hemodynamic effects. Higher pressure may cause hemodynamic compromise and myocardial ischemia; therefore, an open approach is preferred for a patient with cardiac comorbidities.
Several thoracoscopy-related complications are due to lack of the appropriate experience. Early training and close supervision are essential to avoid problems related to the learning curves.
The surgical approach should be tailored based on the patients' size and age and the target structure.
Bleeding is of special importance during thoracoscopy because bleeding control can be problematic. Bleeding can be managed either by open conversion or identifying the bleeding site and clipping or cauterization under direct vision. Avoid blind clipping or cauterization as it may lead to serious injury to vital structures.
Vigorous manipulation during the extraction of the specimen from the chest cavity should be avoided as it can lead to dissemination of infection or implementation of malignant cells on the chest wall. Removal of tissues can be through an endobag for large specimen or direct for the small-sized specimen.
Triangulation should be considered during port placement to provide enough working space. Attention should be paid to avoid liver or diaphragmatic injury during replacement of the lower port. Insert the ports using blunt dissection and use the first port to inspect the cavity for any injury implicated after port placement, and subsequent ports should be placed under direct vision. Inspect the trocar site for bleeding after removal of the ports. Foley catheter can be used to tamponade the bleeding if encountered after trocar removal.
Postoperative subcutaneous emphysema has no clinical impact and usually resolves within a few days.
Serrated ports or suturing ports to the chest wall can prevent easy dislodgement of the ports in small or thin children. If postoperative bleeding or air leak are anticipated, insert a chest tube. Otherwise, use suction through the last port and ask the anesthesiologist to keep the lung expanded until the closure is completed.
Thoracoscopy is used in different surgical procedures in the pediatric population. Various complications were reported [Table 1], and careful planning and training are required for better outcomes. The field is evolving with new researches, and techniques are continuously published [Table 2].
|Table 2: Summary of recent studies in different thoracoscopic procedures in pediatrics|
Click here to view
| Conclusion|| |
Thoracoscopy became an indispensable tool in thoracic surgery. Clinical randomized trials comparing it to the standard approach are deficient. Studies confirmed the feasibility of thoracoscopy in specific procedures in children. The thoracoscopic instruments are still evolving, and the body weight and size are no longer contraindications to this approach.
The cosmetic advantages of thoracoscopy were confirmed; in addition, it decreases postoperative pain and surgical site complications. Proper training is essential as it affects the outcomes and conversion rate and enhances the ability to manage the complications thoracoscopically. Conversion should not be considered as treatment failure, and its possibility should be explained to the patients/parents and stated clearly in the consent.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the newborn: Current status and evidence. Semin Pediatr Surg 2014;23:249-56.
Ponsky TA, Rothenberg SS. Minimally invasive surgery in infants less than 5 kg: Experience of 649 cases. Surg Endosc 2008;22:2214-9.
Ure BM, Schmidt AI, Jesch NK. Thoracoscopic surgery in infants and children. Eur J Pediatr Surg 2005;15:314-8.
Lawal TA, Gosemann JH, Kuebler JF, Glüer S, Ure BM. Thoracoscopy versus thoracotomy improves midterm musculoskeletal status and cosmesis in infants and children. Ann Thorac Surg 2009;87:224-8.
Yang YF, Dong R, Zheng C, Jin Z, Chen G, Huang YL, et al.
Outcomes of thoracoscopy versus thoracotomy for esophageal atresia with tracheoesophageal fistula repair: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2016;95:e4428.
Rothenberg SS. Thoracoscopy in infants and children: The state of the art. J Pediatr Surg 2005;40:303-6.
Jaureguizar E, Vazquez J, Murcia J, Diez Pardo JA. Morbid musculoskeletal sequelae of thoracotomy for tracheoesophageal fistula. J Pediatr Surg 1985;20:511-4.
Rothenberg SS, Chang JH, Toews WH, Washington RL. Thoracoscopic closure of patent ductus arteriosus: A less traumatic and more cost-effective technique. J Pediatr Surg 1995;30:1057-60.
Rodgers BM, Moazam F, Talbert JL. Thoracoscopy. Early diagnosis of interstitial pneumonitis in the immunologically suppressed child. Chest 1979;75:126-30.
Rodgers BM, Ryckman FC, Moazam F, Talbert JL. Thoracoscopy for intrathoracic tumors. Ann Thorac Surg 1981;31:414-20.
Blinman T, Ponsky T. Pediatric minimally invasive surgery: Laparoscopy and thoracoscopy in infants and children. Pediatrics 2012;130:539-49.
Rothenberg SS, Chang JH, Bealer JF. Experience with minimally invasive surgery in infants. Am J Surg 1998;176:654-8.
Rothenberg SS. Developing neonatal minimally invasive surgery: Innovation, techniques, and helping an industry to change. J Pediatr Surg 2015;50:232-5.
Chen MK, Schropp KP, Lobe TE. Complications of minimal-access surgery in children. J Pediatr Surg 1996;31:1161-5.
Stankowski T, Aboul-Hassan SS, Fritzsche D, Misterski M, Marczak J, Szymańska A, et al.
Conversion to thoracotomy of video-assisted thoracoscopic closure of patent ductus arteriosus. Kardiochir Torakochirurgia Pol 2018;15:102-6.
Ure BM, Bax NM, van der Zee DC. Laparoscopy in infants and children: A prospective study on feasibility and the impact on routine surgery. J Pediatr Surg 2000;35:1170-3.
Esposito C, Mattioli G, Monguzzi GL, Montinaro L, Riccipetiotoni G, Aceti R, et al.
Complications and conversions of pediatric videosurgery: The Italian multicentric experience on 1689 procedures. Surg Endosc 2002;16:795-8.
Fan LL, Kozinetz CA, Wojtczak HA, Chatfield BA, Cohen AH, Rothenberg SS. Diagnostic value of transbronchial, thoracoscopic, and open lung biopsy in immunocompetent children with chronic interstitial lung disease. J Pediatr 1997;131:565-9.
Holcomb GW 3rd
, Tomita SS, Haase GM, Dillon PW, Newman KD, Applebaum H, et al.
Minimally invasive surgery in children with cancer. Cancer 1995;76:121-8.
Rothenberg SS, Wagner JS, Chang JH, Fan LL. The safety and efficacy of thoracoscopic lung biopsy for diagnosis and treatment in infants and children. J Pediatr Surg 1996;31:100-3.
Pursnani SK, Rausen AR, Contractor S, Nadler EP. Combined use of preoperative methylene blue dye and microcoil localization facilitates thoracoscopic wedge resection of indeterminate pulmonary nodules in children. J Laparoendosc Adv Surg Tech A 2006;16:184-7.
Lobe TE. Pediatric thoracoscopy. Semin Thorac Cardiovasc Surg 1993;5:298-302.
Becmeur F, Reinberg O, Dimitriu C, Moog R, Philippe P. Thoracoscopic repair of congenital diaphragmatic hernia in children. Semin Pediatr Surg 2007;16:238-44.
Kim AC, Bryner BS, Akay B, Geiger JD, Hirschl RB, Mychaliska GB. Thoracoscopic repair of congenital diaphragmatic hernia in neonates: Lessons learned. J Laparoendosc Adv Surg Tech A 2009;19:575-80.
Rozmiarek A, Weinsheimer R, Azzie G. Primary thoracoscopic repair of diaphragmatic hernia with pericostal sutures. J Laparoendosc Adv Surg Tech A 2005;15:667-9.
Bruns NE, Glenn IC, McNinch NL, Arps K, Ponsky TA, Schlager A. Approach to recurrent congenital diaphragmatic hernia: Results of an international survey. J Laparoendosc Adv Surg Tech A 2016;26:925-9.
Marhuenda C, Guillén G, Sánchez B, Urbistondo A, Barceló C. Endoscopic repair of late-presenting morgagni and bochdalek hernia in children: Case report and review of the literature. J Laparoendosc Adv Surg Tech A 2009;19 Suppl 1:S95-101.
Nguyen TL, Le AD. Thoracoscopic repair for congenital diaphragmatic hernia: Lessons from 45 cases. J Pediatr Surg 2006;41:1713-5.
Guner YS, Chokshi N, Aranda A, Ochoa C, Qureshi FG, Nguyen NX, et al.
Thoracoscopic repair of neonatal diaphragmatic hernia. J Laparoendosc Adv Surg Tech A 2008;18:875-80.
Little DC, Pratt TC, Blalock SE, Krauss DR, Cooney DR, Custer MD. Patent ductus arteriosus in micropreemies and full-term infants: The relative merits of surgical ligation versus indomethacin treatment. J Pediatr Surg 2003;38:492-6.
Burke RP, Michielon G, Wernovsky G. Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 1994;58:864-8.
Laborde F, Noirhomme P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgical technique for interruption of patient ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 1993;105:278-80.
Stankowski T, Aboul-Hassan SS, Fritzsche D, Misterski M, Marczak J, Szymańska A, et al.
Surgical closure of patent ductus arteriosus in extremely low birth weight infants weighing less than 750 grams. Kardiol Pol 2018;76:750-4.
Alipour MR, Mozaffari Shamsi M, Namayandeh SM, Pezeshkpour Z, Rezaeipour F, Sarebanhassanabadi M. The effects of oral ibuprofen on medicinal closure of patent ductus arteriosus in full-term neonates in the second postnatal week. Iran J Pediatr 2016;26:e5807.
Holcomb GW 3rd
, Rothenberg SS, Bax KM, Martinez-Ferro M, Albanese CT, Ostlie DJ, et al.
Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: A multi-institutional analysis. Ann Surg 2005;242:422-8.
Rothenberg SS. Thoracoscopic repair of tracheoesophageal fistula in newborns. J Pediatr Surg 2002;37:869-72.
Borruto FA, Impellizzeri P, Montalto AS, Antonuccio P, Santacaterina E, Scalfari G, et al.
Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula repair: Review of the literature and meta-analysis. Eur J Pediatr Surg 2012;22:415-9.
Rothenberg SS. First decade's experience with thoracoscopic lobectomy in infants and children. J Pediatr Surg 2008;43:40-4.
Rothenberg SS. Experience with thoracoscopic lobectomy in infants and children. J Pediatr Surg 2003;38:102-4.
Eber E. Antenatal diagnosis of congenital thoracic malformations: Early surgery, late surgery, or no surgery? Semin Respir Crit Care Med 2007;28:355-66.
Stanton M, Njere I, Ade-Ajayi N, Patel S, Davenport M. Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg 2009;44:1027-33.
Ozcan C, Celik A, Ural Z, Veral A, Kandiloǧlu G, Balik E. Primary pulmonary rhabdomyosarcoma arising within cystic adenomatoid malformation: A case report and review of the literature. J Pediatr Surg 2001;36:1062-5.
Calvert JK, Lakhoo K. Antenatally suspected congenital cystic adenomatoid malformation of the lung: Postnatal investigation and timing of surgery. J Pediatr Surg 2007;42:411-4.
Diamond IR, Herrera P, Langer JC, Kim PC. Thoracoscopic versus open resection of congenital lung lesions: A case-matched study. J Pediatr Surg 2007;42:1057-61.
Kunisaki SM, Powelson IA, Haydar B, Bowshier BC, Jarboe MD, Mychaliska GB, et al.
Thoracoscopic vs. open lobectomy in infants and young children with congenital lung malformations. J Am Coll Surg 2014;218:261-70.
Engum SA. Minimal access thoracic surgery in the pediatric population. Semin Pediatr Surg 2007;16:14-26.
Arafat AA, Torky MA, Elhamshary M, Aboelnasr M. Immunoglobulin G4 thymic tumor. Ann Thorac Surg 2019. pii: S0003-4975(19)30398-4.
Partrick DA, Rothenberg SS. Thoracoscopic resection of mediastinal masses in infants and children: An evaluation of technique and results. J Pediatr Surg 2001;36:1165-7.
Merry CM, Bufo AJ, Shah RS, Schropp KP, Lobe TE. Early definitive intervention by thoracoscopy in pediatric empyema. J Pediatr Surg 1999;34:178-80.
Kelly MM, Coller RJ, Kohler JE, Zhao Q, Sklansky DJ, Shadman KA, et al.
Trends in hospital treatment of empyema in children in the United States. J Pediatr 2018;202:245-510.
Espinosa CM, Fallat ME, Woods CR, Weakley KE, Marshall GS. An approach to the management of pleural empyema with early video-assisted thoracoscopic surgery and early transition to oral antibiotic therapy. Am Surg 2016;82:295-301.
Alexiou C, Goyal A, Firmin RK, Hickey MS. Is open thoracotomy still a good treatment option for the management of empyema in children? Ann Thorac Surg 2003;76:1854-8.
Ismail M, Nachira D, Meacci E, Ferretti GM, Swierzy M, Englisch JP, et al.
Uniportal video-assisted thoracic surgery in the treatment of pleural empyema. J Thorac Dis 2018;10:S3696-703.
Klena JW, Cameron BH, Langer JC, Winthrop AL, Perez CR. Timing of video-assisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 1998;187:404-8.
Turial S, Schwind M, Kohl M, Goldinger B, Schier F. Feasibility of microlaparoscopy for surgical procedures of advanced complexity in children. J Laparoendosc Adv Surg Tech A 2009;19 Suppl 1:S103-5.
Ahmad NS, Dobby N, Walker E, Sogbodjor LA, Kelgeri N, Pickard A, et al
. A multicentre audit of the use of bronchoscopy during open and thoracoscopic repair of oesophageal atresia with tracheo-oesophageal fistula. Paediatr Anaesth publish online 2019. doi: 10.1111/pan.13621.
Ninomiya I, Okamoto K, Fushida S, Oyama K, Kinoshita J, Takamura H, et al.
Efficacy of CO2 insufflation during thoracoscopic esophagectomy in the left lateral position. Gen Thorac Cardiovasc Surg 2017;65:587-93.
Rothenberg SS, Kuenzler KA, Middlesworth W, Kay S, Yoder S, Shipman K, et al.
Thoracoscopic lobectomy in infants less than 10 kg with prenatally diagnosed cystic lung disease. J Laparoendosc Adv Surg Tech A 2011;21:181-4.
Boubnova J, Peycelon M, Garbi O, David M, Bonnard A, De Lagausie P. Thoracoscopy in the management of congenital lung diseases in infancy. Surg Endosc 2011;25:593-6.
Zhang J, Yuan M, Xu C, Yang G, Li F. Clinical report of 128 cases of meticulous thoracoscopic lobectomy in children. Sichuan Da Xue Xue Bao Yi Xue Ban 2018;49:474-7.
Seong YW, Yoo BS, Kim JT, Park IK, Kang CH, Kim YT. Video-assisted thoracoscopic lobectomy in children: Safety and efficacy compared with the conventional thoracotomy approach. Innovations (Phila) 2012;7:394-8.
Nadlonek NA, Acker SN, Deterding RR, Partrick DA. Intraoperative chest tube removal following thoracoscopic lung biopsy results in improved outcomes. J Pediatr Surg 2014;49:1573-6.
Gamba P, Midrio P, Betalli P, Snijders D, Leon FF. Video-assisted thoracoscopy in compromised pediatric patients. J Laparoendosc Adv Surg Tech A 2010;20:69-71.
Poupalou A, Vrancken C, Vanderveken E, Steyaert H. Use of nonabsorbable spiral tacks for mesh reinforcement in thoracoscopic repair of congenital diaphragmatic hernia. European J Pediatr Surg Rep 2018;6:e27-31.
Liem NT, Nhat LQ, Tuan TM, Dung le A, Ung NQ, Dien TM. Thoracoscopic repair for congenital diaphragmatic hernia: Experience with 139 cases. J Laparoendosc Adv Surg Tech A 2011;21:267-70.
Wu Y, Kuang H, Lv T, Wu C. Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: A systematic review and meta-analysis. Pediatr Surg Int 2017;33:1147-57.
Ehlers M, Pezzano C, Leduc L, Brooks J, Silva P, Oechsner H, et al.
Use of jet ventilation in thoracoscopic tracheo-esophageal fistula repair-can both surgeons and anesthesiologists be happy? Paediatr Anaesth 2015;25:860-2.
Moyer J, Lee H, Vu L. Thoracoscopic lobectomy for congenital lung lesions. Clin Perinatol 2017;44:781-94.
Park S, Kim ER, Hwang Y, Lee HJ, Park IK, Kim YT, et al.
Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation: An analysis of learning curve. Surg Endosc 2017;31:3932-8.
Souzaki R, Kawakubo N, Miyoshi K, Obata S, Kinoshita Y, Takemoto J, et al.
The utility of muscle-sparing axillar skin crease incision with thoracoscopic surgery in children. J Laparoendosc Adv Surg Tech A 2018;28:1378-82.
Scarpa AA, Ram AD, Soccorso G, Singh M, Parikh D. Surgical experience and learning points in the management of foregut duplication cysts. Eur J Pediatr Surg 2018;28:515-21.
Dorman RM, Vali K, Rothstein DH. Trends in treatment of infectious parapneumonic effusions in U.S. children's hospitals, 2004-2014. J Pediatr Surg 2016;51:885-90.
Livingston MH, Colozza S, Vogt KN, Merritt N, Bütter A. Making the transition from video-assisted thoracoscopic surgery to chest tube with fibrinolytics for empyema in children: Any change in outcomes? Can J Surg 2016;59:167-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]