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Children will require surgery for conditions of the chest. Like abdominal surgery, many of these procedures can be accomplished utilizing minimally invasive surgery employing multiple small, incisions. This technique avoids a large incision with injury to chest wall musculature and in rare cases, chest wall deformity. We breath anywhere from 12 to 30 times per minute depending on our age. Large chest incisions are particularly painful and worsened by the need for frequent respiration, making pain control and recovery difficult. Minimally invasive surgery has been demonstrated to reduce pain, hospital stay, and complications with a superior cosmetic result to traditional thoracotomy. We have reported our results in the removal of tumors of the chest utilizing this approach that demonstrates a reduction in hospitalization and complications with the same curative rates associated with traditional thoracotomy. Thoracotomy will still be necessary in selected cases. The following are examples of other procedures surgeons perform at Peyton Manning Children’s Hospital at St. Vincent.
Infection of the pleural space (chest cavity) may complicate pneumonia, particularly in young children. Contamination of the pleural space results in a progressive infection that can culminate in entrapment of the lung restricting expansion and respiration. Children with empyema complain of pleuritic chest pain, demonstrate fever, malaise and cough. Often, the same symptoms observed with pneumonia.
How is the diagnosis made?
A chest X-ray will demonstrate the presence of pneumonia but there may also be a suggestion of fluid within the pleural cavity. Generally, your child will also demonstrate significant respiratory symptoms of rapid, shallow breathing and high fever. Imaging studies are very helpful to differentiate simple pneumonia from pneumonia complicated by empyema. Dense fluid collections with compression of the lung and stranding suggest empyema. Sampling of the fluid may be attempted by introducing a needle into the chest (thoracentesis) and sending the fluid for analysis.
What is the treatment?
Antibiotics and drainage of the pleural space are needed to eradicate the infection. Your surgeon may recommend placement of a tube in the chest to both sample and drain the fluid (tube thoracostomy) or a thoracoscopic procedure to sample the fluid, drain the fluid, and clean the pleural space of infected material. The thoracoscopic procedure is performed under general anesthesia and employs three to four small (3-5mm) incisions to provide access to the pleural space. Utilizing a small camera, the pleural space is cleaned of all infected material and debris allowing the lung to re-expand. Thoracosopy has been demonstrated to accelerate resolution of symptoms and recovery while reducing hospital stay, particularly if employed in the early course of the illness.
Some children will have chronic lung conditions whose etiology remains elusive. Despite numerous tests a diagnosis can not be made and your lung doctor requires more information. Utilizing three small incisions, targeted areas of the lung can be biopsied. The procedure is well tolerated, even in children with advanced lung disease due to limited post-operative pain and discomfort that does not compromise respiration. A diagnosis is achieved in over 95% of biopsies. Interestingly, we have shown that the amount of tissue obtained for analysis is the same as thoracotomy, while eliminating the need for a large incision and its attendant complications.
Collapse of the lung is known as pneumothorax and can be life threatening. The lung needs to be re-expanded to alleviate the symptoms and permit healing of the lung. Spontaneous pneumothorax can be observed in teenagers, particularly as they progress through their adolescent growth spurt. Some, children with have underlying lung disease, like cystic fibrosis or apical cysts that predispose them to pneumothorax.
What is the treatment?
In a child suffering a pneumothorax it is important to promptly re-expand the lung once the diagnosis is made. Typically, the child will complain of chest pain and shortness of breath. A chest X-ray will demonstrate collapse of the lung. Utilizing conscious sedation and local anesthetic, a tube is introduced into the pleural space and the lung re-expanded. The child is hospitalized and the tube is removed once the air leak has resolved indicating that the lung is healed.
If a child should experience a recurrent pneumothorax, then again a chest tube is placed. The risk of a second pneumothorax is 50% but after the second pneumothorax, the risk increases significantly to 70%. If the child has no known lung disease, a high resolution CT scan is performed to assess the apices of the lung for cysts (blebs) that rupture easily and predispose to pneumothorax. With the second pneumothorax, it is recommended that your child undergo thoracoscopy.
How is pneumothorax treated with thoracoscopy?
Utilizing three small incisions (5-12 mm) the apical cysts (if present) are removed by application of an endoscopic stapling device. The lining of the pleural cavity is abraided to promote adherence of the lung to the chest wall and elimination of future air leaks, much like patching a hole in an inner tube. Once there is no evidence of air leak, the chest tube is removed and your child discharged home. The risk of recurrence is low (5%). Sometimes, a pneumothorax has been observed only on one side, but cysts are seen bilaterally. Your surgeon may recommend that your child undergo the procedure on both sides to avoid the need for future hospitalization or procedures. If you live far away from medical care, your surgeon may recommend the procedure at the time of initial presentation, particularly if cysts are identified with imaging.