Surgical and Radiologic Anatomy

, Volume 34, Issue 6, pp 539–549 | Cite as

Thoracoscopic anatomy and approaches of the anterior thoracic spine: cadaver study

Anatomic Bases of Medical, Radiological and Surgical Techniques
First Online:
Received:
Accepted:

Abstract

Propose

In spite of the extensive case studies considering thoracoscopic approaches to the anterior thoracic spine, the literature lacks studies of the thoracoscopic anatomic dissection and approaches. In this article, the authors present their study of thoracoscopic anatomy of the anterior spine with illustrated step-wise dissection and approaches for sympathectomy, discectomy and corpectomy.

Materials and methods

Four adult cadavers with no history of disease, local trauma or surgery were studied and bilateral thoracoscopic anterior spinal approaches were performed. Thoracoscopic dissections were done in the Department of Anatomy, using Karl Storz 30°, 5 mm and 30 cm rod lens rigid endoscope (Karl Storz and Co., Tuttlingen, Germany). As surgical instrumentation, Karl Storz Rosenthal endoscopic surgical set and 15 mm portals were used for all approaches.

Results

For sympathectomy, the cadaver is positioned supine and the port locations are in the third and fifth intercostal spaces in the anterior axillary line. The stellate ganglion is cephalad to the second rib, and the T2 and T3 ganglia are divided just superior to T2 ganglia and inferior to T3. For discectomy, the cadaver is positioned in the lateral decubitus position. The working portal is positioned directly over the affected disc in the posterior axillary line. The camera portal is positioned in the middle axillary line; 2–3 intercostal spaces caudal to the working portal. The rib head is removed and the lateral surface of the pedicle and neural foramen are exposed. The pedicle and the floor of the spinal canal are resected to decompress the ventral aspect of the spinal canal. For corpectomy, the position of the cadaver and ports are as same as for discectomy. The adjacent segmental vessels are divided first, and the discs above and below the targeted corpus are removed. The ipsilateral pedicle is then removed to decompress the anterior spinal cord, followed by median corpectomy.

Conclusions

Thoracoscopic approaches are minimally invasive procedures and they can be used safely in patients who need anterior exposure to the thoracic spine for the treatment of a spectrum of diseases. Knowledge of the normal anatomy and thoracoscopic cadaver dissection are essential steps in improving the learning curve.

Keywords

Anatomy Minimal invasive surgery Surgical technique Thoracic spine Thoracoscopy 
This is a preview of subscription content, log in to check access.

References

  1. 1.
    Anand N, Regan JJ (2002) Video assisted thoracoscopic surgery for thoracic disc disease. Spine 27:871–879PubMedCrossRefGoogle Scholar
  2. 2.
    Bisson EF, Jost GF, Apfelbaum RI, Schmidt MH (2011) Thoracoscopic discectomy and instrumented fusion using a minimally invasive plate system: surgical technique and early clinical outcome. Neurosurg Focus 30(4):E15PubMedCrossRefGoogle Scholar
  3. 3.
    Bohlman HH, Zdeblick TA (1988) Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 70:1038–1047PubMedGoogle Scholar
  4. 4.
    Coveliers HM, Hoexum F, Nederhoed JH, Wisselink W, Rauwerda JA (2011) Thoracic sympathectomy for digital ischemia: a summary of evidence. J Vasc Surg. doi: 10.1016/j.jvs.2011.01.069
  5. 5.
    Da Rocha RP, Vengjer A, Blanco A, de Carvalho PT, Mongon ML, Fernandes GJ (2002) Size of the collateral intercostal artery in adults: anatomical considerations in relation to thoracocentesis and thoracoscopy. Surg Radiol Anat 24(1):23–26PubMedCrossRefGoogle Scholar
  6. 6.
    Dickman CA, Rosenthal D, Karahalios DG, Paramore CG, Mican CA, Apostolides PJ, Lorenz R, Sonntag VK (1996) Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach. Neurosurgery 38:279–293PubMedCrossRefGoogle Scholar
  7. 7.
    Hougan O, Zihai D, Ouyang Z (2011) Vascular components of the posterior mediastinum: applications for video-assisted thoracoscopic surgery. Surg Radiol Anat 33(2):117–122PubMedCrossRefGoogle Scholar
  8. 8.
    Huang TJ, Hsu R, Chen SH, Liu HP (2000) Video assisted thoracoscopic surgery in managing tuberculous spondylitis. Clin Orthop Relat Res 379:143–152PubMedCrossRefGoogle Scholar
  9. 9.
    Huang TJ, Hsu RW, Sum CW, Liu HP (1999) Complications in thoracoscopic spinal surgery. a study of 90 consecutive patients. Surg Endos 13:346–350CrossRefGoogle Scholar
  10. 10.
    Jacobaeus HC (1910) Possibility of the use of the crytoscope for investigation of serious cavities. Munch Med Wochenchr 57:2090–2092Google Scholar
  11. 11.
    Johnson JP, Filler AG, Mc Bride DQ (2000) Endoscopic thoracic discectomy. Neurosurg Focus 9(4):e11PubMedGoogle Scholar
  12. 12.
    Johnson JP, Obasi C, Hahn MS, Glatleider P (1999) Endoscopic sympathectomy. J Neurosurg 91(Suppl 1):90–97PubMedGoogle Scholar
  13. 13.
    Johnson JP, Patel NP (2002) Uniportal and biportal endoscopic thoracic sympathectomy. Neurosurgery 51(5 Suppl):S79–S83PubMedGoogle Scholar
  14. 14.
    Kan P, Schmidt MH (2008) Minimally invasive thoracoscopic approach for anterior decompression and stabilization of metastatic spine disease. Neurosurg Focus 25(2):E8PubMedCrossRefGoogle Scholar
  15. 15.
    Kao MC (2001) Microinvasive transaxillary thoracoscopic sympathectomy: technical note. Neurosurgery 48:702PubMedCrossRefGoogle Scholar
  16. 16.
    Kim DH, Jaikumar S, Kam AC (2002) Minimally invasive spine instrumentation. Neurosurgery 51(5 Suppl):S15–S25PubMedGoogle Scholar
  17. 17.
    Kuntz A (1927) Distribution of the sympathetic rami to the brachial plexus: its relation to sympathectomy affecting the upper extremity. Arch Surg 15:871–877CrossRefGoogle Scholar
  18. 18.
    Lai YT, Yang LH, Chio CC, Chen HH (1997) Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery 41:110–114PubMedCrossRefGoogle Scholar
  19. 19.
    Landreneau RJ, Hazelrigg SR, Mack MJ, Dowling RD, Burke D, Gavlick J, Perrino MK, Ritter PS, Bowers CM, DeFino J (1993) Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 56:1285–1289PubMedCrossRefGoogle Scholar
  20. 20.
    Lin CC (1990) A new method of thoracoscopic sympathectomy in hyperhidrosis palmaris. Surg Endosc 4:224–226PubMedCrossRefGoogle Scholar
  21. 21.
    Mack MJ, Regan JJ, Bobechko WP, Acuff TE (1993) Application of thoracoscopy for disease of the spine. Ann Thorac Surg 56:736–738PubMedCrossRefGoogle Scholar
  22. 22.
    McAfee PC, Regan JR, Zdeblick T, Zuckerman J, Picetti GD 3rd, Heim S, Geis WP, Fedder IL (1995) The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases. Spine 20:1624–1632PubMedCrossRefGoogle Scholar
  23. 23.
    Moore KL (1992) Clinical Oriented Anatomy, 3rd edn. William and Wilkins, BaltimoreGoogle Scholar
  24. 24.
    Pait TG, Elias AJ, Tribell R (2002) Thoracic, lumbar, and sacral spine anatomy for endoscopic surgery. Neurosurgery 51(5 Suppl):S67–S78PubMedGoogle Scholar
  25. 25.
    Picetti G, Ertl J, Bueff U (2001) Endoscopic instrumentation correction and fusion of idiopathic scoliosis. Spine 1:90–97Google Scholar
  26. 26.
    Ragel BT, Amini A, Schmidt MH (2007) Thoracoscopic vertebral body replacement with an expandable cage after ventral spinal canal decompression. Neurosurgery 61(5 Suppl 2):317–322PubMedCrossRefGoogle Scholar
  27. 27.
    Regan JJ, Mack MJ, Picetti GD III (1994) A comparison of video assisted thoracoscopic surgery (VATS) with open thoracotomy in thoracic spinal surgery. Today Ther Trend II:203–218Google Scholar
  28. 28.
    Regan JJ, Mack MJ, Picetti GD III (1995) A technical report on video assisted thoracoscopy in thoracic spinal surgery. Preliminary description. Spine 20:831–837CrossRefGoogle Scholar
  29. 29.
    Riet M, Smet AA, Kuiken H, Kazemier G, Bonjer HJ (2001) Prevention of compensatory hyperhidrosis after thoracoscopic sympathectomy for hyperhidrosis. Surg Endosc 15:1159–1162PubMedCrossRefGoogle Scholar
  30. 30.
    Rosenthal D, Dickman CA (1998) Thoracoscopic microsurgical excision of herniated thoracic disc. J Neurosurg 89:224–235PubMedCrossRefGoogle Scholar
  31. 31.
    Rosenthal D, Rosenthal R, De Simone A (1994) Removal of a protruded thoracic disc using microsurgical endoscopy. A new technique. Spine 19:1087–1091PubMedCrossRefGoogle Scholar
  32. 32.
    Sasani M, Ozer AF, Oktenoglu T, Kaner T, Aydin S, Canbulat N, Carilli S, Sarioglu AC (2010) Thoracoscopic surgical approaches for treating various thoracic spinal region diseases. Turk Neurosurg 20(3):373–381PubMedGoogle Scholar
  33. 33.
    Singh B, Ramsaroop L, Partab P, Moodley J, Satyapal KS (2005) Anatomical variations of the second thoracic ganglion. Surg Radiol Anat 27(2):119–122PubMedCrossRefGoogle Scholar
  34. 34.
    Smith WD, Dakwar E, Le TV, Christian G, Serrano S, Uribe JS (2010) Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine. Spine (Phila Pa 1976) 15;35(26 Suppl):S338–346Google Scholar
  35. 35.
    Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH (1998) Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 88:623–633PubMedCrossRefGoogle Scholar
  36. 36.
    Zhang B, Li Z, Yang X, Li G, Wang Y, Cheng J, Tang X, Wang F (2009) Anatomical variations of the upper thoracic sympathetic chain. Clin Anat 22(5):595–600PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  1. 1.Department of Neurosurgery, Cerrahpasa Medical FacultyIstanbul UniversityIstanbulTurkey
  2. 2.Department of Anatomy, Cerrahpasa Medical FacultyIstanbul UniversityIstanbulTurkey

Personalised recommendations