The surgery was performed under general anesthesia with a double-

The surgery was performed under general anesthesia with a double-lumen endotracheal tube protocol inserted for ipsilateral lung collapse and single lung ventilation. A close watch on all hemodynamic and respiratory parameters was maintained. The patients were placed in the right/left lateral decubitus position, depending on the radiologic findings (i.e., bulk of abscess and caseating tissue and destruction of body) and the relevant part was draped and prepared for a standard posterolateral thoracotomy (for conversion to standard thoracotomy in circumstance of intraoperative complication or the presence of severe pleural adhesion). With selective collapse of right/left lung, the initial trocar incision (2cm) was made usually at the fifth or sixth intercostal space (ICS) or higher along the anterior axillary line depending upon the site of lesion.

An 11-mm trocar was used to introduce the operating thoracoscope and an exploratory thoracoscopy was performed. The lesion site was identified and displayed on the video monitor. Two other stab incisions, the extended manipulating channels, usually 3-4cm in length, were done 2-3 intercostal spaces above and below the first port, slightly posterior to the posterior axillary line. We encountered difficulty in making portals due to overcrowding of ribs in two patients. Visualization of the spine was enhanced by tilting the patient forward so that the collapsed lung fell anteriorly and, if required, a fan retractor for further retraction of ipsilateral lung was inserted. The correct level of diseased vertebrae was determined by counting the ribs as seen through the endoscope.

Putting a spinal needle from the marker site and visualizing the tip of needle through the thoracoscope further confirmed the correct level. With monopolar electrocautery accompanied by a suction tube the parietal pleura overlying the lesion was divided longitudinally. Dacomitinib The larger intercostal arteries and veins were isolated, ligated, and divided if needed. The biopsy and decompression procedure was then performed with conventional disc roungeurs and elongated bone curettes and was carried out down to the epidural space. Additional procedures like placement of bone graft into the intervertebral space using a conventional bone impactor were done in 3 patients. In 2 patients, conversion to minithoracotomy was undertaken. A larger manipulating channel measuring 5 to 6cm in length was created on the right/left lateral chest after introducing the thoracoscope and a short-segment rib of equal length was removed. The incision was made slightly behind the posterior axillary line at the level of right fifth rib. Then a rib spreader was used to open the intercostal space. Adhesionolysis by blunt dissection using finger was done.

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