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Procedures

Minimally Invasive Lung Resection and VATS Lobectomy VATS
Tracheo-bronchial Tumor Resection and Tracheal/Esophageal Stents Minimally Invasive Thymectomy for Tumors and Myesthemia Gravis
Robotic Removal of Mediastinal Cysts and Tumors VATS Treatment of Spontaneous Pnemothorax
Endoscopic Thoracic Sympathectomy Treatment of Malignant Pleural Effusion
Endobronchial Ultrasound (“EBUS”) Esophagectomy and Minimally Invasive Esophageal Surgery
Robotic Treatment of Achalasia Minimally Invasive Para-Esophageal Hernia Repair
Minimally Invasive Hiatal Hernia Repair Pectus Excavatum Repair
Treatment of Empyema Minimally Invasive Thoracic Diskectomy

Minimally Invasive Lung Resection, VATS Lobectomy and da Vinci Robotic Lobectomy
Patients with early stage non-small cell lung cancer have the greatest chance of long-term survival with an anatomic lung resection – also known as a lobectomy. The right lung is composed of three lobes, and the left lung comprises of two lobes. When a lobectomy is performed, the entire affected lobe is removed in conjunction with the lymph nodes that drain the cancerous region. Additionally, lymph nodes located in the mediastinum (the area of the chest between the lungs) are removed in order to determine cancer staging, as well as possible future therapies. A VATS lobectomy has several advantages over the traditional “open” approach due to its minimally invasive approach and faster recovery. Patients not eligible for VATS, such as those with a large tumor near the central blood vessels and airways would undergo an open lobectomy. Advances in robotic technology combined with the superior skills of our surgeons now allow us to offer lobectomy with da Vinci Robotic assistance.

VATS
Video Assisted Thoracoscopic Surgery (VATS) is a minimally invasive surgical technique which is an alternative to traditional thoracotomy. With thoracotomy, a large incision is made in between the ribs which are then spread apart. However, with VATS, two or three 1 cm incisions are made which allow for the presence of the thoracoscope (camera), and surgical instruments inside the chest. The surgeon’s thoracoscope transmits images to a television monitor, allowing him to maneuver inside the chest using different instruments. This surgical approach inflicts less trauma to the body than a thoracotomy, and allows for faster recovery time, decreased hospital stay, and reduced post-operative pain. Patients are also glad to have much smaller scars with VATS.

Tracheo-bronchial Tumor Resection and Tracheal/Esophageal Stents
Management of advanced esophageal and lung cancers can be a technical challenge. 20-30% of patients with lung cancer will present with central airway obstruction. This is a significant cause of morbidity and early mortality, with patients suffering from extreme shortness of breath, hemoptysis (coughing up blood), post-obstructive pneumonia, sepsis and an early death. Further, both a debilitated patient as well as superimposed infection precludes this group of patients from receiving chemotherapy and radiation therapy. Endobronchial airway stenting usually leads to immediate relief of symptoms with minimal post-operative complications. Several clinical trials are underway to study the effects of stenting in conjunction with chemo and/or radiation therapy in improving the quality of life as well as survival in patients with advanced lung cancer. Similarly advanced inoperable esophageal cancers can present with obstruction that makes it difficult to swallow food. Esophageal cancers may also lead to fistulous connection between the esophagus and airway, leading to continuous aspiration, mediastinitis and pneumonia. Esophageal stenting dramatically improves the quality of life in selected patients, with restoration of natural alimentation that enables the patients to swallow soft food and liquids. Our advanced airway program is the busiest in Manhattan, and we are frequently referred the most complex cases, with excellent results.

Minimally Invasive Thymectomy for Tumors and Myasthenia Gravis
The thymus gland is an essential organ in the development and maturation of immune function early in life. After adolescence, the thymus loses most of its functional capacity. Tumors of the thymus usually occur in adulthood. Myasthenia gravis is an auto immune condition that is characterized by weakness of the voluntary muscles of the body. Thymectomy is an operation to remove the thymus gland and is performed for thymic tumors or in myasthenia gravis, where it leads to significant remission of the disease in more than 80% of patients. Surgical approaches include a sternotomy (through the breast bone), transcervical (through a small collar or neck incision) and transthoracic (through one or both sides of the chest, using VATS). Complete endoscopic thymus surgery with the da Vinci robot enables a complete and extended resection of all the thymic tissue in the mediastinum and neck. We are one of only a few centers in the US that can also offer transcervical thymectomy. Due to minimal trauma of both these m inimally invasive techniques, patients can return to full activity in a very short time.

Robotic Removal of Mediastinal Cysts and Tumors
Mediastinal masses are of several types and are derived from various organs including the thymus, trachea or esophagus (foregut cysts), pericardium (pericardial cysts) or neural structures (neurogenic tumors). Most of these masses and cysts are benign but do compress adjacent structures and produce symptoms. Due to their propensity to enlarge and get infected, surgical excision is often recommended. Our group has pioneered Video Assisted Thoracoscopic Surgery (VATS) combined with the da Vinci robotic to achieve complete endoscopic resection of selected mediastinal cysts and tumors, with excellent outcomes.

VATS Treatment of Spontaneous Pnemothorax
A spontaneous pneumothorax, or the sudden collapse of a single lung, may occur without any trauma or injury. The pneumothorax results from the rupture of a blister on the lung, which allows air to leak out. When this condition occurs in an individual without prior history of lung disease, it is known as primary spontaneous pneumothorax. This is most commonly seen in tall, thin individuals between the ages of 17-40 who have a predisposition to spontaneous pneumothorax. The anatomy of their lungs in addition to the large volume of air they hold makes it more likely that a small blister --a bleb -- will burst on the upper part of the lung. The lung collapse is unpredictable, as it may occur during physical activity or simply at rest. When the pneumothorax is due to an underlying lung condition such as emphysema, it is known as a secondary spontaneous pneumothorax. In this, the emphysematous blebs are larger and known as bullae. In both primary and secondary spontaneous pneumothorax, surgery is done with a VATS approach. The bleb or bullae is removed, and the lung is made to adhere to the chest wall in order to prevent future pneumothoraces using mechanical pleurodesis. Talc pleurodesis is used only for a failed primary procedure. This surgical technique almost always prevents recurrence of pneumothorax, whereas non surgical management shows a 30-50% recurrence rate.

Endoscopic Thoracic Sympathectomy
Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive procedure that is more than 97% effective in curing severe palmar hyperhidrosis. Hyperhidrosis – meaning excessive sweating – can be present in patients with sympathetic hyperactivity. Patients afflicted with this disorder can exhibit severe sweating of the hands, underarms and feet, which can be so debilitating that it can affect job performance and a patient’s social well being. Severe focal hyperhidrosis may affect as much as 3% of the population and appears to be genetically related. This sweating is not part of the body’s normal temperature regulation. Unfortunately in patients with a severe case, topical ointments and treatments with iontophoresis devices are unlikely to be effective. Botulinum toxin infections may be effective in some patients especially those with axillary sweat. However the duration of effect is limited and repeat treatments are the norm. In selected patients, especially those with severe palmar sweat or combinations of other areas with palmar sweat, ETS is the preferred method of treatment. The surgery is usually performed with 2 pencil sized incisions in the axillae and entails an overnight stay. Our surgeons are skilled in the procedure and have outstanding results with a minimum of complications. Compensatory sweating in other parts of the body can occur so careful consultation by an experienced team familiar with other treatment options is of paramount importance for patients afflicted with this disorder.

Treatment of Malignant Pleural Effusion
A pleural effusion is a collection of fluid in the chest cavity around the lungs, due to a variety of reasons. A malignant pleural effusion is when fluid collects in the chest due to an underlying cancer. The presence of an effusion represents metastasis of the primary cancer to involve either the lung itself or the pleura, the inner lining of the chest wall and is a poor prognostic sign. This fluid can compress the lung tissue, resulting in shortness of breath that often requires oxygen therapy. Treatment of this condition involves insertion of a tube to drain the fluid, which typically relieves the symptoms; however, recurrence of these effusions is extremely high with drainage alone. Definitive treatment involves an operation where 2-3 small incisions are made in the side of the chest and a fiber optic camera (thoracoscope) is inserted. The chest is inspected for signs of abnormal growths either on the lung or on the inner surface of the chest well. The fluid is drained, all loculations broken up and talc powder is instilled in the chest. This causes an inflammatory reaction which scars the lung against the chest wall, preventing the re-accumulation of fluid. This operation is approximately 75% successful in preventing recurrence of the fluid collection, but does not treat the underling malignancy. Another good option in patients with trapped lung (lungs that do not expand due to severe cancer or scar tissue involvement) is placement of a pleurex catheter.

Endobronchial Ultrasound (“EBUS”)
EBUS is a procedure that aids in the diagnosis and staging of cancers of the chest. The management of lung and other thoracic cancers depends heavily on the extent of disease, which is based on the involvement of lymph nodes in the center of the chest (the mediastinum). Historically, evaluation of these lymph nodes required an invasive surgical procedure called mediastinoscopy, which entails an incision in the neck and dissection of the lymph nodes off the major vascular and airway structures. In selected cases, mediastinoscopy has been replaced, at least as an initial diagnostic test, by EBUS. EBUS involves passing a long, thin flexible camera called a bronchoscope into the airway under light anesthesia. The airway is visualized and extensively inspected for any abnormalities. Suspicious lymph nodes previously identified on CT scan are located using an ultrasound probe built into the bronchoscope. A thin needle is passed out of the bronchoscope, through the wall of the airway and into the lymph node and a biopsy is taken. Depending on the results of the biopsy, mediastinoscopy may be avoided, but it may still be necessary if the EBUS biopsy is non-diagnostic. Some lymph nodes are difficult to reach using EBUS, and a similar procedure with the probe in the esophagus instead of the airway, called endoscopic ultrasound or EUS, may also be necessary.

Esophagectomy and Minimally Invasive Esophageal Surgery
Esophagectomy is the surgical removal of all or part of the esophagus and is typically undertaken as a treatment for high-grade dysplasia (Barrett’s esophagus) or cancer of the esophagus. For cancers involving the upper region of the esophagus, an esophagectomy may be done to remove the cancerous portion along with nearby lymph nodes and reconnect the remaining esophagus to the stomach, which is brought up into the neck. For cancers of the lower esophagus, it may be necessary to perform an esophagogastrectomy, in which a portion of the stomach is removed as well. The stomach can then be reattached to the remaining portion of the esophagus either in the chest or neck. Chemo and/or radiation therapy is often combined with surgery. We are generally able to utilize minimally invasive techniques to perform esophagectomy, avoiding large abdominal or chest incisions. Our outcomes for esophagectomy are one of the best in the country according to the STS database.

Robotic Treatment of Achalasia
Achalasia is a rare motility disorder of the smooth muscles of the esophagus which is characterized by failure of the hypertensive lower esophageal sphincter (LES) to relax and absence of normal esophageal motility in response to swalowing. It can cause difficulty swallowing, regurgitation, chest pain, heartburn and weight loss. Diagnosis is usually made by esophageal manometry and barium swallow studies. Certain medications including Botox can be used, however no medical treatment is definitive. Surgery provides permanent relief by division of the esophageal muscle (Heller myotomy), usually done laparoscopically and aided by the da Vinci robot.

Minimally Invasive Para-Esophageal Hernia Repair
Para-esophageal hernia occurs when a portion of the stomach prolapses up into the chest through the esophageal hiatus alongside the esophagus, while the gastro-esophageal junction remains in its normal location. Serious complications can occur with this type of hernia. When symptomatic, they can cause chest pain, difficulty swallowing, abdominal pain, indigestion, nausea, vomiting and retching. Serious complications include incarceration and strangulation, which can be life threatening. Incarceration results when hernia is stuck and non-reducible, while strangulation results from a lack of blood supply, leading to the death of tissues involved. Surgery is aimed at reducing the hernial sac, with closure of the abnormally wide esophageal hiatus. Immediate surgical intervention is required if strangulation develops and carries a high morbidity and mortality. Most elective cases can be repaired in a minimally invasive fashion, using advanced laparoscopy techniques collaborating with our minimally invasive team.

Minimally Invasive Hiatal Hernia Repair
A hiatal hernia occurs when a portion of the stomach prolapses through the widened diaphragmatic esophageal hiatus (opening). This type of hernia is commonly associated with gastro-esophageal reflux disease also known as GERD, due to widening of the lower esophageal sphincter (LES). Hiatal hernias are themselves asymptomatic, however, in a minority of patients, hiatal hernias can predispose to increased acid reflux or worsen existing reflux. Hiatal hernia with uncontrolled GERD may be responsible for intermittent bleeding from associated esophagitis, erosions or a discrete esophageal ulcer, leading to iron-deficiency anemia. Barrett's esophagus is also associated with this condition. Surgery is indicated in a minority of patients with complications of GERD despite aggressive treatment with acid suppressing medications and involves a laparoscopic Nissen fundoplication.

Pectus Excavatum Repair
Pectus excavatum is a rare deformity of the sternum and ribs, where the cartilages that attach the ribs to the sternum are deformed. Patients complain of shortness of breath on exertion or chest pain. We offer these patients a comprehensive assessment and evaluation for the need for surgical correction and are one of the few centers in Manhattan that offer repair for this condition.

Treatment of Empyema
Empyema is a collection of fluid within the pleural cavity (membranous covering of the lung). It usually occurs due to the extension of pneumonia in the adjacent lung segment or lobe. It starts out as a clear serous effusion which later becomes infected and thick in consistency. With free flowing fluid, chest tube drainage along with antibiotic coverage provides optimum resolution, however with thickening and formation of loculations, chest tube drainage becomes inadequate and surgical drainage, usually VATS is required for complete drainage. If drainage is delayed, VATS may not achieve complete decortication (removal of the infected peel covering the lung) and a conventional open thoracic surgical procedure with decortication is required. VATS drainage is a highly successful procedure with cure rates above 90-95%.

Minimally Invasive Thoracic Dirssectomy
Degenerative disc disease is one of the most common causes of disc herniation, which can be painful and disabling due to impingement on the nerve roots. Thoracic disc herniation occurs less frequently than lumbar and cervical disk herniation. Often thoracic disc herniations fail to respond to conservative treatment like heat, physiotherapy and pain medications. In these cases, the definitive treatment is surgical removal of part of the herniated disc, which can be performed through minimally invasive endoscopic techniques using VATS.

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