Converting from Video-assisted Thoracoscopic Surgery to open thoracotomy during multilevel tuberculous corpectomy and cage reconstruction

The application of VATS to perform multilevel tuberculous corpectomies and vertebral column reconstruction is an exciting frontier in the field of minimally invasive spine surgery. The approach avoids the morbidity of an open thoracotomy and several studies note its significant advantages. Despite the enthusiasm several additional studies note that pleural adhesions, the significant size of the granulomatous mass that must be removed, the inflamed nature of the involved tissues that predispose to bleeding, and infection itself, all of which characterize spinal tuberculosis, to be independent challenges associated with the technique. Despite these challenges the technique is described, and several centers report its success specifically in this context. Together with the technique itself most papers report, as part of any VATS series, a conversion rate from VATS to open thoracotomy of between 0 and 7%. In terms of why the need for conversion occurs, several papers divide the reasons into technical factors, the most important of which being poor visualization due to dense pleural adhesions, bleeding factors, and anatomical factors. How the conversion should be performed is also described, and distinguishing the specific technique in emergent conversions, compared to planned conversions, is a fundamental principle. We describe an adult male patient who presented to our unit acutely paraplegic secondary to T9-T11 tuberculous destruction with acute kyphotic angulation. While we initially took him to the operating room for an intended VATS multi-level corpectomy and vertebral column re-construction, unacceptable bleeding from the intercostal segmental vessels forced us to emergently convert to an open thoracotomy. This conversion enabled us to avoid an emergency, and an adverse patient outcome, and we report him being independently ambulant at his 6-month out-patient appointment. Our case highlights what should not be regarded as a failure, and we further provide a review of the literature on this specific topic.