Introduction

The principles of video-assisted thoracic surgery (VATS) are described in this chapter. Although thoracic surgeons may use many techniques to perform minimally invasive operations, my techniques are highlighted in the following paragraphs.

Key Points

♦ Minimally invasive surgery is good for patients.

♦ Surgeons can use VATS for most standard operations that previously required a thoracotomy.

♦ Standard instruments and simple techniques can ensure these procedures are safe for patients.

Definition and Philosophy

A VATS procedure is not a compromise operation; it is the same operation that can be performed by a thoracotomy.^1,² The standard operation is performed with visualization on a monitor and through incisions without spreading the ribs. Procedures such as a video-assisted lobectomy provide the same complete cancer operation that is performed through a thoracotomy.³^–¹²

Indications for an operation usually do not change because the procedure can be performed with minimally invasive surgery. VATS can be performed with standard instruments that are used for open procedures. Articulating instruments are not required. Proper placement of the incisions is essential for successful completion of an operation by VATS techniques.

Positioning

♦ The position of the patient, monitors, and lights should be set before preparing the patient.

♦ For most VATS procedures, the patient is placed in the lateral decubitus position with a slight posterior tilt. The patient is taped in place. The arms are at 90 degrees, with the elbows bent in a praying position and with two pillows between the arms. Padding between the arm board and the downside elbow minimizes the risk of compression causing damage to the ulnar nerve.

♦ The operating table is flexed with the patient’s anterior-superior iliac crest positioned over the flexion of the table. This opens the rib spaces, and this position shifts the hip out of the way so it does not interfere with the movement of the thoracoscope.

♦ The monitors are placed above the head of the operating table so that the surgeon and all assistants have an unobstructed view of the monitors (Figure 1-1). The surgeon stands on the anterior side of the patient.

♦ Different positioning may be used for other video-assisted thoracic operations. For example, a Heller myotomy is performed with the monitors at the foot of the bed.

Figure 1-1 Setup for VATS. The monitors are placed above the head of the bed, and the surgeon stands anteriorly.

Incisions

Placement of the incisions (Figure 1-2) is key to the performance of VATS. Proper placement of the incisions creates the best angles for the instruments to perform these procedures.