INDICATIONS/CONTRAINDICATIONS/PREOPERATIVE PLANNING

Indications, contraindications, and preoperative planning are the same as for transsternal LVRS and are detailed in the previous chapter.

SURGERY

Working IV lines, an arterial line, and a thoracic epidural are often placed at the beginning of the procedure. A working thoracic epidural is used to ensure adequate pain control thus allowing for adequate pulmonary toilet in the immediate postoperative period.

After induction of general anesthesia, the patient is first intubated with a single-lumen endotracheal tube to allow for bronchoscopy. Bronchoscopy in these cases can be used for pulmonary toilet, to assess airway anatomy and rule out any endoluminal abnormalities. The single-lumen endotracheal tube is then exchanged for a left-sided double-lumen endotracheal tube, with bronchoscopic confirmation of its position. Single-lung ventilation is a necessity for VATS approach. Both sides are operated upon sequentially under the same anesthetic.

Positioning

The traditional bilateral VATS approach consists of positioning the patient in either the right or left lateral decubitus position, performance of the procedure, and then repositioning for the contralateral side. Advantage to this method is clear visualization of the target areas, while the disadvantage is time needed for repositioning, re-prepping, and draping for the contralateral side.

The alternative approach is to position the patient supine on a bean bag rolled under the back and arms that are tucked at its side, and then having the table roll to one side for performance of the procedure, and then rolling to the other. Advantage to this method is access to both sides of the chest without changing position. Disadvantages to this method include the need for larger working incisions, and possible diminished view as flexion of the bed is not used to open up the intercostal spaces. Our preference is bilateral positioning, but either method can be used.

The patient is positioned in the full left lateral decubitus position with full flexion of the operating table to 30 degrees between the nipples and anterior-inferior iliac spine, to open up the intercostal spaces for introduction of thoracoscopic instruments and the thoracoscope.

Technique

Thoracoscopic Port Placement

The chest is prepped and draped in standard surgical fashion. Strategies in VATS cases that can assist in minimizing chest wall trauma and postoperative pain are utilized, including:

Avoiding use of trocar ports (except for the camera) by introducing instruments directly through the wound to avoid intercostal nerve compression.

Utilizing an angled 30-degree scope for visualization to avoid torque in the inferior port site.

Using smaller telescopes (5 mm) when possible.

Intercostal nerve blocks in addition to infiltration with local anesthetic at planned areas of port sites.

Delivering specimen through the anterior port as the anterior intercostal spaces are wider.

Soft tissues of the incision can be spread with a Weitlaner retractor, but rib spreading is avoided during the VATS approach.

One-lung ventilation is initiated. The anesthesia team if at all possible should avoid using PEEP on the down lung if desaturation occurs during the procedure, as this can worsen ventilation-perfusion mismatch, subject hyperinflated lungs on the down side to barotrauma with risk of pneumothorax, and obscure view with shift in mediastinum into the field. Ideally discussion of strategies to deal with desaturation should be done with the anesthesia team before the start of the procedure.

The anterior port site is placed in the fifth or sixth intercostal space at the anterior axillary line. A 2 to 3 cm incision is made after infiltration of local anesthetic and intercostal nerve block. The incision is deepened through the soft tissue and muscle layers, and controlled entry into the thoracic cavity is made. A gentle sweep is made to confirm absence of any adhesions in the area. Either the thoracoscope can be inserted at this time to place the inferior port site under direct vision, or if adequately free, the inferior port can be placed in similar fashion. Placing a plastic Yankeur through the anterior port site to assess the location of the diaphragm can help with placement of the inferior port site. Depending on the size of the 30-degree angled scope used, either a 5 mm or 1 cm incision is made. The inferior port site is placed in the seventh or eighth intercostal space at the midaxillary line. An additional posterior port site is placed a fingerbreadth below the tip of the scapula (Fig. 7.1). Additional ports may be placed if needed for lung retraction, but are rarely necessary. Thoracoscopic port sites should be at a suitable distance from the target lung area (most often the apex) to provide space for manipulation. Visualizing a baseball diamond can help—anterior and posterior ports at “first” and “third base” with the camera port at “home plate” and the target area of the lung at “second base.” In female patients, an attempt should be made to strategically place the ports away from breast tissue to improve cosmesis.

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