VATS requires general anesthesia with selective one-lung ventilation for facilitation of the procedure. This is best achieved by ventilation with a double-lumen endobronchial tube. In young children for whom no suitably sized double-lumen tube is available, a single-lumen tube with either the tip placed into the contralateral mainstem bronchus or in combination with an endoscopically placed bronchial blocker can be used. The correct placement of the double-lumen tube or the bronchial blocker should be confirmed by fiber-optic bronchoscopy. On occasion, if the patient does not tolerate single-lung ventilation (or had undergone pneumonectomy on the contralateral side), short periods of apnea after hyperventilation with FiO₂ 1.0 will allow sufficient time to perform short diagnostic and therapeutic interventions. Monitoring during anesthesia is done following the standards for thoracic procedures.

For most of the procedures (described below), the patient is positioned in the full lateral decubitus position with the operative side up and the table flexed at the patient’s hip level with additional slight reverse Trendelenburg tilts (Fig. 62.1). The patient is either placed on a beanbag or secured by side positioning cushions and elevated arm support. Care should be taken that the patient’s shoulder marks the highest point with the arm positioned as low as possible to allow free angulation of instruments from either direction (Fig. 62.1). The position of the surgeon depends on the procedure performed and the site of the lesion. It is recommended to approach the lesion from the same general direction with instruments and camera. The surgeon best stands facing the lesion with the camera-holding assistant on the same side and direct view on the monitor on the opposite side.

The surgical site extends from the axillary region down to the distal costal arch and from the mammary line backward to the vertebral column (Fig. 62.2). A spacious sterile draping facilitates targeted access to the entire hemithorax. Single-lung ventilation is established with the first skin incision. For most of the procedures and general inspection of the pleural space, the camera port is placed anteriorly (anterior axillary line for right-sided lesions and posterior axillary line for left-sided lesions) and low in the hemithorax (eighth intercostal space). For localized pleural effusions, it is recommended to place the first port site at the center of the fluid collection as seen on X-ray or computed tomography scans. Aspiration of fluid with a small needle may aid in localizing a fluid collection. The first incision is always made bluntly with careful digital intrathoracic exploration. After skin incision (1.5 cm), carefully dissect over the top of the rib with scissors to enter the pleural space (Fig. 62.3). Insert a finger gently to corroborate entry into the pleural space. On occasion, adhesions will be present that can be cautiously disrupted with the finger to allow safe placement of the thoracoscope (Fig. 62.4) (adopted from: SAGES manual). Additional access sites are placed under video guidance and should be positioned at a farthermost distance either cranial in the third or fourth intercostal space, if the first incision was located below the fifth intercostal space, or into the diaphragmatic recesses if the initial approach was above the fifth intercostal space (Fig. 62.5). For a diagnostic approach, two to three incisions usually are adequate; if a pulmonary wedge resection is planned, a third incision may be appropriate. For three (or more) access sites, the ports should be placed within the same 180 ° arc to allow for the comfortable “triangulation” of the instruments enabling them to target the lesion site from either side and avoid mirror image (adopted from: Yim and Sihoe 2009; SAGES manual).

The author prefers the use of a combination of minimally invasive surgery instruments (5-mm diameter) and long standard conventional instruments. The basic preference card includes a long and a short ring clamp, conventional long Metzenbaum scissors, a sponge stick, 5-mm biopsy forceps, 5-mm Metzenbaum scissors, and an electrocautery blade (Fig. 62.6). In addition, an open thoracotomy tray should always be kept ready for use in the OR in an event of bleeding. An actual trocar is only used for the thoracoscope. The 10-mm 30 ° scope is preferred for most adult procedures (5-mm scope in children). A 30 ° scope will provide optimal viewing without undue pressure on the ribs and the intercostal nerves. As described by Yim and Sihoe (2009), prewarming the thoracoscope with a sterile hot water bath effectively prevents fogging of the lens which can result from temperature differences when it is first inserted into the chest. Most working ports can be 5 mm and converted to 10–15 mm if necessary, as for stapling devices. There is a clear trend toward the use of smaller instruments and scopes, and it can be predicted that in the future, 2-mm instruments and scopes will be used as a standard in simple procedures.