Usually general anesthesia, although pleural biopsies or pleurodesis can be performed with local anesthesia and sedation.

Lung collapse is needed to see into the pleural space. That usually means that one-lung ventilation is used via a double-lumen endotracheal tube.

A single-lumen endotracheal tube can be used for some simpler procedures, such as a lung biopsy, if the anesthesiologist hand ventilates the patient with small title volumes and occasional short periods of apnea.

Sympathectomy can be performed with a single lumen tube. The procedure starts with apnea and CO ₂ insufflation in the pleural space to be operated. When the lung has collapsed, ventilation is resumed.

A thoracoscope is placed through a trocar into the pleural space for visualization.

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  A 2- to 3-mm scope may be used for some procedures, such as a sympathectomy

  
  
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  A 5-mm scope with a 30-degree lens is what we use for almost all of the VATS procedures that we perform.

  
  
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  Some surgeons use a 10-mm scope. Current video equipment is of such good quality that smaller scopes provide excellent visualization. Smaller scopes cause less torsion and less trauma to the intercostal nerves.

Visualization is on a monitor, not directly though the incisions.

Incisions vary from 2 to 8 cm.

Generally, the trocar and thoracoscope are placed low in the chest to provide good, panoramic visualization of the chest cavity.

Additional incisions are made as needed to perform the required procedure.

For most VATS procedures, the monitors are placed above the head of the bed.

For some procedures low in the chest (e.g., Heller’s myotomy), the monitors may be placed by the patient’s feet.

VATS procedures were first performed about 1990. In the late 1980s, video equipment was developed to allow general surgeons to perform laparoscopic procedures, such as cholecystectomy. Then, endoscopic staplers were developed. The combination of these two developments created the opportunity for thoracic procedures to be performed by VATS.

The ability to perform a procedure by VATS has not really changed the indications for an operation.

Table 6-1 shows the simpler procedures that are commonly performed by VATS.

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  At present, most thoracic surgeons perform these procedures with VATS.

Table 6-2 shows more complex VATS procedures that some surgeons perform.

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  These procedures are less commonly performed by VATS.

  
  
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  The first VATS lobectomy was performed in 1991. In the United States, approximately 10% to 15% of lobectomies are performed by VATS. In 2005, 94% of our lobectomies were performed by VATS. That included sleeve lobectomies, so it is possible that many thoracic operations can be performed via VATS.

The limitations/contraindications to VATS procedures, as seen in Table 6-3 , are related to the patient’s disease, type of procedure needed, or technical capabilities of the surgeon.

Physical limitations of the patient’s disease, such as a tumor larger than 6 cm or tumors invading the chest wall require a thoracotomy to spread the ribs for removal of the tumor (e.g., Pancoast tumors).

Severe respiratory failure (FIO ₂ = 100% and high positive end-expiratory pressure) preclude one-lung ventilation for an operation or even prevent transporting a patient to the operating room for an operation.

Almost all thoracic surgeons can perform simpler procedures (as listed in Table 6-1 ), but the majority do not have the training or skills for the more complex VATS procedures (see Table 6-2 ).

The workup for a VATS procedure is the same as the workup for any thoracic procedure. The workup includes laboratory studies, such as a complete blood count (CBC), coagulation studies, electrolytes, and an electrocardiogram (EKG), as indicated.

Xray studies appropriate for the symptoms or diagnosis are ordered. For example, a healthy young person for a sympathectomy may not need any xray or may need a chest xray if there has been a history of pneumonia or pulmonary disease.

Pulmonary function studies are indicated if the patient is to undergo a pulmonary resection, such as a lobectomy, or if there is a history of pulmonary disease, such as emphysema, that needs to be assessed to determine the operative risk.

There are no special tests that need to be ordered for a VATS procedure.

There are few randomized studies that compare VATS and thoracotomy approaches with thoracic operations.

Although the National Emphysema Treatment Trial was primarily a randomized trial of maximal medical management versus that plus lung volume reduction surgery, it also compared VATS with median sternotomy for the operation. The morbidity, mortality, and benefits were the same for both groups, but the cost was less and the recovery was faster for the VATS group.

Several studies have shown that patients suffer less pain after VATS than after a thoracotomy. Postoperative pain, measured by a Visual Analog Scale, total dose of narcotic, need for additional narcotic, need for intercostal blocks, and sleep disturbances, is less after VATS than after thoracotomy.

Patients who have undergone VATS have greater shoulder strength at 6 months, although by 1 year, the results were comparable.

The postoperative recovery appears to be better with the VATS approach than with a thoracotomy. Demmy reported earlier returns to full preoperative activities ( P < 0.01). Suguira noted better short term and long term quality of life (QOL). Others have reported less postoperative pain ( P = 0.014) and less shoulder dysfunction.

VATS procedures may be less expensive than a thoracotomy.

Early ambulation (three times a day in the hallways, starting on postoperative day 1)

Laxative if no bowel movement by postoperative day 2

No routine laboratory tests. Order laboratory tests as clinically indicated (e.g., CBC, cultures, and so on for fever workup)

No routine x-ray studies. Presence of a chest tube is not an indication for a chest x-ray study. They are not needed after removal of the tube.

Incentive spirometer q 1 hour during the day and evening shifts.

Nebulizer treatments are ordered as needed.

Patients may shower as soon as the chest tubes are removed.

Pre-emptive analgesia in the operating room with local anesthesia (usually bupivacaine [Marcaine, Wintrop Pharmaceuticals, New York, NY] with epinephrine) that provides pain relief for 12 to 16 hours.

Postoperative analgesia with hydrocodone (Vicodin, Watson Pharmaceuticals, Inc., Corona, CA) po or Dilaudid (Abbott Laboratories, Abbott Park, IL) sq.

In contrast to thoracotomy, rarely is an epidural catheter used after VATS.

Chest drainage system usually to water seal. Air leaks are longer with chest drainage system on suction than on water seal.

Suction on drainage system for patients after pleurodesis, decortication, extensive lysis of adhesions, significant subcutaneous emphysema, and significant postoperative bloody drainage.

The chest tube is generally removed when there is no air leak and when the drainage is less than 450 mL/day. The chest tubes are removed with lower drainage for patients with poor pulmonary function and after pleurodesis.

If the drainage is less than 100 mL/day and the patient has a persistent air leak, then a Heimlich valve is attached to the chest tube. To collect the liquid that drains through the Heimlich valve, a Lukens’s trap is placed on the Heimlich valve.

The patient may be discharged from the hospital and the chest tube is removed when there is no longer an air leak.

To check for an air leak, the Heimlich valve is observed as the patient coughs. When there is no longer an obvious air leak, the end of the Heimlich valve is placed under water and the patient coughs.

When liquid accumulates in the tube proximal to the Heimlich valve, the air leak has resolved.

Ambulate outside the house daily.

Shower twice per day because warm water on the chest wall loosens the muscles and reduces postoperative pain.

Driving is allowed when the patient feels safe to drive.

Shoulder range of motion exercises are encouraged.

Patients return to the office for suture removal approximately 1 week after discharge.

At present, VATS has replaced an open lung biopsy as the standard method for obtaining a lung biopsy.

VATS wedge resection has replaced a thoracotomy for the diagnosis of a solitary pulmonary nodule (SPN).

Before VATS became available, it was reasonable to put the patient through the trouble, cost, and morbidity that might result from transthoracic needle biopsy, even if the chance of obtaining a specific benign diagnosis was low, because the pain and disability resulting from thoracotomy were fairly significant. However, with the advent of VATS wedge excision, which can be performed with a hospital stay of 24 to 48 hours and minimal postoperative disability, we rarely use transthoracic needle biopsy.

In a patient with suspected pulmonary metastases, a VATS resection may be beneficial for diagnosis and treatment.

Resection of pulmonary metastases is performed in the hopes of a cure if the primary is controlled, there is no disease elsewhere, and if all disease can be resected.

When a patient has a history of breast cancer and a solitary pulmonary mass, the patient must not be assumed to have recurrent breast cancer. In fact, the diagnoses were primary lung cancer (48%), pulmonary metastasis from the breast cancer (34%), and benign disease (18%). Ten percent of patients had more than 1 mass found intraoperatively.

There is no standard surgical approach for the treatment of pericardial effusion. The options include thoracotomy, subxiphoid pericardiotomy, and VATS. The choice depends on comorbidities, patient’s health status, the presence of a pleural effusion, and surgeon’s skills with VATS.

Approximately 50% of pericardial effusions that require surgical intervention are due to cancer, usually lung or breast cancer.

A VATS approach can be performed for almost any pericardial effusion, but it is particularly useful when there is a pleural effusion that needs pleurodesis, after a failed subxiphoid window, loculated pericardial effusion, delayed pericardial effusion after cardiac surgery, or posterior effusions.

The cause of the pericardial effusion is established in about 50% of cases where a window is performed.

Piehler found a direct relationship between the amount of pericardial resection and the incidence of recurrent effusion or pericardial constriction.