Video-Assisted Thoracoscopic Surgery




INTRODUCTION


As with most surgical specialties, thoracic surgery has embraced the use of minimally invasive surgery. Video-assisted thoracic surgery (VATS) is not a specific procedure. It simply means the use of less invasive incisions to perform thoracic procedures. Compared with a traditional thoracotomy, VATS may provide patients with a lower rate of morbidity and mortality, a shorter length of stay, and earlier return to regular activities without compromising the quality of the procedures. Most types of chest operations have been performed with VATS. This chapter reviews the current state of the art for VATS procedures.




TERMINOLOGY


VATS is video-assisted thoracoscopic surgery. VATS means different things to different surgeons. Some thoracic surgeons consider any thoracic procedure for which a thoracoscope looks into the chest a VATS procedure, even if the ribs are spread and the surgeon looks into the chest. However, the most common definition is that VATS is any thoracic operation using small incisions and the video camera, but without spreading the ribs. The surgeon looks at the monitor, not through the incisions.


SPN is a solitary pulmonary nodule.




VIDEO-ASSISTED THORACIC SURGERY TECHNIQUES


Anesthesia





  • 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.



Visualization





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




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



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



    • 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





  • 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.



Monitors





  • 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.



Indications





  • 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.




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



    TABLE 6-1 ▪

    SIMPLER PROCEDURES THAT ARE COMMONLY PERFORMED BY VIDEO-ASSISTED THORACIC SURGERY

















    Lung Biopsy
    Pleural Biopsy
    Pleurodesis
    Pericardial Window
    Sympathectomy
    Mediastinal Biopsy
    Drainage of a pleural effusion or empyema



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




    • These procedures are less commonly performed by VATS.



    • 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.



    TABLE 6-2 ▪

    COMPLEX PROCEDURES THAT CAN BE PERFORMED BY VIDEO-ASSISTED THORACIC SURGERY

















    Lobectomy
    Segmentectomy
    Pneumonectomy
    Esophagectomy
    Heller myotomy
    Thymectomy
    Decortication of the lung



Limitations





  • 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.



    TABLE 6-3 ▪

    POSSIBLE LIMITATIONS OR CONTRAINDICATIONS TO PROCEDURES THAT CAN BE PERFORMED BY VIDEO-ASSISTED THORACIC SURGERY








    • Tumor characteristics




      • Tumors larger than 6 cm



      • Tumors invading the chest wall





    • Intrathoracic scarring




      • Preoperative chemotherapy and radiation



      • Extensive adhesions due to granulomatous disease



      • Dense adhesions





    • Inability to tolerate on lung anesthesia




      • Respiratory failure





    • Surgeon’s skills




      • Lack of training in video-assisted thoracic surgery





  • 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 ).



Workup





  • 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.



Imaging Studies





  • 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





  • 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.



Special Diagnostic Studies





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



Video-Assisted Thoracic Surgery versus Thoracotomy





  • 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.





POSTOPERATIVE MANAGEMENT AFTER VIDEO-ASSISTED THORACIC SURGERY


General Principles





  • 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.



Pain Management





  • 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 Tube Management





  • 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.



Discharge Instructions





  • 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.







  • Climb up the wall with fingers until the arm is straight up and the chest is against the wall



  • Shrug shoulders



  • Hold shoulders up and back



  • Hold arms together, straight out in front and rotate the arms and torso 90 degrees in each direction



Shoulder Range of Motion Exercises




OPERATIVE TECHNIQUES AND PROCEDURES





  • The typical VATS operation uses the incisions in Figure 6-1 . Under one-lung general anesthesia, the patient is placed in the lateral decubitus position with a slight posterior tilt. The trocar and thoracoscope are placed through the eighth intercostals space in the midaxillary line.




    Figure 6-1


    The incisions for a VATS lobectomy: Incision 1 is a 2-cm incision through which instruments or a stapler pass to help with the operation. Incision 2 is a 5-mm incision for the 5-mm trochar through which the thoracoscope is passed. Incision 3 is the 4- to 5-cm incision through which the operation is performed without spreading the ribs. Incision 4 is a 1-cm incision through which instruments and a stapler are passed.



Note: Videos demonstrating VATS procedures are available on the accompanying DVD. (Also see video section accompanying the chapter on “Congenital and Developmental Disorders” for VATS in a pediatric patient)




VIDEO-ASSISTED THORACIC SURGERY PROCEDURES


VIDEO-ASSISTED THORACIC SURGERY LUNG BIOPSY FOR INTERSTITIAL INFILTRATES





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



Advantages





  • Because all areas of the lung are accessible to VATS, it allows greater flexibility in the choice of what area of the lung to biopsy than an open lung biopsy.



  • Multiple studies have shown the diagnostic yield of surgical lung biopsy to be more than 90%, with a resulting management change in 27% to 73% of patients.



  • Shorter operation, shorter length of stay, less pain medicine, and comparable diagnostic yield.



  • Some even report that a chest drain may not be necessary after a lung biopsy if there is no air leak; 100% diagnostic yield.



Disadvantages





  • Usually requires general, one-lung anesthesia.



VIDEO-ASSISTED THORACIC SURGERY LUNG BIOPSY FOR PULMONARY MASS





  • 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.



Advantages





  • The safety and effectiveness of VATS excision of indeterminate solitary pulmonary nodules were demonstrated by Mack and associates, who performed the procedure as a primary diagnostic maneuver in 242 patients. A definitive diagnosis was obtained in all cases; two patients required thoracotomy because the lesion could not be identified at VATS. There was no mortality or major morbidity, and minor complications occurred in 3.6% (less than the 5% risk of pneumothorax requiring chest tube placement after transthoracic needle biopsy). The average hospital stay was 2.4 days. Forty-eight percent of the lesions were found to be malignant.



Disadvantages





  • A thorough understanding of the correlation between computed tomography (CT) and a patient’s anatomy is required and good video skills are needed to identify some pulmonary nodules.



  • Some nodules (bronchioloalveolar carcinoma [BAC] <1 cm, nodules deeper in the lung, smaller nodules, and soft nodules) may be difficult to identify with VATS.



VIDEO-ASSISTED THORACIC SURGERY FOR PULMONARY METASTASES





  • 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.



Advantages





  • At least for solitary metastases, survival is the same for procedures performed by VATS or a thoracotomy.



Disadvantages





  • Some authors are concerned that a procedure performed by VATS may miss nodules detected via a thoracotomy. Traditionally, in about 30% of cases, more nodules are found at thoracotomy than are found on the CT scan.



VIDEO-ASSISTED THORACIC SURGERY PERICARDIAL WINDOW





  • 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.



Disadvantages/Contraindications





  • Tamponade



  • Inability to tolerate one lung anesthesia



  • Requires general anesthesia and single-lung ventilation



Advantages



Jun 24, 2019 | Posted by in CARDIAC SURGERY | Comments Off on Video-Assisted Thoracoscopic Surgery

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