Video-assisted thoracic surgery (VATS) has developed very rapidly from last decade. It has replaced conventional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operation.
During a VATS procedure, a tiny camera (thoracoscope) and surgical instruments are inserted into your chest through one or more small incisions in your chest wall. The thoracoscope transmits images of the inside of your chest onto a video monitor, guiding the surgeon in performing the procedure.
The video-assisted imaging system amplifies the function of thoracoscopy. The minimal requirements of VATS include a zero and/or 30-degree rigid telescope(s), a light source and cable, a camera and an image processor. The optional devices include a slave monitor, a semi-flexible telescope and a video-recorder).
The choice of the telescope diameter can range from 3 mm to 10 mm, depending on the type of procedure. The 30-degree angled viewing scope can help us check the pleural cavity with a broader visual field. The choice of light source and cable should accord with the output power.
VATS has revolutionized the approach to and management of many pulmonary and cardiac diseases over the past decade. This procedure was usually performed to evaluate and treat pleural effusions in patients suffering from pulmonary tuberculosis.
Before this technique the standard approach to a thoracic pathology was a thoracotomy. A breakthrough in technology, which ultimately resulted in the advancement of all forms of minimal access surgery, was the development of fiber-optic light. The number of VATS applications have grown over the decade as technological advancements made such procedures safer for the elderly and frail patients.
VATS has multiple advantages over traditional thoracotomy including less postoperative pain, shorter hospital lengths of stay, earlier recovery of respiratory function especially in patients with chronic obstructive pulmonary disease (COPD) and the elderly and overall reduced cost for the procedure.
Why is it done:
We use the video-assisted thoracoscopic surgery technique to perform a variety of procedures, which include diagnostic as well as therapeutic.
Diagnostic includes, Mediastinal lymph node biopsy, Pleuroscopy, pleural biopsy, Tissue, lymph node biopsy for lung cancer, chest wall biopsy, Cancer staging etc.
Therapeutic include Pulmonary resection (most commonly for lung cancer), Pulmonary bleb, bullae resection, Pleural drainage (pneumothorax, hemothorax, empyema), Pericardial effusion drainage, mechanical, chemical pleurodesis, Excision, biopsy of mediastinal masses and nodules, excision of esophageal diverticulum, esophagectomy, Thoracic duct ligation, sympathectomy, chest wall tumor resection, Thoracoscopic laminectomy Spinal abscess drainage and many others.
How do you prepare a patient for VATS?
Patient selection plays a key role in successful surgical outcomes. A detailed preoperative examination with a focus on cardiac and respiratory function is essential to ensure that the selected candidates will tolerate one-lung ventilation (OLV). Physical status assessment, spirometry, computed tomography (CT), and cardiopulmonary exercise testing (CPET) should be reviewed.
Pre-operative assessment is aimed at assessing lung mechanics (FEV1, MVV, FVC, RV/TLC ratio), parenchymal function (PaO2, PaCO2), and cardiopulmonary reserve. The predicted postoperative FEV1 (ppo FEV1%) is a commonly used predictor of postoperative pulmonary.
A complete blood count may reveal polycythemia due to pulmonary diseases or an elevated white cell count suggestive of infection or inflammation. Chest x-ray and CT scan provide relevant anatomical details required for the relevant procedure.
Arterial blood gases may help identify patients at increased risk of postoperative complications. Patients with PaCO2 greater than 50 mmHg or PaO2 less than 60 mmHg are vulnerable.
Preoperative optimization of patients undergoing VATS may also include smoking cessation, treatment of underlying infections and pulmonary rehabilitation.
The standard VATS procedure involves using 3 to 4 incisions made in a triangular configuration for scope and instrument insertion. Alternatively, VATS with a single port has also been described. The patient is administered anesthesia in the supine position. A double-lumen endotracheal tube (DLT) is the airway device of choice for most procedures.
After DLT placement, the position of the tube is confirmed with a fiberoptic bronchoscope via the lumen of the DLT. Care is taken to ensure adequate positioning of the cuff. After confirming adequate tube and cuff placement, the patient is positioned in the lateral decubitus position with the arm over the head.
Arching of the table is done to allow adequate surgical exposure. The position of the DLT is then rechecked after final positioning for the procedure. Three incisions are made for the anterior approach. Together they form a triangular configuration with the utility incision at the apex of the triangle.
The camera is inserted through this incision for the creation of other entry ports safely. A port is created to accommodate the camera in the auscultatory triangle. A third port is created in the mid-axillary line. This is created at the level of the utility port incision. After the creation of the 3 ports, assessment is done using the video thoracoscope.
Further steps of the surgery are usually guided by the specific procedure to be performed. Depending on the surgery performed, one or two pleural drains, connected to an underwater seal drain, are usually placed at the end of surgery.
Why should we go for VATS?
VATS has progressively replaced open thoracotomies in most thoracic surgery centers around the world because of its safety profile in elderly patients, better pain control, faster recovery times, and easier control of bleeding.
It has been shown to decrease the length of hospital stay compared to open thoracotomy. Most of this could be attributed to the shorter chest tube duration as reported by some in studies with removal rates of 54% in the VATS group on day 1 as compared to 21% in open thoracotomies. This pattern of fewer complications and lower in-hospital mortality has been echoed by other studies on lung cancer patients as well.
Significantly, there are lower rates of blood transfusions in the VATS when compared to the open thoracotomy. Besides, lesser postoperative pain and a better quality of life is seen when compared to traditional thoracotomies.
VATS remains the recommended standard of care by a consensus of experts on the management of almost all lung and mediastinal problems.
The advantages offered by VATS over conventional thoracotomy includes decreased surgery time, easier control of bleeding, decreased postoperative pain including opioid usage, decreased chest tube duration, decreased length of hospital stay, decreased inflammatory response and cosmesis.
If you are scheduled for surgery, your doctor will give you specific instructions to help you prepare.
VATS is now available at SKIMS in the department of Cardio-Vascular Surgery free of cost to any patient who may need it. This new service will benefit a large number of patients.
(About the Author: Assistant Professor, cardiovascular thoracic surgery, SKIMS Srinagar)