Patient Education and Consent

Informed consent should be obtained from all patients. A possible conversion to thoracotomy should be emphasized.

Equipment

Equipment involved in thoracoscopic wedge resection (TWR) includes the following:

Thoracoscope (5-mm or 10-mm scope with 0° or 30° lens)
Television monitor
Endoscope instruments
Endostapling/transection devices
Diathermy pen
Thoracotomy tray (on standby)
Suction source and tubing
Chest tube (30F)
Water seal drainage
Sutures

Anesthesia

TWR requires general anesthesia provided through a double-lumen (preferable) or single-lumen tube with a bronchial blocker, in addition to single-lung ventilation. For some solitary pulmonary nodules, resection is performed with a local thoracic epidural, although this is not universal.

Positioning

The patient is placed in the full lateral decubitus position with the nonoperative lung in the dependent position and operated side of the lung unventilated. The operating table is flexed at midthorax to expand the intercostal space.^[22]The patient’s shoulder and arm are extended and secured to a side rest.

Monitoring & Follow-up

Close intraoperative monitoring should include continuous pulse oximetry, capnography, mean arterial pressure, and heart rate.

Postoperatively, most patients are extubated in the operating room to prevent longer positive-pressure ventilation. Postoperative pain management consists of narcotics and narcoticlike agents. Chest tube is removed when the pleural effusion is lower than 400 mL/day and air leak flow < 40 mL/min for more than 8 h (and without spikes of airflow greater than this value).^[22]Early ambulation is recommended.

Complications

A potential anesthesia-related complication is hoarseness of voice.

Potential cardiac complications include arrhythmias and angina.

Potential pulmonary complications include the following:

Hemothorax
Persistent air leak
Subcutaneous emphysema
Wound infection
Ischemic necrotizing pneumonia
Nonobstructive atelectasis
Bronchopleural fistula
Local and port-site recurrence of malignancy ^[23](more common with wedge resection than with lobectomy)

Technique

Wang Y. Video-assisted thoracoscopic surgery for non-small-cell lung cancer is beneficial to elderly patients. Int J Clin Exp Med. 2015. 8(8):13604-9. [QxMD MEDLINE Link].
Cafarotti S, Cusumano G, Giuliani M, et al. Extra-anatomical VATS lung resection: the outpatient experience with the aid of a digital chest drain device. Eur Rev Med Pharmacol Sci. 2015 Oct. 19(20):3850-4. [QxMD MEDLINE Link].
Harrison P. Keyhole Rivals Open Surgery for Lung Cancer Resection. Medscape Medical News. Available at https://www.medscape.com/viewarticle/918017. September 10, 2019; Accessed: April 11, 2022.
Lim EKS, Batchelor TJP, Dunning J, et al. Video-assisted thoracoscopic versus open lobectomy in patients with early-stage lung cancer: One-year results from a randomized controlled trial (VIOLET). J Clin Oncol. 2021 ASCO Annual Meeting. [Full Text].
Kato H, Oizumi H, Suzuki J, Hamada A, Watarai H, Nakahashi K, et al. Thoracoscopic wedge resection and segmentectomy for small-sized pulmonary nodules. J Vis Surg. 2017. 3:66. [QxMD MEDLINE Link]. [Full Text].
Shennib HA, Landreneau R, Mulder DS, Mack M. Video-assisted thoracoscopic wedge resection of T1 lung cancer in high-risk patients. Ann Surg. 1993 Oct. 218(4):555-8; discussion 558-60. [QxMD MEDLINE Link].
Dowling RD, Keenan RJ, Ferson PF, Landreneau RJ. Video-assisted thoracoscopic resection of pulmonary metastases. Ann Thorac Surg. 1993 Sep. 56(3):772-5. [QxMD MEDLINE Link].
Landreneau RJ, Hazelrigg SR, Ferson PF, et al. Thoracoscopic resection of 85 pulmonary lesions. Ann Thorac Surg. 1992 Sep. 54(3):415-9; discussion 419-20. [QxMD MEDLINE Link].
Lin F, Xiao Z, Mei J, et al. Simultaneous thoracoscopic resection for coexisting pulmonary and thymic lesions. J Thorac Dis. 2015 Sep. 7(9):1637-42. [QxMD MEDLINE Link].
Chiang XH, Lu TP, Hsieh MS, Tsai TM, Liao HC, Kao TN, et al. Thoracoscopic Wedge Resection Versus Segmentectomy for cT1N0 Lung Adenocarcinoma. Ann Surg Oncol. 2021 Dec. 28 (13):8398-8411. [QxMD MEDLINE Link].
Shiiya H, Suzuki Y, Yamazaki S, Kaga K. Polypoid pulmonary arteriovenous malformation causing hemothorax treated with thoracoscopic wedge resection. Surg Case Rep. 2018 Mar 12. 4 (1):21. [QxMD MEDLINE Link]. [Full Text].
Bakhos CT, Wang SC, Rosen JM. Contemporary role of minimally invasive thoracic surgery in the management of pulmonary arteriovenous malformations: report of two cases and review of the literature. J Thorac Dis. 2016 Jan. 8 (1):195-7. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J. 2009 Jul. 34 (1):17-41. [QxMD MEDLINE Link]. [Full Text].
Swanson SJ, Miller DL, McKenna RJ Jr, Howington J, Marshall MB, Yoo AC, et al. Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: results from a multihospital database (Premier). J Thorac Cardiovasc Surg. 2014 Mar. 147 (3):929-37. [QxMD MEDLINE Link]. [Full Text].
Sakuma T, Sugita M, Sagawa M, Ishigaki M, Toga H. Video-assisted thoracoscopic wedge resection for pulmonary sequestration. Ann Thorac Surg. 2004 Nov. 78(5):1844-5. [QxMD MEDLINE Link].
Hazelrigg SR, Nunchuck SK, Landreneau RJ, et al. Cost analysis for thoracoscopy: thoracoscopic wedge resection. Ann Thorac Surg. 1993 Sep. 56(3):633-5. [QxMD MEDLINE Link].
Nakajima J, Takamoto S, Kohno T, Ohtsuka T. Costs of videothoracoscopic surgery versus open resection for patients with of lung carcinoma. Cancer. 2000 Dec 1. 89(11 Suppl):2497-501. [QxMD MEDLINE Link].
Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995 Sep. 60(3):615-22; discussion 622-3. [QxMD MEDLINE Link].
Russo L, Wiechmann RJ, Magovern JA, et al. Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Ann Thorac Surg. 1998 Nov. 66(5):1751-4. [QxMD MEDLINE Link].
Refai M, Brunelli A, Salati M, Xiume F, Pompili C, Sabbatini A. The impact of chest tube removal on pain and pulmonary function after pulmonary resection. Eur J Cardiothorac Surg. 2012 Apr. 41(4):820-2; discussion 823. [QxMD MEDLINE Link]. [Full Text].
Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg. 2000 Nov. 70(5):1644-6. [QxMD MEDLINE Link].
Campisi A, Dell'Amore A, Giunta D, Congiu S, Daddi N, Dolci G. Micro-incision thoracoscopic treatment of primary spontaneous pneumothorax: the "loop" technique. J Vis Surg. 2018. 4:35. [QxMD MEDLINE Link]. [Full Text].
Colice GL, Shafazand S, Griffin JP, Keenan R, Bolliger CT, American College of Chest Physicians. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007 Sep. 132(3 Suppl):161S-77S. [QxMD MEDLINE Link].
Parekh K, Rusch V, Bains M, Downey R, Ginsberg R. VATS port site recurrence: a technique dependent problem. Ann Surg Oncol. 2001 Mar. 8(2):175-8. [QxMD MEDLINE Link].
Yim AP. VATS major pulmonary resection revisited--controversies, techniques, and results. Ann Thorac Surg. 2002 Aug. 74(2):615-23. [QxMD MEDLINE Link].
Suzuki K, Nagai K, Yoshida J, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest. 1999 Feb. 115(2):563-8. [QxMD MEDLINE Link].
Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue. AJR Am J Roentgenol. 1994 Aug. 163(2):297-300. [QxMD MEDLINE Link].
Zhou JH, Li WT, Chen HQ, et al. [CT-guided hookwire localization of small solitary pulmonary nodules in video-assisted thoracoscopic surgery]. Zhonghua Zhong Liu Za Zhi. 2009 Jul. 31(7):546-9. [QxMD MEDLINE Link].
Schroeder C, Kim J, Linden P. Single incision (uniport) videoscopic lung resection (UNIVATS). Internet J Thor Cardiovasc Surg. 2009. 14(2):[Full Text].
Sihoe ADL, Yim APC. Video-assisted pulmonary resections. Patterson GA, Pearson FG, Cooper JD, et al, eds. Pearson's Thoracic and Esophageal Surgery. 3rd ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2008. 1: 970-88.
Cooper JD, Perelman M, Todd TR, Ginsberg RJ, Patterson GA, Pearson FG. Precision cautery excision of pulmonary lesions. Ann Thorac Surg. 1986 Jan. 41(1):51-3. [QxMD MEDLINE Link].
Landreneau RJ, Keenan RJ, Hazelrigg SR, Dowling RD, Mack MJ, Ferson PF. VATS wedge resection of the lung using the neodymium:yttrium-aluminum garnet laser. Ann Thorac Surg. 1993 Sep. 56(3):758-61. [QxMD MEDLINE Link].
Yim AP, Rendina EA, Hazelrigg SR, et al. A new technological approach to nonanatomical pulmonary resection: saline enhanced thermal sealing. Ann Thorac Surg. 2002 Nov. 74(5):1671-6. [QxMD MEDLINE Link].
Mizukami Y, Takahashi Y, Adachi H. Single-Port vs Conventional Three-Port Video-Assisted Thoracoscopic Pulmonary Wedge Resection: Comparison of Postoperative Pain and Surgical Costs. Ann Thorac Cardiovasc Surg. 2021 Apr 20. 27 (2):91-96. [QxMD MEDLINE Link]. [Full Text].
Wei S, Zhang G, Ma J, Nong L, Zhang J, Zhong W, et al. Randomized controlled trial of an alternative drainage strategy vs routine chest tube insertion for postoperative pain after thoracoscopic wedge resection. BMC Anesthesiol. 2022 Jan 18. 22 (1):27. [QxMD MEDLINE Link]. [Full Text].