Background
Video-assisted thoracoscopic surgery (VATS) is minimally invasive thoracic surgery that does not use a formal thoracotomy incision. VATS provides adequate visualization despite limited access to the thorax, allowing the procedure to be performed in patients who are debilitated or have marginal pulmonary reserve. [1]
VATS is principally employed in the management of pulmonary, mediastinal, and pleural pathology. Its main benefit has been the avoidance of a thoracotomy, which allows a shorter operating time, less postoperative morbidity, and earlier return to normal activity than can be achieved with a thoracotomy.
The first clinical application of VATS dates back to 1913, when adhesiolysis was performed to enhance pneumothorax therapy of tuberculosis via a cystoscope introduced into the pleural cavity. [1] VATS is now an established and widely used minimally invasive approach to diseases of the chest.
Compared with conventional thoracotomy, VATS lobectomy has resulted in better preservation of pulmonary function. [2] In addition, overall surgical mortality is 0-2% for VATS, which compares favorably with mortality for the conventional thoracotomy technique. [3, 4]
Indications
VATS is used in both diagnostic and therapeutic pleural, lung, and mediastinal surgery. Specific indications include the following:
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Stapled lung biopsy
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Lobectomy, segmentectomy, [5] or pneumonectomy
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Resection of peripheral pulmonary nodule
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Evaluation of mediastinal tumors or adenopathy
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Treatment of recurrent pneumothorax
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Management of loculated empyema
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Pleurodesis of malignant effusions
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Repair of a bronchopleural fistula
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Chest trauma (mainly diaphragmatic injuries)
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Sympathectomy
Although the use of thoracoscopy for pulmonary metastesectomy has been controversial, some authors have found it to be efficacious and safe. [6, 7] In a survey carried out by the European Society of Thoracic Surgeons (ESTS), 72% of respondents preferred a minimally invasive approach to metastasectomy for pulmonary metastases in colorectal cancer patients. [8]
The use of VATS to accomplish cardiac denervation of refractory ventricular arrhythmias and electrical storms has been described. [9]
Contraindications
Absolute contraindications include the following:
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Markedly unstable or shocked patient
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Extensive adhesions obliterating the pleural space
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Prior talc pleurodesis
Relative contraindications include the following:
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Inability to tolerate single-lung ventilation
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Previous thoracotomies
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Extensive pleural diseases
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Coagulopathy
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Prior radiation treatment for thoracic malignancy; plan to resect
Outcomes
In a prospective observational study evaluating long-term survival outcomes of VATS lobectomy with lymphadenectomy in 109 patients with non-small cell lung cancer (NSCLC) who were followed for a median of 27 months, Luan et al reported overall survival rates of 100% after 1 year, 85.9% after 2 years, 65.3% after 3 years, 55.9% after 4 years, and 55.9% after 5 years. [10]
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Video-assisted thoracoscopic surgery (VATS). Examination for evidence of metastasis.
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Video-assisted thoracoscopic surgery (VATS). Pleural adhesions on medical thoracoscopy.
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Video-assisted thoracoscopic surgery (VATS). Example of positioning of VATS instruments; three ports are used, with camera in center position of triangle.
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Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
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Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
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Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
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Video-assisted thoracoscopic surgery (VATS). Pleural biopsy.
