Video-Assisted Thoracoscopic Surgery
One to four incisions are used in video-assisted thoracoscopic surgery (VATS) procedures. For drainage of pleural effusions, it is sufficient to use one small incision to accommodate the 10-mm offset scope, evacuate the effusion, and use the talc poudrage and chest tube. For a VATS lobectomy, four incisions have commonly been used, with the largest being about 4 cm long. However, there is growing interest in and acceptance of uniportal approaches to lobectomy in selected patients. [14, 15]
Incisions are made in a triangulated fashion, typically at least 5 cm apart so that the instruments do not cross. (See the image below.) This so-called baseball diamond approach aligns the camera and instruments to manipulate the lung and perform a resection. For VATS thymectomy, a subxiphoid and subcostal arch approach has been described as an alternative to a lateral intercostal approach. [16, 17]
Video-assisted thoracoscopic surgery (VATS). Example of positioning of VATS instruments; three ports are used, with camera in center position of triangle.
Single-port approaches have been employed for other VATS procedures besides lobectomy. [18] A meta-analysis by Xu et al found that single-port VATS might have certain advantages over three-port VATS for primary spontaneous pneumothorax, though studies of higher quality and greater scale would be needed to confirm this. [19] Liu et al described five cases in which uniportal VATS parietal pleurectomy proved safe and feasible in patients with complex tuberculous pneumothorax. [20] A study by Jiang et al found that single-port VATS was not inferior to three-port VATS for mediastinal cystectomy. [21]
For single-incision cases, curved instruments are helpful.
Procedural limitations may include difficulty in controlling bleeding and a lack of intraoperative palpation.
Various applications of VATS are illustrated in the images and video below.
Video-assisted thoracoscopic surgery (VATS). Examination for evidence of metastasis.
Video-assisted thoracoscopic surgery (VATS). Pleural adhesions on medical thoracoscopy.
Indications for conversion from VATS to thoracotomy
Indications for conversion from VATS to thoracotomy include the following:
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Inability to achieve single-lung ventilation
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Extensive pleural adhesions
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Uncontrolled or significant intraoperative bleeding
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Inability to identify a target lesion for biopsy
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Technical difficulties with or primary failure of video equipment and/or endoscopic instruments
A study by Vallance et al found that with increasing experience and expertise, the rate of unplanned conversion from VATS to thoracotomy could be brought down to about 10%. [22]
Complications
Complications may include the following:
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Persistent air leakage
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Bleeding from pulmonary vessels [4]
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Intercostal nerve damage due to insertion of instruments through the ports
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Complications from single-lung ventilation, including respiratory insufficiency or postoperative reexpansion pulmonary edema
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Tumor implantation following VATS
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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.
