Video-Assisted Thoracoscopic Surgery (VATS) Technique

Updated: Oct 21, 2016
  • Author: Doraid Jarrar, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Technique

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. [8]

Incisions are made in a triangulated fashion, with the incisions 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.

Video-assisted thoracoscopic surgery (VATS). Examp Video-assisted thoracoscopic surgery (VATS). Example of positioning of VATS instruments; three ports are used, with camera in center position of triangle.

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). Exami Video-assisted thoracoscopic surgery (VATS). Examination for evidence of metastasis.
Video-assisted thoracoscopic surgery (VATS). Pleur Video-assisted thoracoscopic surgery (VATS). Pleural adhesions on medical thoracoscopy.
Video-assisted thoracoscopic surgery (VATS). Thora Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
Video-assisted thoracoscopic surgery (VATS). Thora Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
Video-assisted thoracoscopic surgery (VATS). Thora Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
Video-assisted thoracoscopic surgery (VATS). Pleural biopsy.

Indications for conversion from VATS to thoracotomy

Indications for conversion from VATS to thoracotomy include the following:

  • Inability to achieve single-lung ventilation
  • Extensive pleural adhesions
  • Uncontrolled or significant intraoperative bleeding
  • Inability to identify a target lesion for biopsy
  • 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%. [9]  

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Complications

Complications may include the following:

  • Persistent air leak
  • Bleeding from pulmonary vessels [4]
  • Intercostal nerve damage due to insertion of instruments through the ports
  • Complications from single-lung ventilation, including respiratory insufficiency or postoperative reexpansion pulmonary edema
  • Tumor implantation following VATS
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