Video-Assisted Thoracoscopic Surgery - Indications, Procedure, and Complications

Introduction

Video-assisted thoracoscopic surgery (VATS) is a new minimally invasive surgical procedure that has used smaller incisions to manage cardiopulmonary diseases in the last twenty years. Adding fiber optic cameras or thoracoscopes has ultimately led to a breakthrough in minimally invasive surgery. This allows the surgeon to visualize the entire thoracic cavity without the need to open up the chest wall. Previously thoracotomy was used as a standard approach to thoracic pathology. The various advantages of a VATS over traditional thoracotomy methods are less postoperative pain, shorter duration of hospital stay, and early restoration of pulmonary function, especially in chronic obstructive pulmonary disease patients and elderly patients. It also reduces the cost of the procedure.

What Are the Indications of VATS?

The indications of VATS include both diagnostic and therapeutic approaches.

The diagnostic approaches include

• Mediastinal lymph node biopsy.

• Biopsy of the pleura.

• Tissue or lymph node.

• Biopsy of the chest wall.

• Staging of neoplasms.

The therapeutic approaches include

• Pleural drainage, especially in hemothorax, pneumothorax, and empyema. Empyema is the accumulation of pus in the pericardial cavity, especially in frail patients with high surgical risk. Ultrasound confirms the entry site.

• Pulmonary resection, especially in lung cancer.

• A pulmonary bleb or bullae resection.

• Pericardial effusion drainage.

• Mechanical or chemical pleurodesis.

• Excision or biopsy of mediastinal masses and nodules.

• Excision of the esophageal diverticulum.

• Ligation of the thoracic duct.

• Excision of sympathetic nerves or sympathectomy.

• Resection of chest wall tumor.

• Thoracoscopic laminectomy.

• Spinal abscess drainage.

What Are the Contraindications of VATS?

The contraindications of VATS include

• Patients who cannot tolerate lung isolation or depend upon bilateral ventilation.

• Intraluminal airway mass.

• Coagulopathy.

• Hemodynamically unstable patients.

• Severe hypoxic cases.

• Patients with severe chronic obstructive pulmonary disease.

• Patients with pulmonary hypertension.

What Are the Advantages of VATS Over Conventional Methods of Thoracotomy?

The advantage of VATS over conventional thoracotomy include

• Reduced surgical time.

• Decreased postoperative pain.

• Reduced chest tube duration

• Hemostasis can be achieved easily.

• Reduced duration of hospital stay.

• Decreased inflammatory response.

What Are the Procedures Done Before VATS?

Before VATS, the patient may be asked to stop certain drugs, such as anticoagulants like warfarin or heparin. Avoid eating or drinking any liquids after midnight before the surgery. Smoking has to be stopped before surgery. The patient may be asked to do breathing exercises with a spirometer. A well-detailed clinical history with past and present medical illnesses should be assessed. Routine blood tests, pulmonary function test or spirometry, arterial blood gas analysis, chest x-ray, high resolution computed tomography (HRCT), electrocardiogram (ECG), and in some selected patients with suspected cardiac conditions, an echocardiogram should be performed preoperatively.

What Is the Method of Doing a VATS?

The procedure involves an antibiotic prophylaxis regime with administering second-generation cephalosporins injected intravenously half an hour before the surgery to prevent infection. The duration and times depend upon the type of antibiotics used. No other antibiotics are prescribed after the surgery until and unless the patient develops an acute bacterial infection.

Typically, the procedure is carried out under general anesthesia, which induces deep sleep, and surgery may take several hours. The patient is placed in a lateral decubitus position with the arms extended and fixed on an arm-supporting frame. The surgeon may make several small incisions over the chest wall between the ribs. The fiber optic camera fitted in a narrow lumen tube is introduced through any of these incisions. In the case of lung cancer, a part of the lung and adjacent lymph nodes must be resected. Thus a radical approach has to be made.

The surgeon may drain the pleural fluid from and around the lungs in case of effusion or may carry out other procedures on different thoracic organs. Once the procedure is completed, the camera is removed, and a chest tube is inserted through one of the small incisions and left there for a few days to drain fluid or air leakage into the chest cavity or may help the lungs to reinflate. The patient is usually discharged after a few days from the day of surgery. It is important to rest after the surgery; any postoperative discomfort has to be reported immediately.

Although the procedure provides a good surgical view and static operative field for optimal operative management, mechanical ventilation and the use of muscle relaxants during intubation can cause potential adverse effects. For example, mechanical ventilation may cause overexpansion of the lungs and pressure-induced airway injuries. Also, endotracheal intubation may cause damage to the mucosa of the upper respiratory tract.

What Are the Complications of VATS?

The complications of VATS include

• Post-operative pain.

• A post-operative leak or inadequate post-operative suctioning with negative pressure may lead to poor reinflation of the lungs. Therefore, a constant low negative pressure suction in the thoracic cavity or biphasic intermittent positive airway pressure is required to promote lung re-inflation.

• Hypoxemia is not a normal finding. However, if the blood oxygen saturation levels fall below ninety percent, manually assisted ventilation or synchronized intermitted mechanical ventilation may be required.

• Atelectasis or pulmonary collapse: It may be caused by the accumulation of blood and mucus in the airways leading to bronchial obstruction during surgery or the early postoperative period. A bronchoscopic lavage may be considered in such cases.

• Profuse bleeding.

• Infection at the site of the wound.

Conclusion

Video-assisted thoracoscopic surgery is a minimally invasive surgery that allows access to the pleural space by visualizing and working the instruments. It has revolutionized the old, conventional methods. It also allows diagnostic procedures such as suspected tuberculous or malignancies with inconclusive cytology and therapeutic procedures such as pleurodesis in malignant or recurrent pleural effusions and recurrent pneumothorax to be performed safely. Thus, it has revolutionized the old, conventional method with minimum invasive procedures. Surgeons performing this technique should have adequate training and good knowledge of the anatomy of the pleural and thoracic cavities.