VATS Dr K S chalam

2.  Priority on rapid
complete lung collapse
 Possibility of prolonged
periods of OLV,
Particularly during
learning period oflearning period of
surgical team
 Limited options to treat
hypoxemia during OLV
compared to open
thoracotomy
 CPAP interferes with
surgical exposure during
VATS
in
P. Slinger (ed.), Principles and Practice of Anesthesia for Thoracic Surgery, 331
DOI 10.1007/978-1-4419-0184-2_23, © Springer Science+Business Media, LLC 2011

3.  Surgical delay in
treating major
intraoperative
hemorrhage
  LOS,  LOS,
  Pain/blood loss,
 Improved PUL Fx,
 Less inflammation,
 Early mobilization,
  cosmetic concerns

5. General intrathoracicGeneral intrathoracic
cavitycavity
 Diagnosis/biopsy of
any intrathoracic
structure
 Wedge resection,
 segmentectomy,
lobectomy
 Closure of
persistent/recurrent
pneumothorax
structure
 Laser application for
treatment of tumors
 Retrieval of
intrathoracic foreign
body
Lungs andLungs and PleuraPleura
pneumothorax
 Identification of
broncho-pleural fistula,
LVRS
 Diagnosis/drainage of
pleural effusions
 Treat chylothorax
 Debride empyema
Current Opinion in Anaesthesiology 2000, 13:000±000

6.  Lysis of adhesions
 Pleurodesis
 Decortication
MediastinumMediastinum
Removal of
Esophagus andEsophagus and
diaphragmdiaphragm
 Tumor staging or
resection
 Resection of Removal of
mediastinal cysts
 Thymectomy
 Resection of pos.
mediastinal
neurogenic tumors
 Resection of
esophagus/heller’s
operation
 Repair diaphragm
 Anti-reflux operations
Heart and great vesselsHeart and great vessels
 Pericardectomy

7.  Diagnosis of cardiac
herniation after
pneumonectomy
 Minimally invasive
valve/coronary artery
 Drainage of spinal
abscess
 Discectomy
 Fusion/correction of
spinal deformity e.g.valve/coronary artery
procedures
 Ligation of PDA
(infants)
Spine and nervesSpine and nerves
 Dorsal thoracic
sympathectomy
spinal deformity e.g.
scoliosis
TraumaTrauma
 Assess injury
 Treat hemorrhage
Evacuation of clot

8.  Single 5-cm port
 Maintained the same principles of
the traditional open technique as
diverticulectomy, myotomy, and
fundoplication
 Better visualization of
the main esophageal
body, diverticulum,
esophagogastric jx
 better alignment of
stapler cartridge to
longitudinal axis
Ann Thorac Surg 2017;103 :(4) e365–e367

9.  Developmental of
ball-valve
obstruction in the
bronchial treebronchial tree
producing Congenital lobar emphysema
 Resection of a congenital lobar
emphysema in a pt with spontaneous
pneumothorax.
J Thorac Dis. 2013;5(1):101-104

10.  Inserted three 5mm, &
one 10mm ports
 surgeon and camera man
stand on the same side
 scrub technician and 2nd
assistant stand on the
opposite side
 Placing a camera 30
degree angled camera
most lateral 5mm port,
J Vis Surg. 2017; 3: 144

11.  the other ports working
 5mm port is used for
retraction by the 2nd
assistant
 Removal of Removal of
specimen through
the 10mm port /
placement of a
chest tube at end
of the procedure

12.  Effective and
safe option for
managing
intact orintact or
ruptured
solitary
 Pulmonary
hydatid cysts
Journal of Cardiothoracic Surgery 201813:35

13.  First reported by
Carpenter & colleagues
in 1996
 Right antero-lateral Right antero-lateral
VATS (approx. <4 cm)
incision or
minithoracotomy
(approx. ~4 cm) incision
plus accessory ports,
using video assisted
(‘keyhole’) camera
technology Ann Card Anaesth 2018;21:208-11

14. Lesions appropriate
 Mitral regurgitation
 Tricuspid Regurgitation
 Myxoma
 ASD/PFO/ A fib ASD/PFO/ A fib
Procedures possibleProcedures possible
 MV repair/replacement
 TV repair/replacement
 Resection of myxoma
(L & R atria)
 AF ablation + LAA clip
(bilateral VATS procedure)
BJA Education, 18(10): 323e330 (2018)

15.  Cardiopulmonary
bypass cannulae -
Femoral venous and
arterial
 Aortic cross clamping Aortic cross clamping
technique-
 Endoclamp balloon via
femoral arterial
cannula
 or Direct aortic cross
clamp (Chitwood)

16.  GA with OLV
 Spinal cord
monitoring
Can J Surg. 2006 Oct; 49(5): 341–346

17.  Indications for VATS:
 Severe thoracic
scoliosis >70 degrees
 Rigid/stiff severe
curvaturecurvature
 Severe thoracic
hypokyphosis/lordosis
(sway)
 Fusionless Tethering
Procedures/Flexible
Fusion (VBT)
procedures

18.  Detailed history, P/E,
 Complete H/O of cohexting
disease, optimal treatment,
control of assoc conditions
 Functional capacity
 H/O Smoking +: current
cough, sputum,
Eur J Cardiothorac Surg 2018; 53:973
cough, sputum,
orthopnea/dyspnoea
 S/S of COPD
 H/O IHD as smoking leading
to atherosclerosis
 Pre op CV consultation if
major factors for periop cv
risk
 H/O chemotherapy ? toxicity
 airway anatomy for OLV

19.  Labs
CBC, basic metabolic
profile, coagulation
study,, Sputum C/Sstudy,, Sputum C/S
 Renal/liver Fx tests
 ECG, CXR, CT imaging
 TTE
 PFT, Flow VOL loops
 CPET
Chest 2013; 143:e166S.

20.  Cancer patients: consider the Four Ms:
 Mass effects: Obstructive pneumonia, lung abscess,
SVC syndrome, Pancoast syndrome , tracheobronchial
distortion, recurrent laryngeal nerve or phrenic nerve
paresis
 Metabolic effects: Lambert-Eaton syndrome,
hypercalcemia, hyponatremia, Cushing syndromehypercalcemia, hyponatremia, Cushing syndrome
 3. Metastases: Particularly to brain,
bone, liver, and adrenal
 4. Medications: Chemotherapy agents,
pulmonary toxicity (bleomycin, mitomycin),
cardiac toxicity (doxorubicin), renal toxicity
(cisplatin)
 ASA grading
Cleve Clin J Med 2012; 79 Electronic Suppl 1:eS17

21. COMBINATION OF TESTS: “THREE-LEGGED”
STOOL OF PRE-THORACOTOMY
Respiratory
mechanics
Cardiopulmona
ry reserve
VO max*( >
Lung
parenchym
al
mechanics
FEV1*
(ppo >
40%)
MVV,
RV/TLC,
FVC
VO2max*( >
15 mL/kg/min)
Stair climb >
two flights,
6min walk,
Exercise SPO2
< 4%
al
function
DLCO*
(ppo >
40%)
PaO2 > 60
PaCO2 < 45

22. CUT OFF CRITERIACUT OFF CRITERIA
TESTTEST
MBCMBC
(L/MIN)(L/MIN)
NORMALNORMAL
>100>100
PneumonePneumone
ctomyctomy
>50>50
LobectomLobectom
yy
>40>40
Biopsy/SeBiopsy/Se
gmentalgmental
>25>25
MBCMBC (%)(%) 100%100% >50%>50% >40%>40% >25%>25%
FEVFEV1(L)1(L)
>2L>2L >1.7>1.7--2.12.1 >1.0>1.0--1.21.2 >0.6>0.6--0.90.9
FEVFEV11 (%)(%)
>80%FVC>80%FVC >50%FVC>50%FVC >40%FVC>40%FVC >40%FVC>40%FVC
FEFFEF2525--
75%(L)75%(L)
>2L>2L >1.6>1.6 >0.6>0.6--1.61.6 >0.6>0.6

23. PPO FEVFEV11 ::
 PPO FEVFEV11 = Preop
FEVFEV11 % (1-no of
segments
removed/42)removed/42)
 Limitations &
alternatives

24. • >40%
• Extubate in operating room if: patient
AWaC (alert, warm, & comfortable)
• >40%
• Extubate in operating room if: patient
AWaC (alert, warm, & comfortable)
MILD RISK
• 30%–40%
• Consider extubation based on:
Exercise tolerance , DLCO, V/Q scan,
Assoc. diseases
• 30%–40%
• Consider extubation based on:
Exercise tolerance , DLCO, V/Q scan,
Assoc. diseases
MODERATEMODERATE
RISK
• <30%
• Staged weaning, from mech.
ventilation
• Consider extubation if >20% plus:
Thoracic EA
• <30%
• Staged weaning, from mech.
ventilation
• Consider extubation if >20% plus:
Thoracic EA
SEVERE
RISK

25. ppo FEV1; or
DLCO% <30%
Functional
Capacity < 2 METS
Positive high risk-
cardiac evaluation
Positive low risk/negative cardiac
evaluation(Functional Capacity > 2METS)
ppo FEV1;
ppoDLCO% <60%
ppo FEV1; ppoDLCO%
Ppo FEV1; &
ppoDLCO%
Curr Anesthesiol Rep. 2014;4:124–134
DLCO% <30%
Sct<22m/or
SWT<400mCPETCPET
Vo2 max
>20ml/kg/m
in or >75%
<1%,
LOW
RISK
MODER
ATE
>10%
HIGH
<35%
Vo2 max
<10ml/kg
/min or
<35% >400m
>22m or
>400m
Stair climb or
shuttle walk
ppoDLCO% <60%
or both >30%
Vo2 max 10-
20ml/kg/min
or 35-75%
>60%
ppoDLCO%
>60%

26. 5 elements of pre op
regimen:
 Stop smoking, Dilating airways:
bronchodilators/steroids
Loosening/removal of Loosening/removal of
secretions/hydration mucolyte
RX, control of infection
 Corpulmonale: diuretics/digoxin
Rt Upper lobe SCC
 Measures to increase motivation/education-
incentive spirometry to reduce POPC
 Discuss post op analgesia

27.  LA+ Suppl
sedation
 Regional
anaesthetic
techniques
 intrathoracic
vagal block to
attenuate the
cough reflex,
and
combinations of
these techniques
 GA with OLV
Coopdech

28.  GA with two lung
ventilation in
combination with
CO2 insufflation
(Capnothorax)
 Vagal nerve
blocks by
surgeons
 ERAS for VATS
Curr Opin Anesthesiol 2019, 32:39–43

29.  OLV -well
 established
anesthetic technique,
 used to improve used to improve
surgical exposure

30. ABSOLUTE
1. To isolate from
spillage/contamination
Infection, Bronchiestsis & lung
abscess, Massive Hage
2. To control the distribution of
ventilation
BPF, Bronchopleural cutaneous
fistula, Giant unilateral
lung cyst/bulla
ABSOLUTE
1. To isolate from
spillage/contamination
Infection, Bronchiestsis & lung
abscess, Massive Hage
2. To control the distribution of
ventilation
BPF, Bronchopleural cutaneous
fistula, Giant unilateral
lung cyst/bulla
RELATIVE
 Facilitation of surgical
exposure- high priority
a. Thoracic aortic aneurysm
b. Pneumonectomy
c. Upper lobectomy
d. Mediastinal exposure
RELATIVE
 Facilitation of surgical
exposure- high priority
a. Thoracic aortic aneurysm
b. Pneumonectomy
c. Upper lobectomy
d. Mediastinal exposure
Surgical procedures on major
conducting airway
(pneumonectomy/sleeve
resection)
Life threatening hypoxaemia
resulting from unilateral
lung disease
Unilateral bronchopulmonary
lavage
3. To facilitate surgical exposure:
VATS, RATS
Surgical procedures on major
conducting airway
(pneumonectomy/sleeve
resection)
Life threatening hypoxaemia
resulting from unilateral
lung disease
Unilateral bronchopulmonary
lavage
3. To facilitate surgical exposure:
VATS, RATS
lung cyst/bulla
Tracheobronchial tree
disruption/trauma
lung cyst/bulla
Tracheobronchial tree
disruption/trauma
d. Mediastinal exposure
e. Pul resection via median
sternotomy
d. Mediastinal exposure
e. Pul resection via median
sternotomy
 Facilitation of surgical
exposure- Low priority
a. Oesophageal resection
b. Middle & lower
lobectomies & segmental
resection
c. Procedures on thoracic
spine
 Facilitation of surgical
exposure- Low priority
a. Oesophageal resection
b. Middle & lower
lobectomies & segmental
resection
c. Procedures on thoracic
spine

31.  CARLENS, WHITE , BRICE SMITH
SALT,ROBERT SHAW- rubber
 BRONCHOCATH PVC,
PORTEX, RUSCH ,SHERIDAN,
SILBRONCHO
 VIVASIGHT & ECOM-DLT for CO.
Br J Anaesth. 1960; 32: 232-234
 VIVASIGHT & ECOM-DLT for CO.
 NARUKE IN TRAC

32. SEX HT cm Trac
width
DLT
SIZE
Trachea : 15cm , 16-20rings RMB -
2CM. LMB- 5CM, angles 25/450
SELECTION OF SIDE , SIZE & DEPTH
 FRENCH: 4XID+2
 Depth, at teeth for DLT,
=12 +(ht/10) cm
width SIZE
F >160 ≥15mm 37Fr
F <160 ≥14mm 35Fr
M >170 ≥18 41
M <170 ≥16 39
Carlens E .J Thorac Surg. 1950; 20: 151-157

33.  Pathology of LMB,
disruption,
endobronchial
stent, thoraco-abdstent, thoraco-abd
 aneurysm, LT
pneumonectomy,
 sleeve resection,
 Lt transplant
ABSOLUTE CONTRAINDICATION: pig bronchus
Benumof J.L.Margin of safety in positioning modern DLTs Anesthesiology.
1987; 67: 729

34.  Easy to place successfully
 Rarely repositioning
 Suction to isolated lung
 Easy application of CPAP
 Easily alternate one-lung Easily alternate one-lung
ventilation to either lung
 Placement still possible
without bronchoscopy
 Best device for absolute
lung isolation
 Sleeve Resection of
bronchus
Can J Anaesth. 2001; 48: 790-794

35. More difficult Size
selection
Difficult to place in
difficult airwaysdifficult airways
Not optimal for post
op ventilation
Potential laryngeal/
bronchial trauma/cuff
herniation

36.  Size selection rarely an issue
 Easily added to regular ETT
 Allows ventilation during
placement
 Easier placement in patients Easier placement in patients
with difficult airways/ children
 Postoperative two-lung
ventilation by withdrawing BB
 Selective lobar lung isolation
possible
 CPAP to isolated lung possible
Annals of Cardiac Anaesthesia 17;2: 2014

37.  More time needed for
positioning
 More often Repositioning
 Bronchoscope -essential
 Limited right lung isolation Limited right lung isolation
due to RUL anatomy
 Bronchoscopy to isolated
lung impossible
 Minimal suction to isolated
lung
 Difficult to alternate one-lung
ventilation to either lung

38.  Rarely used
 higher air flow resistance
-----
 Longer than regular ETT
 Short cuff designed for lung Short cuff designed for lung
isolation
 Bronchoscopy necessary for
placement
 Does not allow for
bronchoscopy, suctioning, or
CPAP to isolated lung
 Difficult OLV (right lung)

39.  Auscultation
 Bronchoscope
 Collapsed lung, the pleural
line moves with a heart beatline moves with a heart beat
in a pulsatile manner
( ).
Lung-pulse is
93% sensitive/ 100%
specific
Acta Anaesthesiologica Taiwanica 50 ;2012 : 126e130

40.  Similar distribution of blood flow
& ventilation, like that in the
upright position
 Good V/Q matching at the level of
the dependent lung & adequate
oxygenation in the spontaneously
breathing awake patient
 two important concepts in this two important concepts in this
situation
- smaller vertical hydrostatic
pressure gradient in the lateral
than in the upright position;
therefore, less extended zone 1.
- Pushing of dependent hemi
diaphragm higher into the chest by
the abdominal contents
 V/Q matching- maintains
Benumof JL. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB Saunders; 1987:112

41.  Thoracoscopy under
intercostal blocks with
patient breathing
spontaneously
 Two complications
Mediastinal shift -createMediastinal shift -create
circulatory & reflex
changes
 paradoxical respiration in the
spontaneously breathing,
open-chested patient in
lateral decubitus position.
 compromise the adequacy of
gas exchange
Benumof JL. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB Saunders; 1987:112

42.  Anesthetized patient in LDP: most tidal ventilation in the
nondependent
Induction of anesthesia causing a loss in lung volume in both lungs,
with the nondependent (up) lung moving from a flat, noncompliant portion to
a steep, compliant portion of the pressure–volume curve,
 Dependent (down) lung moving from a steep, compliant part to a flat,
noncompliant part of the pressure–volume curve.
nondependent
lung (where the
least perfusion)
 Dependent lung
less tidal ventilation
(where the most
perfusion);
V/Q mismatch
Benumof JL. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB Saunders; 1987:112

43.  Opening the chest
increases nondependent
lung compliance and
reinforces/maintains the
larger part of the TV going
to the nondependent lung.
maintains the larger part of
tidal ventilation going to the
nondependent lung due to
minimal pressing of PAB
against the upper diaphragm
 Paralysis also reinforces /
Benumof JL. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB
Saunders; 1987:112

44.  35% of total flow perfusing the nondependent
lung,(not shunt flow) reduced its blood flow by
50% by HPV= 17.5+5=22.5%
Benumof JL. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB Saunders; 1987:112
LDP-RT:
35+65%
LDP-LT:
45+55%

45.  TV 5-6ml/KG,
PEEP 5CM H2O,
RR 12/MIN
 VCV/PCV
1= PIP; 2= Pplat
A= airway resistance(Raw)
B= alveolar distending
pressure
Entire curve= mean airway
pressure(MAP)
 VCV/PCV
 PIP ( PEAK INSP
PRESS)<35
CMH2O
 & Pplat <25
CMH2O
Anesth Analg 2015; 121:302
pressure(MAP)

46.  Severe or precipitous
desaturation: resume two-
lung ventilation(if possible).
 Gradual desaturation
Ensure that delivered FiO2 Ensure that delivered FiO2
is 1.0.
 Check position of DLT/BB
with FOB
 Ensure that cardiac output
is optimal; decrease volatile
anesthetics to <1 MAC.

47.  Apply a recruitment maneuver to
 ventilated lung (will transiently
 make hypoxemia worse).
 Apply PEEP 5 cm H2O to ventilated
 lung (except in emphysema).
 Apply CPAP 1-2 cm H2O to Apply CPAP 1-2 cm H2O to
 non-ventilated lung
 Use intermittent reinflation of
 nonventilated lung.
 Partial ventilation techniques of the
 non-ventilated lung: --- O2
insufflation
 Use mechanical restriction of blood
 flow to non-ventilated LUNG
 Venovenous ECMO
Indian J Anaesth 2015;59:606-17

48.  Increased usage over the years
 well executed OLV for successful VATS
 Currently OLV with SLT, balloon-tipped
BB e.g. Fogarty embolectomy catheter/
Arndt Endobronchial Blocker 5F,
 3.5mm Univent tubes, HFJV/HFOV 3.5mm Univent tubes, HFJV/HFOV
 MarraroMarraro Paediatric EndobronchialPaediatric Endobronchial
Bilumen Tube/FAST TRACKBilumen Tube/FAST TRACK
 ChallengesChallenges -- V/Q mismatch,V/Q mismatch,
hypoxemia, hypercarbia,hypoxemia, hypercarbia,
displacement of ETT with changedisplacement of ETT with change
in positionin position
Acta Anaesth. Belg., 2014, 65, 45Acta Anaesth. Belg., 2014, 65, 45--4949

49. Approx. 9% of VATS
 Hemorrhage,
 Subcutaneous Emphysema,
empyema, recurrent
pneumothorax,pneumothorax,
 Persistent postoperative air
leaks
 Pulmonary edema/
pneumonia
 Dissemination of
tumor at thoracostomy tube
site
International Journal of Surgery 2008;6 (1)S78-S81

50.  Down Lung syndrome.
 Local wound infection,
pulmonary abscess or
empyema.
 Lung herniation through Lung herniation through
the chest wall.
 Dissemination of malignant
disease.
 Horner syndrome.
 Resection / damage of any
structure
 Impaired gas exchange

51.  during/ after procedure.
 Co2 insufflationCo2 insufflation
HHypercarbia/ inadequate
ventilation, hemodynamic
instability/gas venous
embolism.embolism.
 Atrial arrhythmias, esp
SVT/A fib
 RV dysfunction ~to the
amount of functioning
pulmonary vascular bed
removed.
 Need to convert rapidly
to open thoracotomy

52.  Ideal analgesia :IV drugs
opioids, PCA/NSAIDs
 CRYOANALGESIA/TENS
 LA to the wound site,
 Intrathecal, Thoracic epidural
block, PVB/ICNB, & intra/extrablock, PVB/ICNB, & intra/extra
pleural block
 use of ultrasonography (US
pectoral nerves (PECS) block
Serratus anterior plane (SAP)
block, provides analgesia at
level of T2-T9
 PEC block I & II, and SAP-
easy/effective/circumvent
complications Anesthesia & Analgesia 2018; 126, (4), 1353-1361(9)

53. SO FAR DEALT WITH………...

54. THANK YOUTHANK YOU
LOVE ALL SERVE ALL