Video assisted thoracic surgery

1. CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES,
JAMIA MILLIA ISLAMIA
VIDEO ASSISTED THORACIC SURGERY
SUBJECT – PHYSIOTHERAPY IN
CARDIOPULMONARY CONDITIONS (BPT - 402)
SUBMITTED TO – DR JAMAAL ALI MOIZ
SUBMITTED BY – ABDA KHATOON
CLASS – BPT, 4TH YEAR

2. Introduction
• Video-assisted thoracoscopic surgery is a minimally invasive surgical procedure, used to diagnose
and treat illness or injury to the lungs and other organs in the thorax
• VATS has revolutionized the approach and management of many pulmonary and cardiac diseases
over the past 2 decades’
• It was first performed by Swedish physician Jacobeaus.
• Before this technique, the standard approach to a thoracic pathology was a thoracotomy.
• VATS has multiple advantage over traditional thoracotomy including less postoperative pain,
shorter hospital length of stay, earlier recovery of respiratory function(COPD and elderly) and
overall reduced cost.

3. Contd..
• In VATS procedure, surgeons operate through 2-4 tiny openings between the ribs. Each opening is
less than 1 inch in diameter whereas 6-10 inch incisions are common in open thoracotomy.
• All VATS procedure generally start with the same way.
• Patients are placed under general anaesthesia and are typically positioned on their sides.
• Using a trocar, the surgeon gains access into the chest cavity through a space between the ribs.
• An endoscope is inserted through the trocar, giving the surgeon a magnified view of the patient’s
internal organs on a monitor.

5. Indications for video assisted thoracic surgery
Diagnostic
• Midiastinal lymph node biopsy
• Pleuroscopy/ pleural biopsy.
• Tissue/lymph node biopsy
• Chest wall biopsy
• Cancer staging
Therapeutic
• Pulmonary resection (most commonly for lung
cancer)
• Pulmonary bleb/ bullae resection
• Pleural drainage(pneumothorax ,
hemithorax,empyema)
• Pericardial effusion drainage
• Mechanical/chemical pleurodesis.
• Excision/biopsy of mediastinal masses and
nodules
• Excision of esophageal
diverticulum/esophagectomy
• Thoracic duct ligation

6. Equipments
• Thoracoscope , high resolution video camera.
• A light source and cable
• Camera
• Image processor
• Monitors
• Scissors
• Hook
• Trocar

7. For affective VATS operations, several basic principles should be applied.
• Place trocar sites and thoracoscope at a distance from the lesion to achieve a panoramic view.
• Avoid instrument crowding which may result in fencing.
• Avoid mirror imaging by positioning instruments and thoracoscope within the same 180 degree
arc.
• Instruments should be manipulated only when seen directly through the thoracoscope.
• Work together with anesthesiologist to ensure adequate lung isolation.
• Utilize both hands to manipulate the instruments in coordinated fashion.
• Understand that conversion to thoracotomy is not a failure but an appropriate option when the
performance of VATS is limited by availability of equipment, technical difficulty or clinical
condition of the patient.

8. Patient positioning
• VATS requires most patients to be in a lateral decubitus position.
• This is accompanied by arching the table which helps to separate the ribs for better surgical access.
• This also helps by to relieve any pressure on the intercostal nerves.
• The lateral decubitus position provides adequate access to most thoracic structures which include
the lungs, pleura, esophagus, pericardium amongst other mediastinal structures.
• Care must be taken at all times to avoid nerve injury by adequately padding pressure points.

10. Surgical technique
• The patient is administered anesthesia in supine position and a DLT is the airway device of choice
for most procedures.
• After DLT placement, the position of the tube is confirmed.
• The patient is positioned in lateral decubitus position with the arm over the hand.
• Arching of table is done to allow adequate exposure. The position of DLT is again rechecked.
• Three incisions are made and together they form a triangular configuration with the utility incision
at the apex of the triangle.
• The camera is inserted through this incision for the creation of other entry ports.
• After the creation of 3 ports, assessment is done using the thoracoscope.
• Further steps of the surgery are usually guided by the specific procedure to be performed.

13. Approaches to various thoracic surgical problems
Wedge resection of peripheral pulmonary nodules and closed lung biopsy
• We initiate a closed lung biopsy procedure by introducing the thoracoscope at the 6th or 7th ICS in
the midaxillary to posterior axillary line.
• After thoracoscopic exploration, a second access site is chosen in the 5th ICS along the anterior
axillary line.
• This alignment facilitates exposure and manipulation of most areas of lobar pathology and also
allows the application of the endoscopic stapler to different parts of the lungs for potential wedge
resection of infiltrative lung disease.

14. Apical bullous disease
• Other techniques like laser ablation and endoscopic ligation of the apical bullae can cause
spontaneous pneumothoraces.
• In this procedure, thoracoscopic camera is positioned through the 6th ICS along midaxillary line.
Endoscopic stapler through the posterolateral 4th and 5th ICS.
• A grasping instrument is placed through a small stab wound at the lateral border of pectoralis
muscle in the 4th ICS.

15. Pericardiectomy
• It is an another useful application of thoracoscopic surgery.
• Left sided thoracic approach is usually used but right sided approach can be used if a left sides
thoracotomy has been already performed or if a large right sided pleural effusion is present.
• We approach the pericardium from slightly posterior and lateral 5th, 7th and 9th ICS positions.
• Injury to phrenic nerve can occur if care is not taken.

16. Contraindications
• Patient unable to tolerate lung isolation/dependence on bilateral ventilation
• Intraluminal airway mass (making double lumen tube (DLT) placement difficult)
• Severe adhesions in the pleural cavity/pleural symphysis
• Coagulopathy
• Hemodynamic instability
• Severe hypoxia
• Severe COPD
• Severe pulmonary hypertension

17. Advantages of VATS
• Reduced acute pain
• Reduce use of intravenous narcotics
• Reduced length of hospitalization
• Reduced time to return to regular activities.
• Reduced overall cost.
• Operative time is faster or equivalent
• Blood loss is less.
• Lower incidence of post-thoracotomy pain.

18. References
• Landreneau, R. J., Mack, M. J., Hazelrigg, S. R., Dowling, R. D., Acuff, T. E., Magee, M.
J., & Ferson, P. F. (1992). Video-assisted thoracic surgery: basic technical concepts and
intercostal approach strategies. The Annals of thoracic surgery, 54(4), 800-807.
• https://www.ncbi.nlm.nih.gov/books/NBK532952/