2. Video-assisted thoracoscopic surgery (VATS) is a
minimally invasive surgical procedure, used to
diagnose and treat illness or injury to the lung
and other organs in thorax .
With controlled pneumothorax, the concept of
thoracoscopy developed. Jacobeus used the
cystoscope in 1910 to first visualize the pleural
cavity.
3. In the 1990’s there was a sudden increase in
the use of thoracoscopy. This happened due
to many reasons:
Miniaturization of video equipment
Improvement in quality of pictures and light
sources
Single lung anesthesia improvements to
allow undisturbed examination of the chest.
Development of staplers to enable biopsies
and wedge resections.
4. • Eventually, thoracoscope became part of the
surgical procedure which got named as Video
Assisted Thoracic Surgery ( VATS ).
• In VATS procedures, surgeons operate
through 2 to 4 tiny openings between the ribs.
Each opening is less than one inch in
diameter, whereas 6- to 10-inch incisions are
not uncommon in open thoracic surgery.
5. • All VATS procedures generally start the
same way.
• Patients are placed under general
Anesthesia 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
television monitor.
6. Patients are usually placed in full lateral decubitus
position with all pressure points well padded to
prevent tissue and nerve injury.
The use of a beanbag is optional, but the patient
should be safely secured to the table.
The hips are placed below the break point of the table
to allow opening of the intercostal spaces as the table
is angulated.
The contralateral leg is gently flexed while the
ipsilateral leg is maintained extended.
The ipsilateral arm should rest in a neutral position
to avoid hyperextension and to prevent injury to the
brachial plexus.
7. The thorax is prepared and draped as for open
thoracotomy.
8.
9. All patients require monitoring of the EKG,
continuous pulse oximetry, and carbon dioxide (C02)
capnometry. An arterial line is utilized selectively in
patients in poorer condition or for prolonged
procedures.
For most VATS procedmes, single-lung ventilation is
required in order to facilitate manipulation of the lung
and instruments within the limited pleural space.
Lung isolation may be achieved through a double-
humen tube (DLT) or single-lumen tube (SLT) with a
bronchial blocker.
10. In patients with pneumonia and parapneumonic
empyema,DLT is the method of choice to ensure
strict lung isolation and to prevent soiling of the
dependent normal lung with purulent secretions.
Malposition {migration) or mucous plugging of the
endotracheal tube is usual cause of significant
intraoperative hypoxemia. The anesthesia and
surgical teams must be prepared to immediately
suction secretions from the ventilated lung and to
perform bronchoscopic examination.
11. Thoracic incisions are more painful and less well
tolerated than abdominal incisions.
Complications of poorly controlled incisional pain
include splinting, poor pulmonary hygiene,
atelectasis, and pneumania.
Most patients undergoing VATS do not require an
epidural catheter for pain control.
In patients undergoing pleurectomy and pleurodesis
for recurrent pleural effusion or pneumothorax.
Consideration should be given to an epidural catheter
avoiding the use of NSAIDs .Inflammatory reaction
necessary for successful pleurodesis.
12. Ports are generally placed in the middle,
anterior, and posterior axillary lines
13.
14.
15.
16.
17. -The middle port is usually placed through the
seventh or eighth intercostal space .
-The anterior and posterior ports are usually
placed near their respective axillary lines.
Planning for a possible thoracotomy, the
incisions are made so that they can be
connected later if necessary.
There is no advantage to creating a ‘tunnel’.
This allow 360 arc mobility and postoprative
neuralgia.
20. Diagnostic
Lung biopsy
Interstitial lung disease
Indeterminate pulmonary nodule
Biopsy of mediastinal lymph node
Biopsy of mediastinal mass
Biopsy of pleural-based lesion
Pleural biopsy and drainage of effusion
21. Therapeutic lung
Lobectomy for lung cancer
Sublobar resection (segmentectomy,wedge
for lung cancer)
Placement of brachytherapy mesh for sublobar
resection for lung cancer
Metastasectomy
Resection of blebs for recurrent pneumothorax
Lung volume reduction surgery
22. Pleura and pericardium
Drainage of large pleural effision {benign or
malignant)
Pleurodesis (pleurectomy, mechanical,
chemical)
Drainage of large pericardial effusion
(subclinical or clinical tamponade)
Drainage of empyema and decortication
of the lung
Drainage of retained hemothorax
23. Mediastinum
Excision of mediastinal masses or cyst
Thymectomy for myasthenia gravis
Sympathectomy for hyperhidrosis
Ligation of the thoracic duct for chylothorax
Excision of neurogenic tumor
Esophageal
Resection of leiomyomata
Resection of entericyst
Esophagomyotomy
Esophagectomy
24. Reduced acute pain
Reduced use of intravenous narcotics
Reduced need for epidural catheters
Reduced length of hospitalization
Reduced time to return to regular activities
Reduced impact on immune system
Reduced overall cost
25. Operative time is faster or equivalent
Blood loss is less
Chest tube duration less
Short term PFT’s better
Lower incidence of post-thoracotomy pain
Improved QoL
Less post-operative shoulder dysfunction
Especially when compared to latissimus dividing
thoracotomy
26. 1. Work together with your anestheaiologist to ensure
adequate lung isolation.
2. Place port for thoracoscope and instruments at a
distance across the chest cavity from thetarget lesion to
achieve a panoramic view of the operative field, optimize
working space, and avoid instrument crowding and
fencing.
3. Use anatomic landmarks such as pulmonary vessels,
bronchus, fissure, diaphragm. etc, to aid in localizing the
lesion.
4. Keep the thoracoscope and instruments in the same
180-degree arc to maintain the same videoendoscopic
perspective and avoid "mirror imaging:'
27. 5. Keep ports anterior to the posterior axillary line,if
possible, where the intercostal spaces are wider.
6. Utilize both hands to manipulate the instruments
in coordinated fashion.
7. Mimimize the use of electro cautery to avoid smoke
and the need to suction{thelung will reexpand).
8. Become familiar with the thoracoscopes.
instrumentation and choice of staplers.
9. Ensure good hemostasis and pneumostasis.
10. 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 cllnlcal condition of
the patient.
28. Consider contralndication•
Inability to tolerate single-lung ventilation
Pulmonary hilar mass
Pulmonary lesion invading the mediastinum
or chest wall (relative)
Large pulmonary lesions (5 cm) (relative)
Inability to achieve ipsilateral pulmonary
atelectasis
Not consider contraindications
Neo adjuvant chemotherapy radiotherapy
Lesions abutting mediastinum, chestwall or
diaphragm
Ventilator dependency
Prior thoracotomy
29. In case of empyema, the lung may not expand
due to two reasons:
1.Multiloculated empyema at the level of
parietal pleura .
2.Thickened granulation tissue over the visceral
pleura.
30. In the first situation, a Video assisted
debridement if done early (within 2-3
weeks) leads to good results.
In the second situation, a
decortication is needed to get the lung
to expand again.
31. Thick, fibninous material that would not be
likely to be completely drained by even a large-
bore chest tube.
Early thoracoscopic debridement(VATS) is
indicated in such case.
Pleural biopsy with a needle has enabled most
pleural effusions to be diagnosed
32. In malignant pleural effusion, Video assisted
debridement and pleurodosis can be done.
Especially if collection is loculated and cant
be drained by chest tube and early attempt of
pleurodosis by chest tube failed.
Mechanical AbrasionTalc Slurry
33. VATS techniques have proven useful in the
management of the organizing posttraumatic
hemothorax in which chest tube have been
unable to completely drain the fibninous clot
and debris.
34. Pleural-based tumors may be sampled and
even resected using VATS.
Thick pleura excision & biopsy
35. VATS wedge lung biopsy represents a
significant advance. It offers the advantage of
excellent visualization of and access to the
entire lung (impossible through a small
thoracotomy), allowing biopsies of areas
appearing abnormal and likely increasing
diagnostic yield.
36. • Spontaneous pneumothorax is mainly
associated to subpleural blebs. usually in the
apex of the upper lobes or the apical segments
of the lower lobes.
• Video assisted stapling of apical blebs can be
done in such case.
• VATS allows surgical management of the blebs by
various techniques, including cauterization with a
Yag:Nd laser, ligature at the base of the bulla, or
excision with mechanical suture.
37. Surgical treatment has been indicated for
bilateral and recurrent pneumothorax, and
even for first episodes in patients with a
pleural chest tube and persistent air leakage.
Besides the proper treatment of the blebs, it
can be used in conjunction with a method to
increase pleural adhesion, ranging from
mechanical abrasion, chemical pleurodesis or
resection of the parietal pleura in the apical
region.
40. SPN is defined as a ovoid or spherical lesion up to
3 cm in diameter. Not associated atelectasis,
adenopathy or effusion.
Lesion larger than 3 cm are almost malignant
and referred as masses.
Management of solitary nodule is one of the great
dilemmas of thoracic surgery.
SPN classify in 3 category benign, malignant and
indeterminent.
Malignant potential depend on size, tobacco
smoking, pattern of growth, calcification and
previous malignancy.
41. VATS is used to obtain solitary pulmonary
nodule for histophathological examination for
reliable diagnosis .
Nodule picked up
43. Primary lesions of the mediastinum are ideal
for VATS management. All locations of the
mediastinum are accessible, and whether
sampling or excision is the intent, video-
assisted techniques save many patients from
having to undergo thoracotomy or median
sternotomy.
Video-assisted thoracoscopic (VATS)
thymectomy, excision of parathyroid adenoma.
44. • VATS allows biopsy, and complete resection,
of almost all tumor mass of the mediastinum
to be performed. Most cystic massae, such as
pericardiac cysts, bronchogenic cysts, thymic
cysts can be suitably treated by
videothoracoscopy.
• Some solid, mainly posterior, tumors of
nervous origin such as neurinomas and
Schwannomas can be totally resected by
VATS.
45. VATS allows excellent access to the pericardium.
It is possible to perform pericardiac drainage or
make a pleuro-pericardiac window. Drainage,
pericardiac biopsies, and treatment of
inflammatory or metastatic cardiac tamponade
are all possible.
A large portion of the parietal pericardium can be
removed thoracoscopically. This resection is more
easily performed through the right hemithorax,
although it can also be carried out on the left side,
in which prepericardiac fat is more abundant. The
pleuro pericardiac window is a strategy offering
several advantages over pericardiac drainage via
the subxiphoid route.
46. It is principally indicated in: hyperhidrosis, Raynaud’s
phenomenon, Raynaud’s disease, causalgia,
sympathetic reflex dystrophy, and upper limb arterial
insufficiency.
Most common indication is hyperhidrosis of hands.
VATS approach has several advantages over the open
operation. It’s usually very easy to dissect the
sympathetic chain in the exact amount needed,
always under a very clear, direct vision
47. Video-assisted thoracoscopy (VATS) to mobilize
the thoracic esophagus in combination with a
standard open laparotomy to complete the
esophagectomy.
Surgery for achalasia cardia by thoracoscopy
has now been completely replaced by the
laparoscopic approach. Excision of leiomyoma is
done at few centres by VATS.
48. Excision of symptomatic thoracic herniated
discs by VATS.
49. • The anterior release of stiff thoracic scoliotic
deformities can be done video assisted
nowadays
• Drainage of paraspinal abscess due to
tuberculosis can potentially become a very
common indication of thoracoscopy in india .
