VIDEO-ASSISTED THORACOSCOPIC SURGERY
Video-assisted thoracoscopic surgery (VATS) has become a common tool for thoracic surgeons. It is useful in the evaluation and management of patients with pleural disease, benign and malignant pulmonary parenchymal neoplasms or diseases, mediastinal masses or adenopathy, and esophageal pathology and for resection of posterior mediastinal neurogenic tumors or conditions responsive to sympathectomy. A VATS operation is defined by use of two or more port incisions and video display of the involved hemithorax on operating room monitors, and it does not involve rib spreading. Most standard thoracic surgical instruments have been modified for thoracoscopic surgery.
Preparation for a thoracoscopic operation is similar to
that for thoracotomy because the need for conversion to a conventional open
surgical approach may arise. Reasons to convert include hemorrhage, extensive
adhesions, inability to locate the lesion, a more extensive resection than
planned, and the inability to proceed safely. Prophylaxis against deep venous
thromboses with sequential compression devices and subcutaneous heparin is
standard. The patient is placed in a maximally flexed lateral decubitus
position. A double-lumen endotracheal tube or mainstem bronchial blocker is
used to provide single-lung ventilation and allows the lung within the
operative hemithorax to become fully atelectatic; insufflation is not commonly
used.
Thoracic operating ports (Thoracoports) are shorter and
blunter than laparoscopic ports and are not airtight. Use of a long-acting
local anesthetic (e.g., bupivacaine) at the port sites results in decreased
postoperative pain. A 30-degree, angled, rotating 5- or 10-mm videoscope is
standard, with monitors placed on either side of the operating table at the
level of the patient’s head or pelvis depending on the location of the target
lesion within the thorax. An angled videoscope allows superior visualization of
the pleural space and central pulmonary vessels and bronchi without interfering
with other endoscopic instrumentation. Flexible thoracoscopes allow even
greater visualization and are becoming more common.
It is essential that the Thoracoports are triangulated
relative to the operative lesion being addressed. The ports should face the
lesion in an approximately 180- degree arc placed widely apart to prevent
instrument crowding.
The thoracoscopic approach to resection of a pulmonary
lobe is similar to the open approach. The hilar structures are individually
dissected, and the vessels and bronchi are isolated and controlled. These
structures can then be divided using endomechanical staplers of varying staple
heights ranging from 2.0 to 4.5 mm, depending on the thickness of the tissue
(e.g., pulmonary vessel, lung parenchyma, or bronchus).
Mechanical pleurodesis can be performed videoscopically
to treat recurrent or persistent pneumothoraces by use of a rough object (e.g.,
Marlex mesh, coarse gauze sponge, electrocautery scratch pad). The rough
material mounted on a ring forceps allows mechanical abrasion of the entire
parietal pleural surface to create broad areas of pleural symphysis. Care
should be taken at the apex because the subclavian vessels and stellate
ganglion are superficially located. The pleura overlying the pericardium and
diaphragm are commonly omitted from the process.
Locating a parenchymal lesion thoracoscopically can be
more difficult than through an open incision. Methods to improve localization
have been described. Subpleural lesions are often more visible in a fully
atelectatic lung. A lung clamp or thoracoscopic ring forceps can be gently run
across the lung to “palpate” the lesion. Preoperative computed
tomography–guided needle localization can be used as well. The utility incision
can also be enlarged and a lung clamp used to bring lung tissue to the incision
for direct digital palpation. Anterior intercostal spaces are wider than
posterior spaces, so palpation is often easier at an anterior incision.
At the completion of the operation, a standard chest tube or tubes are placed endoscopically, typically using the most inferior-anterior port site, and are positioned apically for air and posteriorly for dependent drainage. Smaller and softer closed-suction drains (e.g., Blake or Jackson-Pratt drains) may also be used. The lung can be reexpanded and checked for air leaks under thoracoscopic vision as well. If there is no evidence of air leak or excessive bleeding and the postoperative chest radiograph is within expectations, suction is discontinued, and the tubes are allowed to drain via gravity into the closed drainage unit with an under-water seal. If the course continues to be uneventful, the tubes are typically removed on the first postoperative day.
