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pulmonary function, decreased postoperative pain and subsequent narcotic requirements, decreased incidence of postoperative complications, and lower overall cost
[5–8]. Smaller studies have shown similar benets in trauma patients [1, 9].
Accordingly, thoracoscopy has become increasingly and successfully utilized in
both trauma and emergency general surgery settings. This chapter will focus on our
general approach to thoracoscopic surgery. Specic management of commonly
encountered pathology is discussed elsewhere in this text.
A. W. Knight and A. R. Campbell
2 VATS Principles
VATS can be both diagnostic and therapeutic when appropriately employed in acute
care surgical practice. Careful patient selection is essential for safe and successful
thoracoscopic surgery. Common indications for thoracoscopy in the acute care setting are discussed in an earlier chapter. Patients must be sufciently t, hemodynamically stable, and adequately resuscitated to be able to tolerate single- lung
ventilation. Suspicion for injury in another body cavity must be sufciently low or
previously ruled out, as the lateral decubitus positioning necessary for a standard
VATS exploration substantially limits immediate access to the abdomen, retroperitoneum, and extremities. Common contraindications to VATS are discussed later. If
a patient who meets one or more of these criteria still requires urgent thoracic surgical intervention, strong consideration should be given to the pursuit of a standard
open approach in favor of thoracoscopy.
2.1 Single-Lung Ventilation
Single-lung ventilation (SLV) is almost always required for thoracoscopic surgery.
SLV deates the ipsilateral lung and thus creates increased operating space and
improved visibility. Diagnostic thoracoscopy, periodically performed to evaluate for
parenchymal or diaphragmatic injury, may be performed with standard double-lung
ventilation, often with periodic breath holds. Additionally, in certain clinical scenarios, SLV may protect the contralateral lung from exposure to infectious, bloody,
or malignant secretions.
SLV may be achieved by placement of either a double-lumen endotracheal tube
or an ipsilateral endobronchial blocker. A double-lumen tube is larger than a standard, single-lumen endotracheal tube and requires bronchoscopic guidance for correct anatomic placement in the proximal right and left mainstem bronchi.
Endobronchial blocker positioning requires placement of a size 8.5 or 9.0 endotracheal tube, which may be limited by smaller patient body habitus. The blocker itself
has two differently colored balloons and is placed at the carina under bronchoscopic
guidance. Selective ination of the appropriate balloon facilitates blockage of the
ipsilateral mainstem bronchus and thus prevents ventilation of the ipsilateral lung.
Notably, successful endobronchial blockade of the right lung may be more difcult
due to the immediate, acute takeoff of the right upper lobe bronchus, which may
Utility ofVideo-Assisted Thoracoscopic Surgery (VATS) inAcute Care Surgery
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preclude adequate isolation. Endobronchial blockade is limited by passive deation
of the ipsilateral lung. While both are safe and effective SLV options, we prefer
placement of a double-lumen endotracheal tube as it facilitates more rapid deation
of the ipsilateral lung, allows for pre- and intraoperative exible bronchoscopy of
both lungs, and is less likely to become dislodged during patient positioning.
However, neither technique is proven to be superior, and thus, this decision should
be made by the responsible anesthesia and surgical teams.
SLV creates a signicant ventilation-perfusion mismatch and may lead to hypoxemia. While physiologic hypoxic pulmonary vasoconstriction in the ipsilateral lung
offsets some of this phenomenon, hypoxemia may require intraoperative treatment.
Common maneuvers include the use of a higher fraction of inspired oxygen or positive end expiratory pressure to facilitate vasodilation and improved ventilation in
the contralateral lung, respectively. Recruitment maneuvers may also be utilized. In
some circumstances, temporary reversion to double-lung ventilation may be
required and is often the safest treatment of persistent or refractory hypoxemia. This
circumstance highlights the close, frequent communication needed between the
anesthesia and surgical teams to maximize patient safety. Of note, carbon dioxide
clearance is seldom affected by SLV so long as minute ventilation remains adequate. Additionally, the singly ventilated lung must be protected from barotrauma
and ventilator-associated injury. Maintenance of safe peak inspiratory and plateau
pressures is imperative, particularly when larger tidal volumes are utilized to maintain adequate oxygenation. If a patient is ultimately deemed unable to safely tolerate
SLV, consideration should be given to proceeding with traditional open
thoracotomy.
2.2 Contraindications toThoracoscopy
Many common contraindications to VATS are listed in Table1. Importantly, hemodynamic instability is an obvious contraindication and often necessitates conversion
to thoracotomy. It may be additionally exacerbated by low ow insufation that is
commonly utilized during thoracoscopy to optimize visualization. The addition of
positive intrathoracic pressure can worsen hemodynamic instability by compressing
the superior and inferior vena cava and thus decreasing venous return to the heart,
as is also observed in laparoscopy. While thoracoscopy may safely be performed
Table 1 Contraindications to video-assisted thoracoscopic surgery in acute care surgery
Hemodynamic instability requiring ongoing medical management
Inability to tolerate single-lung ventilation (due to injury burden or underlying comorbid
cardiopulmonary disease)
Multi-compartmental injury requiring concomitant operative management
Clinical indication for exploratory thoracotomy (i.e., massive hemothorax)
Suspected cardiac injury
Contraindication to lateral decubitus positioning
Signicant adhesions in the pleural space from prior surgery, infection, inammation, radiation,
etc.
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A. W. Knight and A. R. Campbell
without supplemental insufation, as SLV often provides sufcient operating space,
if adequate visualization cannot be achieved or if treatment of hemodynamic instability is ongoing, the surgeon should have a low threshold to convert to an open
approach.
Historic contraindications to VATS include prior thoracic surgery or chest wall
instrumentation (including tube thoracostomy) as well as irradiation. As thoracoscopy has become more widely utilized by both thoracic and general surgeons, these
factors less commonly preclude a safe VATS approach.Thoracoscopic adhesiolysis
may be necessary in these scenarios, but can be safely and effectively performed to
free the lung from the parietal pleura. Conversion to thoracotomy may still be
required in individual circumstances depending upon intraoperative ndings and
surgeon discretion.
Lastly, pulmonary function tests are an excellent predictor of tolerance of SLV
and magnitude of pulmonary resection. While they commonly inform the decision
to proceed with a thoracoscopic versus open approach in elective thoracic surgery,
these studies are seldom available in an acute care or traumatic setting. Accordingly,
the choice of surgical approach in this circumstance must be dictated by the nature
of the planned operation as well as the patient’s hemodynamic status, degree of
physiologic insult, and comorbidities, if known. If thoracoscopy is pursued, the
operative team must be ready to immediately convert to thoracotomy if necessary.
3 Standard Operative Approach
3.1 Operating Room Setup andEquipment
A VATS-capable operating room should include the typical equipment listed in
Table2, with additional instruments being available per individual surgeon preference [10]. Standard thoracotomy equipment should also be immediately available.
Typically, the operating surgeon and assistant are positioned on the ventral aspect of
Table 2 Standard VATS
equipment
Two standard video monitors
Fiberoptic 5 and 10mm thoracoscopes
High-resolution video camera
Light source and cable
Image processor
Blunt lung graspers
Curved dissecting forceps
Biopsy forceps
Vascular clamps
Thoracoscopic scissors
Electrocautery
Suction
Trocar selection per surgeon preference
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the patient with the scrub nurse or technician opposite the assistant surgeon. The
anesthesia team is positioned at the head of the bed.
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3.2 Patient Preparation, Positioning, andBronchoscopy
The patient is initially placed supine on the operating table and general anesthesia
is induced. Either a single- or double-lumen endotracheal tube may be placed,
depending upon the operating surgeon’s preference for preoperative bronchoscopy.
However, if a single-lumen tube is placed, it must be exchanged for a double-lumen
tube prior to nal patient positioning. Large-bore peripheral intravenous access is
obtained, and a radial arterial line is typically placed for continuous intraoperative
hemodynamic monitoring. A urinary catheter is also commonly placed. An appropriate analgesic plan should be formulated with the anesthesia team, which may
include thoracic epidural placement or regional nerve block techniques in addition
to the use of local anesthetics.
We begin with a standard video bronchoscopy to the level of the subsegmental
bronchi to visualize the tracheobronchial tree and rule out any intraluminal anomalies or occult tracheobronchial injury. Single-lung ventilation is initiated at the conclusion of bronchoscopy. The importance of working with an anesthesia team that
is procient in the management of patients requiring single-lung ventilation in order
to maximize the change of successful thoracoscopic surgery with minimal risk of
intraoperative complications cannot be overstated. From here, the patient is placed
in a standard lateral decubitus position with the ipsilateral shoulder and upper arm
suspended on an arm board. All pressure points are adequately padded to prevent
nerve injury. We use a bean bag to assist with patient positioning, although gel rolls
may be used per surgeon preference.
3.3 Standard Port Placement
We begin by placing a 10 mm camera port in the 7th–8th intercostal space at the
posterior axillary line and then proceed with a diagnostic thoracoscopy. Under
direct vision, two additional 5mm working ports are placed, one each in the 4th–5th
and 7th intercostal spaces at the anterior axillary line. Further operative management is then dictated by the individual patient’s surgical indication. While the specic indications for surgery are discussed in an earlier chapter, this approach allows
for successful thoracoscopic treatment of the majority of these acute pathologies
[11–13].
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A. W. Knight and A. R. Campbell
4 Conclusion
Acute care surgeons continue to encounter and manage a wide variety of thoracic
pathology, a minority of which will require surgical intervention. Multiple studies
in both general thoracic and trauma populations conrm the safety, feasibility, and
improved clinical outcomes associated with a VATS approach compared to a traditional thoracotomy in appropriately selected patients. As such, non-thoracic, acute
care surgeons must remain familiar with diagnostic and therapeutic thoracoscopy as
an effective approach to denitively treat multiple injury patterns and benign disease processes.
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