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74 Video-assisted thoracic surgery
https://t.me/med1917
A preoperative consultation with the anesthesiologist is
very important. In a young, otherwise healthy patient undergoing thoracoscopy for spontaneous pneumothorax or sympathectomy, preanesthetic evaluation can occur the day
before or the morning of surgery. Older patients, however,
and patients with complex medical problems should be seen
in advance of the planned procedure.
ANESTHESIA
With few exceptions, VATS operations are performed with
the patient in the lateral position, under general anesthesia,
and with single-lung ventilation. Most patients are managed
with a double-lumen tube to allow collapse of the ipsilateral
lung. As the first access port is opened to the atmosphere, air
enters the chest, and the lung is deflated. In most thoracic
procedures, no CO
insufflation is required, and a valved port
2
OPERATION
Basic operative setting and general principles
is not necessary. In children and adults too small to allow
placement of a double-lumen tube, a tube with a bronchial
blocker may be used.
The anesthesia team should be familiar with open thoracic
procedures and be prepared for a rapid conversion to an open
thoracotomy should complications arise or difficulties
develop in performing the thoracoscopic operation. One possible exception to this anesthesia setup is the thoracic bilateral
sympathectomy, in which the patient may be placed in a sitting position with a regular single-lumen tracheal tube. In
this operation, a skilled surgeon can perform each side of the
procedure under a few minutes of apnea.
In most simple operations, an arterial line is not used, but
anesthetic monitoring with non invasive blood pressure
measurement, pulse oximetry, and end-tidal CO2measurement are standard monitoring. In advanced procedures, as
well as in compromised patients, an arterial line is placed for
hemodynamic monitoring.
The patient is placed in a full lateral position. A roll or
1
sandbag is placed in the axilla. One or two monitors may
be used. The surgeon must have a direct view of the monitor
across the operative field.
Anesthetist
Monitor
Assistant
camera
person
Surgeon
Monitor
Assistant
Nurse
1
The surgeon, camera, and instruments should be in the
2
same direction with regard to the pathology. This principle avoids an awkward handling of the instruments due to the
‘mirror imaging’ effect that results when instruments are
pointed toward the camera. Triangulation of the scope and
the accessory instruments prevents the interference of one
instrument with the others during the operation. Before the
trocars are inserted, the lung should be deflated. Because collapse of the alveoli takes some time, a useful practice is to
request lung deflation as soon as the patient is positioned.
2
Tray
Tray
The first access port should be planned for visualiza-
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3,4
the hemithorax. After the skin and soft tissue incision, digital
exploration can be very helpful in feeling a chest free of adhesions or in separating adhesions. The presence of firm and
extensive pleural symphysis requires conversion of the procedure to an open thoracotomy.
tion of the lesion from a distance and exploration of
Operation 75
3
4
76 Video-assisted thoracic surgery
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Most operations are performed using three
5a–c
working ports are placed under direct vision from inside the
chest; they are planned after initial evaluation of the whole
hemithorax and placed according to the position of the lesion
and handling of the instruments. Some form of thoracoscopic
port always should be used for passage of the scope. Direct
passage of instruments through the chest wall is an acceptable
technique, however, particularly when standard thoracic
instruments are being used. One or two additional ports may
be necessary for retraction.
Most of the procedures are performed with a 10-mm 0degree scope. Some surgeons often use a 30-degree scope in
several situations. Periodic warming of the thoracoscope is
essential to prevent fogging of the lens due to the temperature
difference between the thorax and operating room air.
Disposable as well as reusable endoscopic instruments are
used. In most VATS operations, regular surgical instruments
– such as ring forceps – may be used that also may be placed
inside the chest without use of the trocar port.
One important issue arises in VATS procedures in which
malignant or infected specimens are removed from the thoracic cavity. Implants of malignant tissue in the port site have
been reported. As a rule, all of these specimens should be
removed inside a plastic bag to prevent the spread of disease
at the port site. In most operations, a chest tube (generally a
24–28 Fr thoracic catheter) is placed in the lower access port.
The other access sites are closed with subcutaneous and subcuticular absorbable stitches. The lung is re-expanded, and
the tube is connected to suction. The chest tube is removed
when all air leaks are sealed and drainage is less than 100 mL
per day.
ports in an inverted triangle position. The two
5a
Operation 77
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5b
5c
78 Video-assisted thoracic surgery
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Procedures
As stated earlier, a large number of thoracic procedures can
be performed successfully through a VATS approach. This
chapter, however, describes only some procedures that have
been widely accepted by most thoracic surgeons as straightforward operations to perform using the videothoracoscopic
approach.
Several advanced procedures performed on VATS, as pulmonary lobectomy, thymectomy, esophagectomy, resection
of first rib for thoracic outlet syndrome, thoracoscopic
approach to spinal surgery and other complex procedures
will be discussed in the respective chapters.
Pleural biopsy
The patient is positioned in a lateral decubitus
6a,b
lapsing the side of highest yield predicted by preoperative
radiographical evaluation. Usually, a standard three- or twoentry port technique is directed at the lower half of the thoracic cavity to maximize the biopsy yield. Identified masses
are incised with an endoscopic scissors, knife, or biopsy forceps. Care should be taken not to excise tissue deeply on the
diaphragm or apex to avoid vascular injury or phrenic perforation. Multiple biopsy specimens are obtained to ensure that
enough tissue is available. Consultation with a surgical
pathologist with or without frozen section diagnosis may be
useful to ensure that a proper amount of tissue is obtained for
appropriate histological and histochemical staining procedures.
When a 10-mm telescope with a 5-mm working channel is
available, the operation can be performed through this single
10-mm incision. Thus, several pleural procedures – including
treatment of most pleural effusions – can be performed via a
single port access site. Use of a spoon-shaped biting forceps
usually allows removal of adequate pleural specimens for
diagnosis and histochemical studies without producing
crushing artifacts.
For diagnosis of a malignant pleural effusion, a therapeutic
procedure such as the surgical creation of pleural symphysis
is often undertaken. The preferred sclerosing agent in malignant cases has been talc. Effective pleurodesis can be achieved
by insufflation of 4–5 g of sterile talc. Under direct vision, talc
powder is insufflated over the lung and parietal surfaces
through the working channel of the thoracoscope or through
the other working port. A chest tube is placed through the
lower port site and left in place until the volume of drainage is
approximately 100 mL daily.
position, and a pneumothorax is created by col-
6a
6b
Lung biopsy – wedge resection of the lung
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A common procedure performed is lung biopsy for diagnosis
of diffuse lung disease or for a detailed histological evaluation
of pulmonary interstitial disease. The videothoracoscopic
procedure allows a complete evaluation of the chest cavity,
and lung tissue can be resected from any area of the lung.
Operation 79
With the operated lung collapsed by one-lung
7a,b
through an initial port site placed in the fifth to seventh intercostal spaces in the mid to posterior axillary line. After a thorough exploratory thoracoscopy, the accessory access sites for
lung biopsy are selected, aimed at the areas of interest under
direct visual control. Two additional access sites are typically
required. They should be placed at least 10 cm apart in the
anterior axillary line and the posterior axillary to midscapular
line. The target area is determined by CT studies, and at least
two specimens are resected. The usual inverted triangle is
used for placing the port access sites, with special attention
given to locating them far enough from the target area to
allow opening of the endostapling device. The target area is
grasped with a lung clamp or a ring forceps. Stapling can be
performed from the same port site, or the first and second
staplings may alternate between grasper port and stapler port
sites.
ventilation, the thoracoscope is introduced
7a
7b
80 Video-assisted thoracic surgery
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The lung is grasped in the area of interest for the
8a,b
endoscopic lung clamps may be used. Alternatively, one can
introduce the traditional thoracotomy instruments (ring forceps, lung forceps) through the access site without using the
thoracoscopic port. The endoscopic stapler is introduced
through another access site for pulmonary biopsy. Usually,
the procedure can be completed with two or three staplings.
The resected specimen can be pulled out from one of the
access sites and is sent for pathological and microbiological
studies. Air leakage can be checked by instillation of saline on
the suture line. Adequate homeostasis is essential. A chest
tube is inserted into the pleural cavity through the lowest
access site for underwater sealed drainage. The incisions are
closed in layers.
application of the stapler. Specially designed
8a
8b
Operation 81
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Pulmonary solitary nodules
Solitary pulmonary nodules up to 2.5–3 cm in diameter and
peripherally located are easily treated by VATS techniques.
The surgical strategy is similar to that of wedge resection of
the lung for biopsy.
With the operated lung collapsed by one-lung anesthesia,
the thoracoscope is introduced through the initial port site.
After a thorough exploratory thoracoscopy, the accessory
access sites for lung resection are selected, aimed at the areas
of interest under direct visual control. The wise course is to
keep all but one trocar site away from the nodule to allow
plenty of room to move the instruments inside the chest and
to provide adequate distance for stapling devices to open.
Once located, the nodule is grasped and resected with
9
stapling techniques. The port sites of the stapler and the
grasper are switched to complete the wedge resection.
Stapling should be planned so as to resect the lesion with generous margins.
Usually, the whole procedure can be completed with two
or three staplings. The resected specimen can be extracted
from one of the access sites. Before removal, the specimen
should be placed in a specially designed plastic bag or a surgical glove. The specimen is sent for frozen section. If the result
is inconclusive, thoracotomy may be required. After hemostasis is ensured, a chest tube is inserted into the pleural cavity
through the lowest access site and connected to an underwater sealed drain. The other incisions are closed in layers.
One trocar site may preferentially be placed near the suspected location of the nodule (as noted from the CT scan).
This strategy allows the index finger to be introduced into the
chest for palpation. Grasping the lung and moving it over the
index finger has proven to be very sensitive in detecting even
small nodules.
The first step is to identify the pulmonary nodule. The
nodule can be identified by inspection, by instrumental palpation, or by digital examination. The trocar site near the
nodule allows the index finger to be introduced into the chest
for palpation. Grasping the lung and moving it over the index
finger has proven to be very sensitive in identifying even small
nodules. Sometimes palpation with inflation of the lung also
may be useful.
Primary spontaneous pneumothorax
The operation for pneumothorax is directed both to treatment of the current episode and prevention of recurrent
episodes. The thoracoscopic operation allows an excellent
evaluation of the lung surface and obliteration and resection
of the blebs, and also allows an efficient method of pleural
symphysis.
Most patients operated on are those experiencing a second
episode of spontaneous pneumothorax or a first episode with
persistent bronchopleural fistula or bilateral disease.
Currently, for patients in whom a chest tube was initially
9
placed and in whom an air leak persists for more than 3–4
days, a thoracoscopic operation is advised.
Working ports are usually placed posteriorly and anteriorly,
near the anterior axillary line. The lung is inspected for blebs,
usually with two lung forceps placed through the working
ports. Most of the blebs are located in the apical area, but fissures, the mediastinal aspect of the superior lobe, and the
superior segment of the lower lobe also are carefully inspected.
Although most of the blebs are easily identified, sometimes
asking the anesthesiologist for a partial inflation of the lung,
placing the patient in the Trendelenburg position, and keeping the target area under saline may be useful.
82 Video-assisted thoracic surgery
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The blebs are resected together with a good portion
10
completed with two or three firings of the stapler. The target
should be approached from different directions by switching
the position of the grasper and the stapler. When no blebs are
found, we recommend that the apex be resected with the
endostapler and a more radical pleurectomy be performed.
formed to decrease the probability of recurrent pneumothorax. A mechanical abrasion with gauze or a piece of Marlex
mesh rubbed vigorously against parietal pleura allows a very
effective abrasion. Alternatively, the parietal pleura may be
excised. The dissection plane is created, and blunt dissection
is performed. This approach is more aggressive, and bleeding
points should be carefully coagulated.
of the lung apex. Usually, the bleb resection can be
After resection of the blebs, pleurodesis should also be per-
10
Mediastinal cysts and tumors
To reach the posterior mediastinum, the first access
11
incision is made at the fifth intercostal space in the
anterior axillary line for introduction of the thoracoscope.
Another incision is made at the fourth intercostal space, also
in the anterior axillary line, for introduction of the lung
retractor. The lung is retracted anteriorly with a fan retractor.
For upper and middle posterior mediastinal tumors, the
working ports should be made at the anterior to middle axillary lines between the second to fourth intercostal spaces. On
the other hand, for lower posterior mediastinal tumors, the
working access sites should be made at the midaxillary line
between the fifth and seventh intercostal spaces. A slight tilting of the operative table to the ventral side of the patient
allows the lung to shift anteriorly and improves the endoscopic visual fields.
11
12a,b
5mm trocar
with blunt
grasper in
fourth
intercostal
space
12mm trocar with video camera
in sixth intercostal space
Sharp
dissection
of avascular
adhesions to
mass in anterior
mediastinum
5mm trocar with scissors
in fifth space
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is placed within the mid to posterior axillary line in the fifth
intercostal space. The other ports for instruments are placed
in the fifth intercostal space in the anterior axillary line and
the third intercostal space in the posterior axillary line. This
trocar positioning properly triangulates the instrumentation
and enables one to add more ports if necessary. The initial
recognition of the pathology is begun inferiorly and laterally
and extended medially, with meticulous clipping and coagulation of all bleeders, especially branches of the innominate
vein.
Cysts can be treated using the same principles as in an open
operation. The cyst usually can be carefully dissected with
sharp and blunt dissection. When rupture occurs, the
remaining cyst content is suctioned, and the cyst walls are dissected and resected as completely as possible. When the procedure is completed and the surgeon is assured that no
bleeding is occurring from the port sites, a chest tube is
inserted through one of the port sites and connected to the
underwater suction.
Operation 83
When anterior mediastinal tumors are
approached, the initial trocar for the camera
12a
12b
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