VATS Procedure

Introduction

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical method that has made significant progress in the diagnosis and management of numerous pulmonary and cardiac disorders during the last two decades.

A thoracotomy was the conventional method to a thoracic pathology prior to this procedure. In the past, the technique was often used to assess and treat pleural effusions in individuals with pulmonary TB. The invention of fiber-optic light was a technological breakthrough that resulted in the progress of all types of minimal access surgery.

The frequency of VATS operations performed has increased over the years as technical improvements have made these treatments safer for the elderly and debilitated. For example, a majority of specialists recommends VATS for the treatment of lobectomies, which are generally performed under general anesthesia with One-Lung Ventilation.

Clinical Significance

Because of its safety profile, VATS has gradually replaced open thoracotomies in most thoracic surgical facilities around the world. VATS has the following advantages over traditional thoracotomy:

• Earlier recovery of respiratory function
• Decreased surgery time
• Easier control of bleeding
• Decreased postoperative pain including opioid usage
• Decreased chest tube duration
• Decreased length of hospital stay
• Decreased inflammatory response
• Cosmesis
• Reduced cost

Indications

VATS is used by healthcare professionals to treat a wide range of thoracic diseases. Conditions of the lungs and heart are among them. If you have cancer, you may require it to remove a tiny amount of tissue. VATS may be used to biopsy a portion of the lung, lymph nodes, tissue surrounding the lung, tissue surrounding the heart, or the esophagus.

The indications can summarized into Diagnostic or Therapeutic:

Technique

• A standardized three-incision approach was used to conduct VATS lobectomies: a 2-cm camera port, a 2-cm posterior port, and a 4-cm utility incision without rib spreading. Individual hilar structures were ligated, fissures were closed, and lymph node dissection was done fully under thoracoscopic guidance.

• Typically, incisions in the intercostal region are used to perform the operation. The intercostal space's long axis is paralleled by the incisions. To avoid damage to the intercostal nerves, which run in a groove along the bottom border of the ribs, the surgeon must make sure these incisions are in the center of the space.

• All VATS operations should begin with the establishment of adequate intravenous access.

Contraindications

• The patient is unable to tolerate lung isolation and requires bilateral ventilation.
• Severe adhesions in the pleural cavity/pleural symphysis
• Coagulopathy
• Hemodynamic instability
• Severe hypoxia /COPD
• Severe pulmonary hypertension

Equipment

• Fiber-optic thoracoscope, high-resolution video camera
• High light source
• Camera
• Image processor
• Monitors
• Scissors
• Hook
• Trocar

Pre-operative Evaluation

• Patient selection is crucial to achieving positive surgical results. To guarantee that the selected individuals would tolerate one-lung ventilation, a thorough preoperative evaluation with an emphasis on cardiac and respiratory function is needed .
• Before the operation, you may need to stop taking certain medications, such as blood thinners. Discuss all of your medications, including over-the-counter medications, with your healthcare practitioner.
• Polycythemia related to respiratory diseases or an increased white cell count indicative of infection or inflammation may be shown by a complete blood count.
• Smoking cessation, treatment of underlying infections, and pulmonary rehabilitation may all be included in the preoperative optimization of patients having VATS. If you smoke, you need to quit before your surgery. You might need to do breathing exercises with a device called a spirometer.

• Your doctor may order tests to determine how well your lungs are performing. Before your operation, he or she may want to examine your overall health. These are partly dependent on the cause for your VATS. Here are a few examples:

• Chest X-ray
• Chest CT scan to get more detailed pictures of the lungs
• Positron emission tomography to look for cancer tissue
• ECG to check the heart rhythm
• Pulmonary function tests to see how well your lungs are working
• Blood tests to check overall health

Post-Operative Care

Pain control, respiratory care, and chest tube management are the three pillars of VATS post-operative care. Restrictive fluid treatment is another important technique for enhancing post-surgery results. You'll have to spend a few days in the hospital.

After you leave the hospital:

• In a subsequent appointment, your stitches or staples will most likely be removed. Keep all of your scheduled follow-up appointments.
• You could feel tired after the procedure. However, you will gradually regain your strength. It might take a few weeks for you to fully recover.
• You need to be up and walking several times a day.
• Follow your healthcare provider's advice for medications, exercise, nutrition, and wound care.

Complications

• Bleeding
• Post-operative pain
• Atelectasis
• Postoperative air leak
• Hypoxemia
• Wound infection

• The most severe consequence with VATS for large lung resection is bleeding owing to vascular damage, which is the most common reason for an emergency conversion to open thoracotomy.

• If an open thoracotomy is required, the surgeon, anesthesiologist, and operating room team should be prepared. Early postoperative morbidity and death rates were similar after VATS with conversion and open thoracotomy.
• If the operation is complicated by pneumothorax, patients who have had VATS should be transferred to the Post Anesthesia Care Unit (PACU), critical care unit, or a step-down unit with supplementary oxygen.
• Patients are at significant risk of rapid pulmonary decompensation and postoperative hemorrhage, therefore the anesthesiologist and PACU or ICU nurses should have a high index of suspicion, and patients should be continuously watched.

Conclusion

Video-assisted thoracoscopic surgery (VATS) is a surgical method that involves inserting a small tube called a thoracoscopic via a small incision between the ribs. A small camera is located at the tube's end. This allows the surgeon to see the whole chest cavity without opening the chest or spreading the ribs. The care and treatment you will receive will be specific to your needs.

References

https://www.ncbi.nlm.nih.gov/books/NBK532952/

https://pubmed.ncbi.nlm.nih.gov/20082195/

https://pubmed.ncbi.nlm.nih.gov/9322329/

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/video-assisted-thorascopic-surgery