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E Thoracotomy vs. VATS: A Clinical Discussion

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Thoracotomy vs. VATS: A Clinical Discussion

(An Online Continuing Education Activity)CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time. Steps for Successful Course CompletionTo earn continuing education credit, the participant must complete the following steps:

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OVERVIEW Surgery is often accomplished to obtain a closer look of the inside of the body to help treat problems or conditions associated with major organs. In the case of lung conditions, tissue, fluid, or even an entire lobe or lung may be removed during surgery. While surgical options vary depending upon physician preference and practice, it is important that techniques are used that best benefit the patient for their specific circumstance.

This continuing education activity will discuss the indications for an open thoracotomy versus VATS and the factors involved in the clinical decision for selecting the most appropriate technique.

LEARNING OBJECTIVESAfter completing this continuing education activity, the participant should be able to:

• Evaluate the indications for an open thoracotomy and VATS.• Identify the types of thoracotomy procedures.• Describe the set-up and instrumentation for open thoracotomy and VATS.• Discuss complications that can occur with open and minimally invasive surgery.

INTENDED PARTICIPANTPerioperative nurses and surgical technologists who are involved in surgical procedures for patients requiring thoracotomies will benefit from this discussion of open verses minimally invasive procedures.

CREDIT/CREDIT INFORMATIONState Board Approval for NursesPfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 1.0 contact hour.

Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

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CEU Statements• As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs

that qualify under the ANSI/IACET Standard. • Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program.

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RELEASE AND EXPIRATION DATEThis continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in May, 2015 and renewed in July, 2016; therefore, this continuing education activity expires July, 2017.

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SUPPORTFunds to support this activity have been provided by Ethicon

AUThORS/PLANNING COMMITTEE/REVIEWERDondra Tolerson, BS, MA Woodstock, GaMedical Writer/Author/Planning Committee Judith I. Pfister, RN, BSN, MBA Aurora, COProgram Manager/Planning CommitteePfiedler Enterprises Julia A. Kneedler, RN, MS, EdD Aurora, COProgram Manager/ReviewerPfiedler Enterprises

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Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Authors/ Planning Committee/Reviewer Dondra Tolerson, BS, MA No conflict of interest

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Judith I. Pfister, MBA, RN Co-owner of company that receives grant funds from commercial entities

Julia A. Kneedler, EdD, RN Co-owner of company that receives grant funds from commercial entities

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INTRODUCTIONThoracic surgery encompasses the operative, perioperative, and post-surgical care of patients with acquired and congenital pathologic conditions within the chest. Surgeons perform both standard (open) and minimally invasive procedures for many types of thoracic surgeries. Although clinical outcomes may be similar between the two, there are pros and cons to both types of surgery and possible complications from each.

OPEN ThORACOTOMyA thoracotomy is a major surgical procedure that allows surgeons to access the throat, lungs, heart, aorta and diaphragm during surgery. The open surgical procedure, performed under general anesthesia, is done to evaluate and treat pulmonary problems when noninvasive procedures are non-diagnostic or unlikely to be definitive.

Generally, a thoracotomy involves making a large (eight to ten inch) incision on the side of the chest, allowing the surgeon to directly view and access the surgical area; however, the exact location of a thoracotomy depends on the disease, disorder or condition that the surgeon is treating. The open surgery involves significant cutting and displacement of muscle, ribs, and other tissues. Some techniques allow surgeons to use a smaller incision (four to six inches). This type of procedure is sometimes called a muscle-sparing thoracotomy because the surgeon does not cut through the latissimus dorsi and serratus anterior muscles. Instead, the surgeon moves the muscles out of the way or separates the muscle fibers. This is not a minimally invasive procedure, but it may provide similar advantages such as faster recovery times and less pain.

Indications and Contraindications for Open ThoracotomyIn general, surgeons may recommend a thoracotomy for:1

• Atelectasis• Benign tumors or cysts• Confirmation of a diagnosis, such as lung disease• Diaphragm disorders• Diseased or damaged blood vessels of the heart or lungs• Empyema, or infection in the chest cavity• Heart disease• Hemothorax• Lung damage caused by emphysema or bronchiectasis• Pleurodesis• Pneumothorax, or injuries that cause the collapse of lung tissue• Pulmonary embolism, or a blood clot in the lungs or pulmonary artery• Severe and very specific types of chest injury or trauma, such as gunshot

wounds • Lung cancer and other types of cancer• Trachea or esophageal conditions

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Contraindications of an open thoracotomy are those general to surgery. They include coagulopathy that cannot be corrected, acute cardiac ischemia, and instability or insufficiency of major organ systems.

Coagulopathy - Also called clotting or bleeding disorder, this is a condition in which the blood’s ability to clot is impaired and can cause prolonged or excessive bleeding.

Myocardial ischemia – This condition occurs when blood flow to the heart muscle decreases due to a partial or complete blockage of the heart’s coronary arteries. The decrease in blood flow reduces the heart’s oxygen supply and can damage the heart muscle, reducing its ability to pump efficiently.

Instability/insufficiency of major organ systems – The altered organ function in acutely ill patients where homeostasis cannot be maintained without intervention. It usually involves two or more organ systems.

TyPES OF OPEN ThORACOTOMyTumors and metastatic growths can be removed through the thoracotomy incision via a procedure called a resection. A biopsy, or tissue sample, can also be taken through the incision, and examined under a microscope for evidence of abnormal cells. A resuscitative or emergency thoracotomy may be performed to resuscitate a patient who is near death as a result of a chest injury.

There are several different types of thoracotomy that can be performed, depending on the indication for surgery and condition being treated. These include:

Posterolateral thoracotomy - The posterolateral approach gives access to pleurae, hilum, mediastinum, and the entire lung. It is the most common procedure, and the usual method of gaining access to the lungs to remove a lung or a portion of a lung to treat lung cancer. Lung cancer is the most common cancer requiring a thoracotomy. Despite significant advances made in the areas of prevention, early detection, and treatment, cancer remains the second leading cause of death in the United States. According to the most recent statistics gathered in 2011 by the Cancer Statistics Working Group (published by Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute) 207,339 people in the United States were diagnosed with lung cancer (110,322 men and 97,017 women). Furthermore, 156,953 people in the United States died from lung cancer (86,736 men and 70,217 women).2

An incision is made along the side of the chest towards the back, between the ribs. The ribs are then spread apart, or a rib may be removed, to visualize the lungs. Surgeons may then remove a lung (pneumonecomy), a lobe of one of the lungs (lobectomy), or a smaller portion of the lung (wedge resection).

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Figure 1. Types of Thoracotomy Procedures3 University of Southern California: Cardiothoracic Surgery

Median thoracotomy - In a median thoracotomy, surgeons make an incision through the sternum (the breastbone) to gain access to the chest. This procedure is commonly done to perform surgery on the heart. When access to both lungs is desired, as in lung volume reduction surgery, a sternal splitting incision is used.

Axillary thoracotomy - An axillary thoracotomy allows surgeons access to the chest through an incision near the armpit. This is commonly done for treating a pneumothorax, but may also be performed for some heart and lung surgeries.

Anterolateral thoracotomy - This procedure is an emergency procedure involving an incision along the front of the chest. It may be done following major chest trauma, or to allow direct access to the heart after a cardiac arrest.

POSITIONING, SET-UP, AND INSTRUMENTATION Once anesthesia has been administered and the patient is asleep, the surgeon, circulating nurse and anesthesia provider reposition the patient from the supine position to the lateral decubitus position with one arm raised. The circulating nurse places pillows

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between the patient’s legs and pressure points of the lower leg, ensuring that the lower leg is bent at a 45°angle and the upper leg is straight. Once the patient is secured in an anatomically correct the nurse ensures that the safety strap is secured over the patient’s thighs and secures their upper arm on a padded, elevated arm board with an axillary roll positioned to prevent compression of the brachial plexus. The patient is then covered with sterile drapes.

During the surgery, a tube is passed through the trachea and usually branches to each lung. The lung to be examined or operated on is deflated, while the other one is inflated and continues working with the assistance of a ventilator.4

The surgeon makes the thoracotomy incision via an axillary, median, posterolateral, or anterolateral thoracotomy. The exact location of the cut depends on the reason for the surgery. The muscle layers of the rib cage are cut and retractors are used to hold the ribs apart to expose the lungs. The joints of the ribs with vertebral bodies have limited flexibility and the use of a retractor has the potential to result in rib fractures. As a result some thoracic surgeons intentionally remove a section of one or more ribs in an effort to prevent splintered rib fractures associated with the use of the retractor. In some cases, the physician is able to make the incision between ribs (an intercostal approach) to minimize cuts through bone, nerves, and muscle with an incision just under five inches. 4

Figure 2. Open Thoracotomy Incision5

A lobectomy, segmentectomy, wedge resection or pneumonectomy is performed removing part or the entire lung. In most cases, nearby lymph nodes may be removed as well.4 When the procedure is finished, one or more tubes are placed in the chest temporarily to drain fluid and air. Then the rib cage is repaired and the muscle and skin are closed with sutures or staples. The entire procedure may take two to five hours.

ComplicationsA thoracotomy is a common but major surgery with serious risks and potential complications. Complications are greater than those of many other pulmonary biopsy procedures because of the risks of general anesthesia, surgical trauma, and a longer hospital stay with more postoperative discomfort. Hemorrhage, infection, pneumothorax, bronchopleural fistula, and reactions to anesthetics are the greatest hazards. Mortality for exploratory thoracotomy ranges from 0.5 to 1.8%.

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After the chest tube is removed, the patient is vulnerable to pneumothorax. Surgeons attempt to reduce the risk of collapse by timing the removal of the tube with the end of inspiration (breathing in) or the end of expiration (breathing out). Deep-breathing exercises and coughing are encouraged as primary ways that patients can improve healing and prevent pneumonia.

The rich supply of blood vessels to the lungs makes hemorrhage a risk; a blood transfusion may become necessary during surgery. General anesthesia is associated with risks such as nausea, vomiting, headache, blood pressure issues, or allergic reaction. After a thoracotomy, there may be drainage from the incision that can lead to infection if the site is not kept clean and dry as it heals.

A thoracotomy requires a very painful incision involving multiple muscle layers, rib resection, and continuous motion as the patient breathes. Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications such as respiratory failure due to splinting; inability to clear secretions by effective coughing, with resulting pneumonia; and incapacitating chronic pain referred to as post-thoracotomy pain syndrome. Managing the patients’ pain post-surgery will enable them to ambulate and to breathe deeply and normally without splinting. 6, 7

MINIMALLy INVASIVE SURGERyCompared to surgery performed through a long, open-chest incision, minimally invasive lung surgery provides several important benefits for patients, which include, but are not limited to:

• Faster recovery and return to normal activities• Shorter hospital stay• Less pain• Little scarring• Minimal blood loss• No cutting of the ribs or sternum• Possible improved cure rates for cancer

Video-Assisted Thoracic Surgery (VATS) Video-assisted thoracic surgery (VATS) came into widespread use beginning in the early 1990s and is a less invasive alternative to thoracotomy. Also called thoracoscopy, VATS involves insertion of a thoracoscope through a small incision, or port, in the chest wall. The thoracoscope has a miniature camera that allows the surgeon to view and examine the chest cavity on a video screen. Specially designed instruments such as a stapler or grasper may be inserted through one or two more ports, allowing the surgeon to remove tissue from the lungs. Although initially used as a diagnostic tool to visualize the lungs or to remove a sample of lung tissue for further examination, VATS may be used to remove some lung tumors. For more extensive operations, such as lung resection for cancer, an extra incision measuring about five centimeters is made for the removal of the lung tissue.

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Figure 3. Video-Assisted Thoracic Surgery5

Indications and Contraindications for VATSVideo-assisted thoracoscopic surgery is largely performed for diagnostic and therapeutic procedures involving the mediastinum, lungs, and pleura. It is quickly replacing surgeries that previously required a thoracotomy and/or sternotomy. 7, 8

A list of general indications for VATS can be found in Table 1.

Table 1. Indications for VATS7, 8, 9

Adapted from Brodsky and Cohen and Fischer and Cohen by AANA

In some situations, a VATS lobectomy operation is not possible. Sometimes lung cancer is detected after the primary tumor has become large, or is located close to major arteries or veins, the heart, the trachea, or the normal tissue of the remaining

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lung. In these situations, VATS is not recommended and a thoracotomy is required. Other contraindications to VATS procedures include a patient’s inability to tolerate one-lung ventilation (OLV), lateral decubitus position, and hemodynamically unstable conditions.10, 11 A general list of contraindications is given in Table 2.

Table 2. Contraindications for VATS9

TyPES OF VATS Surgeons may perform one of the following procedures using the VATS technique:

Wedge resection- The wedge shaped removal of the tumor and tissue surrounding the cancer without regard to anatomical boundaries of the segments of the lung. A wedge resection is typically performed for the diagnosis or treatment of small lung nodules. A wedge resection is performed instead of a lobectomy (removing a complete lung lobe) when there is a danger of decreased lung function if too much of the lung is removed.

Segmental resection- Removal of the entire segment of the lungs containing the tumor and surrounding anatomic structures. This technique removes a larger portion of the lung lobe than a wedge resection, but does not remove the whole lobe.

Lobectomy- Removal of the entire lobe of the lung that contains the cancerous tissue. This is the standard operation for most lung cancers.

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Figure 1. Types of Thoracotomy Procedures12 University of Southern California: Cardiothoracic Surgery

POSITIONING, SET-UP, AND INSTRUMENTATION As a rule, the lateral decubitus position offers the best exposure, and it permits uncomplicated conversion to a thoracotomy if necessary.13, 14 Therefore, the basic procedure for positioning a patient for a traditional thoracotomy are similar to that of VATS.

Instrumentation for VATS includes video equipment, endoscopes and thoracoports, staplers, thoracic instruments (e.g. lung clamps and retractors) modified for endoscopic use, and various devices for tissue cauterization, including lasers. Conversion to thoracotomy is occasionally necessary; a basic set of thoracotomy instruments is generally available in the VATS instrument tray.13 The surgeon and the assistant are positioned on the anterior side of the patient and with the surgeon cranially. The scrub nurse is opposite to the assistant and follows the operation on a separate screen and still positioned face to face with the surgeon (Figure 4).

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Figure 4. Operating room set-up for the anterior approach of video-assisted thorascopic lobectomy

Annals of Cardiothoracic Surgery15

Depending on surgeon preference and the surgical procedure, the VATS approach involves creating small incisions in the chest wall for the placement of two to four ports. The first port is usually placed at the seventh or eighth intercostal space in the midaxillary line. This 10-mm port typically houses the thoracoscope, allowing visualization of the pleural cavity, and aids in the placement of the remaining ports to be used for instrumentation. Historically, this approach to port placement allows for triangulation of the instruments; all instruments should be aligned in the same direction, facing the target pathology within a 180° arc, as shown in above in Figure 5. This approach provides ample spacing and visualization without instrument interference.10 Minimally invasive techniques require a steep learning curve and surgeons with more experience are likely to achieve better outcomes.

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Figure 5. Surgical Instrument Placement During Video-Assisted Thoracoscopic Surgery

ComplicationsThe complication of VATS is generally infrequent but can lead to conversion to an open procedure. The most frequent surgical complications are a prolonged air leak and bleeding. Generally, small air leaks resolve on re-expansion of the non-inflated lung over a course of a few days; however, an air leak lasting more than seven days is considered persistent or prolonged. A prolonged air leak is more likely to occur as a result of small injuries to the visceral pleura from suturing, biopsies, thermal electrocautery and the use of endoscopic graspers. The greater amount of lung tissue resected may increase the likelihood of air leaks.16, 17

Inadvertent injury to pulmonary vasculature and failure of mechanical staples may cause bleeding. Other sources of bleeding are the trocar access sites and dense adhesions or tumors that are near the pulmonary hilum.17

Other potential complications include:11

• Cardiac arrhythmias• Pneumonia• Empyema• Atelectasis• Pneumothorax• Respiratory failure• Dissemination of tumor at the port site• Surgical-site infection, and• Intercostal neuroma

Optimal operative planning, including obtaining baseline pulmonary function tests with diffusion measurements, positron emission tomography and/or computed tomography scans, bronchoscopy, and endobronchial ultrasound or mediastinoscopy, can be used to anticipate and potentially prevent the occurrence of complications.

It should be noted that it is difficult to anticipate which patients may require conversion.

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There is no evidence that these patients suffer from increased morbidity or mortality as a result of conversion to open thoracotomy and should be regarded as a means of completing resections in a traditional manner rather than as a surgical failure.

Although VATS is associated with a reduction in postoperative pain compared with an open thoracotomy, patients remain at risk for significant postoperative pain. Adequate postoperative analgesia facilitates improved respiratory effort, increases patient comfort, and decreases potential postoperative complications (e.g., infection and respiratory insufficiency).7

COMPARISON STUDIESTable 3 demonstrates the results of a study published in 2012 by the American College of Surgeons comparing VATS to open thoracotomy.

Table 3.

In a retrospective study conducted by Cezary Piwkowski, et.al., the results of treatment of 567 lung cancer patients, from 2006 to 2012, were analyzed. The criteria included patients with peripheral tumors less than six centimeters large, without bronchial infiltration, chest wall invasion and mediastinal involvement. VATS lobectomy was performed in 314 patients and thoracotomy was performed in 253 patients. There was no difference between the VATS and thoracotomy group in terms of gender distribution, age, comorbidity rate, preoperative spirometry and stage of the disease. Postoperative outcomes and complication rates were assessed.

Compared with open lobectomy, VATS lobectomy was associated with shorter length of stay (mean 8.1 vs. 10.7 days, P < 0.0001), chest tube duration (mean 4.0 vs. 4.8 days P < 0.0001) and lower intraoperative blood loss (median 100 vs. 200 ml P < 0.0001). There

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was no difference in thirty day mortality (2.3% vs. 2.2%) and time of surgery (mean 123.6 vs. 126.6 mins) between the groups. The total rate of postoperative complications after VATS was 29% (n 91), and 50% (n 128) after thoracotomy. When examining pulmonary complications, thoracotomy patients had markedly increased pulmonary complications compared with VATS patients (22.3% vs. 6.4%, P < 0.0001). The conclusion of the study was that VATS is associated with significantly lower risk of postoperative pulmonary complications.18 The conclusion of the study was that VATS is associated with significantly lower risk of postoperative pulmonary complications.

In another retrospective analysis conducted by China-Japan Friendship Hospital, 659 patients with postoperative stage I and IIA non-small cell lung cancer (NSCLC) underwent lobectomy from February 2008 to June 2012; 277 were performed by thoracotomy, 357 performed by VATS, and 25 performed by VATS converted to open (include in VATS group). Outcomes were analyzed to compare the incidence of significant bleeding.19

Chaoyang Lian. et.al., identified severe intraoperative complications in ten patients (6 in VATS, 4 in open), with no intraoperative deaths. The incidence of severe intraoperative complications was similar between the VATS group and the thoracotomy group (1.57% vs. 1.44%). Most severe intraoperative complications were related to the injury of major pulmonary vessels (9/10), and most of these complications occurred during upper lobectomy (8/10). There was no statistically significant difference in blood loss (242.85±220.47 vs. 240.43±144.36), and operative time (198.00±75.24 vs. 208.05±61.97) between the open and VATS groups, respectively, but blood loss and operative time were significantly different after elimination of conversion cases (214.34±151.85 vs. 240.43±144.36, P<0.01; 193.24±72.64 vs. 208.05±61.97, P<0.01).19

SUMMARyThe debate of whether open thoracotomy or VATS is the optimal surgical technique remains a clinical discussion amongst surgeons. The type of treatment that is right for the patient generally depends upon the progression of their condition, or the stage of the lung cancer and cell type. VATS has experienced major advances in equipment and technique, safety, decreased morbidity and for patients with early stage lung cancer where lobectomy is the treatment of choice, studies indicate that a resection by VATS is superior to an open procedure by thoracotomy. Conversely, advocates for the traditional procedure claim the open technique is oncologically superior and it remains the standard for more advanced disease.

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REFERENCES1. The Society of Thoracic Surgeons. What is a Thoracic Surgeon? http://www.sts.org/

patient-information/what-thoracic-surgeon. Accessed February 17, 2015.

2. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2011 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2014. Accessed February 26, 2015.

3. A Patient’s Guide to Lung Surgery. University of Southern California: Cardiothoracic Surgery. http://www.cts.usc.edu/lpg-thoracotomy-thethoracotomyprocedure.html. Accessed February 19, 2015.

4. Encyclopedia of Surgery. Thoracotomy. http://www.surgeryencyclopedia.com/St-Wr/Thoracotomy.html

5. Open Lobectomy. http://www.ethicon.com/healthcare-professionals/specialties/thoracic/procedures/open-lobectomy. Accessed February 2015.

6. Peter Gerner, M.D. Post-thoracotomy Pain Management Problems. Anesthesiol Clin. 2008 Jun; 26(2): 355–vii.doi: 10.1016/j.anclin.2008.01.007

7. Fischer GW, Cohen E. An update on anesthesia for thoracoscopic surgery. Curr Opin Anaesthesiol. 2010;23(1):7-11. doi:10.1097/ ACO.0b013e3283346c6d.

8. Brodsky JB, Cohen E. Video-assisted thoracoscopic surgery. Curr Opin Anaesthe-siol. 2000;13(1):41-45. doi:10.1097/00001503-200002000- 00007.

9. Loretta Kitabjian, et.al. Anesthesia Case Management for Video-Assisted Thoracoscopic Surgery. AANA Journal Course. http://www.aana.com/newsandjournal/Documents/jcourse6-0213-p65-72.pdf

10. de Hoyos A. Instruments and techniques of video-assisted thoracic surgery. In: Shields TW, Locicero J III, Reed CE, Feins RH. General Thoracic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:487-508.

11. Donahue JM, Smith MA, Battafarano RJ. Complications of thoracos- copy. In: Mulholland M, Doherty GM. Complications in Surgery. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:320-328.

12. A Patient’s Guide to Lung Surgery. University of Southern California: Cardiothoracic Surgery. http://www.cts.usc.edu/lpg-commonreasonsforlungsurgery.html

13. Souba W et al. ACS Surgery: Principles and Practice. Section 4. Ch 10: Video-assisted Thoracic Surgery. BC Decker Inc. 2008. 404-425.

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14. Henrik J. Hansen, René H. Petersen. A video-atlas of video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach. Annals of Cardiothoracic Surgery. Submitted Apr 06, 2012. Accepted for publication Apr 30, 2012. DOI: 10.3978/j.issn.2225-319X.2012.04.19

15. Operating room set-up for the anterior approach of video-assisted thorascopic lobectomy. Annals of Cardiothoracic Surgery. http://www.annalscts.com/article/view/481/614. Accessed February 2015.

16. Onaitis M, D’Amico T. Lung cancer: minimally invasive approaches. In: Sellke FW, del Nido PJ, Swanson SJ. Sabiston & Spencer’s Surgery of the Chest. 8th ed. Philadelphia, PA: Saunders Elsevier; 2010:279-286.

17. Imperatori A, Rotolo N, Gatti M, Antonini C, Dominioni L. The Complications of video-assisted thoracoscopic surgery (VATS). New Technologies in Surgery. 2009;1(1).http://www.newtechnologiesinsurgery.org/Surgery/Surgery.nsf/docCat?OpenForm&Start=1&Count=1000&ExpandView&Section=teleretina&Action=Papers&ActionSec=Articles&Language=EN&Cat=&uniiddoc=DF0D61455EB44C83C1257-5CD00685A2A. Accessed February 2015.

18. Cezary Piwkowski, et.al. Postoperative pulmonary complications after lobectomy: video-assisted thoracoscopic approach and thoracotomy. Interact CardioVasc Thorac Surg (2013) 17 (suppl 1): S29. doi: 10.1093/icvts/ivt288.110.

19. Chaoyang Lian, Huanshun Wen, Yongging Guo, Bin Shi, Yanchu Tian, Zhiyi Song, and Deruo Liu .Severe intraoperative complications during VATS Lobectomy compared with thoracotomy lobectomy for early stage non-small cell lung cancer. J Thorac Dis. 2013 Aug; 5(4): 513–517. doi: 10.3978/j.issn.2072-1439.2013.08.13

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GLOSSARyAtelectasis The permanent collapse of lung tissue.

Benign Non-cancerous (tumors or cysts).

Empyema Infection in the chest cavity.

Endobronchial ultrasound (EBUS) A technique that uses ultrasound along with bronchoscope to visualize airway wall and structures adjacent to it.

hemothorax Blood in the lungs.

Latissimus dorsi muscles One of the largest muscles in the back. The muscle is median dorsally located, and assists with force expiration as well as deep inspiration.

Mediastinoscopy A procedure that enables visualization of the contents of the mediastinum, usually for the purpose of obtaining a biopsy.

Minimally invasive surgery A procedure performed through tiny incisions instead of one large opening.

Non-small cell lung cancer Any epithelial lung cancer, other than small (NSCLC) cell lung cancer, that is relatively insensitive to chemotherapy.

One-lung ventilation (OLV) Mechanical separation of the two lungs to allow ventilation of just one lung, while the other lung is compressed by the surgeon or allowed to passively deflates.

Pleurodesis A procedure to treat a buildup of fluid in the chest cavity.

Positron emission tomography A specialized radiology procedure used to (PET) scan examine various body tissues to identify certain conditions.

Pulmonary embolism A blood clot in the lungs or pulmonary artery.

Pneumothorax Injury that causes the collapse of lung tissue.

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Serratus anterior muscles The muscle originating on the top surface of the eight or nine upper ribs. The function of the serratus anterior muscle is to allow the anteversion of the arm and to pull the scapula forward, coming around the thorax.

Thoracotomy A major surgical procedure that allows surgeons to open the chest to access the throat, lungs, heart, aorta and diaphragm during surgery.

Thorascope A thin, tube-like instrument that has a camera built into the end that allows the surgeon to see inside of the chest.

Video-Assisted Thoracic A surgical procedure where a tiny camera and Surgery (VATS) surgical instruments are inserted into your chest through several small incisions and transmits images of the inside of the chest onto a video monitor, guiding the surgeon in performing the procedure.

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