Video-assisted thoracoscopic surgery (VATS )Video-assisted thoracoscopic surgery (VATS )

Dr . Ahmed AlazzawiDr . Ahmed AlazzawiCardioThoracic&Vascular surgeonCardioThoracic&Vascular surgeonSulaimani University,College of MedicineSulaimani University,College of MedicineM.B.Ch.B,F.I.C.M.S,C.TH.V SurgM.B.Ch.B,F.I.C.M.S,C.TH.V Surg

Video-assisted thoracoscopic surgery (VATS)

• Video-assisted thoracoscopic surgery is a minimally invasive surgical procedure used to diagnose and treat illness or injury to the lung and other organs in the chest cavity (thorax).

• History• Thoracoscopy was developed by Hans Christian

Jacobaeus, a Swedish internist in 1910 for the treatment of tuberculous intra-thoracic adhesions. He used a cystoscope to examine the thoracic cavity, developing his technique over the next twenty years. Today, thoracoscopy is performed using specialized thoracoscopes. These instruments include a light source and a lens for viewing and may have ports through which other instruments may be inserted for the purpose of tissue removal and manipulation.

The 1970s heralded a renewal of interest in this methodology The 1970s heralded a renewal of interest in this methodology that occurred with the refinement of bronchoscope technology. that occurred with the refinement of bronchoscope technology. A decade later, the first international symposium about A decade later, the first international symposium about thoracoscopy was held and the mediastinoscope had emerged thoracoscopy was held and the mediastinoscope had emerged as a popular tool for this practice because of its shorter length as a popular tool for this practice because of its shorter length and accompanying useful instruments. In the late 1980s and accompanying useful instruments. In the late 1980s laparoscopy evolved from a largely gynecological discipline to laparoscopy evolved from a largely gynecological discipline to the preferred method by which cholecystectomies and other the preferred method by which cholecystectomies and other general surgical operations were accomplished. This general surgical operations were accomplished. This revolution took a while to start but exploded in popularity and revolution took a while to start but exploded in popularity and soon there were multiple video systems in every operating soon there were multiple video systems in every operating room. Thoracic surgeons began to borrow these tools and room. Thoracic surgeons began to borrow these tools and applied them to simple diagnostic and therapeutic procedures. applied them to simple diagnostic and therapeutic procedures.

In 1990, the term VATS was coined to differentiate it In 1990, the term VATS was coined to differentiate it from the older direct viewing technology that limited from the older direct viewing technology that limited the involvement of first assistants. The eponym was the involvement of first assistants. The eponym was also invented to incorporate the word “Surgery” to also invented to incorporate the word “Surgery” to emphasize the need for those who practice it to have emphasize the need for those who practice it to have sufficient skill to handle the operations and any sufficient skill to handle the operations and any resulting complications using traditional open resulting complications using traditional open techniques. In the past decade VATS has become the techniques. In the past decade VATS has become the standard of care for many operations like lung and standard of care for many operations like lung and pleural biopsy. It has also been tried for more pleural biopsy. It has also been tried for more complex procedures with variable success and complex procedures with variable success and resulting refinement of the indications for its resulting refinement of the indications for its application. application.

• Port Placement

• Ports are generally placed in the middle, anterior, and posterior axillary lines

The middle is usually placed through the seventh or eighth The middle is usually placed through the seventh or eighth intercostal space although the skin incision can be one or intercostal space although the skin incision can be one or two cm lower than the rib in thin patients. two cm lower than the rib in thin patients.

The anterior and posterior ports are usually placed near their The anterior and posterior ports are usually placed near their respective axillary lines. Planning for a possible respective axillary lines. Planning for a possible thoracotomy, the incisions are made so that they can be thoracotomy, the incisions are made so that they can be connected later if necessary. Since these incisions will be connected later if necessary. Since these incisions will be closed at the completion of the operation, there is no closed at the completion of the operation, there is no advantage to creating a ‘tunnel’. Safety of thoracic advantage to creating a ‘tunnel’. Safety of thoracic penetration and port placement is guided by viewing these penetration and port placement is guided by viewing these moves internally throughmoves internally through

the camera that has been placed through the middle port. the camera that has been placed through the middle port.

The great advantage of VATS over sternotomy or thoracotomy is avoidance of muscle division and bone fractures that allows for diminished duration and intensity of pain and a shorter time to return to full activity.

VATS came into widespread use beginning in the VATS came into widespread use beginning in the early 1990s. Operations that traditionally were carried early 1990s. Operations that traditionally were carried out with thoracotomy or sternotomy that today can be out with thoracotomy or sternotomy that today can be performed with VATS include: biopsy for diagnosis performed with VATS include: biopsy for diagnosis of pulmonary, pleural or mediastinal pathology; of pulmonary, pleural or mediastinal pathology; decortication for empyema; pleurodesis for recurrent decortication for empyema; pleurodesis for recurrent pleural effusions or spontaneous pneumothorax; pleural effusions or spontaneous pneumothorax; surgical stapler assisted wedge resection of lung surgical stapler assisted wedge resection of lung masses; resection of mediastinal or pleural masses; masses; resection of mediastinal or pleural masses; thoracic sympathectomy for hyperhidrosis; operations thoracic sympathectomy for hyperhidrosis; operations for diaphragmatic hernias or paralysis; esophageal for diaphragmatic hernias or paralysis; esophageal resection or resection of esophageal masses or resection or resection of esophageal masses or diverticula; and VATS lobectomy/mediastinal diverticula; and VATS lobectomy/mediastinal lymphadenectomy for lung cancer. lymphadenectomy for lung cancer.

Indications for VATS Indications for VATS • Diagnosis of indeterminate masses and pleural Diagnosis of indeterminate masses and pleural

effusions effusions • Drainage of pleural effusions empyema and Drainage of pleural effusions empyema and

hemothorax hemothorax • Bullectomy, Belb resection and Pleurodesis Bullectomy, Belb resection and Pleurodesis • Biopsy of lymph nodes and mediastinal masses Biopsy of lymph nodes and mediastinal masses • Pericardial window Pericardial window • Thoracodorsal sympathectomy Thoracodorsal sympathectomy • Thymectomy Thymectomy • Lung resections Lung resections • Esophageal Procedures Esophageal Procedures • Spinal SurgerySpinal Surgery

Contraindications for VATS Contraindications for VATS Inability to tolerate single lung ventilation Inability to tolerate single lung ventilation T3 tumor or Established N2 disease T3 tumor or Established N2 disease Pleural symphysisPleural symphysis

Therapeutic proceduresTherapeutic procedures

Solitary Pulmonary Nodule. • Management of solitary nodule is one of the great dilemmas of

thoracic surgery. It is known that most of these nodules are benign, considering for all ages. However, there is a considerable likelihood that an isolated nodule may be a malignant lesion at an early stage. VATS has significantly aided in the treatment of patients with such lesions. Pulmonary nodules of up to 3 or 4 cm diameter, located on the periphery of the lung (on the peripheric third) may be safely resected . Resection of the nodule may be safely performed, or atypical segmentectomy (subsegmentectomy). Anatomo-pathological examination by frozen sections may possibly determine the extent of the procedure

Recurrent Pneumothorax Spontaneous pneumothorax is mainly associated to

subpleural blebs, usually in the apex of the upper lobes or the apical segments of the lower lobes. Spontaneous primary pneumothorax generally affects young subjects and is often a recurring disease. Surgical treatment has been indicated for bilateral and recurrent pneumothorax, and even for first episodes in patients with a pleural chest tube and persistent air leakage. VATS allows surgical management of the blebs by various techniques, including cauterization with a Yag:Nd laser, ligature at the base of the bulla, or excision with mechanical suture. Besides the proper treatment of the blebs, it can be used in conjunction with a method to increase pleural adhesion, ranging from mechanical abrasion, chemical pleurodesis or resection of the parietal pleura in the apical region

Pleural Effusions Pleural biopsy with a needle has enabled most pleural

effusions to be diagnosed. Some cases, however, remain undiagnosed after two or more inconclusive biopsies. VATS not only allows a complete inspection of the pleural cavity to be performed, but also the carrying out of pleural biopsies with good specimens under direct view of suspect areas and immediate assessment by the pathologist. Different pieces of material from different sites can be sent to the pathologist. The quantity of material obtained under direct view makes thorough laboratorial assessment possible, with special stain,

Mediastinal TumorsMediastinal Tumors VATS allows biopsy, and complete resection, of VATS allows biopsy, and complete resection, of

almost all tumor massae of the mediastinum to be almost all tumor massae of the mediastinum to be performed. Most cystic massae, such as pericardiac performed. Most cystic massae, such as pericardiac cysts, bronchogenic cysts, thymic cysts and enteral cysts, bronchogenic cysts, thymic cysts and enteral cysts, can be suitably treated by videothoracoscopy. cysts, can be suitably treated by videothoracoscopy. Some solid, mainly posterior, tumors of nervous Some solid, mainly posterior, tumors of nervous origin such as neurinomas and Schwannomas can be origin such as neurinomas and Schwannomas can be totally resected by VATS. Use of thoracoscopy in totally resected by VATS. Use of thoracoscopy in thymectomy as a part of the treatment of myasthenia thymectomy as a part of the treatment of myasthenia gravis has been reported by several centers, although gravis has been reported by several centers, although there is concern as to whether fragments of the there is concern as to whether fragments of the thymus not viewed in the video assisted operation thymus not viewed in the video assisted operation remain remain

► Mediastinal Lymph nodesMediastinal Lymph nodes ► VATS can be used for staging mediastinal lymph VATS can be used for staging mediastinal lymph

ganglia to replace Chamberlain’s mediastinotomy. ganglia to replace Chamberlain’s mediastinotomy. In the open operation (mediastinotomy) there is In the open operation (mediastinotomy) there is little exposure, although palpation of the lymph little exposure, although palpation of the lymph nodes is easy. Whereas in VATS, with suitably nodes is easy. Whereas in VATS, with suitably placed "ports", full and unrestricted vision of the placed "ports", full and unrestricted vision of the various mediastinal ganglia is allowed without various mediastinal ganglia is allowed without palpation. This exposure facilitates palpation. This exposure facilitates oncopathological study of the mediastinal oncopathological study of the mediastinal extension of both primary and secondary tumors, extension of both primary and secondary tumors, as well as their local extension, and local and as well as their local extension, and local and regional metastases, in the upper and lower regional metastases, in the upper and lower lymphonodal groups, trachaeobronchial tumors, lymphonodal groups, trachaeobronchial tumors, the aortopulmonary window, and so on.the aortopulmonary window, and so on.

Pericardiac Effusion, PericarditisPericardiac Effusion, Pericarditis VATS allows excellent access to the VATS allows excellent access to the

pericardium. Given correct positioning of the pericardium. Given correct positioning of the orifices, it is possible to perform pericardiac orifices, it is possible to perform pericardiac drainage or make a pleuro-pericardiac drainage or make a pleuro-pericardiac window. Drainage, pericardiac biopsies, and window. Drainage, pericardiac biopsies, and treatment of inflammatory or metastatic treatment of inflammatory or metastatic cardiac tamponade are all possible. A large cardiac tamponade are all possible. A large portion of the parietal pericardium can be portion of the parietal pericardium can be removed thoracoscopically. This resection is removed thoracoscopically. This resection is more easily performed through the right more easily performed through the right hemithorax, although it can also be carried hemithorax, although it can also be carried out on the left side, in which prepericardiac out on the left side, in which prepericardiac fat is more abundant. The pleuro pericardiac fat is more abundant. The pleuro pericardiac window is a strategy offering several window is a strategy offering several advantages over pericardiac drainage via advantages over pericardiac drainage via the subxiphoid route. the subxiphoid route.

Cervical Sympathectomy • Resection of the cervico-thoracic sympathetic chain has been

performed by VATS in several services. Cervico-dorsal sympathectomy by thoracoscopic video has provided a less surgically aggressive treatment of several diseases. It is principally indicated in: hyperhidrosis, Raynaud’s phenomenon, Raynaud’s disease, causalgia, sympathetic reflex dystrophy, and upper limb arterial insufficiency. This operation performed through a VATS approach has several advantages over the open operation. It’s usually very easy to dissect the sympathetic chain in the exact amount needed, always under a very clear, direct vision. It is not difficult to fully identify the stellate ganglion, and ivy's upper two thirds can be spared, avoinding the postoperative Claude Bernard Horner Syndrome, quite usual when the open approch is used and easilly avoidable when a thoracoscopically approach is used. The VATS cervical sympathectomy is a really straighforward operation and operative indications seems to be increasing..

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