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Video Assisted Thoracic Surgery (VATS)

Role in Pulmonary Medicine.

Dr L.M.Darlong.MS(AIIMS)

Fellow Thoracic Surg (KUMC Seoul)

. Key Words: Video Assisted Thoracic Surgery (VATS), Thoracoscopy,

Minimal access Surgery.

Introduction;

Medicine is both science and art and sometimes there are more than one way to solve the problem. Ever since the evolution of the endoscopy the medical profession has tried to

duplicate and perform surgical skills which had been done in the traditional open waysand thus reduce the suffering of the patients. In pulmonary medicine and thoracic surgery

this has resulted in the evolution of various techniques as we know today as medical

thoracoscopy, Video assisted thoracic surgery (VATS) minimal access surgery. This is

unlike the open thoracic surgery where for any procedure ranging from diagnostic totherapeutic a liberal skin incision had to be given across the chest wall between the ribs

and the ribs spread apart for access to organ site and not to forget the associated

postoperative morbidity, pain and ugly scar. (Fig 1, 2).

Medical thoracoscopy which was first practiced by jacobeus way back in 1913 for the

treatment of pulmonary Koch when he introduced the cystoscope into the pleural cavityto lyse adhesion for facilitating pneumothorax is done under local anesthesia withsedation. 1 Medical thoracoscopy is mainly used as a diagnostic tool for the disease of

pleura.

This is unlike VATS which is a minimal access procedure which is done under generalanaesthesia for diagnostic as well as therapeutic indications. The therapeutic indication of

VATS has not limited itself to the disease of lung pleura and mediastinum but is also

being increasingly used for dorsal spine, esophagus and cardiac surgery since the

development of better video and endoscopic imaging system along with endostapplingdevices since the 1990s. Ever since the introduction of endoscopic surgery the dictum

“big surgeons big incision” is slowly giving way to “no scopy no scope” with a limited

small incision.



Fig 1 Thoracotomy wound

Fig 2. VATS wound

Indications of Video assisted thoracic surgery:

The various indications of VATS can be briefly classified as Diagnostic and Therapeutic.VATS has been mainly utilized by thoracic surgeons for pulmonary and mediastinal

diseases however it has also been used for disorders of the spine by spine surgeons and ina few centres for cardiac surgery. The various indications of VATS are shown in table 1.



Table 1.

LUNG

PARENCHYMA

PLEURA MEDIASTINUM ESOPHAGUS

/SPINE

Biopsy Biopsy Lymph node biopsy Benign tumor

Bulla/bleb excision Drainage Cyst/mass excision Myotomy

Wedge ressection /

Metastatectomy

Pleurectomy Sympathectomy Diverticulectomy

Segmentectomy Pleurodesis Thymectomy Esophagectomy

Lobectomy Decortication PDA ligation Spine abcess

drainage / Fixation

Pneumonectomy Drain empyema Pericardial window

VATS Procedure:The VATS procedure is basically an access procedure with all the surgical techniquesremaining the same as in open surgery and only the access route being smaller and

operative field viewed on a monitor. The procedure is done under General anesthesia in

the lateral decubitis , supine or prone position based on the area of interest. A doublelumen tube endotracheal tube is required so as to collapse the ipsilateral lung on the area

of interest and thus provide a working space for instrumentation and coduct of surgery.

Some centres use CO2 insufflation to achieve pneumothorax on the side of surgery to

obtain working space with the disadvantage of possible air leak during instrument

withdrawl and loss of space and the need for specific endoscopic instruments. However in our center the preferred approach is to collapse the ipsilateral lung with a double lumen

endotracheal tube (Fig 3). This is crucial as most of the instruments used are long versionof open surgical instruments (Fig 4) like sponge holding forceps ,long scissors,

disposable suctioncannula etc. It is always necessary to have a set of open thoracotomy

instruments aside in case of the need for conversion to open thoracotomy.



As in any procedure VATS also has its contraindication. The only absolute

contraindication 2 is the patients inability to tolerate single lung ventilation and

hemodynamic instability. The other relative contraindications are :1. Pleural symphysis.

2. Previous history of thoracotomy.

3. Tumor beyond a certain size or stage.

Fig 3. Double lumen tube with tube insitu at trachea and left main bronchus.

Fig 4. Instruments used in VATS.

Diagnostic indications in pulmonogy:



PLEURAL DISEASE

For pleural effusions, thoracentesis is the first line of management. A biochemical,

cytological and microbiological analysis of fluid is done and further studies depending onwhether the fluid is an exudate or a transudate. Exudates can be infectious and non-

infectious and require further investigation. A combination of thoracoscopy and lung

//pleural

biopsy usually reaches the final diagnosis where others have failed. Malignant pleural effusions, primary or metastatic, are particularly suited for diagnosis by

thoracoscopy, as the disease is focal rather than uniform and blind biopsies tend to have a

low yield.3-5

INTERSTITIAL LUNG DISEASE

Despite diagnostic efforts by sputum analysis, bronchoscopy, bronchoalveolar lavage,

and transbronchial biopsy, some parenchymal infiltrates remain idiopathic. In suchinstances surgical biopsy is indicated, the thoracoscopic approach being generally

superior to the open techniques.4-6

PULMONARY NODULESSolitary pulmonary nodules can be malignant in up to a third of cases and tissue

diagnosis is therefore a mandatory end point. Percutaneous biopsy aided by variouslocalisation techniques still produces a too high rate of false negative results. The data of

Calhoun et al showed that after a fine needle percutaneous biopsy a specific diagnosis of

benignity is reached in less than 5% of cases.7 It follows logically that surgical excision is

a safer option, with thoracoscopy ideally suited for nodules in the outer third of the parenchyma. Nodules that appear to be seated deeper in the parenchyma on imaging can

actually be very close to the surface in a fissure and these too are readily accessible. 8 In

cases where frozen section histology of a thoracoscopically extracted specimen confirmsmalignancy, the surgeon can proceed to excision via thoracoscopy or thoracotomy.

MEDIASTINAL MASSESlymph node mass in the Paratracheal and subcarinal areas are accessible by cervical

mediastinoscopy, however masses and lymph nodes situated in the aortopulmonary

window and pulmonary hila are not accessible by mediastinoscopy and anterior mediastinotomy (the Chamberlain procedure) was the standard in such cases. VATS has

made this areas accessible and is superior to mediastinotomy, in that it is less invasive and

provides access to other areas too, such as the posterior mediastinum. Routine

prethoracotomy mediastinal exploration with thoracoscopy in patients with confirmedlung cancer is advocated by some groups, especially if multifocal lesions are suspected or

to assess invasion of chest wall or other adjacent structures. This policy reduces the

number of "open and close" thoracotomies to a minimum.8

Therapeutic procedures in pulmonology:

PLEURAL DISEASE

Benign effusions usually disappear when the underlying disease is successfully dealt

with. Malignant effusions are by definition associated with unresectable disease (T4 inthe tumour, node, metastases (TNM) classification). If the lung retains the capacity to re-

http://pmj.bmj.com/cgi/content/full/76/899/547#B5%23B5










expand, tube thoracostomy and chemical pleurodesis with tetracycline / Talc can be

sufficient. If the diagnosis is established by thoracoscopy, additional options include

mechanical abrasion, instillation of talc or other sclerosants, and pleurectomy.4 Themagnitude of the latter makes it unsuitable for this group of debilitated patients. In more

advanced disease the effusion recurs or the lung becomes trapped. The same measures of

tube

thoracostomy, or thoracoscopy in better risk cases, can be reapplied

but the chancesof success are less as the disease progresses.

VATS is most useful in the intermediate phase of empyema, before the lung is encased in

a thick fibrous peel that would require decortication.9 In this fibropurulent phase tubedrainage is unsuccessful if loculations are present, and thoracoscopic drainage and

decortication is indicated. (Fig 5,6)

Fig 5 Thickened pleura in VATS Decortication.

Fig 6 Fibrinopurulent phase with loculation.







BULLOUS LUNG DISEASE

Primary spontaneous pneumothorax occurs in patients without underlying lung disease. Itis caused usually by rupture of an apical bleb in a young adult. Spontaneous secondary

pneumothorax occurs in a different age group; the patients have underlying pulmonary

pathology, the most common being emphysematous bullae.

Removal of blebs and bullaecan be achieved thoracoscopically with endoloops or endostaples. (Fig 7,8) The

advantage over the formal thoracotomy is that there is better view, an apical pleurectomy

or mechanical abrasion is easily performed and the surgical indication can be extended toa number of patients that are not fit enough for an open procedure.10,11 Lung volume

reduction surgery by excision of giant bullae can be performed in carefully selected cases

with good results.12,13

Fig 7 Apical bulla Fig 8 Stapled bullectomy









LUNG RESECTION

The principal roles of VATS in lung cancer are diagnosis of the indeterminate pulmonary

nodule, staging of the pleura and mediastinum, wedge resection of early tumours indebilitated patients, lobectomy/pneumonectomy, and treatment of malignant pleural

effusion.14

Some of the above indications have already been discussed. The data from the LungCancer Study Group showed that for stage I lung cancer there is no survival benefit of

lobectomy over non-anatomical wedge resection.15 However, there is a significantly

higher rate of local recurrence after wedge resection, so this procedure is reserved for patients who are too debilitated to tolerate a formal oncological resection. Resection of

solitary metastases is a good indication for VATS, but excision of multiple metastases as,

for example, those of osteogenic sarcoma is best accomplished via a conventional

thoracotomy that allows palpatory detection of small nodules.Lobectomy and pneumonectomy can now be performed thoracoscopically, with the

possibility of excising the ipsilateral lymph notes as necessary. Ideally the tumour should

be small, located peripherally, preferentially in the lower lobes.14 It cannot be

overemphasised that there should be no compromise

in the extent of resection by theminimal access route and a conversion to thoracotomy should be considered sound

judgment and not failure of VATS in case adequate clearance of tumour and lymph nodescannot be achieved.14

MEDIASTINUM

It has already been mentioned that VATS is complementary to cervical mediastinoscopyin assessing lymphadenopathy in the mediastinum. Mediastinal masses can be removed

thoracoscopically from different locations in the mediastinum.16 Likewise, thymic

tumours can be excised thoracoscopically,

Conclusion:

The advantage of VATS over thoracotomy lies in the reduction of both acute and chronic

postoperative pain with improved chest physiotherapy and recovery, together with earlier return to normal activity and better cosmesis. (Fig 9,10) In terms of costs, VATS is

expensive but several studies demonstrated a reduced high dependency and hospital stay

which probably neutralise the expense.17 Table 2 shows a comparative chart of thenormally asked questions when comparing VATS with Thoracotomy. Adequate exposure

and a long learning curve is essential before performing on complex procedures. The

complications of thoracoscopy are by and large related to the surgical complications of the treated condition and are similar to those that follow conventional open operations.

The necessity to convert

a thoracoscopic procedure to an open one usually arises fromone of the following: significant adhesions, uncontrollable bleeding, inadequate view,inability to obtain single lung ventilation, removal of large lesions, and inability to

perform an adequate excision.2Conversion thus should be taken as a wise decision and

not a failure as the ultimate aim is a completion of the procedure with no mortality and

minimal morbidity.It can be seen from this overview that most thoracic operations can betackled in this day and age thoracoscopically. The available studies suggest that simple

parenchymal sampling, wedge resection, and pneumothorax surgery are best performed





















thoracoscopically. Selected cases of lung volume reduction are also suitable for VATS.

More controversial is the role of VATS in cancer resection, but the minimal access route

and conventional techniques should be seen as complimentary and not opposed. Theminimal access approach is best reserved for peripheral early tumours, while the more

advanced and central lesions will be managed by open resection. The debate over patient

outcomes and cost effectiveness will

continue until the practice becomes morestandardized and thoracoscopic surgery widely accessible.

Table 2 18

Questions VATS ThoracotomySize of incision 1 inch 10-14 inch

Average hospital stay 2 days 10-12 days

Return to work 7-10 days 6-8 weeks

Fig 9 VATS scar.



Fig 10 Open thoracotomy scar.

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spontaneous pneumothorax. Thorax 1997;52:307-308

12. Menconi GF, Melfi FM, Mussi A, et al . Treatment by VATS of giant bullous

emphysema: results. Eur J Cardiothorac Surg 1998;13:66-70.



13. Weder W, Schmid RA, Russi EW. Thoracoscopic lung volume reduction surgery

for emphysema. Int Surg 1996;81:229-23420.

14. Landreneau RJ, Mack MJ, Dowling RD, et al . The role of thoracoscopy in lung

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