Faaiez VATS

Post Graduate Department of Surgery, GMC Srinagar
Video assisted thoracic surgery

Overview and General Principles
Mohammad Faaiez Farooq Dr. Hashmat S. Rather Preceptor: Prof Dr. Iqbal Saleem
Introduction:
Video-assisted thoracoscopic surgery

(VATS) is a set of minimally invasive
thoracic surgical (MITS) procedures
used to diagnose or treat conditions
of the chest (pulmonary,
mediastinal, chest wall). 1
Advantages:
• Like Laproscopy in abdominal
surgeries, VATS eliminates the
need for thoracotomy that
requires:
Figure 1
1. Spreading of the ribs (fig. 1)
2. Sternotomy incisions (fig. 2).2-6
• Smaller incision
• Less postoperative pain
• Fewer complications
• Larger picture
• Shorter hospitalization time compared with thoracotomy. Figure 2
Disadvantages:
Some disadvantages of VATS are:

• Less surgical space
• Incomplete lymph node dissection.
• Higher surgical skills required
Indications:
• Diagnostic thoracoscopy:
1. Pleuroscopy/Medical thoracoscopy
2. visually inspect the structures of the chest
3. To obtain fluid
4. Tissue for histologic examination or cultures
5. Pleural biopsy
• Therapeutic MITS:
A. Pulmonary resection
B. Pleural disease/chest cavity
C. Diaphragm surgery
D. Chest wall surgery Incision sites

E. Others—Heart, spine surgeries
Stats and Facts:
32.7%
of all the lobectomies were
done by MITS
26% only 6.7% only

Of which were VATS for lung Were RATS
lobectomy of all lobectomies lobectomy.10
Reference:
1) Yang CF, Sun Z, Speicher PJ, et al. Use and
Outcomes of Minimally Invasive Lobectomy for
Stage I Non-Small Cell Lung Cancer in the National
Cancer Data Base. Ann Thorac Surg 2016; 101:1037.
A later report showed that general adoption of MITS for
lobectomy was highly dependent on surgeon specialty
(general thoracic surgeon highest), location, and case density
of the surgeon (>15 per year). 11
GENERAL PRINCIPLES OF VATS
1) Patient positioning 2) Incisions 3) Insufflation
Patient positioning:
• Patient positioning- Patient positioning is
generally in the lateral decubitus position
with the operative side up, although
positioning is influenced by the surgical
indication (eg, supine for some
mediastinal operations, prone positioning
preferred by some surgeons for thoracic
portion of esophagectomy). 11
Incision:
• The "dissection" or "access" port is placed in the 4th or 5th intercostal space
anteriorly since the intercostal spaces are wider in this area.
• The "camera" port is placed in the midaxillary line 8th intercostal space,
and the "retraction" port is placed in-line with the major fissure lateral to the
insertion of the diaphragm to the chest wall.
• Primary access or utility incision (2.5cm-8cm), Additional incisions (0.3cm-
1.5cm) and total thoracoscopy incision(.5cm-2cm). 12-14
Insufflation:
• Some procedures are benefited by insufflation while in others it is not
required.
• Situations where CO2 insufflation is helpful are when there is significant
emphysema with suboptimal lung deflation, anterior mediastinal
procedures, relatively elevated unilateral hemidiaphragm, and inability
or desire not to attain selective lung ventilation.
• If CO2 insufflation is used, different trocars with airtight seals will be
necessary. 12-14
VATS PROCEDURES
All procedures traditionally performed as open procedures can be performed using video assistance.
• Mediastinal lymph node biopsy

• Excision of mediastinal masses
• Chest drainage/pleurectomy
• Pulmonary resection (Anatomical and non-anatomical)
• Lung volume reduction surgery
• Sympathectomy
Patient selection:
• Pulmonary function tests, including spirometry, lung volume measurements, and

quantification of diffusing capacity, are performed preoperatively to identify high-risk
patients who may not tolerate one-lung ventilation, which is necessary for most MITS
procedures
• A complete blood count may reveal polycythemia due to pulmonary diseases or an elevated
white cell count suggestive of infection or inflammation. Chest x-ray and CT scan provide
relevant anatomical details required for the relevant procedure.
• Arterial blood gases may help identify patients at increased risk of postoperative
complications. Patients with PaCO2 greater than 50 mmHg or PaO2 less than 60 mmHg
are vulnerable.
• Preoperative optimization of patients undergoing VATS may also include smoking
cessation, treatment of underlying infections and pulmonary rehabilitation.
Video assisted thoracic surgery for resection of giant bulla
Source: https://youtu.be/oe2N7s2WE6c
More about minimal invasive thoracic surgeries:
Robotic-assisted thoracic surgery, a related technology to VATS, uses

computers to aid surgeon instrument control. The essential difference between
VATS and RATS is that with VATS, the surgeon holds the instruments, whereas
with RATS, the surgeon controls the instruments from the console and does not
directly handle the instruments but does directly control all aspects of the
instruments' movement. 4
RATS:
Video obviously not mine: da-Vinci surgical system
References:
1. Bravo Iñiguez CE, Armstrong KW, Cooper Z, et al. Thirty-Day Mortality After Lobectomy in Elderly Patients Eligible for Lung Cancer Screening. Ann Thorac Surg 2016; 101:541.
2. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg 2012; 256:487.
3. Fernandez FG, Kosinski AS, Burfeind W, et al. The Society of Thoracic Surgeons Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes. Ann Thorac Surg 2016; 102:370.
4. Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009; 138:419.
5. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;
139:366.
6. Agzarian J, Fahim C, Shargall Y, et al. The Use of Robotic-Assisted Thoracic Surgery for Lung Resection: A Comprehensive Systematic Review. Semin Thorac Cardiovasc Surg 2016; 28:182.
7. Fukuda N, Shichinohe T, Ebihara Y, et al. Thoracoscopic Esophagectomy in the Prone Position Versus the Lateral Position (Hand-assisted Thoracoscopic Surgery): A Retrospective Cohort Study of 127
Consecutive Esophageal Cancer Patients. Surg Laparosc Endosc Percutan Tech 2017; 27:179.
8. Tacconi F, Ambrogi V, Pompeo E, et al. Substernal hand-assisted videothoracoscopic lung metastasectomy: Long term results in a selected patient cohort. Thorac Cancer 2011; 2:45.
9. Hao L, Long J, YongBin L, et al. Hand-assisted thoracoscopic surgery for pulmonary metastasectomy through sternocostal triangle access: superiority in detection of non-imaged pulmonary nodules. Sci Rep
2014; 4:4539.
10. Blasberg JD, Seder CW, Leverson G, et al. Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: Current Practice Patterns and Predictors of Adoption. Ann Thorac Surg 2016; 102:1854.
11. Gonzalez-Rivas D, Fieira E, Delgado M, et al. Evolving from conventional video-assisted thoracoscopic lobectomy to uniportal: the story behind the evolution. J Thorac Dis 2014; 6:S599.
12. Carvalheiro C, Gallego-Poveda J, Gonzalez-Rivas D, Cruz J. Uniportal VATS Lobectomy: Subxiphoid Approach. Rev Port Cir Cardiotorac Vasc 2017; 24:141.
13. Shen Y, Zhang Y, Sun J, et al. Transaxillary uniportal video assisted thoracoscopic surgery for right upper lobectomy. J Thorac Dis 2018; 10:E214.
14. Ko HJ, Chiang XH, Yang SM, Yang MC. Needlescopic-assisted thoracoscopic pulmonary anatomical lobectomy and segmentectomy for lung cancer: a bridge between multiportal and uniportal thoracoscopic
surgery. Surg Today 2019; 49:49.
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Post Graduate Department of Surgery, GMC Srinagar

Video assisted thoracic surgery

Video-assisted thoracoscopic surgery

1. Spreading of the ribs (fig. 1)

2. Sternotomy incisions (fig. 2).2-6

Some disadvantages of VATS are:

2. visually inspect the structures of the chest

4. Tissue for histologic examination or cultures

B. Pleural disease/chest cavity

D. Chest wall surgery Incision sites

26% only 6.7% only

• Mediastinal lymph node biopsy

• Pulmonary function tests, including spirometry, lung volume measurements, and

Robotic-assisted thoracic surgery, a related technology to VATS, uses

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