VATS is minimally invasive thoracic surgery that is used to diagnose or treat conditions of the chest (pulmonary, mediastinal, and pleural). It avoids a formal thoracotomy incision. VATS scores over thoracotomy in terms of significantly less postoperative pain, better pulmonary function, and less shoulder dysfunction.
VATS uses an access (or utility) incision that ranges from 2.5 to 8 cm in length and allows manipulation of multiple traditional or thoracoscopic instruments through the same incision at the same time. VATS can be performed with one (UNIPORTAL) or multiple chest incisions (0.5-1 cm each) (MULTIPORTAL)
Compared with laparoscopic surgery in the abdominal cavity, the thoracic cavity provides some challenges but also some advantages. The chest has a more rigid structure and does not routinely require insufflation. Avoiding insufflation allows the use of standard instruments or multiple low-profile tools through a single port, which can be an advantage.
VATS requires selective one-lung ventilation, which is achieved by placing a double-lumen endotracheal tube. Patients are placed in a lateral decubitus position with adequate cushioning.
VATS is facilitated by using a variety of thoracoscopes with lens angles from 0 to 45° for optimal visualization of the pleural and thoracic cavity. Thoracoscopes are available in different widths, including 2- (needlescope), 3-, 5-, 8-, and 10-mm diameters, and are able to provide high-definition resolution and project enough illumination for excellent visualization, resolution, and magnification. Typically, at a minimum, two monitors are used, one on each side of the table for the facing surgeon and assistant to view.
For multiportal, true thoracoscopic procedures, traditional laparoscopic instruments are used. However, many surgeons perform unilateral VATS, wherein a small utility incision is made, and after placing a wound protector, specialized VATS instruments are used, which are similar to open instruments but are longer, curved, and have double action mechanisms. For stapling of the lung, vessels, or bronchus, articulating endostaplers similar to those used for laparoscopy are used. Energy devices like Harmonic and vessel sealant devices are used for dissection along with traditional monopolar and bipolar cautery.
Complications are similar to any open thoracotomy. Bleeding from major vessels may be catastrophic, as there is very little time to perform a thoracotomy to control bleed.
Robotic-assisted thoracic surgery (RATS) uses computers to aid surgeon instrument control. Articulated instruments with a stable platform and 4 robotic arms controlled by the surgeon offer unique advantages for RATS over VATS
These are:
However, the higher cost of robotic surgery, the need for a skilled bedside assistant, and the lack of tactile haptic feedback may be deterrents for some.
Large database and retrospective analysis studies have shown that the oncological outcomes of VATS lobectomies are not inferior to open thoracotomies. However, postoperative functional outcomes like length of hospital stay, less prolonged pain, and faster recovery of physical function are better with VATS. Similarly, with regards to minimally invasive esophagectomy, one RCT and multiple retrospective studies have shown that postoperative complications (especially pulmonary) are significantly less with VATS.
The author reports a total personal experience of 61 major VATS procedures, including 27 esophagectomies, 16 mediastinal tumor resections, 5 lobectomies, 4 wedge resections, 2 mediastinal node excisions, 2 bullectomies, 5 decortications, and 3 chyle duct ligations. Conversion to open surgery was required in the case of 2 lung resections, one mediastinal cyst, and one attempted chyle duct repair (due to extensive adhesions). Only one major post-operative morbidity was recorded (anastamotic leak post-esophagectomy leading to sepsis, which required prolonged ICU and hospital stay)
There are very few dedicated thoracic surgery units in the country. Centers specializing in MIS lung cancer resections are even less. This is a niche area where there is potential for both oncosurgeons and thoracic surgeons to specialize. In fact, in many centers, oncosurgeons are performing VATS procedures for benign conditions as well.
Mediastinal Schwannoma resected through VATS. Small incision for specimen retrieval
VATS left lower lobectomy: lung hilum being dissected and Left lower lobe vessels being stapled; specimen retrieval through small utility incision, patient seen on POD 2, full lung expansion on Chest X-ray on Day 2
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