Videoassisted thorascopic surgery

Video-assisted thorascopic surgery (VATS) has the advantage of avoiding the necessity to spread the ribs, which reduces postoperative neuralgia and muscle damage. The patient is placed in the lateral position with a double-lumen tube and two or more ports introduced after collapsing the lung. The first port is generally introduced in the mid-axillary line at the sixth or lower interspace after carefully passing a finger into the chest to make sure there are no pleural adhesions. The other ports are then introduced under vision and placed in an arc pointing to the expected pathology so that the surgeon is working forwards and instrument clash is prevented (Fig. 18.10).

Vision is obtained using a telescope to which a video camera is attached and this allows everyone in the operating theatre to observe the operation. Although a superb view of the intrathoracic organs is obtained, the downside is that tactile ability is lost. Practically every intrathoracic procedure can be done using a video-assisted thoracoscopic approach.

Figure 18.10. Placement of ports in an arc for video-assisted thoracoscopic.

There are some procedures for which this approach is the method of choice and these include management of:

• spontaneous pneumothorax,

• malignant pleural effusion,

• pleural biopsies,

• pleural-based lesions,

• excisional biopsy of peripheral nodules in the lung.

This approach can also be used for pulmonary resections particularly if the mass lesion in the lobe is less than 3 cm in diameter. Quite apart from patient satisfaction with faster recovery and less post operative neuralgia, there have been studies to show that the immune response for malignancy is better preserved in these patients because of the lessened trauma of operation.

One drawback of a VATS approach is the inability to palpate the lung either to localize the lesions or for detection of all lesions when secondary tumours are being resected. Ultrasound probes are helpful but can be difficult to interpret. A simple approach is to pass the hand up from below through the diaphragm from a subcostal incision, hand-assisted tho-racoscopic surgery (HATS). The fingers pass between the radial fibres of the diaphragm with minimal effect on diaphragmatic function (Figure 18.11b,i&ii). The necessary abdominal excision is much better tolerated than the alternative of performing a thoracotomy and spreading the ribs. This technique can also be adapted for minimally invasive oesophageal surgery; however, in this instance a special port is required in order to retain the intra-abdominal gases.

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