Overview of Video-Assisted Thoracoscopy
In the last 20 years, a procedure called video-assisted thoracoscopic surgery (VATS) has greatly changed how certain lung, esophagus, and heart conditions are treated. This technique was originally introduced in 1912 by a Swedish doctor named Jacobeaus. He used it to look at and treat a condition where fluid builds up around the lungs in patients with tuberculosis. Since then, VATS has grown and evolved dramatically. A key development in the process was when fiber-optic light was introduced. This allowed doctors to perform much safer surgeries without needing to make large cuts.
Today, doctors often prefer using this method over the more traditional and invasive surgery known as thoracotomy. This is because VATS provides several benefits including less pain after the operation, shortened hospital stays, and a quicker return of normal lung function. This is especially helpful for patients who are older or frail, and for those with chronic lung conditions, such as chronic obstructive pulmonary disease. The advancements in this area have widened the number of situations where VATS can be used. This has improved results for patients while also reducing the costs of healthcare.
Anatomy and Physiology of Video-Assisted Thoracoscopy
The trachea, or windpipe, of an adult is around 15 cm long, beginning at C6 (the sixth bone in your neck), and splitting into the right and left main branches at around T5 (the fifth bone in your upper back). The right branch, which is wider and more aligned with the trachea, splits into upper, middle, and lower sections. The left branch is more horizontally placed and divides into upper and lower parts.
These sections are further divided into smaller parts, each supplied by an artery and a bronchus, with veins scattered around them. Surgeons need to be aware of these different parts of the lung while performing surgery. There are also other structures near the lungs that need to be taken into consideration while performing certain procedures. These include the esophagus (food pipe), pleura (the membrane that wraps the lungs), diaphragm (a muscle that helps in breathing), pericardium (the outer covering of the heart), thymus (a gland behind the breastbone), sympathetic chain (a bundle of nerve fibers), thoracic duct (a large vein in the neck), spine, and heart.
Why do People Need Video-Assisted Thoracoscopy
VATS, or video-assisted thoracic surgery, is a procedure that allows doctors to visualize, diagnose, and treat various conditions related to the chest, lungs, and heart. It uses a tiny camera (called a thoracoscope) and special instruments inserted through small cuts in the chest. Let’s look at why a doctor might use this procedure:
Diagnostic purposes:
- To take a sample of swollen glands in the middle part of the chest (mediastinal lymph node biopsy),
- To examine the space between the lungs and chest wall (pleuroscopy) and take a sample if needed (pleural biopsy),
- To get a tissue sample or lymph node biopsy for lung cancer,
- To biopsy a piece of the chest wall,
- To determine the stage of cancer (how much it has spread).
Treatment uses:
- To remove part of the lung, often due to lung cancer – for example, the entire lobe (lobectomy), a part of a lobe (segmentectomy), or a small, wedge-shaped part (wedge resection),
- To remove small, balloon-like sacs from the lung’s surface (pulmonary bleb and bullae resection),
- To drain fluid from the space around the lungs caused by a collapsed lung (pneumothorax), bleeding into the chest (hemothorax), or pus due to infection (empyema),
- To drain excess fluid around the heart (pericardial effusion drainage),
- To stick the layers of the tissue covering the lungs together to prevent fluid buildup (mechanical and chemical pleurodesis),
- To remove or take a sample of abnormal growths in the chest (excision or biopsy of mediastinal masses – for example thymectomy) and small lumps (nodules),
- To tie off the main lymph vessel of the chest (thoracic duct ligation),
- To cut off nerves to treat excessive sweating or other disorders (sympathectomy),
- To remove tumors from the chest wall,
- To remove a portion of the backbone to relieve pressure on the spinal cord (thoracoscopic laminectomy),
- To drain an infection of the spine (spinal abscess drainage),
- To remove the esophagus, often due to cancer (esophagectomy),
- To remove fluid-filled sacs from the esophagus (esophageal cyst removal),
- To fix a type of stomach hernia that occurs when part of the stomach pushes upward into the chest cavity (hiatal hernia repair),
- To perform procedures on the diaphragm (like plication, which tightens a paralyzed diaphragm),
- To treat chest injuries, including damage to the diaphragm,
- To cut certain nerves in the stomach to reduce acid secretion (truncal vagotomy),
- To place a lead for a pacemaker directly on the heart (epicardial lead placement).
The main benefit of VATS is that it avoids large incisions, minimizing pain and recovery time for patients. However, it’s not suitable for everyone or for every condition, so a doctor will consider many factors to decide if it’s the right choice for a given patient.
When a Person Should Avoid Video-Assisted Thoracoscopy
There are certain conditions where the Video-Assisted Thoracoscopic Surgery (VATS) cannot be performed:
If a person is unable to handle breathing with only one lung during the surgery, VATS cannot be done. This technique is called single lung isolation ventilation and it’s critical for the operation.
If an abnormal growth blocks the breathing tube, double-lumen tube placement for VATS will be either difficult or impossible.
If there are severe adhesions, or sticky scar tissue, in the pleural space, the space around the lungs, VATS cannot be performed.
If a person’s heart is not stable and they’re not able to maintain a steady blood circulation, the surgeon will not do a VATS. This situation is called hemodynamic instability.
If a person has had a treatment where a powder, talc, was put into the lungs in the past, VATS cannot be done.
There are also situations where VATS may be avoided or considered with caution:
If a person has had thoracic surgeries done before, it may make VATS difficult. These are surgeries on the chest area, and the scar tissue left behind can complicate the surgery.
If radiation treatment was done before for chest tumors, VATS might not be the best option.
If a person’s oxygen level in their body is too low, known as severe hypoxia, VATS could be risky.
In cases of severe Chronic Obstructive Pulmonary Disease (COPD), a lung disease that makes it hard to breathe, VATS might not be chosen for treatment.
If a person has severely high blood pressure in the arteries that supply blood to the lungs, known as severe pulmonary hypertension, having VATS could be dangerous.
If a person has a blood clotting disorder, known as coagulopathy, which can lead to excessive or prolonged bleeding, VATS might be too hazardous.
Equipment used for Video-Assisted Thoracoscopy
To carry out a procedure known as VATS (Video-Assisted Thoracic Surgery), a specific set of tools and equipment is required. This includes:
1. A tiny specialized camera known as a fiber-optic thoracoscope with a 0° or 30° lens, either 5 or 10mm in size. This tool allows your doctor to clearly see inside your body during the operation.
2. A source of light that connects to the camera, which helps the doctor navigate through your body by illuminating the area.
3. Video monitors to display the live footage from the camera, so the doctor can perform the operation with precision.
4. Special tools that are used specifically for thoracic surgeries. These include scissors, devices that use heat for cutting or coagulation (hook or straight-blade cautery), forceps for biopsies, a grasper, and a dissecting tool.
5. An endoscopic stapler, if a resection (removal of part of an organ or structure) is part of the plan.
6. Trocars, which are pointy, pen-shaped tools that are used to insert surgical instruments or fluids.
7. A thoracotomy tray, which has all the necessary tools, ready to switch to an open surgery method if required.
8. Tubes for your chest and tools for draining, which are used to remove excess fluid and air from the surgical site.
9. Sterile gloves, gowns, and drapes to maintain a clean and infection-free environment during the surgery.
10. A special type of breathing tube called a double-lumen endotracheal tube or a single-lumen tube with bronchial blockers. These tubes help manage your breathing during the procedure.
Who is needed to perform Video-Assisted Thoracoscopy?
A Video-Assisted Thoracoscopic Surgery (VATS) is a type of surgery that is done with the help of a small camera. It requires several medical professionals to make sure everything goes as planned during the surgery. The team includes:
The surgeon, who is the doctor specially trained to perform the operation, leads the team.
They are supported by an assistant, who helps the surgeon during the surgery.
An anesthesiologist is also part of the team. This type of doctor is responsible for making sure you are in a deep sleep during the surgery so you don’t feel any pain.
Meanwhile, the circulating nurse is there to make sure all the medical tools and equipment are prepared and in place during the surgery.
Lastly, the surgical technologist helps by preparing and sterilizing the surgical instruments and may assist during the procedure. Each of these roles is important to ensure a safe and efficient surgical procedure.
Preparing for Video-Assisted Thoracoscopy
Before planning a surgery that requires breathing from only one lung, it’s critical to evaluate the patient’s health status thoroughly. This check-up is aimed at understanding the overall health of the patient, focusing primarily on the heart and lung functions. It helps in identifying patients who are capable of withstanding the process of breathing from a single lung during surgery.
The examination involves checking the physical wellbeing of the patient, lung functionality, ability of the lungs to transfer gas from inhaled air to the red blood cells (also known as diffusing capacity of the lungs for carbon monoxide or DLCO), and a detailed scan of the chest region. The findings from these tests help in determining whether the patient is fit enough for the operation. The goal of this extensive evaluation is to reduce the chances of complications that may occur during or after the operation and, therefore, improving the outcomes of the surgery.
The lung function tests provide insights on how well the lungs and respiratory system works. One test checks how much air can be forcefully exhaled in one second (FEV1); generally, if FEV1 is greater than 60% it means that the lungs are healthy enough for a certain type of lung surgery. If FEV1 is less than 30%, it indicates a likely need for the patient to use a ventilator or extra oxygen after surgery. If FEV1 is less than 60%, another test known as ventilation-perfusion scan, could be done to understand the chance for postoperative complications. Another test, DLCO, checks how well gases move from the lungs into the blood; if this value is greater than 40%, it’s generally considered safe to proceed with the surgery.
Before a type of lung surgery called VATS, doctors also check blood counts for signs of too many red blood cells or infections. Images of the chest taken by X-rays and CT scans help the doctor in having a clearer picture of the lung region which in turn aids in surgical planning. Another important measure taken is to check for the levels of oxygen and carbon dioxide in the blood, if the carbon dioxide level is more than 50mm Hg or oxygen level is less than 60mm Hg, it can be an indication of post-surgery risks. Quitting smoking, dealing with infections, and improving lung function can be some strategies to better prepare the patient for the surgery.
When preparing for the VATS surgery, the operation room is set up in a way that allows all the hospital staff to watch the procedure effectively. The doctors performing the operation stand in front and by the side of the patient and the anesthesiologist is at the head of the bed. The patient lies on the side or back with some support to access the chest area. Incisions are made in between the ribs to avoid nerve damage. A camera is inserted through one of these incisions which allows doctors to clearly see the surgical site and proceed with the operation.
How is Video-Assisted Thoracoscopy performed
VATS, or video-assisted thoracic surgery, is a type of procedure where the patient is placed on their side to make it easier to access the chest. This is known as a lateral decubitus position. To prevent any damage to the nerves during surgery, patients are carefully cushioned.
During this procedure, the patient is typically put under anesthesia and made to breathe from one lung while the other one is collapsed intentionally. This allows the surgeons to have an easier access to operate. However, one lung can only do so much in providing oxygen and removing carbon dioxide from our body, so the doctor carefully controls the breathing rate and the amount of air the patient breathes in (known as tidal volume) to achieve the most optimal oxygenation. But despite medical intervention, some patients can still face low oxygen levels, also known as hypoxemia.
Hypoxemia, or low oxygen in the blood, is something that can happen in 5% of cases during this kind of surgery. Factors like the patient’s position, anesthesia, the mechanical support for breathing, muscle relaxation drugs, and surgical tools used can affect the patient’s lung function during the procedure. If hypoxemia occurs, the doctor may have to increase the oxygen level in the air the patient breathes or may have to revert to two-lung ventilation. It is generally recommended to avoid using continuous positive airway pressure or CPAP as it may affect surgery.
To achieve one-lung ventilation various methods are used, each with their unique benefits and considerations according to the patient’s needs. For instance, double-lumen endotracheal tubes help to ventilate each lung independently. But their position in the patient’s windpipe needs to be carefully adjusted and confirmed with a special type of tiny camera called a bronchoscope as they can sometimes move out of place.
On the otherhand, single-lumen endotracheal tubes partnered with bronchial blockers can be used as an alternative. Their placement is confirmed similarly with a bronchoscope. A major advantage of single-lumen tubes is they can stay in place after the procedure if the patient needs ongoing support for breathing. However, similar to double-lumen tubes, the placement of bronchial blockers should be checked after the patient is positioned for the surgery.
In some cases, apneic oxygenation (providing oxygen without triggering breathing) or high-frequency positive-pressure ventilation (enhancing oxygen delivery with intermittent airway pressure) can also be used. However, their use can be limited due to risk factors including progressive respiratory acidosis (increase in carbon dioxide level due to breathing irregularity) and a possible hamper to surgery due to the mediastinal bounce (movement of chest structures). It’s crucial to carefully analyse the potential limitations to ensure patient’s safety and successful procedure.
For the actual surgical procedure, the standard VATS method involves 3 to 4 incisions or cuts made in a triangular pattern on the chest for the surgeon to pass a scope and work with instruments. Sometimes a single-port VATS might be used. Initially, the patient is placed flat on their back, and once they’re asleep because of the anesthesia, a double-lumen tube is typically inserted into the windpipe for breathing control. Once in place, the doctor uses a small camera called a bronchoscope to confirm the tube is correctly placed before repositioning the patient for surgery. After the procedure, 1 or 2 tubes are usually placed to drain the excess air or fluid from the chest area. The postoperative care involves adequate pain management, respiratory support, and chest tube monitoring to ensure the proper recovery of the patient.
Possible Complications of Video-Assisted Thoracoscopy
Video-assisted thoracic surgery (VATS) is a type of surgery that uses a small camera to guide the procedure. Like all surgeries, there are potential complications, including leaks of air after the procedure, pain, low oxygen levels in the blood (hypoxemia), collapsed lung tissue (atelectasis), bleeding, wounds infection, and fluid buildup in the lungs (pulmonary edema).
In particular, bleeding due to a blood vessel being injured during the VATS is a serious complication. If this happens, doctors might need to switch to a traditional open chest surgery (thoracotomy) quickly. To prepare for this situation, the surgical team ensures there is good intravenous access before starting the VATS. This will allow them to respond quickly if they need to switch to an open surgery. Although switching to an open surgery is not ideal, the benefits of trying VATS first still make it the preferred choice, even if there is a chance they might have to convert to an open surgery.
There are other situations where traditional chest surgery might be necessary. If the lung can’t be ventilated adequately during VATS, an open thoracotomy might be needed to ensure good oxygenation. Technical issues, such as the inability to see or reach the right area due to dense scars in the chest, or failure of the video equipment, might also require conversion to an open approach. This ensures that the surgery can progress properly and all the intended goals of the surgery can be achieved.
What Else Should I Know About Video-Assisted Thoracoscopy?
VATS, which stands for Video-Assisted Thoracic Surgery, has become the preferred method for performing chest surgeries in many medical centers around the world. This cutting-edge procedure is safer than traditional open chest surgery, especially for older patients, and results in fewer complications.
One of the major upsides of VATS is that patients typically experience less pain after surgery. This means they recover faster and get to return home sooner. Researchers have found that VATS reduces the time you have to stay in the hospital mainly because the chest tube used in the surgery doesn’t have to be in place as long. VATS also lowers the risk of complications like bleeding after surgery and additional health issues during your hospital stay.
Aside from experiencing less pain after surgery, people who undergo VATS need fewer blood transfusions and generally report a better quality of life. Even though VATS can cost more upfront, it can save money in the long run because the hospital stays are shorter and there are fewer complications.
Long-term survival rates, which are a measure of how effective the treatment is, are similarly good whether patients receive VATS or traditional open surgery. This has led a group of thoracic surgery experts to endorse VATS as the standard for care for lobectomies, which is a type of surgery where a portion of the lung is removed.
Not only is VATS the favored method for lobectomies, but it’s also showing promising results for other types of surgery, such as removing a section of a lung (segmentectomy) or part of the esophagus (esophagectomy). All in all, VATS provides a safer, more efficient, and cost-effective surgical solution for various chest conditions, and improves the overall quality of healthcare for patients.
