• Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique first described by Dr. Jacobeus in 1910. However, it did not gain widespread use until the early 1990s (1).
• Although it was initially used to treat tuberculosis-induced pleural effusions, it has much broader applications today:
  • Diagnostic uses: Assessing pleural disease (TB); staging of lung, esophageal, mediastinal, and other cancers; diagnosing parenchymal disease; and pericardial biopsy (2).
  • Therapeutic uses: Decortications; empyemectomy; lung resection (wedge, lobectomy, bilobectomy, pneumonectomy); pericardial window; esophageal surgery (vagotomy, antireflux procedures, minimally invasive esophagectomy); sympathectomy; and coronary artery disease and valve procedures (2).
• Carbon dioxide is utilized for insufflation and lung collapse. A thoracoscope is inserted into the chest and allowed for images to be transmitted to a video monitor. Additional surgical instruments can be inserted depending upon the procedure (biopsy, resection, bovie, etc.) in a similar manner as laparoscopic instruments. At the end of the procedure, the lung is reinflated, a chest tube may be placed through one of the incisions, and the remaining incisions are closed.
• Potential benefits of VATS compared to thoracotomies (however, randomized controlled studies to support these benefits are lacking) (3):
  • Minimally invasive
  • Cosmetically more pleasing (smaller incisions, muscle sparing)
  • Decreased pain
  • Shorter hospital stays
  • Improved pulmonary mechanics
  • Decreased cost

Lateral decubitus, often with a bean bag and axillary roll.

Ranges from 2–5 small incisions used to introduce thoracoscopic instruments

1.5–3 hours

Usually minimal; however, as large vascular structures are nearby, the risk of significant bleeding is a possibility

2–3 days

• Thoracoscope
• Video monitors
• Double lumen tube (DLT) or bronchial blocker (BB)
• Capability to convert to open thoracotomy
• Postoperative chest tube

Prevalence

Depending on the institution, between 60–80% of all thoracic cases performed involve some component of a VATS procedure

• Potential for major vascular injury (pulmonary artery or vein, SVC, aorta)
• Atrial fibrillation: 10% (4)
• Air leak: 7.2%
• Pneumonia: 2%
• Respiratory failure: 2%
• Arrhythmias, particularly atrial fibrillation
• Conversion to open thoracotomy

<1% for elective procedures

History

• Underlying respiratory or intrathoracic pathology
• Careful assessment of other comorbid disease processes (e.g., coronary artery disease [CAD], COPD)

Signs/Physical Exam

• Wheezing, rales, rhonchi, tachypnea
• Frequent upper respiratory infections

Labs/Studies

• Electrolytes, creatinine, CBC, coagulation profile (PT/PTT/INR).
• Pulmonary function tests (PFTs) and arterial blood gases (ABGs) may be useful for prognostication.
• CT scan if obstruction, large lesions, or vascular involvement is suspected.
• CXR combined with CT can help discern any potential obstruction which may make DLT placement difficult.

• Antiarrhythmics: Perioperative beta-blockade, calcium channel blockers, amiodarone, flecainamide, and fish oils may be instituted and continued perioperatively.
• Bronchodilators (puffs or nebulizers), steroids
• Deep venous thrombosis (DVT) prophylaxis
• Type and screen or cross

• Blood consent for possible need for transfusion
• Potential to convert to open
• Potential for postoperative intubation
• Consent for possible epidural catheter, or intercostal block placement

• General anesthesia with a DLT is utilized for the vast majority of procedures.
• Simple diagnostic or drainage procedures may be performed with a combination of local anesthesia and sedation; however, spontaneous ventilation can make the procedure more challenging.
• Epidural placement at a T7–T8 level or higher may be considered.

• Standard ASA monitors
• Arterial line is useful for close hemodynamic monitoring and drawing of frequent labs (HCT, ABGs); may not be necessary for short procedures or healthier patients (ASA I, II)
• 2 large-bore IVs for rapid resuscitation in cases where conversion to open thoracotomy becomes necessary
• Foley catheter should be considered

• Slow, controlled induction is advised as many patients have CAD, PVD, HTN
• Lung isolation and separation is best accomplished with a DLT, but BBs may be needed in patients where this is not feasible. Although BBs may be easier to place in patients with difficult airways, they may be easily dislodged (particularly in right sided placement) and do not allow for intermittent suctioning or continuous positive airway pressure (CPAP) to the operative lung.

• The controversy regarding total intravenous anesthesia (TIVA) versus inhalation agents still persists in thoracic surgery; a recent meta-analysis failed to demonstrate one technique being superior to the other. Proponents of TIVA suggest that it avoids inhibition of hypoxic pulmonary vasoconstriction seen with inhalational agents. Conversely, advocates of inhalation anesthesia assert that it is associated with a lower release of inflammatory mediators and provides bronchodilation.
• Ventilation
  • Settings: FIO₂ of 1.0. Lower tidal volumes (TVs) of 5–7 cc/kg are utilized to decrease ventilator-induced alveolar damage.
  • Hypoxia: Although CPAP can improve oxygenation to the "shunted" non-dependent lung, it can simultaneously hinder visualization and impair the feasibility of the procedure. Alternatively, positive end expiratory pressure (PEEP) may be applied to the dependent lung. Intermittent inflation of the non-dependent lung is less likely to hinder the progress of VATS procedures.
• Epidural infusion: The decision to begin the infusion intraoperatively, after blood loss is complete, at closure, or with smaller local anesthesia concentration or higher opioid dosing intraoperatively, is practitioner dependent. One should weigh the risks of a combined sympatholysis with blood loss against the benefit of decreased anesthetic requirements
• Volume restriction is a point of contention; the literature suggests that other factors such as advanced age, smoking history, large amount of lung tissue resected, history of congestive heart failure, and/or TVs exceeding 10–12 cc/kg are more important factors. The concept of goal-directed therapy with non-invasive cardiac output monitors or TEE (high risk patients) is advocated by some.

• Standard criteria
• In patients with pulmonary disease, an ABG may be drawn to aid in assessing extubation parameters.
• Avoidance of coughing and bucking are desired to decrease the incidence of injury to new anastomosis of the trachea or pulmonary vessels.