VIDEO-ASSISTED THORACIC SURGERY FOR LUNG LESIONS

Brief intro to vats procedure for lung lesions.

1. VIDEO-ASSISTED THORACIC SURGERY FOR LUNG LESIONS DR. RESHMA CHANDRASEKARAN DNB SURGERY RESIDENT

2. Doctor Carson inducing artificial pneumothorax for the treatment of pulmonary Kochs.

3. OBJECTIVES Introduction Equipment's for VATS Anaesthesia in VATS Preoperative workup Patient positioning Port placement The OR setup Indication and VATS procedures Benefits of VATS Advancements

4. INTRODUCTION Video assisted thoracoscopic surgery is a minimally invasive surgical procedure, used to diagnose and treat illness or injury to the lung and other organs in the thoracic cavity. With controlled pneumothorax, the concept of thoracoscopy developed. In 19 th century Hans-Christian Jacobaeus performed the first thoracoscopic diagnosis visualizing pleural cavity using a cystoscope.

5. EQUIPMENTS FOR VATS 5- or 10-mm high-resolution fiber-optic thoracoscope with a 0° or 30°lens A light source with a cable Video monitors Thoracoscopic instruments (scissors, hook or straight-blade cautery, biopsy forceps, grasper, and dissector)

6. Endoscopic stapler if resection is planned . Trocars Thoracotomy tray (to convert to open procedure if needed) Chest tubes and drainage devices Sterile gloves, gowns, and drapes Double-lumen endotracheal tube or single-lumen tube with bronchial blockers

7. ANAESTHESIA IN VATS General anesthesia along with single lung ventilation using Double lumen endotracheal tube or bronchial blocker. In single lumen ET tube usage, the intrapleural pressure is kept lower than 10 mm Hg to avoid mediastinal tension and hemodynamic compromise. It is necessary to use air-tight valves trocars to seal the gas within the thorax when this carbon dioxide insufflation technique is used.

8. PREOPERATIVE WORK UP The assessment should focus on pulmonary and cardiac conditions, as these represent the most common complications after thoracic surgery. PFT: Respiratory mechanics and parenchymal function. Laboratory studies: Complete blood count, electrolyte panel, clotting parameters, renal and liver function tests.

9. Preoperative imaging studies: they help to confirm the planned extent of resection and the suitability of a VATS approach. Contrast-enhanced computed tomography (CT). Positron emission tomography (PET) in malignant cases.

10. brachial plexus.

11. PATIENT POSITIONING : LATERAL DECUBITUS POSITION

12. PORT PLACEMENT The first port incision should be at the seventh or eighth intercostal space anterior to midaxillary line. The second incision site is the anterior fourth and fifth intercostal space between the midclavicular and anterior axillary line. The third incision is posterior, at the fifth and sixth intercostal space adjacent to the scapula

13. THE OR SET UP VATS requires a HD video monitor, together with VATS instruments allowing the surgeon to view a sharp, high- resolution image within the chest cavity. The organization of the operation room is done based on the surgeon’s surgical approach. There are two types of approaches: Anterior. Posterior.

14. VATS IN LUNG LESIONS Spontaneous pneumothorax Solitary pulmonary nodule Parenchymal disease Tuberculoma CPAM Malignant pleural effusion Empyema thoracis Lung tumour

15. SPONTANEOUS PNEUMOTHORAX

16. SOLITARY PULMONARY NODULE

17. Solitary pulmonary nodule (SPN) is defined as a relatively well-defined round or oval pulmonary parenchymal lesion equal to or smaller than 30 mm in diameter. It is surrounded by pulmonary parenchyma and/or visceral pleura and is not associate with  lymphadenopathy ,  atelectasis , or  pneumonia .

18. VATS WEDGE RESECTION Lesions at the periphery or outer one-third of the lung are for wedge resections. Preoperative CT-guided needle placement or placement of radio-opaque dye (methylene blue) can be used for guidance and lesion detection intraoperatively with fluoroscopy. Its therapeutic in early-stage (NSCLC; T1N0M0) and early- stage in patients with limited cardiopulmonary reserve

19. TUBERCULOMA

20. CONGENITAL PULMONARY AIRWAY MALFORMATION

21. MALIGNANT PLEURAL EFFUSION

22. PLEURODESIS Pleurodesis is draining the pleural fluid or intrapleural air followed by either a mechanical procedure or instilling a chemical irritant into the pleural space, which causes intense inflammation and fibrosis subsequently leading to adhesions between the two pleural membranes. INDICATION: Recurrent malignant pleural effusions, e.g., in the metastatic breast or ovarian cancer and lung cancer.

23. Chemical pleurodesis: It is done by inserting a sclerosing agent into the pleural cavity via a chest tube. 2. Mechanical/surgical pleurodesis: This is done through medical thoracoscopy, video-assisted thoracoscopy (VATS), or open thoracotomy.

24. To attain pneumostasis

25. LUNG TUMOR TREATMENT OF CHOICE: early-stage NSCLC by the American College of Chest Physicians evidence-based guidelines VATS lobectomies have recently turned 30 years-old. It was performed with two small incisions and one specimen retrieval port , subsequently a biportal and then uniportal VATS lobectomy developed, with the latest subxiphoid approach proposal.

26. BENEFITS OF VATS Operative time is faster or equivalent Blood loss is less Short term PFT's better Lower incidence of post thoracotomy pain Reduced need for epidural catheters Improved QoL Less post operative shoulder dysfunction especially when compared to latissimus dividing thoracotomy

27. BIBLIOGRAPHY Mastering Endo-Laparoscopic and Thoracoscopic Surgery. Bailey and love 28 th edition. PUBMED central articles.

28. THANK YOU