Video assisted thoracic surgery (vats)

VATS

1. Video Assisted Thoracic Surgery (VATS) Dr Vijender verma

2. Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical procedure, used to diagnose and treat illness or injury to the lung and other organs in thorax . With controlled pneumothorax , the concept of thoracoscopy developed. Jacobeus used the cystoscope in 1910 to first visualize the pleural cavity. Introduction

3. In the 1990’s there was a sudden increase in the use of thoracoscopy . This happened due to many reasons : Miniaturization of video equipment Improvement in quality of pictures and light sources Single lung anesthesia improvements to allow undisturbed examination of the chest. Development of staplers to enable biopsies and wedge resections . .

4. Eventually , thoracoscope became part of the surgical procedure which got named as Video Assisted Thoracic Surgery ( VATS ). In VATS procedures, surgeons operate through 2 to 4 tiny openings between the ribs. Each opening is less than one inch in diameter, whereas 6- to 10-inch incisions are not uncommon in open thoracic surgery.

5. All VATS procedures generally start the same way. Patients are placed under general Anesthesia and are typically positioned on their sides. Using a trocar , the surgeon gains access into the chest cavity through a space between the ribs. An endoscope is inserted through the trocar , giving the surgeon a magnified view of the patient’s internal organs on a television monitor.

6. Patient Positioning Patients are usually placed in full lateral decubitus position with all pressure points well padded to prevent tissue and nerve injury. T he use of a beanbag is optional, but the patient should be safely secured to the table . The hips are placed below the break point of the table to allow opening of the intercostal spaces as the table is angulated. T he contralateral leg is gently flexed while the ipsilateral leg is maintained extended. T he ipsilateral arm should rest in a neutral position to avoid hyperextension and to prevent injury to the brachial plexus.

7. The thorax is prepared and draped as for open thoracotomy . .

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9. All patients require monitoring of the EKG, continuous pulse oximetry , and carbon dioxide (C02) capnometry . An arterial line is utilized selectively in patients in poorer condition or for prolonged procedures. For most VATS procedmes , single-lung ventilation is required in order to facilitate manipulation of the lung and instruments within the limited pleural space. Lung isolation may be achieved through a double- humen tube (DLT) or single-lumen tube (SLT) with a bronchial blocker. Anesthetic Considerations

10. In patients with pneumonia and parapneumonic empyema,DLT is the method of choice to ensure strict lung isolation and to prevent soiling of the dependent normal lung with purulent secretions. Malposition {migration) or mucous plugging of the endotracheal tube is usual cause of significant intraoperative hypoxemia . The anesthesia and surgical teams must be prepared to immediately suction secretions from the ventilated lung and to perform bronchoscopic examination. .

11. Thoracic incisions are more painful and less well tolerated than abdominal incisions. Complications of poorly controlled incisional pain include splinting, poor pulmonary hygiene , atelectasis, and pneumania . Most patients undergoing VATS do not require an epidural catheter for pain control. In patients undergoing pleurectomy and pleurodesis for recurrent pleural effusion or pneumothorax. Consideration should be given to an epidural catheter avoiding the use of NSAIDs .Inflammatory reaction necessary for successful pleurodesis . Pain Control

12. Port Placement Ports are generally placed in the middle, anterior, and posterior axillary lines

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17. - The middle port is usually placed through the seventh or eighth intercostal space . -The anterior and posterior ports are usually placed near their respective axillary lines. Planning for a possible thoracotomy, the incisions are made so that they can be connected later if necessary. There is no advantage to creating a ‘ tunnel ’. This allow 360 arc mobility and postoprative neuralgia. .

18. INDICATIONS .

19. Indications for Video-. Assisted thoracoscopic Surgery Diagnostic Lung biopsy Interstitial lung disease Indeterminate pulmonary nodule Biopsy of mediastinal lymph node Biopsy of mediastinal mass Biopsy of pleural-based lesion Pleural biopsy and drainage of effusion

20. Therapeutic lung Lobectomy for lung cancer Sublobar resection ( segmentectomy,wedge for lung cancer) Placement of brachytherapy mesh for sublobar resection for lung cancer Metastasectomy Resection of blebs for recurrent pneumothorax Lung volume reduction surgery .

21. Pleura and pericardium Drainage of large pleural effision {benign or malignant) Pleurodesis ( pleurectomy , mechanical, chemical) Drainage of large pericardial effusion (subclinical or clinical tamponade ) Drainage of empyema and decortication of the lung Drainage of retained hemothorax .

22. Mediastinum Excision of mediastinal masses or cyst Thymectomy for myasthenia gravis Sympathectomy for hyperhidrosis Ligation of the thoracic duct for chylothorax Excision of neurogenic tumor Esophageal Resection of leiomyomata Resection of entericyst Esophagomyotomy Esophagectomy .

23. Reduced acute pain Reduced use of intravenous narcotics Reduced need for epidural catheters Reduced length of hospitalization Reduced time to return to regular activities Reduced impact on immune system Reduced overall cost Benefits of Video Assisted Thoracoscopic Surgery

24. Operative time is faster or equivalent Blood loss is less Chest tube duration less Short term PFT’s better Lower incidence of post-thoracotomy pain Improved QoL Less post-operative shoulder dysfunction Especially when compared to latissimus dividing thoracotomy .

25. 1. Work together with your anestheaiologist to ensure adequate lung isolation. 2. Place port for thoracoscope and instruments at a distance across the chest cavity from thetarget lesion to achieve a panoramic view of the operative field, optimize working space, and avoid instrument crowding and fencing. 3. Use anatomic landmarks such as pulmonary vessels, bronchus, fissure, diaphragm. etc, to aid in localizing the lesion. 4. Keep the thoracoscope and instruments in the same 180-degree arc to maintain the same videoendoscopic perspective and avoid "mirror imaging:' Basic Concepts of Video-Assisted Thoracoscopic Surgery

26. 5. Keep ports anterior to the posterior axillary line,if possible, where the intercostal spaces are wider. 6. Utilize both hands to manipulate the instruments in coordinated fashion. 7. Mimimize the use of electro cautery to avoid smoke and the need to suction{ thelung will reexpand ). 8. Become familiar with the thoracoscopes . instrumentation and choice of staplers. 9. Ensure good hemostasis and pneumostasis . 10. Understand that conversion to thoracotomy is not a failure but an appropriate option when the performance of VATS is limited by availability of equipment, technical difficulty, or cllnlcal condition of the patient. .

27. Consider contralndication • Inability to tolerate single-lung ventilation Pulmonary hilar mass Pulmonary lesion invading the mediastinum or chest wall (relative) Large pulmonary lesions (5 cm) (relative) Inability to achieve ipsilateral pulmonary atelectasis Not consider contraindications Neo adjuvant chemotherapy radiotherapy Lesions abutting mediastinum, chestwall or diaphragm Ventilator dependency Prior thoracotomy Contraindications of video assisted thoracoscopic Surgery

28. In case of empyema, the lung may not expand due to two reasons: 1.Multiloculated empyema at the level of parietal pleura . 2.Thickened granulation tissue over the visceral pleura. Empyema

29. In the first situation, a Video assisted debridement if done early (within 2-3 weeks) leads to good results. In the second situation, a decortication is needed to get the lung to expand again.

30. T hick , fibninous material that would not be likely to be completely drained by even a large-bore chest tube. Early thoracoscopic debridement(VATS) is indicated in such case. Pleural biopsy with a needle has enabled most pleural effusions to be diagnosed Pleural Effusion

31. In malignant pleural effusion, Video assisted debridement and pleurodosis can be done. Especially if collection is loculated and cant be drained by chest tube and early attempt of pleurodosis by chest tube failed. Malignant pleural effusion Mechanical Abrasion Talc Slurry

32. VATS techniques have proven useful in the management of the organizing posttraumatic hemothorax in which chest tube have been unable to completely drain the fibninous clot and debris. Post-traumatic Heamothorax

33. Pleural-based tumors may be sampled and even resected using VATS. Pleural-based tumors Thick pleura excision & biopsy

34. VATS wedge lung biopsy represents a significant advance. It offers the advantage of excellent visualization of and access to the entire lung (impossible through a small thoracotomy ), allowing biopsies of areas appearing abnormal and likely increasing diagnostic yield. PARENCHYMAL DISEASE

35. Spontaneous pneumothorax is mainly associated to subpleural blebs. usually in the apex of the upper lobes or the apical segments of the lower lobes. Video assisted stapling of apical blebs can be done in such case . VATS allows surgical management of the blebs by various techniques, including cauterization with a Yag:Nd laser, ligature at the base of the bulla, or excision with mechanical suture. Spontaneous pnemothorax

36. Surgical treatment has been indicated for bilateral and recurrent pneumothorax, and even for first episodes in patients with a pleural chest tube and persistent air leakage. Besides the proper treatment of the blebs, it can be used in conjunction with a method to increase pleural adhesion, ranging from mechanical abrasion, chemical pleurodesis or resection of the parietal pleura in the apical region. .

37. Bronchopleural fistulae Bronchopleural fistulae can sometimes be sutured thoracoscopically

38. Bronchopleural fistula Sutured with vicryl

39. Solitary Pulmonary Nodule SPN is defined as a ovoid or spherical lesion up to 3 cm in diameter. Not associated atelectasis, adenopathy or effusion. Lesion larger than 3 cm are almost malignant and referred as masses. M anagement of solitary nodule is one of the great dilemmas of thoracic surgery . SPN classify in 3 category benign, malignant and indeterminent . Malignant potential depend on size, tobacco smoking, pattern of growth, calcification and previous malignancy.

40. VATS is used to obtain solitary pulmonary nodule for histophathological examination for reliable diagnosis . . Nodule picked up

41. Stapler applied Specimen removal

42. Primary lesions of the mediastinum are ideal for VATS management. All locations of the mediastinum are accessible, and whether sampling or excision is the intent, video-assisted techniques save many patients from having to undergo thoracotomy or median sternotomy . Video-assisted thoracoscopic (VATS) thymectomy , excision of parathyroid adenoma. Mediastinum

43. VATS allows biopsy, and complete resection, of almost all tumor mass of the mediastinum to be performed. Most cystic massae , such as pericardiac cysts, bronchogenic cysts, thymic cysts can be suitably treated by videothoracoscopy . Some solid, mainly posterior, tumors of nervous origin such as neurinomas and Schwannomas can be totally resected by VATS.

44. VATS allows excellent access to the pericardium. I t is possible to perform pericardiac drainage or make a pleuro-pericardiac window. Drainage, pericardiac biopsies, and treatment of inflammatory or metastatic cardiac tamponade are all possible. A large portion of the parietal pericardium can be removed thoracoscopically . This resection is more easily performed through the right hemithorax , although it can also be carried out on the left side, in which prepericardiac fat is more abundant. The pleuro pericardiac window is a strategy offering several advantages over pericardiac drainage via the subxiphoid route. Pericardiac Effusion, Pericarditis

45. It is principally indicated in: hyperhidrosis, Raynaud’s phenomenon, Raynaud’s disease, causalgia , sympathetic reflex dystrophy, and upper limb arterial insufficiency. M ost common indication is hyperhidrosis of hands. VATS approach has several advantages over the open operation. It’s usually very easy to dissect the sympathetic chain in the exact amount needed, always under a very clear, direct vision ENDOSCOPIC THORACIC SYMPATHECTOMY

46. Video-assisted thoracoscopy (VATS) to mobilize the thoracic esophagus in combination with a standard open laparotomy to complete the esophagectomy . Surgery for achalasia cardia by thoracoscopy has now been completely replaced by the laparoscopic approach. Excision of leiomyoma is done at few centres by VATS. Esophageal Surgery

47. Excision of symptomatic thoracic herniated discs by VATS. Spine Surgery

48. The anterior release of stiff thoracic scoliotic deformities can be done video assisted nowadays Drainage of paraspinal abscess due to tuberculosis can potentially become a very common indication of thoracoscopy in india .

49. Thoracic disc space Pus aspiration Pus drainage

50. THANKS FOR YOUR PATIENCE