Group 2 - Rose & Sadava - VATS

VIDEO-ASSISTED
THORASCOPIC
SURGERY
ALLIAH RAE ANTONETTE D. ROSE & JOHN DENMER T.
SADAVA
VATS: OVERVIEW
• Video-assisted thoracoscopic surgery (VATS) is

minimally invasive thoracic surgery that does not use
a formal thoracotomy incision. VATS provides
adequate visualization despite limited access to the
thorax, allowing the procedure to be performed in
patients who are debilitated or have marginal
pulmonary reserve.
• VATS is principally employed in the management of
pulmonary, mediastinal, and pleural pathology. Its
main benefit has been the avoidance of a thoracotomy
incision, which allows a shorter operating time, less
postoperative morbidity, and earlier return to normal
activity than can be achieved with thoracotomy.
PROCEDURE
During thoracoscopic surgery, three small

(approximately 1-inch) incisions are used, as
compared with one long 6- to 8-inch chest
incision that is used during traditional, "open"
thoracic surgery. Surgical instruments and the
thoracoscope are inserted through these small
incisions. The thoracoscope transmits images
of the operative area onto a computer monitor
that is positioned next to the patient.
INDICATIONS
DIAGNOSTIC THERAPEUTIC
• Mediastinal lymph node • Pulmonary resection (most commonly for lung cancer)
biopsy • Pulmonary bleb/bullae resection
• Pleuroscopy/pleural biopsy • Pleural drainage (pneumothorax, hemothorax, empyema)
• Tissue/lymph node biopsy for • Pericardial effusion drainage
lung cancer • Mechanical/chemical pleurodesis
• Chest wall biopsy • Excision/biopsy of mediastinal masses and nodules
• Cancer staging • Excision of esophageal diverticulum/esophagectomy
• Thoracic duct ligation
• Sympathectomy
• Chest wall tumor resection
• Thoracoscopic laminectomy
• Spinal abscess drainage
PREOPERATIVE CARE
• Perform a detailed preoperative examination with a focus on the cardiac and respiratory
function. This is essential to ensure that the selected candidates for VATS will tolerate one-
lung ventilation (OLV).
• Review preoperative ASA physical status assessment, spirometry, plethysmography, diffusing
capacity of the lungs for carbon monoxide (DLCO) measurement, computed tomography
(CT), and cardiopulmonary exercise testing (CPET).
• Assess the patient’s lung mechanics (FEV1, MVV, FVC, RV/TLC ratio), parenchymal
function (DLCO, PaO2, PaCO2), and cardiopulmonary reserve (VO2 max, exercise
tolerance).
• Assist the patient in routine preoperative screening tests.
• A complete blood count may reveal polycythemia due to pulmonary diseases or an elevated
white cell count suggestive of infection or inflammation. Chest x-ray and CT scan provide
relevant anatomical details required for the relevant procedure. Arterial blood gases may help
identify patients at increased risk of postoperative complications. Patients with PaCO2 greater
PREOPERATIVE CARE
• Obtain the patient’s complete health history, and perform a thorough physical examination
including vital signs to establish baseline values for comparison.
• Assess the patient’s activity and functional levels, including that involving aerobic exercise.
• Assess the patient’s nutritional and fluid status.
• Ask the patient if they have any known allergies that could interfere with the anesthesia and
other preoperative medications or the procedure itself.
• Ask the patient if they consume cigarettes, alcohol, or any recreation drugs.
• Ask the patient about medications used, including OTC and herbal medications. Check if
they are consuming any blood-thinning medications or have any bleeding disorder.
Prothrombin time, activated partial thromboplastin time, and a platelet count are used
routinely to identify bleeding tendencies.
• Identify the patient’s blood type and make preparations for blood replacement, blood must
be made available for routine and emergency transfusions.
PREOPERATIVE CARE
• Reinforce the surgeon’s discussion about the procedure and answer the patient’s questions.
• Begin health teaching with the patient about postoperative exercises, wound care, and
surgical drain care.
• Secure the patient’s cardiopulmonary clearance and written informed consent form.
• Establish IV access for fluid replacement and blood transfusions.
• Place the patient in a Foley catheter to measure urine output.
• Administer prescribed preoperative medications to the patient.
• Place the patient in NPO after midnight.
• Ensure the patient is kept warm during the transfer to the operating room.
• Identify the patient and identify surgical site, whether it has been marked or not according to
hospital policy.
• Provide psychological support to the patient and their family.
• Preoperative optimization of patients undergoing VATS may also include smoking
cessation, treatment of underlying infections and pulmonary rehabilitation.
ANESTHESIA
For most VATS procedures, general anesthesia with selective single-lung ventilation using a
double-lumen endobronchial tube is preferred. Left-side intubation is usually performed unless a
left pneumonectomy is anticipated. A single-lumen endotracheal tube with a bronchial blocker is
an acceptable alternative.
In the current environment of enhanced recovery protocols and cost containment, minimally
invasive VATS operations suggest adoption of individualized tailored, precise anesthesia.
POSITIONING
The patient is placed in the lateral decubitus position with the table
break maximally flexed at the patient's hip level. Reverse
Trendelenburg is used to tilt the table so that the patient's lateral
chest wall is parallel to the floor.
The positions of the surgeon and assistant depend on the site of the
pathology as suggested by preoperative imaging. The surgeon
stands facing the site of the pathology, with the camera-holding
assistant on the same side. The television monitor is positioned so
that the surgeon, the site of pathology, and the monitor are aligned
to allow the surgeon to look straight ahead when operating.
Alternatively, the patient can be positioned supine with a roll under

the back to bump him or her up and provide access to the pleural
space from a more anterior approach.
POSITIONIN
G
SKIN PREPARATION
• The surgical team member who will perform skin preparation must first perform
mechanical hand washing and done sterile gloves.
• Sterile technique must be observed during the procedure.
• Skin preparation will begin at midline, extending from the neck to the hips or upper
thigh and to the table bilaterally as far as possible. Skin preparation will depend on
which side the surgical site is.
• Using sterile gauze and 2% chlorhexidine solution, wipe from the planned incision site
towards the periphery in a circular motion, cleaning the from the cleanest (area of
incision site) to the dirtiest area.
SURGICAL
DRAPING
The procedure for surgical draping for radical

video-assisted thoracoscopic surgery is the same
for all thoracic surgeries. The surgical site exposed
depends on the position of the patient. The side of
the chest, where site for the small surgical incision
for the thoracoscope is made, is exposed for the
procedure.
SURGICAL EQUIPMENT
AND SUPPLIES
SURGICAL EQUIPMENT
AND SUPPLIES
SURGICAL EQUIPMENT
AND SUPPLIES
SURGICAL EQUIPMENT
AND SUPPLIES
SURGICAL EQUIPMENT
AND SUPPLIES
POSTOPERATIVE
CARE
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POSTOPERATIVE
CARE
POSTOPERATIVE
CARE
POSTOPERATIVE
CARE
POSTOPERATIVE
CARE
THANKS
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VIDEO-ASSISTED

• Video-assisted thoracoscopic surgery (VATS) is

During thoracoscopic surgery, three small

Alternatively, the patient can be positioned supine with a roll under

The procedure for surgical draping for radical

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