What are the guidelines for video-assisted thoracoscopic surgery (VATS)?

Guidelines for Video-Assisted Thoracoscopic Surgery (VATS)

Regional analgesic techniques such as paravertebral block and erector spinae plane block are strongly recommended as first-line pain management options for VATS procedures, with serratus anterior plane block as a second choice. 1

Pain Management Recommendations

VATS, while less invasive than thoracotomy, still causes significant postoperative pain that requires effective management to improve outcomes. The PROSPECT guidelines provide a comprehensive approach:

Pre-operative and Intra-operative Analgesia

• Basic systemic analgesia:

  • Paracetamol (acetaminophen)
  • NSAIDs or COX-2 inhibitors
  • These should be administered pre-operatively or intra-operatively and continued postoperatively 1

• Regional analgesia (first-line options):

  • Paravertebral block - provides excellent analgesia with fewer side effects than thoracic epidural
  • Erector spinae plane block - equally effective as paravertebral block
  • Consider adding preservative-free dexmedetomidine to local anesthetics to prolong analgesic effect 1

• Regional analgesia (second-line option):

  • Serratus anterior plane block - simple to perform but may provide less effective analgesia than first-line options 1

• Intravenous adjuncts:

  • Dexmedetomidine infusion - recommended when basic analgesia and regional techniques cannot be administered 1

Postoperative Analgesia

• Continue basic analgesia (paracetamol and NSAIDs/COX-2 inhibitors)
• Reserve opioids for rescue analgesia only 1
• Continue regional analgesia techniques when catheters are placed

NOT Recommended for VATS

• Thoracic epidural analgesia - more invasive with higher risk of hypotension, urinary retention, and limb weakness 1
• Gabapentinoids - inconsistent evidence
• IV lidocaine - lack of procedure-specific evidence
• Wound infiltration - limited evidence
• Intrapleural analgesia - limited evidence 1

Surgical Approach Recommendations

For pleural infection management, the British Thoracic Society guidelines state:

• VATS access should be considered over thoracotomy for surgical management of pleural infection (Conditional recommendation) 1
• Initial drainage of pleural infection should use small bore chest tubes (14F or smaller) before considering surgical intervention 1
• Early surgical drainage under VATS should not be considered over chest tube drainage for initial treatment of pleural infection 1

Technical Considerations

• Ensure the VATS technique facilitates optimal clearance of infected material and achieves lung re-expansion 1
• Tailor the extent of surgery according to patient and disease stage 1
• Decortication decisions should be individualized based on patient fitness and disease stage when the lung is trapped 1

Complications and Risk Factors

VATS is generally considered safe with low complication rates, but awareness of potential complications is essential:

• Most common complications include:

  • Prolonged air leak
  • Bleeding
  • Infection
  • Postoperative pain 2

• Risk factors for complications:

  • Advanced patient age
  • Longer procedure duration
  • Redo-VATS procedures
  • Conversion to open thoracotomy
  • Immune deficiency (highest risk group with 31.7% complication rate) 3

• Catastrophic complications are rare (approximately 1%) but may include:

  • Pulmonary vessel transection
  • Unplanned pneumonectomy or bilobectomy
  • Airway injury 4

Diagnostic Applications

• Ultrasound may support diagnosis of pleural malignancy when appropriate sonographic skills are present 1
• CT allows assessment of the entire thorax and may support diagnosis of pleural malignancy 1
• PET-CT can be considered when there are suspicious CT features but negative histological results 1

Practical Algorithm for VATS Management

1. Pre-operative assessment:

   • Evaluate patient risk factors (age, immune status, previous thoracic surgery)
   • Plan appropriate analgesia strategy

2. Analgesia implementation:

   • Administer basic analgesia (paracetamol and NSAIDs/COX-2 inhibitors)
   • Perform regional block (paravertebral or erector spinae plane block preferred)
   • Consider dexmedetomidine as adjunct when needed

3. Intra-operative management:

   • Use appropriate VATS technique based on indication
   • Be prepared for potential conversion to thoracotomy if needed
   • Limit procedure duration when possible to reduce complication risk

4. Post-operative care:

   • Continue basic analgesia
   • Use opioids only as rescue medication
   • Monitor for common complications (air leak, bleeding, infection)
   • Implement early mobilization and respiratory therapy

By following these evidence-based guidelines, clinicians can optimize outcomes while minimizing complications in patients undergoing VATS procedures.