What are the preoperative, intraoperative, and postoperative considerations for a left-sided Video-Assisted Thoracic Surgery (VATS)?

Considerations for Left-Sided Video-Assisted Thoracic Surgery (VATS)

For left-sided VATS procedures, regional analgesia techniques such as paravertebral block or erector spinae plane block are strongly recommended as first-line pain management strategies, combined with multimodal systemic analgesia including paracetamol and NSAIDs to optimize patient outcomes. 1

Preoperative Considerations

Patient Selection

• Assess pulmonary function:
  • FEV1 and DLCO >40% predicted indicates acceptable operative risk
  • Even patients with severe COPD may be candidates if:
    • Upper lobe tumors are present
    • VATS approach is used (better outcomes than open thoracotomy)
    • Limited resection is planned 1

Contraindications

• Inability to tolerate single-lung ventilation:
  • Patients on mechanical ventilation
  • Prior contralateral pneumonectomy
  • Abnormal airway anatomy preventing double-lumen tube placement 1
• Extensive pleural adhesions that would prevent safe thoracoscope insertion 1
• Insufficient surgical expertise to manage potential complications 1

Preoperative Assessment

• Cardiac evaluation to identify ischemic heart disease
• Pulmonary function tests (PFTs) including:
  • Spirometry (FEV1)
  • Diffusion capacity (DLCO)
  • Calculate predicted postoperative (PPO) values 1
• Consider referral to high-volume centers for elderly patients, as outcomes are better 1

Intraoperative Considerations

Anesthetic Management

• General anesthesia with single-lung ventilation using double-lumen endotracheal tube
• For patients with prior contralateral pneumonectomy, consider:
  • High-frequency jet ventilation through a single-lumen ETT 2
  • This approach can maintain adequate oxygenation despite rising CO2 levels

Pain Management

• Intraoperative IV dexmedetomidine is recommended as it:
  • Reduces pain scores and opioid demand
  • Decreases postoperative agitation and cognitive dysfunction
  • Reduces postoperative nausea and vomiting
  • Improves lung function (increased FEV1 and vital capacity) 1
• Caution: Avoid dexmedetomidine in patients with severe cardiac disease, conduction or rhythm disorders 1

Regional Analgesia Techniques

• Paravertebral block (first choice):
  • Consider catheter placement by surgeon under direct visualization
  • Use continuous infusion rather than intermittent bolus technique 1
• Erector spinae plane (ESP) block (alternative first choice):
  • Non-inferior to paravertebral block
  • Especially useful when parietal pleural damage precludes effective paravertebral block 1
• Serratus anterior plane block (second choice):
  • Simple and quick to perform with limited side effects
  • Higher morphine consumption compared to ESP block 1

Surgical Approach

• Typically requires 3-4 small incisions for port placement
• Left-sided approach requires careful retraction of the heart
• Consider the learning curve - surgeons should perform 30-60 operations to achieve consistent results 3

Postoperative Considerations

Pain Management

• Continue regional analgesia techniques started intraoperatively
• Multimodal systemic analgesia:
  • Paracetamol and NSAIDs/COX-2 inhibitors should be administered regularly
  • Reserve opioids for rescue analgesia 1
• Not recommended:
  • Thoracic epidural (more invasive with higher risk of hypotension, urinary retention)
  • Postoperative IV dexmedetomidine (conflicting evidence, risk of side effects)
  • Gabapentinoids, IV lidocaine, corticosteroids (inconsistent or limited evidence) 1

Monitoring for Complications

• Prolonged air leak (most common complication)
• Bleeding
• Infection
• Port site recurrence 4
• Chest tube management:
  • Typically removed when drainage <200 mL/24h and no air leak
  • Often possible by postoperative day 2-6 5

Advantages of VATS vs Open Thoracotomy

• Shorter hospital stay (median 5 days vs 6 days)
• Lower complication rates (28% vs 45%)
• Reduced severity of complications
• Lower perioperative mortality
• Less postoperative pain 1
• Smaller reduction in postoperative lung function 1

Special Considerations

Elderly Patients

• VATS is particularly beneficial for elderly patients:
  • Lower postoperative cardiopulmonary complications
  • Shorter hospital stays
  • Comparable 5-year survival rates to younger patients 1
  • Consider limited resections (wedge/segment) rather than lobectomy 1

Patients with Limited Pulmonary Reserve

• VATS approach results in better preservation of lung function
• Patients with severe COPD may demonstrate smaller reduction in FEV1 postoperatively due to "lung volume reduction" effect 1
• Consider bronchoplastic resection for patients with impaired pulmonary reserve 1

Common Pitfalls to Avoid

1. Inadequate pain management leading to respiratory compromise
2. Failure to identify patients who cannot tolerate single-lung ventilation
3. Underestimating the learning curve for surgical teams
4. Neglecting to perform bronchoscopy when endobronchial lesions are suspected 1
5. Attempting pneumonectomy in elderly patients (higher mortality) 1

By following these considerations, VATS procedures can be performed safely with low morbidity and mortality rates, providing better outcomes than traditional open thoracotomy approaches.