What is the recommended approach for patients requiring thoracic surgery using Video-Assisted Thoracoscopic Surgery (VATS)?

Video-Assisted Thoracoscopic Surgery (VATS): Recommended Approach for Thoracic Surgery

For patients requiring thoracic surgery, a minimally invasive approach using Video-Assisted Thoracoscopic Surgery (VATS) is strongly recommended over traditional thoracotomy due to lower mortality, fewer complications, reduced postoperative pain, and shorter hospital stays. 1, 2

Benefits of VATS vs. Open Thoracotomy

• Mortality: Lower with VATS compared to thoracotomy (35/1000 vs 47/1000 patients) 2
• Complications: Fewer with VATS (152/1000 vs 197/1000 patients) 2
• Hospital stay: 2.3 days shorter with VATS 2, median 4 days vs 6 days for open procedures 1
• Chest tube duration: Earlier removal with VATS (median 3 days vs 4 days) 1
• Blood transfusions: Less frequent with VATS (2% vs 5%) 1

Optimal Pain Management Protocol for VATS

The PROSPECT guidelines recommend a multimodal approach to pain management for VATS procedures 1:

1. Regional analgesia (first-line):

   • Paravertebral block or erector spinae plane block
   • Serratus anterior plane block (as second choice)

2. Systemic analgesia:

   • Paracetamol and NSAIDs/COX-2 inhibitors (started pre-operatively or intra-operatively and continued postoperatively)
   • Intravenous dexmedetomidine during operation (when basic analgesics cannot be administered)
   • Opioids only as rescue analgesics postoperatively

3. Not recommended:

   • Thoracic epidural analgesia (more invasive with risks of hypotension, urinary retention, and lower limb weakness that can delay mobilization) 1

Patient Selection for VATS

Ideal candidates for VATS procedures include 2:

• Patients with early-stage lung cancer (particularly clinical stage I NSCLC)
• Patients without extensive pleural adhesions
• Patients with good pulmonary function
• Patients without previous thoracic surgery

Technical Considerations

When performing VATS lobectomy, surgeons should follow these oncological principles 3:

• Individual division of vessels and bronchus of the target lobe
• Systematic lymph node dissection (mandatory)
• Minimal manipulation of lymph nodes to prevent capsule rupture

Uniportal vs. Multiportal VATS

Uniportal VATS (single incision) is a viable alternative to conventional multiportal VATS, offering:

• Comparable clinical outcomes
• Potential for reduced postoperative pain
• Equivalent mortality and morbidity rates 2
• Shorter anesthesia time (177.6 vs 202.5 minutes) 4
• Lower postoperative pain scores 4

However, uniportal VATS has a steep learning curve, particularly for anatomic lung resections 5.

Common Complications and Management

The most frequent complications after VATS procedures include 6:

• Prolonged air leak
• Bleeding
• Infection
• Postoperative pain
• Port site recurrence
• Conversion to thoracotomy

Conversion Rates

Conversion from VATS to thoracotomy may be necessary in some cases:

• For lung anatomic resections, conversion rates of approximately 15-18% have been reported 5
• The majority of conversions occur during the early learning curve period 5

Caveat and Pitfalls

• Proper patient selection is critical to successful outcomes
• Surgeons should be prepared for potential conversion to thoracotomy if necessary
• A learning curve exists, particularly for complex procedures and uniportal approaches
• Regular auditing of VATS procedures for morbidity and mortality is recommended to compare results and outcomes 6

VATS is not only beneficial for lung resections but also effective for managing pleural infections and diseases, as recognized by multiple thoracic surgery societies 2.

In summary, VATS represents the standard of care for thoracic surgical procedures when technically feasible, with clear benefits for patient outcomes and recovery compared to traditional open approaches.