What is Video-Assisted Thoracic Surgery (VATS)?

Video-Assisted Thoracic Surgery (VATS): Overview and Applications

Video-assisted thoracic surgery (VATS) is a minimally invasive surgical technique performed under general anesthesia that allows access to the pleural space through small incisions in the chest wall, enabling diagnosis and treatment of various thoracic conditions with lower morbidity compared to traditional thoracotomy. 1

Definition and Technical Aspects

• VATS is performed by introducing a small video camera and surgical instruments into the pleural cavity through separate ports (small incisions) in the chest wall, allowing visualization of the pleural space while avoiding the need for a full thoracotomy 2, 3
• The procedure is typically performed under general anesthesia and, in most cases, requires single-lung ventilation 1
• VATS is generally limited to assessment of one side of the mediastinum, with access to right-sided nodes being more straightforward than left paratracheal nodes 1
• Various approaches exist, including single-port (uniport), two-port, or three-port techniques, depending on the specific procedure and surgeon preference 3

Safety and Complications

• VATS has demonstrated excellent safety with no reported mortality for mediastinal staging and complications in only approximately 2% of cases (range 0-9%) 1
• Common complications include:
  • Prolonged air leak
  • Bleeding
  • Infection
  • Postoperative pain
  • Port site recurrence (in malignancy cases)
  • Conversion to thoracotomy (when complications arise or complete procedure cannot be performed via VATS) 4
• The overall complication and mortality rates for VATS procedures are generally very low, making them safe and effective alternatives to open procedures 4

Clinical Applications

Lung Cancer Management

• VATS plays important roles in lung cancer diagnosis, staging, and treatment:
  • Evaluation of indeterminate pulmonary nodules 5, 6
  • Mediastinal lymph node staging with sensitivity ranging from 50-100% 1
  • Assessment of T stage to detect or rule out T4 lesions (radiographically suspected T4 involvement was shown to be absent by VATS in 38% of patients) 1
  • Anatomic pulmonary resection for early-stage lung cancer (Stage I) 1
• For clinical stage I NSCLC, a VATS approach is preferred over thoracotomy for anatomic pulmonary resection in experienced centers 1
• VATS lobectomy is associated with fewer total complications (26% vs 35%), fewer pulmonary complications (8% vs 12%), less atrial fibrillation (7% vs 12%), fewer blood transfusions (2% vs 5%), earlier chest tube removal, and shorter hospital stays compared to open lobectomy 1

Pleural Disease Management

• VATS is valuable for diagnosis and management of pleural diseases:
  • Diagnosis of undiagnosed pleural effusions (after VATS, less than 10% of effusions remain undiagnosed) 1
  • Management of malignant pleural effusions through pleurodesis 1
  • Treatment of pneumothorax 1, 3
  • Pleurectomy for recurrent pneumothorax 4, 5
• For pneumothorax treatment, VATS access can be considered for surgical pleurodesis, though thoracotomy may provide lower recurrence rates for high-risk occupations 1

Mediastinal Disease

• VATS provides access to mediastinal nodes for diagnostic purposes and staging 1
• It serves as a complementary tool to standard cervical mediastinoscopy in the invasive staging of mediastinal lymph nodes 2
• VATS can replace anterior mediastinoscopy for biopsies of lymph nodes not accessible by cervical mediastinoscopy 6

Mesothelioma Diagnosis

• VATS plays an important role in the diagnosis of malignant pleural mesothelioma, providing earlier diagnosis and better histological classification than closed pleural biopsy 1
• It allows for larger and more representative biopsies and more accurate staging of mesothelioma 1

Advantages Over Open Procedures

• Reduced postoperative pain compared to thoracotomy 1
• Shorter hospital length of stay (median 4 days vs 6 days for open procedures) 1
• Earlier chest tube removal (median 3 days vs 4 days) 1
• Fewer overall complications and pulmonary complications 1
• Comparable long-term survival outcomes to open procedures for early-stage lung cancer 1
• Ability to detect unsuspected causes of irresectability before proceeding with standard resection, reducing the "open and close thoracotomy" rate 1

Limitations and Considerations

• VATS is contraindicated when:
  • The patient cannot tolerate single-lung ventilation (e.g., mechanical ventilation, prior contralateral pneumonectomy, abnormal airway anatomy) 1
  • The pleural space contains adhesions that would prevent safe insertion of instruments 1
  • There is insufficient expertise to manage potential complications 1
• Pleurodesis failure after VATS may occur due to:
  • Incomplete visualization of the entire pleural surface 7
  • Trapped lung or incomplete lung expansion preventing apposition of pleural surfaces 7
  • Suboptimal technique including inadequate talc distribution 7
  • Less intense pleural inflammatory reaction compared to open thoracotomy 7
• VATS procedures typically have longer operative times compared to open procedures (median 173 min vs 143 min) 1

Evolution and Current Status

• VATS has evolved from primarily a diagnostic tool to a therapeutic approach for various thoracic conditions 2, 5
• It is now the preferred approach for pleural disease management, lung biopsy, recurrent pneumothorax, and sympathectomy among thoracic surgeons 5
• While initially controversial for anatomic lung resections, VATS lobectomy is now widely accepted for early-stage lung cancer in experienced centers 1, 5