What is Video-Assisted Thoracic Surgery (VATS)?

What is Video-Assisted Thoracic Surgery (VATS)?

VATS is a minimally invasive thoracic surgical technique performed under general anesthesia (though local anesthesia is possible in select cases) that uses a small video camera and instruments inserted through small chest wall incisions ("ports") to diagnose and treat various thoracic diseases, offering superior visualization compared to traditional open surgery while reducing postoperative pain and recovery time. 1

Technical Description

• VATS involves inserting a video camera through a scope into the patient's chest, allowing the surgeon to view both the instruments and the anatomy on a video monitor 2
• The camera and surgical instruments are introduced through separate small incisions in the chest wall called "ports"—procedures can be performed with one port ("uniport"), two ports, or three ports depending on the specific case 2
• The procedure is typically performed under general anesthesia, though it can be performed under local anesthesia in non-intubated patients in selected circumstances 1
• Access is generally limited to one side of the mediastinum per procedure, with right-sided nodes being more straightforward to access than left paratracheal nodes 1

Primary Clinical Applications

Diagnostic Indications

• Mediastinal lymph node staging in non-small cell lung cancer, with a median sensitivity of 99% for N2 node staging 1
• Pleural disease diagnosis, including undiagnosed pleural effusions (90% diagnostic yield) and malignant pleural mesothelioma (95% sensitivity, 100% specificity) 1, 3
• Lung biopsy for undiagnosed diffuse lung disease, with tissue diagnosis obtained in 100% of cases in reported series 3
• Evaluation of indeterminate pulmonary nodules, particularly peripheral solitary nodules less than 3 cm 3, 4
• Assessment of T-stage in lung cancer, particularly for detecting or ruling out T4 lesions (38% of radiographically suspected T4 involvement shown to be absent by VATS) 1

Therapeutic Indications

• Treatment of pneumothorax (recurrent, post-traumatic, or complicated spontaneous) and bullous lung disease with 100% success rate at 12-month follow-up 3
• Evacuation of pleural effusion with simultaneous pleurodesis using talc poudrage 1
• Management of empyema, particularly stage II empyema 3
• Resection of peripheral early-stage lung cancer (stage I), now an accepted approach in many centers worldwide 4
• Thoracic trauma management in hemodynamically stable patients, including evacuation of retained hemothorax, hemostasis, diaphragmatic injury repair, and wedge lung resections 5

Performance Characteristics and Safety Profile

• Mortality: No mortality reported from VATS for mediastinal staging in 669 patients reviewed 1
• Complications: Average complication rate of 2% (range 0-9%) for mediastinal staging, with overall postoperative complications of 7.5% across all VATS procedures 1, 3
• Conversion to thoracotomy: Required in approximately 6.6% of cases, often due to adhesions or inadequate visualization 3
• Hospital stay: Mean postoperative stay of 3 days with median chest tube drainage of 2.7 days 3
• Pain control: Postoperative pain typically controlled with non-narcotic analgesics, with patients scoring pain <50% on visual analogue scale 3

Advantages Over Open Thoracotomy

• Smaller incisions result in fewer wound infections and faster recovery 2
• Significantly reduced postoperative pain compared to thoracotomy, though still requires multimodal analgesia including regional blocks 6
• Shorter hospital stays and faster return to normal activities 3
• Excellent visualization of thoracic structures despite the minimally invasive approach 1

Critical Technical Considerations

• Incision placement: VATS incisions should be aligned with possible future thoracotomy incisions to allow resection of VATS tracts if subsequent surgery is needed, preventing tumor recurrence in these areas 1
• Conversion readiness: Surgeons must be prepared to convert to open thoracotomy when visualization is inadequate, particularly when adhesions prevent safe examination (occurs in approximately 20% of cases) 7
• Bilateral assessment limitation: VATS generally assesses only one side of the mediastinum per procedure, unlike cervical mediastinoscopy which can access bilateral paratracheal nodes 1

Important Caveats

• VATS has a false-negative rate of approximately 4% for mediastinal node staging in both enlarged and normal-sized nodes 1
• The American College of Chest Physicians advises against persisting with VATS when visualization is inadequate, as this risks incomplete evacuation and missed pathology 7
• In malignant pleural mesothelioma, tumor seeding can occur along VATS tracts, identified as a negative prognostic factor for long-term survival 1
• VATS should be used with caution in patients with severe life-threatening intra-abdominal injuries when performed for thoracic trauma 5