What are the complications of Video-Assisted Thoracic Surgery (VATS)?

Complications of Video-Assisted Thoracic Surgery (VATS)

Intraoperative Complications

The most critical intraoperative complication during VATS is major vascular injury, occurring in approximately 1.4-1.6% of cases, with the majority (90%) involving major pulmonary vessels and most frequently during upper lobectomy. 1

Bleeding and Vascular Injury

• Major bleeding represents the primary reason for conversion to thoracotomy, though experienced surgeons can manage most bleeding events thoracoscopically using compression, hemostatic sealants, or suture repair 2, 1
• The incidence of severe intraoperative complications is similar between VATS and open thoracotomy (1.57% vs 1.44%, P=1.0) 1
• Intraoperative mortality is essentially zero in contemporary series, though severe bleeding requires immediate sponge stick compression and rapid decision-making regarding conversion 2, 1
• Small arterial injuries can be managed with hemostatic matrix sealant agents without conversion, particularly useful for surgeons in their learning curve 3

Conversion to Thoracotomy

• Conversion rates range from 0-12% and should not be considered a failure but rather a safety resource 4, 2
• The primary indication for conversion is inadequate control of bleeding or inability to achieve adequate visualization 2

Early Postoperative Complications

Pulmonary Complications

• Prolonged air leak is the most common postoperative complication, occurring in 7-35% of patients 4, 5
• Pneumonia occurs less frequently with VATS compared to open thoracotomy, particularly in elderly patients 4
• Atrial arrhythmias occur at significantly lower rates with VATS versus open procedures 4

Infectious Complications

• Wound infection occurs in approximately 6% of cases and represents the most common early morbidity 4
• Pleural space infection (empyema) occurs in 7-24% of cases depending on the indication and complexity 4
• Bronchopleural fistula is reported in 7-35% of surgical series, particularly after extensive resections 4

Cardiovascular Complications

• VATS demonstrates significantly lower rates of overall perioperative morbidity compared to thoracotomy 4
• Postoperative cardiac complications are reduced in elderly patients undergoing VATS versus open procedures 4

Mortality

Operative mortality is essentially zero in contemporary VATS series, with postoperative mortality ranging from 0-9% depending on patient selection and extent of resection. 4

• The 60-day mortality ranges from 0-11% across various indications 4
• Postoperative mortality in elderly patients (>80 years) is remarkably low at <2% for VATS compared to higher rates with open thoracotomy 4
• Pneumonectomy carries higher mortality risk and should be avoided when possible, particularly in elderly patients 4

Late Complications and Recurrence

Disease Recurrence

• Recurrence of underlying disease (bronchiectasis, NTM infection) depends on completeness of resection and underlying etiology 4
• Mean time to symptom recurrence is approximately 34 months when incomplete resection occurs 4
• Persistent infection with Pseudomonas aeruginosa, immunocompromised status, and extent of residual disease predict shorter recurrence-free intervals 4

Chronic Complications

• Post-thoracotomy pain syndrome occurs but at lower rates than open surgery 5
• Chronic pleural thickening and restrictive lung disease occur more frequently when surgical intervention is delayed 6
• Port site recurrence is reported but remains rare in the literature 5

Specific High-Risk Scenarios

Failed VATS Requiring Reoperation

• Incomplete decortication occurs in approximately 20% of cases when VATS visualization is inadequate, requiring early reoperation 7
• Failed VATS decortication with persistent pleural infection mandates surgical consultation within 7 days, not prolonged antibiotic therapy alone 6
• Conversion to open thoracotomy should occur promptly when source control cannot be achieved thoracoscopically 6

Diaphragmatic Complications

• Pneumoperitoneum after diaphragmatic repair is expected and does not require re-exploration unless peritonitis develops 7
• Serial abdominal examinations every 4-6 hours for 48 hours post-operatively are essential to detect evolving peritonitis 7

Risk Factors for Complications

Comorbidities—particularly cardiac and pulmonary disease—represent the most significant predictors of postoperative complications, more so than chronological age alone. 4

• Poor functional capacity (<4 METs) predicts increased mortality after thoracic surgery (relative risk 18.7) 4
• Extent of resection impacts outcomes, with pneumonectomy carrying higher risk than lobectomy or limited resection 4
• Immunocompromised patients and those with persistent resistant organisms have worse outcomes 4

Critical Pitfalls to Avoid

• Never delay conversion to thoracotomy when bleeding cannot be controlled or visualization is inadequate—this increases morbidity without improving outcomes 2, 1
• Do not pursue prolonged antibiotic therapy alone for organized empyema or failed VATS decortication; source control through definitive surgery is paramount 6
• Avoid pneumonectomy in elderly patients when possible due to significantly higher mortality rates 4
• Do not assume pneumoperitoneum after diaphragmatic repair requires immediate reoperation; clinical peritonitis must be present 7
• Ensure adequate preoperative cardiac and pulmonary assessment, as comorbidities predict complications more reliably than age 4