Video-Assisted Thoracoscopic Surgery

  • Rasmi AsapuM.B.B.S, MSc in Laparoscopic Surgery and Surgical Skills, M.R.C.S part A
  • Lauren Willis Bachelor of Science in Medical Sciences and Engineering, MSc Clinical Science (Medical Physics/Clinical Scientific Computing)

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Video-assisted thoracoscopic surgery (VATS) is a “keyhole” or minimally invasive surgical technique used to perform procedures in the chest area with smaller incisions compared to traditional open surgeries. Instead of making a large cut, the surgeon creates several tiny openings in the chest. A specialised surgical tool with a small camera at the end, known as a thoracoscope, is inserted through a small incision between the ribs. The camera helps the surgeon see inside the chest cavity on a screen, providing a clear and magnified view of the organs and tissues.

With this enhanced visual access, the surgeon can precisely navigate and perform the necessary surgery or treatment. Whether it's removing a part of the lung affected by cancer, addressing a pneumothorax (collapsed lung), draining fluid or addressing infections in the chest, VATS allows for these procedures to be performed more precisely and with minimal invasion.

The smaller incisions made during VATS result in tiny scars, which are considerably smaller than the scars from traditional open surgeries. These smaller scars are less invasive and contribute to a quicker recovery process for patients. Because VATS involves less cutting and disruption to the body's tissues, patients often experience less pain after surgery. Additionally, the reduced trauma to the body enables a quicker healing process, allowing patients to return to their regular activities sooner than with traditional surgeries.

VATS is beneficial for patients in several ways. It lowers the risk of complications associated with larger incisions, such as infections and bleeding. Moreover, it leads to shorter hospital stays, reduced discomfort, and faster recovery times. Overall, VATS not only offers a more precise approach to surgery but also aims to improve patient comfort and promote a quicker return to normal life after the procedure.1

What is thoracic surgery?

The thorax, often referred to as the chest, plays a vital role in keeping us alive and healthy. The thorax is the part of the body between your neck and abdomen (tummy), which houses some of our most crucial circulatory and respiratory organs. Imagine it like a protective shield for our heart, lungs, and big blood vessels, keeping them safe and working properly.

Inside the thoracic cavity, the heart beats to pump blood carrying oxygen and nutrients all over the body. The lungs, which help us breathe, are located on each side of the heart within the thoracic cavity. The lungs take in oxygen when we inhale and get rid of carbon dioxide when we exhale. This process is really important for our body because it helps us get the oxygen we need to survive.2

Thoracic surgery is the surgical speciality that involves the bony thorax, consisting of the ribs and sternum, as well as the pleural cavity, consisting of the pleura, lungs, and pericardium. It also includes surgical treatment of the mediastinum, which contains the heart, aorta, and thymus gland.3 A large proportion of thoracic surgery is involved in the diagnosis and treatment of cancers such as lung cancer and mesothelioma. Surgery on the heart and aorta is carried out by cardiothoracic surgeons. 

If there are any problems in this chest area, like issues with the heart, lungs, or other important organs inside, there are different ways doctors can help fix these problems. They might use traditional open surgery, where they make a bigger cut in the chest to reach the troubled area, or they might use more modern minimally invasive surgical techniques. These techniques involve making smaller cuts and using special tools and a tiny camera to see inside the chest. This way, doctors can fix things without needing to make a big cut, which can help people heal faster and with less pain.

Traditional open thoracic surgery is performed through a thoracotomy which is a large incision (cut) made between the ribs. The ribs are then cut and spread apart to allow the surgeon to access the thoracic cavity. The sternum is closed after the surgery with metal wires which hold the bones in place whilst they heal.3 

Keeping the thorax (chest) healthy is important because it's where our breathing and circulation happen. If there are any issues here, it can affect how well our body works. By using different surgical techniques to treat problems in this area, doctors help make sure our body stays in good shape and keeps working the way it should, keeping us healthy and feeling our best.

So, what's so cool about VATS? 

Video-assisted thoracic surgery (VATS) offers several advantages over traditional open thoracic surgery (thoracotomy) and is important for patients in different ways. 

Worried about scar marks or pain? 

One of the biggest benefits is that VATS is less invasive compared to traditional open surgeries. Instead of making a large incision, surgeons use small incisions in the chest, resulting in smaller scars. This means less pain and a faster recovery time.1

Concerned about work post-surgery? 

As VATS involves smaller incisions, it reduces the risk of post-operative complications. Patients often spend less time in hospital and can get back to their regular activities sooner. This procedure also lowers the chance of infections and bleeding, which are common concerns with more invasive surgeries.4

Can surgery be performed with tiny incisions? 

A significant advantage of VATS is its precision. The tiny camera used in VATS gives surgeons a clear view of the thoracic (chest) cavity, allowing them to perform delicate procedures with greater accuracy. This precision can lead to better outcomes for patients, especially when dealing with conditions like lung cancer, collapsed lungs, or infections in the chest.

Furthermore, VATS can improve the overall quality of life for patients. Because it causes less trauma to the body, patients often experience less pain and discomfort during the recovery period. They can return to their regular routines faster, positively impacting their physical and emotional well-being.5

What risks are associated with VATS?

Like all surgical procedures, video-assisted thoracoscopic surgery has risks.7

  • Air leaks after lung surgery
  • Bleeding during surgery or after surgery
  • Pneumothorax (collapsed lung)
  • Chest infection
  • Wound infection
  • Blood clots
  • Pain
  • Other risks involved with general anaesthesia

In some cases, it may be necessary to revert to open surgery (thoracotomy) if it is not safe to continue with keyhole surgery. For example, if bleeding occurs during VATS, the surgeon may need to extend the incision to get better visibility and to control the bleeding. Your doctor should discuss this with you before the procedure.6

How is a VATS procedure performed? 

  • VATS can be performed under local, regional, or general anaesthesia
  • The surgeon makes a small incision (cut) in the chest, usually about the size of a keyhole
  • The thoracoscope and other surgical instruments are inserted through the incision
  • The lung is deflated to allow the surgeon to access the thoracic cavity
  • A camera is inserted through the port to allow the surgeon to see inside the chest on a screen
  • Using these instruments and guided by the camera, the surgeon performs the necessary surgery or treatment without making a large cut
  • The surgeon can remove parts of the lung, take tissue samples, or treat specific conditions like collapsed lungs or infections using these specialised tools
  • After the surgeon has finished the surgery, they will place chest drains into the chest
  • After the procedure, the instruments are removed, and the incisions are closed with removable stitches or special tape

Are you aware of the various other types of VATS? 

Common types of VATS procedures include:

  • Lobectomy: This procedure involves the removal of a lobe (section) of the lung, typically performed to treat lung cancer or other conditions affecting a specific part of the lung
  • Biopsy: A VATS biopsy is when the surgeon takes a tissue sample from the lung or lining of the chest wall (pleura) surrounding areas for diagnostic purposes to determine the presence of infections, tumours, or other lung diseases
  • Pleurodesis: This procedure aims to treat conditions like recurrent pneumothorax (collapsed lung) or pleural effusion by creating adhesions between the lung and the chest wall to prevent the accumulation of air or fluid in the chest cavity8
  • Decortication: Used to treat conditions like pleural empyema or lung infections, this procedure involves removing infected or scarred tissue from the surface of the lung
  • Thymectomy: Thymectomy via VATS is the surgical removal of the thymus gland

These procedures are performed using the minimally invasive VATS technique, allowing surgeons to access the chest cavity and perform necessary treatments with smaller incisions, specialised instruments, and a camera for visualisation. Each type of VATS procedure is tailored to address specific thoracic conditions while minimising patient discomfort and promoting faster recovery.7

Patient selection for VATS

The selection of patients for video-assisted thoracic surgery (VATS) depends on various factors that doctors consider before recommending this procedure. Some key patient selection criteria for VATS include:

  • Diagnosis and condition: Patients with specific thoracic conditions like early-stage lung cancer, pneumothorax (collapsed lung), pleural effusion, or certain lung infections may be suitable candidates for VATS1
  • Tumour size and location: For lung cancer, smaller tumours and those located in accessible areas of the lung are often more amenable to VATS. The size and position of the tumour play a role in determining whether VATS is a suitable approach
  • General health status: Patients who are generally in good health and have acceptable lung function are typically considered for VATS. Doctors assess overall health, lung function tests, and other medical conditions to ensure that the patient can tolerate the procedure3
  • Stage of disease: In lung cancer cases, VATS may be recommended for early-stage cancers that haven't spread extensively. The stage of the disease helps determine the most appropriate treatment approach7
  • Surgical history: Patients who have had previous surgeries in the chest area may still be considered for VATS depending on the specifics of their medical history and the nature of the previous procedures
  • Patient preference: Sometimes, patient preferences and their willingness to undergo a minimally invasive procedure like VATS are also taken into account when deciding on the surgical approach

These criteria help doctors evaluate whether VATS is a suitable and safe option for a particular patient. The goal is to ensure that the benefits of VATS outweigh the risks and that the patient can undergo the procedure with the best possible outcomes and recovery.

VATS vs open surgery

Advantages of VATS

  • Less invasive
  • Fast recovery
  • Reduced scarring
  • Improved visualisation

Disadvantages of VATS

  • Costly
  • Technically challenging
  • Limited accessibility

Advantages of open surgery

  • Great accessibility & visibility
  • Most surgeons are experienced

Disadvantages of open surgery

  • Larger incision
  • Longer hospital stay
  • High risk of complications

Robotics, AI and VATS

The incorporation of robotics and artificial intelligence (AI) in video-assisted thoracoscopic surgery (VATS) is a remarkable breakthrough in the field of minimally invasive surgery.8 Robotic-assisted thoracoscopic surgery (RATS) is a next-generation surgical technique that gives surgeons 3D vision and 7 degrees of freedom.9

This innovative technology enables surgeons to perform VATS procedures with enhanced precision and efficiency, leading to better patient outcomes. Nevertheless, it is crucial to recognise that implementing these technologies demands specialised training for surgeons and continuous refinement to ensure their effectiveness in improving VATS operations.

Postoperative care

  • A leaflet is provided with doctor’s instructions post-procedure, and it should be strictly followed
  • Change surgical dressings regularly
  • Monitor surgical sites and seek urgent medical advice if you experience any redness, swelling or fluid leaking as this may indicate an infection
  • Avoid lifting heavy weights and gradually build up physical activity during recovery
  • Follow a fibre-rich diet and stay hydrated
  • Adequate rest must be taken

Comparative analysis of VATS and traditional open surgery

  Image source: Rasmi Asapu. Mural

  Image source: Rasmi Asapu. Mural

Summary

Video-assisted thoracoscopic surgery, or VATS for short, is a modern surgical technique that entails smaller incisions and specialized tools and cameras. Compared to traditional open thoracic surgeries, VATS provides numerous benefits to patients, including reduced pain, faster recovery times, and smaller scars. Thanks to the precision and better visualization offered by VATS, surgeons can perform delicate procedures with greater accuracy, leading to better outcomes for patients. Overall, VATS represents a minimally invasive approach that has revolutionised the field of thoracic surgery and is increasingly becoming the preferred option for many patients.

References

  1. Kaiser D, Ennker I, Hartz C. Video-assisted Thoracoscopic Surgery - Indications, Results, Complications, and Contraindications. Thorac cardiovasc Surg [Internet]. 1993 [cited 2024 Apr 17]; 41(06):330–4. Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-2007-1013884.
  2. Rehman I, Rehman A. Anatomy, Thorax, Heart. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 17]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470256/.
  3. Shields TW, editor. General thoracic surgery. 7th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009.
  4. Pilav I, Pasalic A, Musanovic S, Kadic K, Dapcevic M, Custovic O. Efficacy of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Pleural Empyema. Acta Inform Med [Internet]. 2020 [cited 2024 Apr 17]; 28(4):261. Available from: https://www.ejmanager.com/fulltextpdf.php?mno=35121.
  5. Hazelrigg SR, Nunchuck SK, LoCicero J. Video Assisted Thoracic Surgery Study Group data. The Annals of Thoracic Surgery [Internet]. 1993 [cited 2024 Apr 17]; 56(5):1039–44. Available from: https://linkinghub.elsevier.com/retrieve/pii/000349759590011X.
  6. Waller DA, Forty J, Morritt GN. Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax. The Annals of Thoracic Surgery [Internet]. 1994 [cited 2024 Apr 17]; 58(2):372–7. Available from: https://linkinghub.elsevier.com/retrieve/pii/0003497594922101.
  7. Brunelli A, Gooseman MR, Pompili C. Evaluation of Risk for Thoracic Surgery. Surgical Oncology Clinics of North America [Internet]. 2020 [cited 2024 Apr 17]; 29(4):497–508. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1055320720300417.
  8. Holbek BL, Petersen RH, Kehlet H, Hansen HJ. Fast-track video-assisted thoracoscopic surgery: future challenges. Scandinavian Cardiovascular Journal [Internet]. 2016 [cited 2024 Apr 17]; 50(2):78–82. Available from: https://www.tandfonline.com/doi/full/10.3109/14017431.2015.1114665.
  9. Zeng L, He T, Hu J. Minimally invasive thoracic surgery: robot-assisted versus video-assisted thoracoscopic surgery. wiitm [Internet]. 2023 [cited 2024 Apr 7]; 18(3):436–44. Available from: https://www.termedia.pl/doi/10.5114/wiitm.2023.128714

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Rasmi Asapu

M.B.B.S (NTR University of Health Sciences)
MSc in Laparoscopic Surgery and Surgical Skills from Queen Mary University of London (Barts and the London School of Medicine and Dentistry)
M.R.C.S part A (Member of Royal College of Surgeons) Edinburgh



Dr.Rasmi Asapu has completed her MSc in Laparoscopic Surgery and surgical skills from Queen Mary University of London (Barts and the London School of Medicine and Dentistry). Rasmi's passion for research is also evident in the systematic review she conducted, which showcased her extensive knowledge and scholarly abilities. She is a writer and enjoys expressing herself through the written word, dedicating her free time to this creative pursuit.

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