Why Is Video-Assisted Thoracoscopic Surgery (VATS) Done?

A video-assisted thoracoscopic surgery (VATS) is a minimally invasive thoracic surgery that provides adequate visualization despite limited access to the thorax.

A video-assisted thoracoscopic surgery (VATS) is a minimally invasive thoracic surgery that does not use a traditional open surgery approach. VATS provides adequate visualization despite limited access to the thorax. 

The operating time and postoperative recovery time in VATS is shorter than those in open surgery. The postoperative morbidity rates in VATS are lower than those in open surgery, and the patients can resume normal activities sooner than in open surgery. VATS can also be performed as a diagnostic procedure to study the thorax.

VATS is principally used in the management of pulmonary, mediastinal, and pleural pathology. Its main benefit is the avoidance of a thoracotomy incision, which allows a shorter operating time, less postoperative morbidity, and earlier return to normal activity, compared with what can be achieved with a thoracotomy.

Anatomy of the lungs

During inhalation, air travels through the nose and/or mouth into the trachea (windpipe). The trachea further divides into two tubes called the bronchus (bronchi). The bronchi open into the lungs and branch out into smaller tubes called the bronchioles. The end of bronchioles opens into little air sacs called the alveoli that aid in gaseous exchange. The alveoli are surrounded by the blood vessels, through which the exchange of gases, oxygen, and carbon dioxide takes place.

The mediastinum is an area present in the midline of the thoracic cavity (chest cavity), which is surrounded by the left and right pleural sacs. The pleura is a thin membrane that lines the outer surface of the lungs (visceral pleura) and the inner surface of the chest wall (parietal pleura). The space between these two pleurae is called the pleural space. The pleural space is less than 1 mm thick and is filled with the pleural fluid. 

When the pleural space is affected by pathologic disorders, it can lead to medical consequences. One of the complications is fibrothorax, which is an abnormal accumulation of fibrous tissues (scar tissue) over the visceral pleura. The deposition of fibrous tissues over the lungs can be so intense that the layers of the pleural space fuse, preventing the lungs to expand adequately. Over time, the lungs become entrapped, and breathing becomes difficult.

Video-assisted thoracoscopic surgery (VATS) is used in both diagnostic and therapeutic pleural, pulmonary (lung), and mediastinal surgery. Some common indications for VATS include the following:

• Lung, mediastinal, and pleural biopsies
• Lobectomy (removal of part of the lungs)
• Resection of the lung nodule
• Evaluation of mediastinal tumors or adenopathy
• Bullectomy: It is the surgical removal of a bulla. Bulla or bullae is a pathological condition in the lungs that is usually caused by chronic obstructive pulmonary disease (COPD).
• Treatment of recurrent pneumothorax (air in the pleural cavity)
• Management of empyema (pus in the pleura)
• Repair of a broncho-pleural fistula (an abnormal connection between the bronchus and pleura)
• Chest trauma 
• Pericardial window (a procedure done on the sac surrounding the heart)

Absolute contraindications include the following:

• Markedly unstable or anxious patient
• Extensive adhesions of the pleural space
• Prior pleural procedures

Relative contraindications include the following:

• Inability to tolerate the procedure
• Previous procedures of the thorax
• Extensive pleural diseases
• Bleeding disorders
• Prior radiation treatment for thoracic cancers

Video-assisted thoracoscopic surgery (VATS) is performed under anesthesia. One to four small incisions (the largest being 4 cm) are used in VATS procedures. A 5- or 10-mm video thoracoscope (a camera with a light source) of various angles and surgical instruments are introduced into the incisions. For diagnostic procedures or simple procedures such as drainage of pleural effusions, a single effusion is usually sufficient. 

Complications may include the following:

• Persistent air leak
• Bleeding
• Infection
• Damage to the nerves and other structures 
• Reaction to anesthesia 
• Tumor implantation following a video-assisted thoracoscopic surgery (VATS) (transfer of tumor cells to other unaffected areas)