General Setup and Techniques

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CHAPTER 1 General Setup and Techniques

Robert J. McKenna, Jr.

Introduction

The principles of video-assisted thoracic surgery (VATS) are described in this chapter. Although thoracic surgeons may use many techniques to perform minimally invasive operations, my techniques are highlighted in the following paragraphs.

Key Points

♦ Minimally invasive surgery is good for patients.
♦ Surgeons can use VATS for most standard operations that previously required a thoracotomy.
♦ Standard instruments and simple techniques can ensure these procedures are safe for patients.

Definition and Philosophy

A VATS procedure is not a compromise operation; it is the same operation that can be performed by a thoracotomy.1,2 The standard operation is performed with visualization on a monitor and through incisions without spreading the ribs. Procedures such as a video-assisted lobectomy provide the same complete cancer operation that is performed through a thoracotomy.3–12

Indications for an operation usually do not change because the procedure can be performed with minimally invasive surgery. VATS can be performed with standard instruments that are used for open procedures. Articulating instruments are not required. Proper placement of the incisions is essential for successful completion of an operation by VATS techniques.

Positioning

♦ The position of the patient, monitors, and lights should be set before preparing the patient.
♦ For most VATS procedures, the patient is placed in the lateral decubitus position with a slight posterior tilt. The patient is taped in place. The arms are at 90 degrees, with the elbows bent in a praying position and with two pillows between the arms. Padding between the arm board and the downside elbow minimizes the risk of compression causing damage to the ulnar nerve.
♦ The operating table is flexed with the patient’s anterior-superior iliac crest positioned over the flexion of the table. This opens the rib spaces, and this position shifts the hip out of the way so it does not interfere with the movement of the thoracoscope.
♦ The monitors are placed above the head of the operating table so that the surgeon and all assistants have an unobstructed view of the monitors (Figure 1-1). The surgeon stands on the anterior side of the patient.
♦ Different positioning may be used for other video-assisted thoracic operations. For example, a Heller myotomy is performed with the monitors at the foot of the bed.
image

Figure 1-1 Setup for VATS. The monitors are placed above the head of the bed, and the surgeon stands anteriorly.

Incisions

Placement of the incisions (Figure 1-2) is key to the performance of VATS. Proper placement of the incisions creates the best angles for the instruments to perform these procedures.

image

Figure 1-2 Incisions for a video-assisted lobectomy.

Incision 1

♦ Incision 1 is 2 cm long and placed in the intercostal space that is just below the inframammary crease. It is placed as far anteriorly and inferiorly as possible (approximately the sixth intercostal space in the midclavicular line).
♦ The incision through the chest wall is angled posteriorly so that it automatically directs instruments through this incision toward the major fissure and away from the pericardium.
♦ Creation of this incision first allows air into the pleural space so the lung can decompress.
♦ A finger through this incision confirms that there is no pleural symphysis. If one is detected, blunt dissection is performed to create a space for the trocar to pass through incision 2.
♦ A finger through this incision protects the diaphragm and liver as the trocar is placed through incision 2.

Incision 2

♦ Incision 2 is used for the trocar and thoracoscope.
♦ It is placed low in the chest to provide a panoramic view of the chest. It is in the eighth intercostal space in the posterior axillary line.
♦ It is angled superiorly so that there is less torque on the intercostal nerve.

Incision 3

♦ Incision 3 is a utility incision through which much of the dissection is performed and through which a lobe is removed.
♦ It extends 4 to 6 cm anteriorly from the border of the latissimus dorsi muscle.
♦ The location of the interspace for the incision is based on the superior pulmonary vein. Through incision 1, a ring forceps pushes the lung posteriorly to expose the superior pulmonary vein. Pressure on the chest wall helps to identify the interspace that is directly up from the vein. That space is used for an upper lobectomy, and one space lower is used for a middle or lower lobectomy.
♦ Digital palpation of almost all areas of the lung is possible through this incision. I have been able to palpate 3-mm masses through this incision.

Incision 4

♦ Incision 4 is 1 cm long and placed in the space in the auscultatory triangle.
♦ It is approximately 3 fingerbreadths below the tip of the scapula and halfway to the spine.
♦ A slightly higher incision provides slightly better access to help with the paratracheal node dissection. A slightly lower incision provides a better angle for the stapler to cross the superior pulmonary vein.

Instruments

♦ Standard thoracotomy instruments are the mainstay for VATS. Although there are instruments for thoracoscopic procedures, open instruments are primarily used.
♦ We primarily use 14-inch Metzenbaum scissors, 14-inch DeBakey pickups, and curved ring forceps (Figure 1-3).
image

Figure 1-3 Standard instruments used for a video-assisted lobectomy.

Visualization and Lenses

♦ A 5-mm thoracoscope is preferred over a 10-mm thoracoscope because it causes less torque on the intercostal nerves (reducing pain), and video equipment can provide excellent visualization through small thoracoscopes.
♦ A 30-degree lens allows the surgeon to see around structures better than a 0-degree lens.
♦ A more panoramic view of the pleural space usually is preferable to a closer view. The wider view provides a better understanding of the overall anatomy. When using electrocautery, a wider view shows nearby structures such as nerves and blood vessels, which may be inadvertently cut if not directly visualized. I often tell our residents that if their instinct is to move closer with the camera, they should instead back up the camera.
♦ A rigid/flexible endoscope (Olympus, Center Valley, Penn) can be helpful, but it requires an experienced person to control it.

Operative Techniques and Complications

Decompression of the Lung

♦ A double-lumen tube is preferable to a bronchial blocker for VATS because the larger channel of the double-lumen tube enables better lung decompression.
♦ Clamp the double-lumen tube early (as soon as the patient is positioned for preparation or before turning) to begin the lung decompression.
♦ Fiberoptic bronchoscopy is important.

image To confirm proper placement of the tube after intubation
image For suctioning in the mainstem bronchus to decompress the lung (better than a suction catheter)
image To evaluate the position of the tube if the patient desaturates during the procedure, or if the decompressed lung begins to expand, or to be ventilated during the procedure

♦ Right-sided double-lumen tubes is preferred for left-sided operations and left-sided tubes for right-sided operations because a contralateral tube is needed for a sleeve resection, because it is easier for a pneumonectomy (compared with manipulation of an ipsilateral tube during a pneumonectomy), and because the anesthesiologist is comfortable with right-sided tubes when they are really needed, as for a left pneumonectomy or a left sleeve resection.

Hypoxia During Video-Assisted Thoracic Surgery

♦ Hypoxia usually is related to improper positioning of the tube.
♦ Bronchoscopy should be performed to determine if a left-sided tube is too low in the bronchus, causing only the left lower lobe to be ventilated, or to see if a right-sided tube is out of position and the Murphy hole is not aligned correctly with the right upper lobe bronchus.
♦ Occasionally, the surgeon needs to break scrub to check the positioning of the tube.
♦ Patients almost never require continuous positive airway pressure (CPAP) or temporary ventilation of the operated lung.

Dissection

♦ Dissect on named structures (e.g., pulmonary artery, pericardium). Dissecting in the fat may seem safer to a novice, but the anatomy is clearer when named structures are clearly visualized, and the major vessels and nerves are better seen and better protected.
♦ Surgeons can use sharp or blunt dissection. Simply pushing on a pulmonary artery with the Metzenbaum scissors often defines the vessel.
♦ Through the utility incision, DeBakey pickups can lift the soft tissue, and Metzenbaum scissors can dissect around vessels (Figure 1-4), or blunt dissection may be performed with the tip of the Yankauer suction or a peanut.
♦ Pulmonary vessels can be safely lifted with instruments. This maneuver better defines the deeper margin of the vessel. A good purchase on the vessel makes lifting the vessel safer, but a tiny purchase on a vessel increases the likelihood of tearing the vessel.
image

Figure 1-4 Dissection around pulmonary vein.

Stapling Blood Vessels

♦ Spreading the right angle widely behind the vessel creates a tunnel for the stapler to transect the vessel (Figure 1-5). The stapler requires a large tunnel.
♦ The anvil passes behind the vessel into the tunnel that has been created by spreading the right angle. Surgeons primarily use endoscopic staples (EZ 45, Ethicon EndoSurgery, Cincinnati, Ohio; Endo-GIA, Covidien, Mansfield, Mass).
♦ Articulating staples are not needed if the incisions are placed properly.
♦ There are several methods to safely pass a stapler across a vessel.

image Usually, passing the stapler from the proper angle allows the anvil of the stapler to pass through the tunnel behind the vessel.
image Occasionally, a tie placed around the vessel lifts it to facilitate passing the stapler across the vessel (Figure 1-6A and B).
image Alternatively, pass an 8-mm, red Robinson-Nelaton (Rob-Nel) catheter around the vessel. The anvil of the stapler is placed into the wide end of the Rob-Nel catheter. Leading the Rob-Nel catheter positions the stapler across the vessel (Figure 1-6C and D).

♦ Be prepared for the possibility of bleeding from a staple line. The thoracoscope should be retracted so vision is not compromised if there is bleeding, the scrub nurse should have a sponge stick available, and the surgeon should have a ring forceps in the incision to apply pressure as needed.
image

Figure 1-5 Spreading a right angle creates a tunnel for stapling.

image

Figure 1-6 A, A tie lifts the right upper lobe vein. B, The tie can be used to facilitate passage of the stapler around a vessel. C, Alternatively, a red Rob-Nel catheter can be placed around the vessel. D, This catheter can be used to pass the stapler around the vessel.

Alternative Techniques for Vessels

♦ Staples may be too large and may be an unnecessary expense for smaller vessels.
♦ Small vessels can be clipped with standard clips used during thoracotomy (Figure 1-7).
♦ Vessels may be tied with standard extracorporeal knot tying. Through the utility incision, a finger can pass the tie to the vessel (Figure 1-8). Knot pushers are also available (Figure 1-9).
♦ A suture ligature may be used.
image

Figure 1-7 Placement of a clip for a small pulmonary artery.

image

Figure 1-8 Tying a small vessel.

image

Figure 1-9 A knot pusher.

Stapling Parenchyma

♦ Surgeons primarily use endoscopic staples (EZ 45, Endo-GIA) to complete a fissure or perform a nonanatomic wedge resection.
♦ Articulating staples are not needed if the incisions are placed properly. The mobile lung can be positioned properly into the jaw of the stapler.
♦ Pass the stapler carefully across the lung parenchyma so that the device is parallel to the surfaces of the lung, rather than poking into the lung parenchyma (Figure 1-10).
♦ When completing the fissure, place the anvil of the stapler on the pulmonary artery. Hold the stapler in that position as the parenchyma is pulled into the device. This protects the pulmonary vessels and minimizes the chances of damage to the vessels or inadvertent transaction of a vessel.
image

Figure 1-10 A, Correct positioning for the stapler to transect the RUL bronchus B, and the fissure.

Suturing

♦ The ability to suture is important for advanced VATS procedures.
♦ Endoscopic needle holders are unnecessary. A standard needle holder or a thoracoscopic needle driver can be inserted through the utility incision. The mobile lung can be moved so that the tissue is aligned for suturing (Figure 1-11).
♦ Knots are tied outside the body in the same fashion as for a thoracotomy. A finger can push the knots to the tissue. If the tissue is too far away, a ring forceps can bring it closer to the incision. Rarely is a knot pusher needed.
image

Figure 1-11 Suturing with a standard needle holder.

Removal of Specimens

♦ All specimens that may be cancer should be removed in a bag to minimize the chance of tumor recurrence in an incision.
♦ Smaller specimens can be removed in a tissue bag (EndoCatch, Covidien).
♦ Larger specimens, such as a lobe, are placed in a larger bag for removal (LapSac, Cook, Bloomington, Indiana) (Figure 1-12). Removing an entire lobe through a 4- to 6-cm incision requires a strong pull, and smaller bags break with a strong pull.
image

Figure 1-12 Placement of a lobe into the LapSac tissue pouch.

References

1 McKenna R.J.Jr, Houck W., Fuller C.B. Video-assisted thoracic surgery lobectomy: experience with 1100 cases. Ann Thorac Surg. 2006;81:421-426.

2 Onaitis M.W., Petersen R.P., Balderson S.S., et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg. 2006;244:420-425.

3 Mahtabifard A., Fuller C.B., McKenna R.J.Jr. VATS sleeve lobectomy. Ann Thorac Surg. 2008;85(2):5279-5332.

4 McKenna R.J.Jr, Mahtabifard A., Fuller C.B. Fast tracking after VATS pulmonary resection. Ann Thorac Surg. 2007;84(5):1663-1667.

5 Cerfolio R.J., Bass C., Katholi C.R. Prospective, randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg. 2002;73:1727-1731.

6 Whitson B.A., Boettcher A., Bardales R., Kratzke R.A., Dahlberg P.S., Andrade R.S., Maddaus M.A. Comparison of video assisted thoracoscopic surgery to thoracotomy for resection of clinical stage I non-small cell lung cancer. Presented at the American College of Surgeons Congress, Chicago, IL, October 10; 2006.

7 Nomori H., Ohtsuka T., Horio H., et al. Difference in the impairment of vital capacity and 6-minute walking after a lobectomy performed by thoracoscopic surgery, an anterior limited thoracotomy, an antero-axillary thoracotomy, and a posterolateral thoracotomy. Surg Today. 2003;33:7-12.

8 Nakata M., Saeki H., Yokoyama N., et al. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg. 2000;70:938-941.

9 Demmy T.L., Curtis J.J. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg. 1999;68:194-200.

10 Demmy T.L., Plante A.J., Nwogu C.E., et al. Discharge independence with minimally invasive lobectomy. Am J Surg. 2004;188:698-702.

11 Nakajima J., Takamoto S., Kohno T., Ohtsuka T. Costs of videothoracoscopic surgery versus open resection for patients with lung carcinoma. Cancer. 2000;89(Suppl):2497-2501.

12 Petersen R.P., Pham D., Burfeind W.R., et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg. 2007;83:1245-1249. discussion 1250

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CHAPTER 1 General Setup and Techniques

Robert J. McKenna, Jr.

Introduction

The principles of video-assisted thoracic surgery (VATS) are described in this chapter. Although thoracic surgeons may use many techniques to perform minimally invasive operations, my techniques are highlighted in the following paragraphs.

Key Points

♦ Minimally invasive surgery is good for patients.
♦ Surgeons can use VATS for most standard operations that previously required a thoracotomy.
♦ Standard instruments and simple techniques can ensure these procedures are safe for patients.

Definition and Philosophy

A VATS procedure is not a compromise operation; it is the same operation that can be performed by a thoracotomy.1,2 The standard operation is performed with visualization on a monitor and through incisions without spreading the ribs. Procedures such as a video-assisted lobectomy provide the same complete cancer operation that is performed through a thoracotomy.3–12

Indications for an operation usually do not change because the procedure can be performed with minimally invasive surgery. VATS can be performed with standard instruments that are used for open procedures. Articulating instruments are not required. Proper placement of the incisions is essential for successful completion of an operation by VATS techniques.

Positioning

♦ The position of the patient, monitors, and lights should be set before preparing the patient.
♦ For most VATS procedures, the patient is placed in the lateral decubitus position with a slight posterior tilt. The patient is taped in place. The arms are at 90 degrees, with the elbows bent in a praying position and with two pillows between the arms. Padding between the arm board and the downside elbow minimizes the risk of compression causing damage to the ulnar nerve.
♦ The operating table is flexed with the patient’s anterior-superior iliac crest positioned over the flexion of the table. This opens the rib spaces, and this position shifts the hip out of the way so it does not interfere with the movement of the thoracoscope.
♦ The monitors are placed above the head of the operating table so that the surgeon and all assistants have an unobstructed view of the monitors (Figure 1-1). The surgeon stands on the anterior side of the patient.
♦ Different positioning may be used for other video-assisted thoracic operations. For example, a Heller myotomy is performed with the monitors at the foot of the bed.
image

Figure 1-1 Setup for VATS. The monitors are placed above the head of the bed, and the surgeon stands anteriorly.

Incisions

Placement of the incisions (Figure 1-2) is key to the performance of VATS. Proper placement of the incisions creates the best angles for the instruments to perform these procedures.

image

Figure 1-2 Incisions for a video-assisted lobectomy.

Incision 1

♦ Incision 1 is 2 cm long and placed in the intercostal space that is just below the inframammary crease. It is placed as far anteriorly and inferiorly as possible (approximately the sixth intercostal space in the midclavicular line).
♦ The incision through the chest wall is angled posteriorly so that it automatically directs instruments through this incision toward the major fissure and away from the pericardium.
♦ Creation of this incision first allows air into the pleural space so the lung can decompress.
♦ A finger through this incision confirms that there is no pleural symphysis. If one is detected, blunt dissection is performed to create a space for the trocar to pass through incision 2.
♦ A finger through this incision protects the diaphragm and liver as the trocar is placed through incision 2.

Incision 2

♦ Incision 2 is used for the trocar and thoracoscope.
♦ It is placed low in the chest to provide a panoramic view of the chest. It is in the eighth intercostal space in the posterior axillary line.
♦ It is angled superiorly so that there is less torque on the intercostal nerve.

Incision 3

♦ Incision 3 is a utility incision through which much of the dissection is performed and through which a lobe is removed.
♦ It extends 4 to 6 cm anteriorly from the border of the latissimus dorsi muscle.
♦ The location of the interspace for the incision is based on the superior pulmonary vein. Through incision 1, a ring forceps pushes the lung posteriorly to expose the superior pulmonary vein. Pressure on the chest wall helps to identify the interspace that is directly up from the vein. That space is used for an upper lobectomy, and one space lower is used for a middle or lower lobectomy.
♦ Digital palpation of almost all areas of the lung is possible through this incision. I have been able to palpate 3-mm masses through this incision.

Incision 4

♦ Incision 4 is 1 cm long and placed in the space in the auscultatory triangle.
♦ It is approximately 3 fingerbreadths below the tip of the scapula and halfway to the spine.
♦ A slightly higher incision provides slightly better access to help with the paratracheal node dissection. A slightly lower incision provides a better angle for the stapler to cross the superior pulmonary vein.

Instruments

♦ Standard thoracotomy instruments are the mainstay for VATS. Although there are instruments for thoracoscopic procedures, open instruments are primarily used.
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