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.
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