Video-Assisted Thoracic Surgery (VATS)
Video-assisted thoracic surgery is surgery of the chest that is performed with a videothorascope and other special instruments, that are inserted into the chest via small incisions. This procedure avoids trauma associated with large chest incisions of 6-8 inches long that is normally used in conventional open-chest surgery.
- The videoscope transmit the images of the operation procedure inside the chest onto a computer screen positioned opposite the operator, where the operation can be seen. Special instruments allow a surgical procedure to be done through the small incision.
- The advantages as compared with ‘open’ chest surgery are:
- Less postoperative pain.
- Shorter hospital stays.
- Faster return to work.
Types of Video-Assisted Thoracoscopic Surgery (VATS)
- Surgical Pleurodesis for recurrent Pneumothorax
- Lung Biopsy
- Wedge Lung Resection
- Lobectomy or Pneumonectomy
- Drainage of Pericardial and Pleural Effusion
- Mediastinal, Pericardial and Thymus surgical procedures
- Bilobectomy
- Segmentectomy
- Wedge resection
- Pneumothorax (VATS Pleurodesis)
- Pleural Effusion (VATS Pleurodesis)
- Chylothorax
- Empyema (Decortication)
- Thymoma (Thymic Tumours)
- Myasthenia Gravis (Thymectomy)
- Lymphoma (Chamberlain procedure)
VATS Surgical Pleurodesis
Pneumothorax is a condition where the air has leaked into the chest cavity. A common cause is the rupture of a bleb or a weak spot in the lung causing air to leak out of the lung, like a hole in a balloon. In this procedure, the ruptured bleb in the lung is removed by an endo stapler device inserted through a small chest incision under direct vision with a videothorascope inserted through a separate chest incision. The lung is then made to stick to the chest wall to obliterate the space between the lung and chest wall so that it cannot collapse again.
VATS Lung Biopsy
This is a procedure where a small sample of the lung tissue is removed through a small incision between the ribs. The most appropriate lung specimen is removed under the video thoracoscopic vision and this specimen is sent to the pathologist to be examined for the presence of lung diseases such as infection, interstitial disease or presence of cancer.
VATS Wedge Lung Resection
This is excision and stapling of a wedge-shaped portion of lung tissue for diagnoses or treatment of lung nodules.
VATS Lobectomy
This procedure involves removing a lobe of the lung and is primarily used to treat small lung cancer mass. Usually, a 3 to 4 inches incision is made to provide access to the chest cavity with or without spreading the ribs. The patient usually experiences less pain, shorter hospital stay and faster recovery to work than through the conventional open surgical approach in which a ‘hockey stick’ incision is made on the side of the chest and the ribs are spread apart for the surgeon to see and remove the tumour.
VATS drainage of Pericardial and Pleural Effusion
- The pericardium is the fibrous bag covering the heart.
- The pleura is the smooth lining surrounding the lung and underlying the chest wall with a potential space in between.
A pericardial fluid can accumulate excessively between the heart and pericardium caused by inflammatory condition, infection or cancer spread. The pericardial fluid can cause compression of the heart and prevent it from expanding. The fluid can be removed by video-assisted thorascope procedure which involves creating a window in the pericardium through small incision in the chest wall.
A pleural effusion can accumulate within the chest wall due to inflammation, infection, cancer, heart failure, kidney disease or liver disease. The excess fluid can be removed by videothorascope procedure through a small incision in the chest wall if gets loculated.
VATS Mediastinal and Thymus procedure
- The mediastinum is the space between the lungs in the middle of the chest.
- The thymus is a small gland extending from the base of the neck into the chest inlet to the front part of the heart.
Videothorascope procedure can be used to examine the mediastinum and able to remove tissue sample or remove the gland if there is a tumour in it or to remove the gland in a condition called Myaesthenia gravis. Cancerous growth in the mediastinum also can be removed by the same method.
FAQs
How long is the videothorascope operation and how long do one have to stay in the hospital after videothorascopy?
The length of the procedure depends on the procedure which is performed. In general the procedure requires a general anaesthesia and varies from ½ hour to 4 hours depending on the procedure.
(VATS surgical pleurodesis take 1hour, biopsy may be ½ hour and VATS lobectomy up to 4 hours to mention a few).
Patients who have videothorascope lung biopsy, wedge lung resection usually stay for 1 day and VATS lobectomy stay for 3-4 days in the hospital.
What happen after discharge?
A follow up appointment will be scheduled 5-7 days after surgery. The surgeon will asses the wound sites and your recovery at the follow up appointment.
Most patients undergo VATS procedure can go back to work 2-4 weeks after the procedure depending on the type of the procedure and the nature of the work.
Lung Cancer
Lung cancer occurs when there is an uncontrolled overgrowth of the cells in the tumour of the lung. They can be localized or spread to other parts of the body and this spreading is known as metastasis.
There are 2 major types of lung cancer and are categorized as small cell lung cancer and non-small cell cancer.
Non-small Cell Lung Cancer
This accounts for about 80-90% of all lung cancer and the most common types are:
Adenocarcinoma is the most common type and it originates from the mucous producing cells of the lungs. It occurs in about 40-45% of all lung cancer.
They tend to develop quickly and spread to other parts of the body especially the brain. Other areas are the lymph nodes, liver, adrenal, bone and other parts of the lung.
Squamous Cell Carcinoma originates from the epithelial cell lining the air passages. They tend to be slower growing, but it also can spread to other parts of the body like the adenocarcinoma and is most associated with a smoking history. It occurs in about 20-25% of all lung cancer.
Large Carcinoma is less common forming about 10% to 15% of all lung cancer and also tends to spread to all parts of the body.
Small Cell Lung Cancer
This is less common and constitutes about 10-15% of lung cancer. They tend to spread early to other parts of the body. Usually by the time they are discovered they are rather extensive. Because they are rapidly dividing, they do respond to chemotherapy and they are generally treated by chemotherapy and radiation. Surgery is limited to localised disease which is uncommon.
Symptoms of Lung Cancer
Most lung cancers are asymptomatic until they are already well established or spread to other parts of the body. Surgery for localised disease is only possible in about 10-15% of cases by the time they are discovered.
However, if symptoms do appear, it includes:
1) Persistent coughing
2) Coughing out blood (Hemoptysis)
3) Unexplained weight loss or appetite
4) Hoarseness of voice
5) Shortness of breath
6) Swelling of the face or upper extremities
7) Unexplained pain in the back, chest, shoulder or leg.
Diagnosis of lung cancer
As there are no symptoms in the early stages, often by the time a patient presents with symptoms, the tumour has grown. The following tests are done to make a diagnosis.
Sputum Test – Cancer cells may be present in the phlegm.
Chest X-ray (CXR) – Small or a large lesion can be seen.
Computer Tomography (CT or CAT Scan) – Special X-ray creating a series of sliced images of the inside. CT scan of the lung is more sensitive than CXR.
Positron Emission Tomography (PET scan) – This technique uses radioactive glucose substances which can detect cancerous tumour because more of the radioactive glucose material is absorbed by the rapidly dividing cancer cells compared to the surrounding cells, causing it to light up on the scan.
Bronchoscopy – This is an instrument with a camera that looks into the airways (bronchus) and allow the doctor to see any tumour and also to remove a small piece of tissue (biopsy) for study under the microscope.
Needle aspiration biopsy – A needle is used to remove some tissue from the lung for microscopic study and is done through the skin under CT- image guidance.
Mediastinoscopy – A small incision is made above the breastbone in the neck under anesthesia and a lighted scope is passed behind the breastbone along the windpipe (the space between the lung) to remove tissue or piece of lymph node for microscope study.
Open Lung Biopsy – Usually this is done through a scope inserted into the chest, (videothorascope with a camera inbuilt in the scope) through a small incision to allow visualization of the lung. A tissue sample for biopsy is taken from the tumour in the lung.
All or some of the tests may be used to determine if the lung tumour is cancerous and to evaluate whether it is localised or spread to other parts of the body- a process known as staging.
How is Lung Cancer treated?
Treatment depends on the type of cancer, the stage of the disease and the patient’s overall condition.
If the disease is localised in a fit individual, some examples of surgery are:
– Limited wedge resection (taking out a small area containing cancer)
– Lobectomy (removing a lobe of the lung)
– Pneumonectomy (removal of the entire lung on one side)
Chemotherapy and Immunotherapy
Use of drugs to kill the cancer cells in the lung and those that have spread beyond the lung to other parts of the body. This can be in the form of a pill or drugs injected into the blood. They can be combined with radiation or surgery.
Radiation Therapy
Use of high energy x-rays to kill the cancer cells which can be administered from outside the body (external high beam radiation) or through a scope inserted inside the tumour where the cancer cells are found (internal radiation therapy). This can be combined with chemotherapy or surgery.
Prognosis of people with Lung Cancer
This depends on the type and stage of the lung and the patient’s general health. As a rule, early lung cancer if detected and treated have a better prognosis than if detected in the advanced stage of the disease. Hence, early detection is the key to improve prognosis but unfortunately, there is no proven screening test for lung cancer although recent data suggest low dose CT screening for lung cancer in a high-risk individual may be useful.
Prevention of Lung Cancer
Avoid smoking and being in a smoking environment (passive smoking) and taking precautions when working in asbestos, fumes and chemical environment.
Neurogenic Tumour of the Chest
Neurogenic tumour of the chest is observed in all age groups, although they are rare in the elderly.
- In the adult, they tend to arise in the nerve sheath and likely to be benign and asymptomatic
- In the child, they are more likely to be malignant and symptomatic
- Some of the benign lesions can extend to the spinal canal and have an hourglass appearance on MRI or CT scan and this group need to be dealt with by a multi-disciplinary team of neurosurgeon and thoracic surgeon.
- The prognosis after the removal of the benign neurogenic tumour is good and curative and can be done by minimally invasive endoscopically.
Hyperhidrosis (Sweaty Palms)
- Endoscopic Thoracic Sympathectomy
- Primary hyperhidrosis (excessive sweating) is a distressing problem of the hands (palm), armpits (axilla), feet and face.
- Some are due to a secondary cause following a variety of medical disorders, such as excess thyroid hormones (hyperthyroidism), hypertension, diabetic mellitus, infections, brain lesions, and these should be diagnosed and treated medically first.
- The incidence of hyperhidrosis depends on the culture, on the climate and how defined. a subjective definition. It is believed that primary (no known cause), focal hyperhidrosis affects 1 – 3% of the population with a predominance in countries near the equator. It affects both sexes equally and in predominantly adolescents or young adults. Characteristically the hand (palm) symptoms start in early childhood, armpit (axillary) symptoms in adolescence and facial (craniofacial) symptom in adulthood and worsen with puberty.
- The cause of the excessive sweating is unknown but thought to be an abnormal central brain response to emotional stress, but it can occur spontaneously and intermittently.
- Sympathetic ablative surgery (SAS) has been used for more than 50 years to treat a variety of sympathetic disorders. In the last 30 years, sympathetic ablative surgery of hyperhidrosis of the hands, armpits and feet has been performed by minimally invasive endoscopic means (keyhole), the nerve associated with sweating of the palm, overlying the ribs, is ablated with good curative result.
- The main indication for the surgery is severe intolerable sweating which interferes with daily activities. The main complication is compensatory sweating in other parts of the body but this incident can be reduced by a lower level of sympathetic chain ablation.
Chest Trauma
- Trauma surgery (Thoracotomy)
- Rib Fixation by Plating
Chest Wall
- Tumour Resection & Reconstruction
- Pectus Excavatum (sunken chest) Repair (NUSS procedure)
Lung Failure
- Lung Volume Reduction Surgery
- Veno-venous ECMO
Pulmonary Embolism
- Acute Pulmonary Embolectomy
- Emergency ECMO Resuscitation
A Misstep of Nature: Pectus Excavatum
Pectus Excavatum is a chest disorder occurring in approximately one in every 1000 children.
This congenital deforming is characterised by a concave funnel-shaped chest. The chest appears sunken, as if punched in. Often, this can be accompanied by scoliosis of the spine.
Caving In
The inward facing sternum can apply pressure to vital organs of the chest resulting in restricted organs growth and shortness of breath. In extreme cases, the sternum or breastbone nearly meets the spine. The pectus excavatum is usually mildly present at birth but become more serious throughout childhood, often magnifying considerably during the teenage years.
The condition can be familial although the majority is not. The condition is more common in the males than females, in a ratio of roughly 4:1.
Many children self-consciously hunch forward as they grow older, a posture that has become a badge of pectus. Half or more need surgery because their lungs are compressed and their heart squeezed out of position. They may have little endurance and are often short of breath. Heart murmurs are common.
The ideal age for surgery is between six to 12 years of age, prior to the adolescent growth spurt. Not uncommonly, the condition can be associated with other cardiac conditions or abnormalities such as Marfan’s syndrome, Ehlers-Danlos or Poland’s syndrome.
Reinforcing the chest wall
Previously, surgical correction of the deformity was done by an invasive procedure which requires resection of the deformed cartilages and bones, requiring a lengthy incision
A new minimally invasive surgical procedure has been developed by Dr Donald Nuss to treat the problem. A long curved metal bar shaped according to the patient ‘s chest is inserted beneath the ribs and sternum to push the sternum and hold it in position until the bones remodel themselves into the new configuration. In two to three years time, the bar could be removed.
The stainless-steel bar is pushed in from the side of the chest through a small opening between the ribs and out through the other side of the chest under video guidance.
The surgery can be completed within one hour and the procedure will only leave two faint scars. Dr Nuss only reported his result 10 years after the first procedure in 1988.
The mean follow up was 4.6 years and he reported good to excellent result in almost 90% of cases.
Since 2009, most of the pectus excavatum surgery are done using this minimally invasive method. The procedure has been extended to adults even up to 40 years of age in selected cases with surprisingly good results even though they have stiffer bones.
As for my patients, the results are very gratifying. They feel a lot more confident and reassured. If they are symptomatic in the past, they are generally symptom free now.