Video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery

Anesthesia type	General (rarely, monitored anesthesia care for selected cases)
Airway	Double-lumen endotracheal tube
Lines and access	Adequate peripheral IV access; arterial line
Monitors	Standard with arterial monitoring
Primary anesthetic considerations
Preoperative	Pulmonary function testing, prehabilitation to optimize pulmonary status; consider appropriateness of thoracic epidural catheter
Intraoperative	One-lung ventilation
Postoperative	Pain control, pulmonary hygiene
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Anesthesia for minimally invasive, video-assisted thoracoscopic surgery (VATS) is similar to anesthesia for open thoracic cases in many respects. However, achieving lung isolation quickly and completely is even more important, since even a slightly inflated lung may obstruct the surgeon’s view. Procedures that are amenable to VATS include but are not limited to:

• Mediastinoscopy
• Wedge resection or lung biopsy
• Lobectomy or segmentectomy
• Pleurodesis, mechanical or talc, for pleural effusion or spontaneous pneumothorax
• Decortication, including evacuation of empyema or hemothorax
• Lung volume reduction for severe emphysema
• Thoracic sympathectomy for hyperhidrosis or treatment of refractory ventricular tachycardia

Any patient may be a candidate regardless of extremes of age or pulmonary disease.  Procedures still requiring open thoracotomy include pneumonectomy, tracheal resection, and chest wall resection.  The advantages of VATS include decreased hospital length of stay, decreased morbidity, and the ability to do more cases per day in each OR.

The keys to anesthesia success include:

• Facility with placing both right and left endobronchial tubes;
• Skill with fiberoptic bronchoscopy and thoracic epidural anesthesia;
• Having a dedicated team of personnel who routinely handle these cases;
• Hospital investment in a high-quality video laryngoscopy system.

Preoperative management

Patients may present for VATS in sound health or with substantial disease burden. A young patient who presents for thoracic sympathectomy for hyperhidrosis or bleb resection with mechanical pleurodesis for spontaneous pneumothorax may require no preoperative testing. At the opposite extreme, patients may present with decreased lung function on the affected side, pleural or pericardial effusion, anemia, poor nutritional status, and effects of neoadjuvant chemotherapy and/or radiation. Whenever possible, prehabilitation in preparation for surgery should be considered to correct anemia, improve nutritional status, and improve functional capacity.

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Respiratory	History of COPD, asthma, pleural effusion: adequacy of pulmonary function
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications