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INDICATIONS

Video-assisted thoracic surgery (VATS) is a general term used to describe operations on the thorax accomplished with the use of a video camera, monitor, and long instruments. This approach using only a thoracoscope was originally described in 1910, but had limited application due to poor visibility. With the advent of high resolution cameras and monitors it has been increasingly applied over the last 10 to 20 years to operations traditionally performed through a thoracotomy. VATS is now commonly used to treat diseases of the lung, pleura and mediastinum.

PREOPERATIVE PREPARATION

The preparation required depends largely on the procedure to be accomplished. Although VATS may be accomplished with the patient prone, using a low-pressure pneumothorax (<8 mm Hg) and a standard endotracheal tube, most patients undergoing VATS surgery require single-lung ventilation, as the standard is not to use positive-pressure pneumothorax. In most circumstances this mandates pulmonary function testing. A forced expiratory volume of greater than 1 liter in 1 second (FEV1 >1 L) generally represents adequate lung function. Functional testing is also useful, with patients able to tolerate climbing at least one flight of stairs without stopping to catch their breath representing adequate function. As with other thoracic operations, VATS procedures are commonly carried out on relatively sick patients, and an electrocardiogram and laboratory evaluation including complete blood count, electrolytes, glucose, blood urea nitrogen, creatinine, and prothrombin and partial thromboplastin times are generally recommended. All patients undergoing VATS procedures should have a current type and screen.

Chest radiograph, computed tomography (CT) scan, and positron emission tomography (PET) scan are done as part of the investigation of the primary problem for which thoracoscopy is being performed.

ANESTHESIA

General endotracheal anesthesia with single-lung ventilation either via a double-lumen endotracheal tube or a bronchial blocker is generally necessary. The other option is CO2 insufflation of the thoracic cavity. This provides a working space without single-lung ventilation, but limits the ports and instruments that can be used, because an airtight seal must be present and mini-thoracotomy is not possible.

The double-lumen endotracheal tube should be placed with the distal balloon in the left main-stem bronchus to avoid occlusion of the right upper-lobe bronchus. Flexible bronchoscopy down the proximal lumen should reveal the carina, right upper-lobe bronchus, and bronchus intermedius. The blue balloon will be visible in the left main-stem bronchus (Figure 1). Care should be taken to identify the right upper-lobe bronchus, as its absence may indicate that the distal balloon is in the right bronchus intermedius, and the bifurcating airway that you see is the take-off of the right upper-lobe bronchus rather than the carina.

A bronchial blocker offers a reasonable alternative to achieve single-lung ventilation. Blocking the left main-stem bronchus with confirmation via bronchoscopy is generally straightforward (Figure 2). Blocking the right main-stem bronchus is often difficult because the short main-stem bronchus predisposes the balloon to herniation into the trachea or migration distally, incompletely occluding ventilation of the right upper lobe. In either case, effective ...

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