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INDICATIONS

Video-assisted thoracoscopic wedge resection is most commonly used to obtain tissue diagnosis in patients with either suspected interstitial lung disease or lung nodules. It is also indicated for the treatment of known lung cancers less than 3 cm in diameter in patients whose comorbidities or lung function suggest they will not tolerate an anatomic lung resection.

PREOPERATIVE PREPARATION

A current computerized tomography scan of the chest is essential as a roadmap to identify the area to be resected. For nodules, the location, depth, and size of the nodule are noted, as well as position relative to the pulmonary arteries, pulmonary veins, and airway. Nodules that are too small or located too deep to be found by visual inspection of the surface of the lung or by palpation can be needle localized prior to surgery. For interstitial disease, the lobes or segments affected are noted. As with other thoracic procedures, a type-and-screen should be available. Routine laboratory examination including blood counts, prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, electrocardiogram, and pulmonary function testing are recommended.

ANESTHESIA

General anesthesia with single-lung ventilation is standard. A large-bore intravenous line and pulse oximetry are required. Arterial-line blood pressure monitoring and Foley catheter placement may be necessary, based on the individual patient and the anticipated length of the procedure.

POSITION

The patient is placed in the lateral decubitus position, as for thoracotomy. A slight lean toward the back may facilitate instrument placement and manipulation anteriorly. The surgeon stands in front of the patient with the assistant standing to the surgeon’s left or behind the patient. The anesthesiologist stands at the head of the patient. The surgical nurse stands opposite the side of the surgical assistant. Monitors are positioned at the head of the bed and on either side of the patient (Figure 1).

OPERATIVE PREPARATION

The skin of the chest is sterilized from the shoulder to the iliac crest with either an iodine or chlorhexidine preparation. Care is taken to prep to the sternum anteriorly, to the spinous processes posteriorly, superiorly to above the shoulder, and inferiorly to below the costal margin. Drapes should be placed in such a way that conversion to thoracotomy is possible if necessary.

DETAILS OF THE PROCEDURE

The incision for the thoracoscope is made in the 7th intercostal space in the anterior axillary line or anterior to the anterior superior iliac spine. The lung is deflated and the 30-degree thoracoscope introduced. If the nodule was wire localized, the wire is brought into the chest cavity before full deflation of the lung is attempted. This prevents the wire from pulling out of the lung as the lung falls away ...

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