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Video-assisted thoracic surgery (VATS) is indicated for resection of early-stage lung cancer (stages I and II). In experienced centers, VATS lobectomy can also be performed for more advanced-stage disease (stage IIIA).


Preparation focuses on accurate staging of the malignancy, including computed tomography scanning of the chest and whole-body positron emission scanning. Mediastinal staging with endobronchial ultrasound or mediastinoscopy should be performed before resection and can be incorporated into the same operation, as long as frozen-section pathology is available before resection is attempted. Pulmonary function tests should be completed, including diffusion capacity of the lungs for carbon monoxide (DLCO). In general, patients with a postoperative predictive forced expiratory volume in 1 second (FEV1) and a DLCO greater than 50% can tolerate a lobectomy via either thoracotomy or thoracoscopy. Patients with lung function below this must be considered on a case-by-case basis. Before operation, patients should also be counseled to quit smoking, and two units of packed red blood cells should be cross-matched and available.


General endotracheal anesthesia with single-lung ventilation via either a double-lumen endotracheal tube or a bronchial blocker is essential. An arterial line and two large-bore intravenous lines are needed. A central line should be placed if needed for postoperative monitoring. A thoracic epidural catheter can be considered for postoperative pain relief; however, in most cases pain can be controlled with intercostal nerve blocks and oral narcotics. A Foley catheter should be placed.


The patient should be placed in the lateral thoracotomy position. The patient should be leaning slightly posterior to allow instrument placement and increased exposure of the anterior hilum of the lung. 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).


The skin of the chest is sterilized from the shoulder to the iliac crest with either an iodine preparation or chlorhexidine. Care is taken to extend the surgical field to the sternum anteriorly and to the spinous processes posteriorly. Drapes should be placed in such a way that emergent thoracotomy is possible.


The working port is a 3- to 5-cm incision in the 5th or 6th intercostal space between the mid and anterior axillary lines. The camera port is in the 7th or 8th intercostal space in line with the midaxillary line for the two-incision technique (...

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