Editing VATS


== Theory ==

* Carbon dioxide insufflation at 10mm Hg (higher pressures impede venous return)

== Anaesthetic considerations ==

* Can be done under epidural with awake patient, but epidural not required if done under GA
* Use double lumen ETT or bronchial blocker with single lung ventilation

== Equipment ==

* Bronchus division requires a stapler for thick tissue (staple length of 4mm or greater)

== VATS port placement ==

* Consider specimen size - lobectomy removal will need a dedicated utility port, which is the anterior superior port
* Wedge resection: classically two ports in 4th ICS (anterior axillary line and posterior axillary line) and one in 7th or 8th
*
* Lobectomy: 7th ICS anterior axillary line, 8th ICS in line with scapula, and utility port 4th ICS mid-axillary line
*


== Technique ==

* Lateral decubitus (operative side up, top arm on gutter tray, break in bed at bottom of ribs, iliac crest in middle of vacuum pillow, two pillows between legs in T configuration)
* IV Abx
* Alcoholic betadine
* Port placement
** Mark incisions (start counting upwards from 11th ICS to reach 8th ICS)
** Diathermy for skin bleeding
** Artery forceps to dissect through subcostal fat/intercostals/pleura
** Port
* Two additional ports
* Closure
** 28Fr chest tube through 10mm port site, secured with 1 SurgiPro vertical mattress
** Leave an additional SurgiPro in centre of port site for tying later, and a single Monocryl at other end of port site
** Large port sites should have muscle and fascia closed in layers (muscle continuous) then Monocryl to skin, then Comfeel
** Chest tube taped across join (one longitudinal, then one circular on each side)
** Hypafix to tape down intercostal catheter across shoulder, then another piece over the intercostal catheter exit site, then another piece to create a mesentery for the chest tube

== Post-op ==

* Chest tube on suction initially, to be taken off when 24 hour output is less than 250 (however have toilet privileges)
* Chest tube to come out when daily output <100-150mL
* Review 1-2/52 AB clinic with CXR prior

[[Category:Thoracics]]