VATS
Theory
[edit | edit source]- Carbon dioxide insufflation at 10mm Hg (higher pressures impede venous return)
Anaesthetic considerations
[edit | edit source]- 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
[edit | edit source]- Bronchus division requires a stapler for thick tissue (staple length of 4mm or greater)
VATS port placement
[edit | edit source]- 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
[edit | edit source]- 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
[edit | edit source]- 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