Taking it to a Whole New Level: Video Assisted Thoracoscopic Surgery

It’s another typical day at the hospital where doctors are busy conducting their rounds, nurses are busy catering the needs of patients and performing nursing tasks, and people are roaming around the hospital halls. Nurse Rina is on morning shift, the busiest shift. Just a few hours more before her shift ends, but she still has tons to do, assisting the physician as he conducts his rounds, for example.

She watches the exchange between the doctor and her patient as Dr. X explains the results of the recently conducted Xray and CT scan. Patient Z, who has been admitted for 4 days now and is intubated listens intently to the doctor as he explains the air found in her lungs and the surgery recommended for her to get through this. She couldn’t speak, but she writes her questions on a piece of paper provided to her by the nurses. It is said that she is advised to undergo a thoracoscopic surgery to remove the excess air from around her lungs.

The patient looks worried as she writes “Do I really need to be operated? Will it scar?”. The doctor explains further about the procedure and presents another option for the patient to choose from – a video assested thoracoscopic surgery. Nurse Rina furrows her brows as it is her first time to ever hear about the procedure.

“That is possible now?” she asks quietly as she tells herself to read more of the procedure later. That way, she’ll be able to understand better, and even formulate more appropriate nursing plans for the patient who is about to undergo the procedure.

Video Assisted Thoracoscopic Surgery (VATS): What exactly is it?

VATSVideo-assisted thoracoscopic surgery (VATS) is a recently developed type of surgery that enables doctors to view the inside of the chest cavity after making only very small incisions. It is a minimally invasive surgical technique used to diagnose and treat problems in your chest (it allows surgeons to remove masses close to the outside edges of the lung and to test them for cancer using a much smaller surgery than doctors needed to use in the past).

Also, it can be very useful when it comes to diagnosing certain pneumonia infections, diagnosing infections or tumors of the chest wall, and treating repeatedly collapsing lungs. The main benefit of this development is to avoid a thoracotomy incision, which allows a shorter operative time, less postoperative morbidity, and earlier return to normal activity than with thoracotomy. Also, compared with a traditional open operation (thoracotomy), video-assisted thoracoscopic surgery may result in less pain.

At present, doctors are still continuing to develop other uses for Video Assisted Thoracoscopic Surgery (VATS).

This technique is used to perform a variety of operations:

  • Biopsy to diagnose lung cancer, mesothelioma and other chest cancers
  • Esophagus surgery (esophagectomy)
  • Hiatal hernia repair
  • Lung surgery, such as surgery to treat lung cancer and lung volume reduction surgery
  • Procedures to remove excess fluid or air from the area around the lungs
  • Surgery to relieve excessive sweating (hyperhidrosis)
  • Surgery to relieve gastroesophageal reflux disease
  • Thymus gland removal surgery (thymectomy)

However, the procedure may not be advised for patients who: (Absolute contraindications include the following)

  • Markedly unstable or shocked patient
  • Extensive adhesions obliterating the pleural space
  • Prior talc pleurodesis
  • Relative contraindications include the following:
  • Inability to tolerate single lung ventilation
  • Previous thoracotomies
  • Extensive pleural diseases
  • Coagulopathy
  • Prior radiation treatment for thoracic malignancy; plan to resect

Preparation

Prior to the procedure, a lot of things should be taken into consideration. After the physician explains the procedure to the patient, a consent form must be signed giving the surgeon permission to perform this test.
The patient may talk to the doctor about whether he/she is required to stay in the hospital for any time after the procedure. Tests called pulmonary function tests may also be done before the surgery in order to make sure that the patient can recover well.

Patients taking insulin must inform the doctor before the test. Other medicines must also be noted such as aspirin, nonsteroidal anti-inflammatory drugs, or other medicines that affect blood clotting, since it may be necessary to stop or adjust the dose of these medicines before the test.

The patient may be ordered to be on NPO (Nothing per orem) for at least eight hours before the surgery since an empty stomach helps prevent the nausea that can be a side effect of anesthesia medicines.
Before the surgery (sometimes on the same day), an anesthesiologist may assess the patient and interview him/her about his/her medical history (including medicines and allergies) and to discuss the anesthesia.

Procedure

VATS is usually done with general anesthesia, putting the patient to sleep so he/she is unconscious during the procedure. General anesthesia is administered by an anesthesiologist, through letting the patient breathe a mixture of gases through a mask. After the anesthetic takes effect, a tube is put down the patient’s throat to help him/her breathe. The anesthesiologist can use this tube to make the patient breathe using only one of his/her lungs. This way the other lung can be completely deflated and allow the surgeon a full view of the chest cavity on that side during the procedure.

If VATS is being used only to evaluate a problem on the inside of the ribcage (not the lung itself), then it can sometimes be done using regional anesthesia where the patient is given medicines (spinal block or an epidural block) that make him/her very groggy and that keep him/her from feeling pain in the chest.

During the procedure, the patient lies on the side (Full lateral decubitus position) and a very small incision (less than an inch long) is made, usually between the seventh and eighth ribs. Carbon dioxide gas is allowed to flow into the chest through this opening, while the lung on that side is made to partly or completely collapse.

A tiny camera on a tube, called a thoracoscope, is then inserted through the opening. The doctor can then see the work he or she is doing by watching a video screen. For those procedures more complicated than inspection of the chest and lung, one or two other small incisions are made to allow additional instruments to reach into the chest.

A wide variety of instruments are useful in VATS such as those instruments that can cut away a section of the lung and seal the hole left in the lung using small staples, instruments that can burn away scar tissue, and tools to remove small biopsy samples such as lymph nodes from the chest.

The instruments are then removed at the end of the procedure, the lung is reinflated, and all but one of the small incisions are stitched closed. In most cases, a tube (called a chest tube) is placed through the remaining opening to help drain any leaking air or fluid that collects after the surgery.

After the procedure: What’s next?

After the procedure, most patients stay in the hospital for at least one day after a VATS procedure to recover from the surgery. Most patients have a chest tube left in the chest for a few days, to help drain out leaking air or collections of fluid. The patient must be taught to report to a health care provider immediately for signs such as fever, shortness of breath, or chest pain.

Sources:
http://www.health.harvard.edu/diagnostic-tests/video-assisted-thoracic-surgery.htm
http://emedicine.medscape.com/article/1970013-overview#a15
http://www.mayoclinic.org/tests-procedures/video-assisted-thoracic-surgery/basics/definition/prc-20021362

Photo Credits: www.infospine.net

Liane Clores, RN MAN

Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.

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