What Is Minimally Invasive Surgery?
Minimally invasive thoracic surgery is a way of performing surgery in the chest through small incisions, without making large cuts or incisions in the body, and does not require spreading apart of the ribs. Surgeons use a camera and instruments to get to the lung through small incisions in between the ribs. There are two different options available for minimally invasive thoracic surgery; video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery.
Video-assisted thoracoscopic surgery (VATS) is a procedure in which a small tube called a thoracoscope is inserted through a small incision between the ribs. At the end of the tube is a small camera. This lets the surgeon see the entire chest cavity without having to open up the chest or spread the ribs. The surgeon then removes lung tissue with specially designed instruments inserted through one or two additional small incisions.
In robotic-assisted surgery, a surgeon will sit at a console next to the patient in the operating room and control the instruments, including a camera, on the robotic surgical system. A small 3D high definition camera is placed through one of the small incisions to provide a good view of the inside of the chest cavity, while wristed robotic instruments are inserted through the other small incisions made in between the ribs. The surgeon removes lung tissue through one of the small incisions. The use of the wristed instruments lets the surgeon perform the surgery without having to make larger incisions to open up the chest or spread the ribs.
What to Expect
- Your surgery will begin with you being placed under general anesthesia.
- Once you are asleep, a breathing tube is placed into your airway to allow each lung to be separately inflated during surgery.
- You are then positioned on your side.
- The surgeon then makes one to five small incisions, each about an inch wide, in between your ribs. The surgeon inserts the camera and VATS or wristed robotic instruments between the ribs.
- At the end of the surgery, the surgeon will insert a chest tube through one of the small incisions to drain extra fluid or air leaking into the chest and help your lungs to re-inflate. This tube remains in place for a few days and is typically removed at the bedside before you go home.
- Recovery time is generally shorter after minimally invasive surgery compared to open surgery, but you will still need time to rest and recover. Once home, most patients will regain most of their strength, energy and breathing after two to three weeks.
What Are the Risks and Benefits?
Like all surgery, there are risks to minimally invasive thoracic surgery. They include infection, bleeding, abnormal heartbeats and air leakage from your lungs and pain. Robotic-assisted surgery may be associated with longer operative times and a longer time under anesthesia. Your surgeon may have to convert to a more invasive approach if needed to complete the surgery.
However, there are benefits to minimally invasive surgery compared to open chest surgery through a thoracotomy, depending on which minimally invasive approach you receive you may experience:
- Faster recovery and return to normal activities
- Fewer complications
- Shorter hospital stay
- Less pain and decreased need for pain medications
- Smaller scars
- Less blood loss
- No cutting of the ribs or breastbone (sternum)
Each person handles surgery a little differently and your outcomes may depend on a number of factors, like your health history, the type of lung cancer you have and/or your surgeon’s experience.
Who Is Eligible?
Surgeons evaluate whether each patient is a candidate for minimally invasive thoracic surgery on a case by case basis. Surgeons consider the patient’s specific condition, medical history and anatomy when deciding if they are eligible for minimally invasive surgery. Talk to your doctor about whether this type of surgery is right for you.
What is video assisted thoracic surgery?
VATS (video-assisted thoracic surgery) is a type of minimally invasive thoracic surgery of the chest, performed with a thoracoscope (small videoscope) using small incisions and special instruments to minimize trauma.
Other names for this procedure include thoracoscopy, thoracoscopic surgery or pleuroscopy,
During thoracoscopic surgery, three small (approximately 1-inch) incisions are used, as compared with one long 6- to 8-inch chest incision that is used during traditional, “open” thoracic surgery. Surgical instruments and the thoracoscope are inserted through these small incisions.
The thoracoscope transmits images of the operative area onto a computer monitor that is positioned next to the patient.
As compared with traditional surgery, patients who undergo minimally invasive surgery experience:
- Decreased postoperative pain
- Shorter hospital stay
- More rapid recovery and return to work
Other possible benefits include reduced risk of infection and less bleeding.
Who is a candidate for minimally invasive surgery?
Almost all traditional thoracic surgeries can be performed using a minimally invasive technique.
If you need thoracic surgery, a minimally invasive surgical approach will first be considered. However, there are still some procedures that are best performed using a traditional, “open,” technique. Your surgeon will carefully evaluate you to determine the safest surgical approach to treat your medical condition.
Types of Thoracoscopic Surgery Procedures
Thoracic surgery procedures routinely performed using a minimally invasive technique include:
Video-Assisted Lobectomy
Lobectomy (removal of a large section of the lung) is the most common surgery performed to treat lung cancer. Lobectomy has been traditionally performed during thoracotomy surgery. During thoracotomy surgery, an incision is made on the side of the chest between the ribs. The ribs are then spread apart so the surgeon can see into the chest cavity to remove the tumor or affected tissue.
Surgeons routinely perform lobectomy using a minimally invasive approach. During video-assisted lobectomy, three 1-inch incisions and one 3- to 4-inch incision are made to provide access to the chest cavity without spreading of the ribs. The patient experiences a more rapid recovery with less pain and a shorter hospital stay (usually 3 days) with video-assisted lobectomy as compared with traditional thoracotomy surgery.
There are few centers in the nation with significant experience in video-assisted lobectomy. In addition, the surgical outcomes of video-assisted lobectomy are comparable to traditional lobectomy outcomes.
Although minimally invasive approaches are considered for every patient, in some cases, patients who have a large or more central tumor may not be candidates for video-assisted lobectomy.
Wedge Resection
A wedge resection is the surgical removal of a wedge-shaped portion of tissue from one, or both, lungs. A wedge resection is typically performed for the diagnosis or treatment of small lung nodules.
Lung Biopsy
A lung biopsy is a procedure in which a small sample of lung tissue is removed through a small incision between the ribs. The lung tissue is examined under a microscope by expert pathologists and may also be sent to a microbiological laboratory to be cultured. The lung tissue is examined for the presence of lung diseases such as infectious or interstitial lung disease.
Drainage of Pleural Effusions
A pleural effusion is the build-up of excess fluid between the layers of the pleura – the thin membrane that lines the outside of the lungs and the inside of the chest cavity. Normally, very little fluid is present in this space. The excess fluid is removed (drained) during a thoracoscopic procedure called thoracentesis and may be collected for analysis to indicate possible causes of pleural effusion such as infection, cancer, heart failure, cirrhosis, or kidney disease. Sterile talc or an antibiotic may be inserted at the time of surgery to prevent the recurrence of fluid build-up.
Mediastinal, Pericardial, and Thymus Thoracoscopic procedures
The mediastinum is the area in the middle of the chest between the lungs.
The pericardium is the area surrounding the heart.
The thymus is a small organ located in the upper/front portion of the chest, extending from the base of the throat to the front of the heart. The cells of the thymus form a part of the body’s normal immune system. Early in life, the thymus plays an important role in the development of the immune system.
Thoracoscopic techniques can be used to examine the mediastinum, pericardium, or thymus, remove tissue samples, or surgically remove cancerous growths in the affected area.
How can I be evaluated for thoracoscopic surgery?
When you meet with the thoracic surgeon, a physical exam will be performed and your treatment options will be discussed. The thoracic surgeon will discuss the benefits and potential risks of the surgical procedure that is recommended for you.
In general, preoperative tests include:
- Blood tests
- Pulmonary function test (breathing test)
- CT scan
- Electrocardiogram
Your surgeon will determine if any additional preoperative tests are needed, based on the type of procedure that will be performed. If a cardiac (heart) evaluation is necessary, a consultation with a cardiologist will be scheduled.
As part of your preoperative evaluation, you will meet with an anesthesiologist who will discuss anesthesia and postoperative pain control.
The thoracic surgery scheduler will schedule any additional tests and consultations that have been requested by your surgeon. In general, after your first meeting with your surgeon, all tests are scheduled on a single returning visit for your convenience.
RECOVERY AND OUTLOOK
How long will I stay in the hospital after thoracoscopic surgery?
The length of your hospital stay will vary, depending on the procedure that is performed. In general, patients who have thoracoscopic lung biopsies or wedge resections are able to go home the day after surgery. Patients who have a VATS lobectomy are usually able to go home 3 to 4 days after surgery.
What happens after the procedure?
Your thoracic surgery team, including your surgeon, surgical residents and fellows, surgical nurse clinicians, social workers, and anesthesiologist, will help you recovery as quickly as possible. During your recovery, you and your family will receive updates about your progress so you’ll know when you can go home.
Your health care team will provide specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care, and diet.
Follow-up appointment: A follow-up appointment will be scheduled 7 to 10 days after your surgery. Your surgeon will assess the wound sites and your recovery at your follow-up appointment and provide guidelines about your activities and return to work.Most people who undergo minimally invasive thoracic surgery can return to work within 3 to 4 weeks.
REFERENCES
- Cleveland Clinic
- American Lung Association
- Featured image Credit: Columbia Surgery