General Principles

VATS require both basic instruments and techniques which have been adapted from laparoscopic technique. Generally, the patient is placed in a lateral decubitus position, although the position may vary depending on the exact location of the lesion. General anesthesia is utilized and a double lumen endotracheal tube is required. Single lung ventilation is an prerequisite to permit adequate visualization of the thoracic cavity. Unlike laparoscopy where a pneumoperitoneum is induced, visualization of the chest is usually achieved by collapsing the ipsilateral lung rather than depressing it via an induced pneumothorax.

There are instances in which a single lumen endotracheal tube can be utilized. The pleural space is insufflated with CO2 to depress the lung, making visualization possible. Initially the pressure not exceed 15 mm Hg but can be raised to 20 mm Hg with close hemodynamic observation. Tension pneumothorax can lead to electromechanical dissociation, particularly on insufflation of the left hemitho-rax.

A 10 mm Olympus thoracoscope is used with a camera adapted to a video monitor. The video monitor should be positioned on the opposite side of the surgeon. The surgeon generally stands posterior to the patient and the video monitor is anterior. It is preferred to have two video monitors, one on either side of the patient. The video monitor should be in a straight line drawn between the surgeon, the lesion and the monitor. Ports are generally beneficial for instrument placement, although this is not absolutely required. Generally, these thoraco-ports are most useful for inserting the camera since placing the camera directly through an incision may smear the lens and produce a poor image.

The other trocars used are: The 5 mm trocar for the instruments although frequently these can be left out and the instruments placed directly through the incision in the chest wall. A larger 15 mm trocar is used for placement of the stapling device.

A biopsy forceps, scissors or electrocautery/suction/irrigator are the primary tools used in thoracoscopy. For a general overview of the thoracic cavity, the best trocar placement for initial inspection is the midaxillary to posterior axillary line in the sixth intercostal space. This gives good visualization of the entire thoracic cavity. It is important after making the incision to dissect down into the pleural space and use blunt dissection to enter the pleural cavity after the lung has been deflated in a similar way as for insertion of a chest tube. This is to avoid injury to the lung should the lung be stuck up against the chest wall. Another helpful hint is that, with the patient placed in the lateral decubitus position, the table should be bent such that the lower extremities are brought down to open up the intercostal spaces. This will help in placing the trocars.

The technique of thoracoscopy requires a new set of manual skills which, although applicable from the open technique, still need to be refined in terms of hand/eye coordination. Several useful hints are mandatory in allowing for a smooth operation.

1) The trocar sites and thoracoscope should be placed far away from the lesion. Initially, it was thought that placing the camera directly over the lesion permitted the best view. This, however has since been found to be exactly the wrong approach. Placing the thoracoscope far away from the lesion allows for a panoramic view of the entire thoracic cavity and allows for evaluation of the lesion with respect to surrounding structures.

Figure 25.1 shows the relationship of the thoracoscope and various instruments to the lesion in terms of the "baseball diamond concept". In this model, the surgeon with the thoracoscope stands at home plate. The lesion is at second base, far away from home plate, and the various instruments including dissector, scissors, cautery/suction/irrigator are at first and third bases. Generally, the surgeon uses both hands to manipulate the instruments at first and third base while the assistant holds the telescope which is positioned far away from the lesion.

2) Instruments should be placed away from the lesion and pointed in the same general direction, i.e. toward the lesion and in the same direction as the telescope. This is to avoid the phenomenon called mirror imaging, in which the instrument is placed towards the camera resulting in an extremely awkward situation for performing surgery, as if watching one's actions in a mirror. Placing all instruments in the same direction with the thoracoscope avoids this major problem.

3) The instruments should not be crowded together, lest the phenomenon of "fencing" ensues with the instruments clanging against one another.

4) Random motion should be kept to a minimum. The surgeon should del-

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