Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection
- Philip Hartigan, MD
Philip Hartigan, MD
- Assistant Professor of Anesthesia
- Harvard Medical School
The term video-assisted thoracoscopic surgery (VATS) describes minimally invasive thoracic surgical procedures performed with the aid of a video camera to avoid more invasive open thoracotomy. VATS typically involves one small, 4- to 8-cm incision for the camera, plus up to three additional small incisions for insertion of other instruments (figure 1). This approach is used in selected patients to diagnose or treat intrathoracic or chest wall masses and other abnormalities, such as pericardial or pleural effusions. Compared with a thoracotomy, postoperative pain is minimized and other early outcomes may be improved by avoiding use of a rib spreader, severing of the intercostal nerves, or division of muscle tissue [1-3].
This topic will review anesthetic care for patients undergoing VATS for pulmonary resection. Anesthetic management for other VATS procedures (eg, pericardial window, drainage of pleural effusion, esophageal procedures) is similar. Anesthetic considerations for open thoracotomy with pulmonary resection as well as details regarding principles of one lung ventilation (OLV) and lung isolation techniques that are necessary for many VATS procedures are found in other topics:
●(See "Lung isolation techniques".)
- Rocco G, Internullo E, Cassivi SD, et al. The variability of practice in minimally invasive thoracic surgery for pulmonary resections. Thorac Surg Clin 2008; 18:235.
- US National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer (version 2.2016); Principles of Surgical Therapy (version 1.2016). 2015. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on January 29, 2016).
- Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg 2012; 256:487.
- Alam NZ. Lung resection in patients with marginal pulmonary function. Thorac Surg Clin 2014; 24:361.
- Cowie B. Cardiovascular collapse and hypoxemia in a man with a right-sided mediastinal mass, undiagnosed atrial septal defect, and right-to-left shunt. J Clin Anesth 2014; 26:688.
- Lohser J, Slinger P. Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung. Anesth Analg 2015; 121:302.
- Arslantas MK, Kara HV, Tuncer BB, et al. Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections. J Thorac Cardiovasc Surg 2015; 149:314.
- Gill RR, Zheng Y, Barlow JS, et al. Image-guided video assisted thoracoscopic surgery (iVATS) - phase I-II clinical trial. J Surg Oncol 2015; 112:18.
- Sunaga H, Blasberg JD, Heerdt PM. Anesthesia for nonintubated video-assisted thoracic surgery. Curr Opin Anaesthesiol 2017; 30:1.
- Pompeo E, Dauri M, Awake Thoracic Surgery Research Group. Is there any benefit in using awake anesthesia with thoracic epidural in thoracoscopic talc pleurodesis? J Thorac Cardiovasc Surg 2013; 146:495.
- Kiss G, Claret A, Desbordes J, Porte H. Thoracic epidural anaesthesia for awake thoracic surgery in severely dyspnoeic patients excluded from general anaesthesia. Interact Cardiovasc Thorac Surg 2014; 19:816.
- Piccioni F, Langer M, Fumagalli L, et al. Thoracic paravertebral anaesthesia for awake video-assisted thoracoscopic surgery daily. Anaesthesia 2010; 65:1221.
- Kiss G, Castillo M. Non-intubated anesthesia in thoracic surgery-technical issues. Ann Transl Med 2015; 3:109.
- Chen KC, Cheng YJ, Hung MH, et al. Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution. J Thorac Dis 2012; 4:347.
- Chen KC, Cheng YJ, Hung MH, et al. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation. J Thorac Dis 2014; 6:31.
- Liu J, Cui F, Li S, et al. Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study. Surg Innov 2015; 22:123.
- Guo Z, Yin W, Wang W, et al. Spontaneous ventilation anaesthesia: total intravenous anaesthesia with local anaesthesia or thoracic epidural anaesthesia for thoracoscopic bullectomy. Eur J Cardiothorac Surg 2016; 50:927.
- Irons JF, Miles LF, Joshi KR, et al. Intubated Versus Nonintubated General Anesthesia for Video-Assisted Thoracoscopic Surgery-A Case-Control Study. J Cardiothorac Vasc Anesth 2017; 31:411.
- McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81:421.
- Nagahiro I, Andou A, Aoe M, et al. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001; 72:362.
- Misiołek H, Karpe J, Copik M, et al. Ipsilateral shoulder pain after thoracic surgery procedures under general and regional anesthesia - a retrospective observational study. Kardiochir Torakochirurgia Pol 2014; 11:44.
- Burgess FW, Anderson DM, Colonna D, et al. Ipsilateral shoulder pain following thoracic surgery. Anesthesiology 1993; 78:365.
- Pennefather SH, Akrofi ME, Kendall JB, et al. Double-blind comparison of intrapleural saline and 0.25% bupivacaine for ipsilateral shoulder pain after thoracotomy in patients receiving thoracic epidural analgesia. Br J Anaesth 2005; 94:234.
- Bunchungmongkol N, Pipanmekaporn T, Paiboonworachat S, et al. Incidence and risk factors associated with ipsilateral shoulder pain after thoracic surgery. J Cardiothorac Vasc Anesth 2014; 28:979.
- Scawn ND, Pennefather SH, Soorae A, et al. Ipsilateral shoulder pain after thoracotomy with epidural analgesia: the influence of phrenic nerve infiltration with lidocaine. Anesth Analg 2001; 93:260.
- Danelli G, Berti M, Casati A, et al. Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine. Eur J Anaesthesiol 2007; 24:596.
- Martinez-Barenys C, Busquets J, de Castro PE, et al. Randomized double-blind comparison of phrenic nerve infiltration and suprascapular nerve block for ipsilateral shoulder pain after thoracic surgery. Eur J Cardiothorac Surg 2011; 40:106.
- Steinthorsdottir KJ, Wildgaard L, Hansen HJ, et al. Regional analgesia for video-assisted thoracic surgery: a systematic review. Eur J Cardiothorac Surg 2014; 45:959.
- Wang X, Wang K, Wang B, et al. Effect of Oxycodone Combined With Dexmedetomidine for Intravenous Patient-Controlled Analgesia After Video-Assisted Thoracoscopic Lobectomy. J Cardiothorac Vasc Anesth 2016; 30:1015.
- PREANESTHESIA PREPARATION
- INTRAOPERATIVE ANESTHETIC MANAGEMENT
- Induction and maintenance
- Airway management and surgical bronchoscopy
- Fluid management
- Intraoperative technical considerations
- Final bronchoscopy and emergence
- ROBOTIC-ASSISTED THORACOSCOPIC SURGERY
- NONINTUBATED THORACOSCOPIC SURGERY
- POSTOPERATIVE PAIN MANAGEMENT
- Causes of pain
- - Incisional and local surgical trauma
- - Ipsilateral shoulder pain
- Options for pain control
- SUMMARY AND RECOMMENDATIONS