By: Kim Patrick S.P.

Marallag

Video Assisted Thoracoscopic Surgery (VATS)

Diagnosis and treatment of pleural effusions and recurrent pneumothorax, and for lung biopsy, lobectomy or segmental resection, resection of bronchogenic and mediastinal cysts, esophageal myotomy, and intrathoracic esophageal mobilization for esophagectomy.

VATS
Performed via two to four incisions measuring 0.5 to 1.2 cm in length to allow insertion of the thoracoscope and instruments. Endoscopic staplers are used to divide the major vascular structures and bronchus.

VATS
Examples of VAST lobectomy maneuvers done with the pt in left lateral decubitus position

VATS
At the conclusion of a thoracic operation: - Chest tube placement not needed if pleural viscera is not violated - Positive pressure ventilation to re-expand the lungs

Post Operative Care

Chest Tube
2 purposes: - For air evacuation - For blood and pleural fluid drainage

- The ability of the pleural lymphatics to absorb fluid is substantial. It can be as high as 0.40 mL/kg per hour in a healthy individual, possibly resulting in the absorption of up to 500 mL of fluid over a 24-hour period.

- pleural tubes can be removed after VATS lobectomy or thoracotomy with 24-hour drainage volumes as high as 400 mL without subsequent development of pleural effusions. - If the pleural space is altered, strict adherence to a volume requirement before tube removal is appropriate.

- The use of suction and the management of air leaks vary. - To eradicate residual air spaces and to control postoperative parenchymal air leaks, suction level of -20 H2O have been commonly used.

Evaluation of an air leak and/or

incompletely drained pneumothorax with associated pulmonary collapse - Check for tube patency - Ask patient to cough or perform valsalva maneuver - During the cough, the water seal chamber is observed. ( bubbles = air leaks ) , (stationary fluid level = mech. blockade )

Pain Control
The most common routes for pain medication are: Epidural Paravertebral IV

Epidural anesthesia
inserted at about the T6 level, roughly at the level of the scapular tip. Fentanyl with bupivacaine or robivacaine urinary retention

Paravertebral anesthesia
2.5 cm lateral to the spinous process at T4 to T6

narcotics with topical analgesics Local anesthesia may cause hypotension or vasodilation

IV narcotics
often in conjunction with ketorolac Oversedation and narcotization of patients risk of secretion retention and development of atelectasis or pneumonia

 The patient typically is transitioned to oral pain medication on the third or fourth postoperative day. During both the parenteral and oral phase of pain management, use of a standardized regimen of stool softeners and laxatives is advisable to prevent severe constipation.

Respiratory Care
- Patient should be able to deliver an effective cough, if it is impossible to cough, use of suction is required to remove secretions. - Preoperatively, give instructions of applying pressure over the wound - Postoperatively, proper pain control without over sedation is essential.