Overview
Definition:
Video-assisted thoracoscopic surgery (VATS) wedge resection is a minimally invasive surgical technique used to remove a small, peripheral portion of lung tissue (a wedge) that contains a lesion or abnormality
It utilizes a thoracoscope and specialized instruments inserted through small incisions, offering advantages over open thoracotomy.
Epidemiology:
VATS wedge resections are increasingly performed for the diagnosis and treatment of solitary pulmonary nodules (SPNs), particularly those with suspicious features on imaging
The incidence is rising with advancements in VATS technology and surgeon expertise
Prevalence of SPNs varies, with a higher incidence in smokers and older individuals.
Clinical Significance:
VATS wedge resection provides a less invasive approach to obtaining tissue for diagnosis or excising small, peripheral lung lesions, crucial for early lung cancer detection and management
It minimizes trauma, reduces postoperative pain, shortens hospital stays, and allows for quicker patient recovery compared to open surgery, making it a preferred method for many thoracic surgeons and a key topic for surgical exam preparation.
Indications
Surgical Indications:
Resection of suspicious solitary pulmonary nodules (<3 cm) for diagnosis and treatment
Excision of small peripheral lung tumors
Management of benign lung lesions such as hamartomas or infections
Lung biopsy for interstitial lung disease diagnosis
Management of small primary lung cancers when lobectomy is not indicated or feasible.
Patient Selection:
Patients with suspicious pulmonary nodules on imaging
Individuals with suspected primary or metastatic lung cancer
Patients with known benign lung lesions requiring removal
Suitable candidates must have adequate pulmonary function to tolerate single-lung ventilation and the procedure
Careful assessment of comorbidities is essential.
Contraindications:
Extensive bilateral lung disease
Severe cardiopulmonary insufficiency
Inability to tolerate single-lung ventilation
Large central tumors requiring pneumonectomy or lobectomy
Uncontrolled coagulopathy
Presence of extensive adhesions that would preclude safe dissection
Tumor invading mediastinal structures.
Preoperative Preparation
Diagnostic Workup:
Comprehensive evaluation including chest CT scan with contrast, PET-CT scan for staging of suspected malignancy, bronchoscopy, and possibly EBUS-TBNA or mediastinoscopy
Pulmonary function tests (PFTs) are critical to assess respiratory reserve
ECG and echocardiogram for cardiac evaluation.
Imaging Guidance:
Preoperative localization of small or deep nodules may be necessary using CT-guided percutaneous needle placement of a hook wire or radiotracer (Technetium-99m)
This aids in precise identification and resection during VATS.
Anesthesia Considerations:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation is standard
Epidural or intercostal nerve blocks may be used for postoperative pain management
Careful monitoring of hemodynamics and oxygenation is paramount.
Patient Counseling:
Detailed discussion with the patient regarding the procedure, potential risks and benefits, expected recovery, and alternatives
Informed consent is mandatory
Explanation of the minimally invasive nature and potential need for conversion to thoracotomy.
Procedure Steps
Port Placement:
Typically 2-4 small incisions (0.5-1.5 cm)
One for the thoracoscope (camera) and others for instruments
Camera port is often placed in the 4th or 5th intercostal space at the mid-axillary line
Working ports are positioned based on the location of the lesion.
Dissection And Identification:
The operative field is insufflated with CO2 or room air
The lesion is identified visually and often palpated
Dissection is performed using electrocautery, harmonic scalpel, or Maryland dissector to mobilize the lung parenchyma around the lesion.
Parenchymal Excision:
The wedge of lung tissue is resected using an endoscopic linear stapler
The stapler is fired across the base of the wedge, ensuring adequate margins and hemostasis
Multiple firings may be required depending on the size and shape of the specimen.
Specimen Retrieval:
The resected specimen is placed into an endoscopic retrieval bag to prevent tract seeding and contamination
The bag is then withdrawn through one of the port sites
Careful inspection of the staple line for air leaks or bleeding is performed.
Pleural Drainage:
A chest tube (typically 24-28 Fr) is inserted into the pleural space to evacuate air and fluid, and to re-expand the lung
The tube is connected to an underwater seal drainage system.
Postoperative Care
Pain Management:
Effective pain control is crucial
Intravenous analgesics, patient-controlled analgesia (PCA), epidural anesthesia, or intercostal nerve blocks are utilized
Early mobilization is encouraged.
Respiratory Support:
Monitoring for air leaks and lung re-expansion
Chest tube management and removal criteria (e.g., absence of air leak, minimal drainage)
Early ambulation and deep breathing exercises to prevent atelectasis and pneumonia.
Ambulation And Discharge:
Patients are typically mobilized within 24 hours postoperatively
Discharge criteria usually include adequate pain control, absence of significant air leak, stable vital signs, and ability to tolerate oral intake
Hospital stay is usually 1-3 days.
Follow Up Plan:
Regular follow-up appointments with chest X-rays or CT scans to monitor for recurrence or complications
Further investigations or treatment will depend on the final pathology report and staging.
Complications
Early Complications:
Persistent air leak (most common), bleeding, infection, pneumonia, atelectasis, phrenic nerve injury, intercostal neuralgia, conversion to open thoracotomy, subcutaneous emphysema.
Late Complications:
Chronic pain, incisional hernia, pleural effusion, tumor recurrence, pneumothorax.
Prevention Strategies:
Meticulous surgical technique, appropriate stapler use, secure closure of air leaks, vigilant postoperative monitoring, effective pain management, early mobilization, and adherence to postoperative care protocols.
Key Points
Exam Focus:
Indications for VATS wedge resection vs
lobectomy
Management of solitary pulmonary nodules
Complications like persistent air leak and their management
Role of localization techniques
Differences between VATS and open thoracotomy.
Clinical Pearls:
Always consider the final pathology when deciding on resection margins
Use retrieval bags to prevent contamination
Adequate pain control is key for early recovery and preventing pulmonary complications
Be prepared to convert to open thoracotomy if necessary for patient safety.
Common Mistakes:
Inadequate margins for malignant lesions
Failure to adequately manage persistent air leaks
Underestimating the risk of conversion to open surgery
Poor pain control leading to prolonged recovery
Insufficient preoperative workup, especially PFTs.