MISCELLENEOUS Complications and Limitations of Video Assisted Thoracic Surgery Dewan Ravindra Kumar, M.

Ch Video-assisted Thoracic Surgery is a new approach to deal with intrathoracic pathology surgically. It has got exciting possibilities. However, there are many complications associated with this technique, which need to be comprehended well by chest physicians and surgeons. There are many limitations of the procedure, which are more conspicuous in the Indian context. An overview of literature addressing these issues is being presented. (CURRENT MEDICAL TRENDS 2001; 5 : 946-50) Key Words : Thoracoscopy, Video-assisted thoracoscopic surgery (VATS). Minimal access surgery as a concept has witnessed an exponentially rapid progress and wide acceptance in almost all the surgical sub-specialties. The traditional adage big surgeons make big incisions was of course a hyperbolic expression meant to convey that the surgeon should never be struggling while operating as a result of a needlessly small incision. This scenario has changed as the recently available video technology and advanced From the Department of Thoracic surgery, L.R.S. Institute Of T.B. and allied Disease, New Delhi. Manuscript received June 11, 2001; revision accepted May 5. Reprint requests : Dr. Ravindra Kumar Dewan, 128, Aravali apartments, Alaknanda. New Delhi-110 019.

instrumentation has extended the reach and possibilities of a small keyhole incision. The main attractions of keyhole surgery are shorter incision, cosmetically better scar, less postoperative pain 1 and early discharge from the hospital. The approach also offers the prospect of greater safety and lesser physiological insult to the body at the time of surgery. 2 As a result of these obvious attractions, practitioners of this approach experience better patient acceptability, increased physicians referrals and the prospect of being labeled as more advanced surgeon. Video-assisted thoracic surgical procedures for the purposes of diagnosis and management of intrathoracic diseases are being widely and rapidly adopted 946 MISCELLANEOUSespecially in the last decade. In fact, the application of these techniques is limited only by our imagination, access to new technology and the need to justify and demonstrate their superiority over the conventional techniques in an evidence-based manner. 3 To be able to appreciate the role of thoracoscopy in a balanced manner, it is essential to be familiar with some elementary facts. Thoracoscopy is not a new procedure. After the Swedish internist Jacobeus used it in 1910, it has been continuously in use by the

physicians and surgeons working in the field of chest medicine and surgery. Video-assistance and newer technology were made available in the 1980s, which revolutionised the fields of abdominal, gynaecologic and orthopaedic surgery and the hype about video-assisted thoracic surgery increased. As is usual in medicine, there was excessive enthusiasm in some advocates of the procedure. On the other hand, a lot of concern was raised by others who did not have first hand experience of the technique. As the dust has settled, a decade of extensive experience and debates has now clarified the role of this procedure much more clearly. COMPLICATIONS OF THORACOSCOPY Dangers and complications inherent in these procedures can be divided into three headsA. Anesthesia related: These complications can be averted by careful adherence to the principles of the safe anesthesia practice. The following complications are possible:- (i) Pressure injuries: Careful positioning of the patient on the operation table with padding at the pressure points is essential. As the position most commonly adopted for VATS procedures is similar to that of posterolateral thoracotomy, the same established prescribed precautions apply. 4 (ii) Nerve damage:

The technique of thoracoscopy involves creation of three or more ports in the chest wall and other instruments are inserted through these ports. As the ports are bounded by ribs, use of instruments and telescopes entails some manipulation all around. Intercostal nerves could get damaged in the process. This can result in postoperative neuralgia and persistent pain. 5 One of the main attractions of thoracoscopic techniques lies in less post operative pain as the use of rib- spreader is avoided. This benefit may get offset if intercostal neuralgia takes place, (iii) Drug related anaesthesia complication may take place if these procedures are considered as anything lesser than thoracotomy. The physiological consequences of VATS may be almost same or even more than those of conventional thoracotomy. Hence, all possible precautions in drugs and their dosages etc. need to be taken. Monitoring of oxygen saturation and ETCO2 monitoring are essential, (iv) Respiratory insufficiency: Proper preparation of cases as done in thoracotomy patients and scrupulous attention to the maintenance of oxygenation during surgery should prevent it from happening. As VATS

techniques necessarily involve collapse of one lung, careful watch over oxygen saturation and other parameters is essential, (v) Post operative pulmonary oedema should be avoided by CURRENT MEDICAL TRENDS/5/2/JUNE, 2001 947judicious use of fluids during the procedure and

monitoring of central venous pressure in selected cases. B. Instrument related complications: 3 These have to be carefully understood and prevented. As the experience of using these techniques is accumulating, these are being recognized more frequently, the common ones are : (i) Inadvertent insertion of trocar below the diaphragm. This can be avoided by careful study of radiographs. In any case, the site of port formation should always be individualized as per the requirements in a particular case. The risk of this complication is similar as in the case of intercostal chest tube insertion done in other situations, (ii) Equipment malfunction: The entire set of thoracoscopy equipments involves many components and malfunction at any point of the series can cause failure of the procedure. The technical and operational aspects of instruments and equipments have to be understood quite well before their actual use on the patients, (iii) Jamming or breaking of endostaplers has been reported occasionally. Such situations can usually be retrieved. However, as the

cartridges and stapler guns are costly items, the expenditure of the procedure suddenly rises in these situations. Hence one should have spare sets available while using them, (iv) Compression of intercostal nerves: Manipulation of telescopes and instruments needs to be gentle so to avoid pressure on these nerves. It may be more prudent to make small thoracotomy incisions in place of a port in some situations. C. Procedure related: As in any other newer technique the rate of these complications is higher during the learning curve of the operator and his or her team. As surgeons are gaining more experience, such situations are better anticipated as well as better dealt with. The complications include: (i) Dissection into the apex and near the internal mammary artery is dangerous as torrential bleeding may take place, (ii) Inadvertent trocar insertion into the lung parenchyma, (iii) Injury to larger vessels may require conversion to an open thoracotomy. Such a situation should virtually never arise as injury to larger vessel is a critical situation even in open thoracotomy. In fact, the possibility of this happening is one of the major factors in the initial reluctance of conservative and experienced surgeons in adopting these techniques enthusiastically in contrast to some physicians talking about VATS with animated enthusiasm which is partly borne out of

ignorance.

LIMITATION
There are some special problems and limitations about VATS procedures, which should be appreciated well: 1. Pleural symphysis which is invariably present in inflammatory lung disease is a centra-indication to VATS procedures as trocar insertion into the lung parenchyma can easily occur in these situations. As most of the thoracic surgical practice in India includes disease like tuberculosis, it poses a major limitation to the use of VATS in our country . 948 MISCELLANEOUS2. Dangerous bleeding which is always a possibility in thoracic surgery may not be adequately dealt with keyhole incisions. Conversion to thoracotomy may be needed in such cases. 3. Double lumen endotracheal tube with lung collapse on the side of the surgery may not be tolerated in patients with poor pulmonary reserve. This limitation is acutely felt in patients with extensive interstitial lung disease and compromised pulmonary function in whom a referral for a thoracosocpic lung biopsy is sent. Generally the referring physician feels thoracoscopy to be a lesser procedure than thoracotomy which is not necessarily true in such

settings. 4. Chest wall implantation of the tumor may take place while retrieving the specimen. 6 However, the perception of this risk may be exaggerated and retrieval with the help of endobags should be able to minimize such a possibility. 5. The benefit of pain relief may not last. The inclination that the technique may reduce post operative pain is yet to be supported by objective data. 6. Use of a lot of costly equipment like endostapler etc. may increase the cost of the procedure to unacceptable level. 7. The procedure is very time consuming especially during the learning curve of the surgeon and his team. 8. The risk of the procedures may increase especially with poorly trained surgeons or physicians performing such procedures. Hence, anyone performing VATS surgery must be competent to convert to an open thoracotomy if there is a need. 9. In malignancy, a surgeon may be tempted to perform less than adequate resection because of the difficulty being experienced in operating via the limited access.

7 Having discussed complications and limitations of endoscopic thoracic surgery, it needs to be added here that VATS is a wonderful technique with exciting possibilities. At least in the following situations, 8 use of VATS technique may be better than conventional technique and offer many advantages during: 1. Cervical sympathectomy 2. Diagnostic biopsy 3. Pericardial window 4. Small mediastinal masses 5. Empyema and complicated parapneumonic complications-early and subacute phase. 6. Chest trauma and haemothorax 7. Pulmonary metastatectomy and curative lung nodule resection. 8. Lung volume reduction surgery 9. Recurrent pneumothorax. Some of the expanding indications include excision of leiomyoma, hiatus hernia surgery , achalasiacardia surgery and oesophageal mobilization for carcinoma oesophagus and chylothorax. While the technology is continuing to evolve skill of thoracic surgeons, employing these techniques are also improving. Hopefully, the spectrum of indications may also increase with further advances. VATS should be acknowledged as a wonderful tool in the armamentarium of thoracic surgeons.