ANAESTHETIC CHALLENGES IN VIDEO ASSISTED THORACOSCOPIC SURGERY  & KEYHOLE SURGEY OF THE CHEST

 

ANAESTHETIC CHALLENGES IN VIDEO ASSISTED THORACOSCOPIC SURGERY

Dr. Deepak R. Nair, 
MD,DA,DNB, Consultant Anaesthesiologist, Ernakulam Medical Centre, Kochi 

KEYHOLE SURGEY OF THE CHEST

Dr. Nasser Yusuf, 
Assoc Prof & Cardiothoracic Surgeon, 
Ernakulam Medical Centre

Almost all the patients coming for VATS will be crippled by intra thoracic (usually lung) pathology.This makes a thorough pre operative evaluation and optimisation of respiratory and cardiovascular systems vital for the successful anaesthetic management of VATS. Intra operative monitoring should include capnography and arterial blood gas analysis. During surgery the patient will usually be in lateral decubitus position, which necessitates protection of pressure points and management of physiological changes. Since proper exposure is a must, VATS is an absolute indication for One Lung Ventilation. This is usually carried out using a Double Lumen Endotracheal tube.One Lung ventilation causes major changes in physiology making the patient prone for hypoxia. After the surgery the patient may have to be ventilated, in which case care should be taken to avoid high inflation pressures and to decrease oxygen concentration as soon as possible. Post operative respiratory care regimen in the ICU with bronchodilatation, antibiotics, incentive spirometry and chest physiotherapy will help in early mobilization of the patient.The pain, though less than that in open surgery, should be adequately treated with analgesics and regional blocks to prevent respiratory compromise.

The singlemost exciting advancement in Chest medicine is the development of Keyhole Surgery of the Chest. This is essentially of 2 types VATS and MEDIASTINOSCOPY.VATS is the acronym of Video Assisted Thoracoscopic Surgery.What Surgery is usually performed by a 30 cm long incision on the back and side of the chest is achieved by 2.5 cm. Needless to say, not only is it cosmetic but significantly carries very little morbidity. Pneumonia, collapse of lung, pain, wound dehiscence and bleeding rarely occur.

Of the many applications of VATS, the most

common are : 1) There are various causes of collection of Pleural Effusion, such as Cancer,Tuberculosis, Infection etc. Despite presently available investigations 20% of these patients are treated empirically without arriving at a proper diagnosis and thereby patients receive improper, and inadequate treatment with avoidable side effects. VATS conclusively establishes the diagnosis. 2) Tremendous relief and often no re-accumulation of fluid in the chest is achieved by Thoracoscopic Talc (Asbestos free) Pleurodesis in recurrent pleural effusion of any cause including malignancy; may it be of the lung,breast or GI tract. 3) Tissue diagnosis of mediastinal, lung or pleural lesions including Solitary Pulmonary Nodule is certain when all other methods fail. 40% of SPNs are cancerous. 4) There is a general belief that the colour of the fluid found in the chest indicates the nature of disease hemorrhagic in cancer and straw coloured in TB. VATS has clearly proved that this is not always true, that hemorrhagic could mean TB and similarly straw coloured could harbor cancer.5) Pericardial Effusion can be removed effectively by VATS and pericardoidesis performed along with pericardial biopsy to prevent further formation of fluid with excellent result. 6) Any Surgery of the chest such as lobectomy, resection of tumour, bullectomy, drainage of empyema and others can be done through VATS.

Mediastinoscopy is examination of the central portion of Chest(Mediastinum) endoscopically. Biopsy of tumours or lesions behind the sternum, adjacent to the heart and great blood vessels (Aorta and Pulmonary Artery) can easily be accessed.
In India, the common causes of tumours in this region are Cancer,Tuberculosis and Lymphoma. Mediastinoscopy has demonstrated
that Sarcoidosis very much exists in Kerala, which is an easily treatable condition.The approach is via a 2.5 cm incision in the lower part of the neck just above the sternum. The alternative is a 20 cm inch sternal splitting incision in the middle of the chest. Over 1000 patients have benefitted fom VATS and Mediastinoscopy in Kerala.