2. Video Assisted Thoracoscopic Surgery
“A mode of entry into the chest”
Prof Dr Samieh Amer
Professor of
cardiothoracic surgery

3. History
 1853 Dr A. J. Desormeaux used the term “Endoscope”
for the first time
 1865 Sir Francis Richard Cruise advanced the
endoscope by improving the light source and the first
to use it for the thoracic cavity
 1910 Hans Christian Jacobaeus first published
physician to use Thoracoscopy
 1990 introduction of the fibroptic camera, USA

4. Era of enthusiasm Era of neglect Era of rapid development
1910-1950 1950-1990 1990-Present

5. Indications
 Diagnosis  exploration, biopsy and staging of
malignancies
 Decortication of empyema
 Pleurodesis
 Management of spontaneous pneumothorax
 Resection of lung, mediastinal, pleural and esophageal
masses and cysts
 Thoracic sympathectomy
 Surgical intervention for diaphragm
 Management of thoracic trauma
 Cardiac surgery

6. Advantages
 Minimally invasive, no more thoracotomy or sternotomy
incisions thus avoidance of muscle division and bone fractures
 Reduces blood loss and transfusion consequently reduces risk of
hepatitis & HIV
 Less post-operative effects on pulmonary function (FEV1)
 Reduces post-operative inflammatory reaction (reduced pro-
and anti-inflammatory cytokines e.g. IL-6, IL-8 & IL-10)

7. Continue…..
 Reduces incidence of infection
 Faster recovery
 Decreased post-operative pain
 Shorter hospital stays
 Reduced usage of narcotics
 Smaller post-operative scars  more cosmetic
 Better wound healing
 Reduces morbidity

8. Disadvantages
 Loss of tactile sensation??
 Lengthier procedures??
 Surgical assistance limited
 Limitations
 Absolute:
 Obliterated pleural space due to adhesions
 Anatomical difficulties
 Relative:
 Intolerable lung anaesthesia
 Lack of experience
 Mechanical ventilation
 Intolerable hypoxemia
 Bleeding diathesis
 Unstable cardiovascular status

9. Popularity
 100% of patients with spontaneous
pneumothorax management, worldwide
 75% of the total Lung resections in Ireland
 69% of mediastinal tumours
and cysts resection in UK
 25% of the total
thoracic operations in USA
 16% of lobectomies in USA

10. Invasive staging
 Fiber-optic Mediastinoscopy
 Transbronchial needle aspiration
 Transthoracic needle aspiration
 Esophageal endoscopic ultrasound needle aspiration
 Chamberlain procedure (anterior mediastinatomy)
 VATS
Direct comparison among the tests is not possible, the
issue is to define which procedure is most useful for a
particular lesion (sensitivity, specificity, false positive
rate, false negative rate)

11. Examples
 Fiber-optic Mediastinoscopy; gold standard among staging
tests of mediastinal lymph nodes
stations: 2&4R, 2&4L, 3 and anterior subcarinal (7)
sensitivity: 82-85%
specificity: 100%
false-negative: 10%
 VATS; used to assess stations not accessible by
Mediastinoscopy
stations: 5,6,7,8, 9 and allows inspection of the pleura
sensitivity: 90%
specificity: 100%
false-negative: <10%

12. Continue….
 Transbronchial needle aspiration
stations: subcarinal (7)
sensitivity: 75%
false-negative: 50%
 Transthoracic needle aspiration; tumours larger than 1.5 cm and
bulky mediastinal tumours
sensitivity: 90%
false-negative: 50%
 Chamberlain procedure
stations: 5 (aorta-pulmonary window)
sensitivity: 87%
false-negative: 10%

13. Recent developments
 Cost reduction compared to the past
 Advanced diagnostic imaging techniques
 64-slice helical CT scan with IV-contrast
 Integrated FDG-PET scan
 Advanced instrumentation
 3D cameras
 Increased experience
 Shorter learning curve
 Anastomotic technology

14. Continue.....
 Introduction of the thoracoscope (deflectable)
 Auto-fluorescence Thoracoscopy for more accurate
mesothelioma staging and early stage pleural malignancies
 Fluorescein-enhanced Autofluorescence Thoracoscopy
(FEAT)
 Narrow Band Imaging (NBI) technique which enhances
vascular architecture of tissues, aids in biopsy site selection
as it clearly demarcates tumour margins
 Total development
Video  Robot

15. Auto-fluorescence Thoracoscopy
VS
White light thoracoscopy view Auto-fluorescence thoracoscopy
of breast cancer metastasis to view of breast cancer metastasis
parietal pleura to parietal pleura

16. Fluorescein-enhanced
Autofluorescence Thoracoscopy
White Light view Bleu Light view

17. Narrow Band Imaging
 New alternative light wavelength capture system
VS
Pleural cavity of patient X with Pleural cavity of patient X with
metastatic adenocarcinoma, metastatic adenocarcinoma,
white light NBI

18. Deflectable tip thoracoscope

19. Robotic applications in cardiac surgery
 Pericardiectomy
 Implantation of automatic cardiac defibrillator
 Mitral Valve repair or replacement
 Harvesting of Internal Mammary Artery
 Coronary Artery Bypass Grafting
 Closure of PDA
 PA banding
 Management of cardiac injuries
 Atrial Ablation

20. Who and Where?
When and How?

21. Knowing it does not mean that we
should do it!
Knowing it means that we should
do it!