A Health Professional's Guide to Video-Assisted Thoracoscopic Spinal Surgery(VATS)
Florida Foundation for Research in Spinal Disorders
Florida Fellowship in Reconstructive Spinal Surgery
General Indications for Spine Surgery
One of the most difficult jobs of a spine surgeon is deciding when surgical intervention is appropriate. There are five basic reasons to offer surgical treatment to patients with spinal disorders.
- Neurological dysfunction (compression)
- Structural instability (abnormal displacement)
- Pathologic lesions (such as a tumor or infection)
- Deformity (abnormal alignment)
- Pain (spinal column/discogenic/facetogenic)
Placing the patient in one or more of these categories allows the spinal surgeon to organize his/her thoughts. In general, nonoperative treatment should be considered first prior to surgical intervention. All of the groups can be managed nonoperatively or operatively. Once all conservative measures have been exhausted over a reasonable period of time, then surgical intervention may be appropriate. In general, minimally invasive endoscopic techniques may be considered prior to more extensive reconstructive procedures. The use of endoscopes allows surgical procedures to be performed through small incisions which may minimize postoperative pain, decrease length of hospital stay, facilitate recovery times, hasten return to work, and decrease costs of medical care.
Indications for Thoracoscopic Spinal Surgery (VATS)
Indications for performing a thoracoscopy can be extrapolated from the five basic indications for surgery of the spine patient.
Deformity: These include an anterior release for scoliosis or Scheuermann's kyphosis.
Fig.1: Patient with kyphosis
Instability: In cases of spinal fractures for instance, in addition to decompression, anterior column reconstruction using bone grafts and/or internal fixation devices can also be applied through a thoracoscopic approach.
Neural compression: This is probably the most common indication for a thoracoscopic spinal surgery. Nerve roots and the spinal cord can be decompressed through the resection of thoracic herniated nucleus pulposus.
Fig.2: Herniated Nucleus Pulpous
Pathologic lesions: A thoracoscopic approach may be used for the treatment of infection or tumor through biopsy, debridement, drainage of an abscess, resection of a tumor, or corpectomy.
Pain: Thoracoscopy may be used for the treatment of symptomatic spondylosis and/or degenerative disc disease by fusion of the painful motion segment (bone dowels or cages).
Thoracoscopy is a technique used in managing herniated thoracic discs. The advantages of thoracoscopy over the conventional transthoracic open procedures are
- enhanced visualization while using standard instruments through minimal incisions
- more extensive visualization of thoracic anatomy
- decreased incisional pain
- decreased need for chest tube drainage
- decreased respiratory complications
- decreased blood loss
- decreased potential for infection
- decreased postoperative pain which results in shorter hospital duration, shorter rehabilitation, and decreased medical costs.
The obstacles associated with thoracoscopy are that it requires
- technical skill
- deflation of the ipsilateral lung.
This procedure is therefore contraindicated for patients who:
- cannot tolerate one lung ventilation;
- have medical reasons that would prohibit surgery (uncontrollable coagulopathy, irrecoverable terminal illness, or severe cardiac or pulmonary disease );
- have had prior thoracotomy or another procedure in which they may have developed adhesions that might prohibit adequate access.
Figure used with Permission; John J. Regan, M.D.
Fig.3: O.R. Set–up for VATS
Fig.4: High Tech O.R. Equipped for Video Assisted Thoracoscopic Spine Surgery
Approach and Technique for Thoracoscopic Spinal Surgery (VATS)
Prior to attempting endoscopic techniques, the physician should be comfortable performing open thoracic procedures because they involve essentially the same surgical techniques and procedures. There are some basic technical concepts that are important to understand prior to initiating the thoracoscopic procedure.
Trocar site placement is critical. If the trocars are placed too close together, the instruments will not have adequate working space and Afence@ with each other. Additionally, the trocars should be place far enough away from the surgical lesion as to permit adequate visualization of the surgical lesion. Rigid trocars should be avoided to prevent intercostal neuralgia.
Instrumentation should be inserted and positioned at a 180–degree arc and face the same direction as the camera to avoid mirror imaging.
Do not manipulate instrumentation without visualizing through the scope to avoid soft tissue injuries.
Avoid random movements of the camera to avert confusion. Zoom in and out to gain adequate visualization and perspective.
Figure used with Permission; John J. Regan, M.D.
Fig:5: O.R. Set up for VATS
Once the patient is laterally positioned, anesthesia is induced, and the surgical site is prepped. The first incision is made in the 6th or 7th intercostal space on the midaxillary line for the insertion of the first trocar. The camera is inserted so that all other trocar insertions may be visualized.
Fig.6: Lateral Decubitus Position
The insertion technique for trocars is similar to that of a chest tube insertion. An incision 15–20 mm long is made over the intercostal space and extended through the parietal pleura. The first trocar is usually inserted at the 6th or 7th intercostal space. Caution is exercised when inserting a trocar below the T7 level to avoid penetrating the diaphragm. Once the first trocar is placed one lung ventilation should be confirmed and hemostasis verified. The remaining trocars may then be placed. Usually 4 or more trocars are required.
Figure used with Permission; John J. Regan, M.D.
Fig.7: Trocar Placement
Visual inspection of the contents of the thoracic cavity should be performed initially. If the surgical lesion is in the mid–thorax, the azygos vein, aorta, intercostal vessels, and rib heads should be identified. If the surgical lesion is in the upper thorax, the subclavian artery and veins, ribs one and two, longus colli muscle and superior intercostal vein should be identified. Ribs should be counted and x–rays performed to confirm the location of a surgical lesion such as a herniated nucleus pulposus.
Fig.8: Anatomy of Chest Cavity
Once the general exposure is complete, which may require a thoracic surgeon, the spinal exposure may be initiated by the orthopaedic surgeon or neurosurgeon.
The surgical approach to the midthoracic spine (T6–T10), lower thoracic spine (T10–L1), and upper thoracic spine (T2–T6) differ slightly with respect to the placement of trocars. Once, the approach is made and the anatomy identified, the spine surgeon may then begin the specific thoracic procedure, most commonly a thoracic microdiscectomy.
Equipment for Thoracoscopic Spinal Surgery (VATS)
The following is a list of commonly used instruments for thoracoscopy.
- Radiolucent table
- Double lumen endotracheal tube
Figure used with Permission; John J. Regan, M.D.
Fig.9: Instrumentation Placement for VATS
- Scope angled 30–45 degrees with antifogging solution
- Flexible trocars
Fig.10: Flexible Trocars
- Inverted monitor, 3–D endoscopy (optional), cameras, light source, video recorders, robotic arm, and suction/irrigation
- Fan retractors
- Long handled manual instruments (graspers, cobb elevator, currettes, osteotomes, rongeurs, etc.)
- Clip appliers (straight and 90 degree angled)
- Harmonic scalpel
- Bipolar cautery devices
- Hemostatic agents (Gelfoam, bone wax, endoavitene, etc.)
- Long drill bits (Midas Rex, Mednext, Anspach)
An angled scope is utilized to allow better visualization of the instrumentation and surgical lesion at various angles. Antifogging solutions save time by decreasing the number of times the scope must be removed and cleaned.
The most commonly used grasper in spine surgery is the curved tip. It is used to palpate the disc and dissect around the segmental vessels. The fan retractor is useful for retracting the atelectatic lung. Caution should be used when opening the fan retractor to avoid soft tissue injury. Manipulation of any instrumentation should be visualized at all times. Commonly used instrumentation in spine surgery such as currettes, cobb elevators, and pituitary rongeurs have been modified for endoscopic procedures. They have been made longer to extend from the chest wall to the spine. Bipolar cautery is essential to any procedure involving the spine, as are hemostatic agents. Additionally, an open thoracotomy tray with large vessel clamps should be ready for those cases in which the thoracoscopy must be converted to an open procedure.
Fig.11: Cautery and Suction Device
Perioperative Nursing Care for Thoracoscopic Spinal Surgery Patients
History and Physical Examination
A routine history and physical is a vital component of the perioperative care of the patient who is to undergo a thoracoscopic spinal procedures.
A thorough history should include such components as: past spinal surgeries or surgeries on the ipsilateral chest wall or lung (adhesions), past treatments (physical therapy, medications, chiropractic adjustments, injections, pain clinic, and orthotics), past diagnostic tests (radiographs, MRI, CT scan, or bone scan); medical risk factors (smoking, alcohol, illicit drugs), and current symptoms.
The physical exam should contain a complete neurologic and musculoskeletal exam. Of importance are a visual inspection of the spine, sensory and motor exam, pathologic reflexes (Hoffman, Babinski, and Clonus), deep tendon reflexes, and gait.
Additional assessment of the patient who is to undergo spinal surgery should include chest x–ray, ECG, complete blood count with differential, chemistry profile, and bleeding studies. A patient over the age of 40 may have medical clearance by an internist or family practitioner. A pulmonary consult may also be necessary to see if the patient will tolerate one lung ventilation or if history of previous thoracic pathology (empyema, etc.) exists.
The use of diagnostic exams is indispensable in the treatment of a patient with a spinal disorder. Plain radiographs before and after surgery are fundamental to the follow–up care of the patient who has undergone spinal surgery. Plain x–rays are excellent tools for the evaluation of bony detail. Additionally, evaluation of motion over the fused segments can be performed by comparing previous flexion/extension radiographs with current flexion/extension radiographs.
An MRI is an excellent tool to use in the initial evaluation of a patient with complaints of thoracic pain (either spinal or radicular) or if myelopathy is detected. It is rapid, noninvasive, and can be done on an outpatient basis. If surgery is indicated, a CT/myelogram is extremely helpful. Generally, many diagnostic tests are used in conjunction with one another to evaluate a patient for surgical intervention, including thoracoscopy.
Providing the patient with instructions and detailed information is an important step in the preoperative period and should include treatment options, informed consent, and an explanation of potential complications, the expected hospital course, as well as anticipated eventual outcomes. The spinal surgeon is responsible for adequately informing the patient of the potential risks and benefits of the pending surgical intervention. A signed consent is mandatory to proceed with surgery.
The use of a spine model is helpful when explaining the surgical procedure. Explain to the patient and his or her their family that there will be four or more small incisions on the side of his or her chest. Also explain any instrumentation or bone grafts that might be used.
Potential complications of a thoracoscopy include intercostal neuralgia, atelectasis, pneumothorax, hemothorax, chylothorax, pneumonia, infection, hardware–related complications, excessive epidural blood loss, major vessel injury, penetration of the diaphragm, pulmonary lacerations, etc. Conversion to open thoracotomy is always a possibility and should be included on the informed consent.
The surgical procedure generally takes 2 to 6 hours, depending on the number of levels and level of technical difficulty. The hospital course generally is a 2 to 5 day stay. It is important that the patient know exactly what to expect while in the hospital. He or she will may have one or two chest tubes for 24 to 72 hours after surgery. Patients are also usually administered patient–controlled IV pain medication for the first 24 to 72 hours then PO pain medication for one to three months postoperatively.
Patients are encouraged to begin ambulation as soon as day one postoperatively. They may be told to wear a dorsolumbar corset at all times while out of bed for at least six weeks and possibly longer as bone grafts do not fully mature for six to twelve months. Active exercise and stretching is encouraged after the acute phase (4–6 weeks) and at all times, physical therapy (PT) is utilized. Most importantly, patient education should include the patient and significant family members to reduce anxiety for everyone.
During the intraoperative period the surgical nurse is responsible for the patient. She/he must correctly identify the patient and identify the correct surgical site to be prepped. Appropriate positioning of a patient undergoing a thoracoscopy is usually in the lateral decubitus position. The patient is then prepped for a standard posterolateral thoracotomy with the iliac crest available in case autogenous bone grafting is necessary. Caution should be exercised to ensure preservation of skin over bony prominences. Foam padding and rolls should be used as necessary. Sequential compression devices and TED hose are routinely used to prevent deep venous thrombosus.
Diagnostic studies should be available to ensure that the proper surgical lesion is operated upon. The entire surgical team should have a good understanding of the procedure to be performed to ensure that proper equipment is available. Additionally, the surgical nurse should be aware of what blood products are available and what allergies the patient has.
The use of fluoroscopy and x–ray are necessary during the procedure to ensure that the correct surgical lesion is located and that instrumentation is placed properly. Neurological monitoring such as the wake–up test is occasionally used in thoracoscopy.
The most important role of the surgical nurse postoperatively is assessment of neurological status. The neurological exam should include an assessment of muscle strength and sensation. The exam should include both upper and lower extremities. It should be performed frequently in the recovery room, every 4 hours for 48 hours, and then every shift until discharge. If the patient complains of heaviness in the extremities, numbness, tingling, or inability to move an extremity that did not exist preoperatively, then immediate attention is warranted.
An assessment of lung status is critical in this patient population. This assessment should take place every 4 hours for the first 24 hours then every shift until discharge. Patients run a higher risk of developing pneumonia and should be encouraged to use their incentive spirometer every hour while awake. Diet should be advanced as tolerated if bowel sounds are present.
Patient–controlled analgesia (PCA) is used for the first 24 to 72 hours postoperatively; the patient is then changed to oral pain medication. Oral pain medication is continued for one to three months postoperatively. The dose is gradually reduced as the patient's activity increases and his or her operative pain decreases.
The patient should be instructed to wear his or her corset at all times while out of bed. He or she also should be instructed on proper wound care and the signs and symptoms of infection. Prior to discharge, patients must be:
- taking oral pain medication only
- ambulating independently with or without assistive devices.
- able to take off and put on their brace with little difficulty.
- able to get in and out of bed independently.
- afebrile (<100.5) for 24 hours.
Patients are seen in clinic 4 to 6 weeks after discharge for a follow–up appointment and radiographs or earlier if problems arise.
With proper planning and patient education, thoracoscopic spinal surgery is a valid surgical intervention for those patients for whom it is indicated. A good–to–excellent outcome can be expected with a low rate of morbidity.