VATS - Video-Assisted Thoracic Surgery

Less pain, faster recovery after chest surgery

In traditional open-chest surgery, or thoracotomy, doctors cut through muscle and cut through or spread apart the rib cage. Now patients at Seattle Cancer Care Alliance (SCCA) have a less-invasive alternative if they need lung tissue removed: video-assisted thoracic surgery. VATS lung resections are only available at specialized thoracic surgery programs, including University of Washington Medical Center, an SCCA parent organization.

Small incisions are easier on patients

VATS allows doctors to perform chest surgery through two to four small incisions, most less than an inch long. A camera inserted through one of the incisions guides their work. Images from the camera show on a video monitor. They use the other small incisions to insert their surgical instruments.

In a traditional thoractomy, the surgeon makes a longer incision – usually about 6 to 10 inches long – often from the patient’s back around to her side. Then, in order to see and reach the organs that need repair, removal, or other work, the surgeon must move the ribs out of the way by cutting or spreading them. This method, while sometimes necessary, is more traumatic to the body. So recovery can be painful and take many weeks.

People who undergo VATS appeart to spend less time in the hospital, need less pain medication, have less scarring and recover faster than those who undergo open-chest surgery.

“I would find somebody who could do this for me if I needed thoracic surgery done,” says Dr. Michael Mulligan about VATS. “I do things for my patients that I would want someone to do for me. We’re in it together.

Mulligan is one of the few board-certified thoracic surgeon in Seattle who routinely performs anatomic lung resections using VATS. He has also performed more than 200 lung transplants and hundreds of other thoracic surgeries at University of Washington Medical Center. Furthermore, he is a part of a large multidisciplinary team of surgeons and oncologists that perform more lung operations than anywhere else in the Pacific Northwest.

VATS candidates

The best candidates for VATS among people who have cancer are those in the early stages of their disease. Generally it’s not suitable for people receiving neoadjuvant chemotherapy (given before surgery) or those with bulky areas of disease in the thorax. Also, VATS may not be appropriate for people whose surgery will exceed a certain threshold of complexity because of the location or other characteristics of their cancer.

Home and back to life within days

While survival rates are about the same for open-chest surgery and for VATS, other measures of success favor VATS, Mulligan explains.

“Our average time to discharge [after VATS] is just over two days,” says Mulligan. Many people are back to their usual activities in about one week. In contrast, after open-chest surgery, most patients spend one week in the hospital and four to six weeks recovering.

Studies so far show that people who undergo VATS have:

• Less post-operative pain than those who have open-chest surgery
• Better shoulder function
• Better lung function when the same amount of lung tissue is removed.
• The stamina to walk further in six minutes than patients who have open surgery.

Though VATS takes longer to perform than open-chest surgery, patients fair so much better that it’s been refreshing, says Mulligan. Their response has only reinforced his passion for his work.

World-class surgery for the region

The VATS technique is simply another way for the surgeon to access the thorax, or chest. Once his instruments are inside the patient’s body, the rest of the surgery – such as removal of tissue – is the same as with an open-chest approach, says Mulligan. “I’m doing the exact same operation,” he says. “I’m just changing the incisions.”

Thanks to the knowledge he’s gained from his extensive lung transplant experience, Mulligan began taking a less-invasive approach to other thoracic surgeries years ago.

“I started using smaller and smaller incisions because of a heightened awareness of where things are in three dimensions,” he says.

For instance, after making a traditional skin incision, Mulligan would shift muscles out of the way, rather than cutting through them. Knowing he’d need to place drainage tubes in the chest at the end of the surgery, he performed surgery through the small drainage incisions from the outset when he could.

In June 2005, Mulligan traveled to Cedars-Sinai Hospital in Beverly Hills to observe Dr. Robert McKenna. McKenna is one of the first doctors in the United States to use VATS to do anatomic resections. He typically spends a year or so training doctors in the technique, says Mulligan. But because Mulligan had progressed so far toward minimally invasive techniques on his own, their work together took only four days.

In his first few months back at UW Medical Center, Mulligan performed VATS resections on more than 20 patients. “We started right out of the blocks,” he says, with no complications related to the procedure and no VATS patients needing a last-minute switch to a traditional open surgery.

“It's good for any patient in the nation that wants this procedure done by a world-class surgeon at a world-class institution,” says Lois Wedlock, a representative for U.S. Surgical, which makes laparoscopic and endoscopic surgical instruments used in VATS. “UW is the leading institution for the WWAMI Region (Washington, Wyoming, Alaska, Montana and Idaho).”

Illustration courtesy of United States Surgical, a division of Tyco Healthcare Group LP, all rights reserved.