The Surgeon
Dr. Nasser was born in Bombay. He did his schooling from both Calcutta and Bombay. He took his bachelor's (MBBS) and Master's Degree (MS) in surgery from Jawaharlal Nehru Medical College, AMU. He has ...

 
   
News and Events
Dr. Nasser Yusuf discussed Key Hole Surgery at the Fourth State meet of the Cardio thoracic Surgeons held at Kadavu resort on 25th May


Dr. Nasser successfully did an open heart surgery and replaced the valve in the heart of a young lady in Calicut
 
 
   
VATS-Video Assisted Thoracoscopy Surgery (Keyhole Surgery)


VATS-Video Assisted Thoracoscopic Surgery (Keyhole Surgery) or in other words Endoscopic Surgery of the Chest is one of the exciting advancements in Respiratory Medicine and Chest Surgery. It is an excellent diagnostic tool in the hands of the Chest Specialist. It is also an alternative to many open procedures.

Thoracoscopy means approaching the pleural cavity (which means the space between the lung and inside of the chest wall) via chest between the ribs with the endoscopic instrument. This allows direct visualisation, sampling of the diseased area and at times surgical treatment.

History of Thoracoscopy goes back to early 20th century, when a modified endoscopic instrument was used for creating artificial pneumothorax which was the only available form of treatment for TB (Tuberculosis), before the advent of anti-TB drugs. But with the introduction of effective anti- TB treatment, Thoracoscopy fell into disuse. Recently interest has been rekindled because of advent of video-optics, improved instrumentation, better aneasthetic drugs and facilities.

For diagnostic purposes indications for thoracoscopy are :

1. Undiagnosed fluid collection around the lungs
2. TB
3. Pleural disease
4. Indeterminate lung masses
5. Lung Cancer
6. Biopsy of  structures  surrounding  the heart
7. Disease of lung parenchyma

With thoracoscopy any of the above disease can be diagnosed with 100% accuracy and treatment initiated at the earliest. This is achieved by direct visualisation of the diseased area as well as adequate amount of tissue obtained for sampling.

Tuberculosis which is one of the most common diseases of a developing country like India is often over diagnosed or empirical treatment instituted without diagnosis.The general impression is that blood stained fluid collection is cancerous and non-blood stained or clear yellow coloured fluid is usually due to TB. But with Thoracoscopy and biopsy we have been able to prove that it is not always true .

Although the diagnostic yield is high, it is an invasive procedure and hence it is the final test in the algorithm for investigating pleural, lung and mediastinal diseases. When all other investigative measures have failed to establish a diagnosis of diffuse lung disease, thoracoscopic lung biopsy provides a specific diagnosis which helps in further management and prediction of survival time.


Often we encounter delay in diagnosing a surgically resectable lung cancer, current opinion is that the survival rate can be improved if the cancer mass is removed when its size is less than 2cm, making early diagnosis critically important. Even in a cancer which has spread to the lung from some other primary site, less invasive thoracoscopic procedure allows earlier pallative care which will enhance survival as well as quality of life.

Pericardial effusion or the collection of fluid within the space between 2 layers of the pericardium (covering of the heart) is another entity where VATS plays a helpful role. This condition may be caused by Cancer, TB, Lymphoma etc. Biopsy of the pericardium, window procedure for drainage which solves the problem permanently can be achieved by VATS.

When tissue diagnosis cannot be established by any other means, VATS remains the only option. Moreover, procedure-related morbidity is very low compared to a full-fledged thoracotomy procedure as the recovery period is short thereby decreasing hospital stay, of course less painful as the wound is small giving it a better cosmetic appearance.

Moving on to the therapeutic uses of thorocoscopy i.e., as a part of treatment, it is an aid to performing thoracic surgery in a minimally invasive manner.

Some of the procedures performed using VATS include :

1. Treatment of recurrent, intractable pleural effusion from any cause.
2. Removal of multiple  collections of pus surrounding the lungs.
3. Pleurectomy (resection of pleura)
4. Control of bleeding in chest trauma.
5. Resection of  benign  or cancerous  peripheral lung masses.
6. Ablation of sympathetic trunk - a treatment procedure for hyperhydrosois (excessive sweating of extremities).
7. Lobectomy (resection of one lobe of the lung) or Pneumonectomy (removal of a whole lung).

The most encouraging and rewarding result is in the treatment of cancerous pleural effusion, hitherto a vexing and neverending problem which needs further mention. Once diagnosed, available methods of treatment are not entirely satisfactory. It required repeated drainage of the fluid along with chemotharapy and / or radiotharapy. Another option is to insert a chest tube & let the fluid drain, followed by various chemicals or drugs to obliterate the space so that no further fluid can accumulate.

For this procedure to be successful and effective there should be even distribution of the chemical on the lung surface. Thoracoscpy achieves this by complete drainage of fluid and uniformly spraying Asbestos free talc (chemical).

Pleural Effusion of Unknown Etiology

Adenocarcinoma
Carcinoma of salivary gland (Mucoepidermoid)
Non-hemorrhagic
Malignant Effusion

Pulmonary Parenchymal Disease

Diffuse infiltrates Lung biopsy

Mediastinal Staging and Biopsy


Left hilar mass Lymph node biopsy

VATS video

Pleural Effusion (Fluid in the Plueral Cavity)

 
Pneumo thorax and Bullectomy

 

Complications

Complications following VATS are very less and some of them that can be seen are persistent air leak, leakage of air in the subcutaneous plane & post-operative fever. Death is extremely rare.

Conclusion


Thoracoscopic procedures have helped us in reaching the diagnosis of rare and otherwise undiagnosable conditions like catamenial effusion (periodic collection of fluid in pleural cavity during menstruation) sarcoidosis, tumour embolism etc. It also helps in identifying specifically from over hundred odd types of diffuse parenchymal lung diseases.

Benefits

VATS is superior to a standard open procedure in that it reduces trauma, post operative pain, narcotic use and preserves lung function. This in turn reduces post-operative complications, shortens hospital stay, offers lower cost, better outcome & increased patient satisfaction.

This is usually performed under General Anesthesia, but it may also be done under Local Anesthesia.

The benefits of VATS can be understood by the photographs added below.

Long (Postero-lateral) incisions Small (Lateral) incisions – Video assisted mini thoracotomy
VATS - Video Assisted Thoracoscopy Surgery (Keyhole Surgery)

Procedure

After proper preparation and anaesthesia, a 10 mm incision is made on the chest wall above the rib margin on the required side. The site depends on the anticipated location of abnormality. The endoscopic instrument is introduced through this wound and it is possible to visualise the entire surface which is 20 times magnified and adequate sampling of specimen achieved. A chest tube is inserted for removal of air and fluid at the completion of the procedure which is removed after a couple of days.

Duration of Stay

3 to 5 days

Expense


Approximately Indian Rupees 40,000/-