Tricks - Supine Positioning For Bilateral VATS

Lateral decubitus positioning has been adopted from the transition from open thoracotomy to VATS and provides ease of exposure and rapid conversion to open thoracotomy, but with advancements in VATS this no longer applies.

Lateral positioning may add unnecessary morbidity including brachial plexus injury and decubitus ulcers.

The patient is a 17-year-old male with history of asthma who presented with shortness of breath and chest tightness when running, found to have bilateral apical blebs and a large right spontaneous pneumothorax treated with chest tube, later developing a small left spontaneous pneumothorax that resolved with observation.

Bilateral VATS with bilateral apical bleb resections and mechanical pleurodesis was performed in the supine position due to the routine nature of the procedure.

Port placement for supine VATS included 25mm ports at the 7th intercostal space midclavicular line and 6th intercostal space mid-axillary line, plus a 12mm port at the 4th intercostal space mid-axillary line to accommodate the GIA stapler.

Bilateral VATS was safely completed in the supine position, providing simplicity, convenience, decreased operative time, and decreased positioning-related morbidity.

Patient selection for supine VATS is important; appropriate cases include bilateral VATS with low morbidity and well-defined pathology where you won't encounter surprises.

Bilateral thoracic sympathectomies for hyperhidrosis can be performed in the supine position at one sitting.

For sympathectomy in supine position, the lung falls away adequately with table tipping and CO2 compression of the lung to help with exposure.

Supine VATS is useful in low-risk-to-conversion thoracoscopic cases; any low-risk pleural-based lesion case for biopsy or superficial wedge resection would be applicable, but if there's high risk of conversion or difficulty with exposure, traditional decubitus positioning is preferred.

Bilateral phrenic nerve stimulators for patients with central hyperventilation syndrome can be placed in supine position because the phrenic nerve is quite anterior.

In the presented case, a double-lumen tube was used with positive pressure in the chest being worked on, providing great exposure.

Mechanical pleurodesis was performed circumferentially from about the 5th intercostal space up to the apex, which was as easy as the standard approach with decubitus positioning.

The patient was moved to the side edge of the bed to allow full mobility of the surgeons' hands.

Parietal pleurectomy is fairly easy—you get into the space underneath the parietal pleura and strip it off—and is a far more effective way to seal the pleural cavity than mechanical pleurodesis.

There have been recurrences after mechanical pleurodesis, but no recurrences after pleurectomy in the speaker's experience.

The blood patch technique is very effective for pleurodesis, and you don't want to suction out any blood for this reason.

Pleurodesis may not be necessary in these cases because the cause of the problem is blebs in the apex of the lung; removing the blebs should prevent recurrent pneumothorax.

Blebs are not just a one-point-in-time thing; they have to do with the anatomy of the lung and overstretch, so if you take out one bleb, another bleb could form in a few months.

These are congenital blebs that don't form over time at age 16.

There are certain congenital problems where you go in and there are blebs all over the place; you see the largest ones at the apex and assume those burst, but you can have blebs you can't see or identify.

The speaker strips the cupola of the pleura and uses the abrading technique for the lower aspects of the chest where stripping becomes harder.

Pleurectomy is incredibly painful postoperatively.

Patients who received talc pleurodesis had more pain postoperatively compared to mechanical pleurodesis, based on anecdotal observation.

Pleurectomy and talc are very painful postoperatively, and if you've ever had to re-operate in a chest that's had talc in it, you'll never do it again because the whole lung becomes frozen.

Mechanical pleurodesis works effectively because you just need the apex of the lung to stick up, not the whole lung frozen.

In the presented case, when starting on the right side, the area where the previous bleb had spontaneously erupted was well adhered to the apex of the chest.

The more painful the pleurodesis, probably the more effective it is.

Once you start pleurectomy, it's hard to stop because it strips away easily, and with modern analgesics the pain is manageable.