VATS Surgery - Video-Assisted Thoracoscopic Surgery

The same lobe comes out, with the same lymph nodes. What changes is the ribs stay where they are.

A lung operation once meant a cut across the side of the chest and ribs spread apart with a steel retractor. Video-assisted thoracoscopic surgery does the same operation through one to four keyhole incisions with a camera inside the chest, and the largest randomized trial to test it, 503 patients at nine British hospitals, found less pain, fewer complications, a day less in hospital and the same cancer result. Send us your CT and PET scans, your lung function tests and the biopsy report, and a thoracic surgeon will tell you whether your operation can be done this way.

What do the trials show?

1. VIOLET, United Kingdom, 503 patients. Randomized to VATS or open lobectomy at nine hospitals, with patients kept unaware of which they had received until discharge. Physical function five weeks later was better after VATS, pain on day two was lower, painkiller use was 10 percent lower, hospital stay was four days against five, and complications before and after discharge were fewer. Lymph node staging, uptake of chemotherapy afterward, survival and cancer-free survival were the same.
2. Odense, Denmark, 206 patients. Randomized to VATS or open lobectomy with identical dressings so that neither patients nor nurses could tell. Significant pain in the first 24 hours affected 38 percent after VATS and 63 percent after open surgery, moderate-to-severe pain episodes were fewer through the whole first year, and quality of life on one of the two measures used was better. Serious complications were the same.
3. Society of Thoracic Surgeons database, 2,562 matched patients. Comparing VATS with open lobectomy across American hospitals, 73.8 percent of VATS patients had no complication at all against 65.3 percent, with fewer heart rhythm disturbances, fewer returns to the ventilator, fewer transfusions, and a stay of four days against six. Deaths were the same.

Video-assisted thoracoscopic surgery lobectomy was associated with less pain, fewer complications and better quality of life without any compromise to oncologic outcome.

Conclusion of the VIOLET trial, Health Technology Assessment, 2022

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How much lung comes out

For decades a lung cancer meant the whole lobe. A trial published in the New England Journal of Medicine in 2023 changed that for the smallest tumors. It randomized 697 patients with a cancer of two centimeters or less at the edge of the lung, and no spread to lymph nodes on testing during the operation, to removal of the lobe or of a smaller piece, a segment or a wedge. Seven years later, disease-free survival was the same, 63.6 against 64.1 percent at five years, overall survival was the same, and the patients who kept more lung breathed a little better six months on. For a small peripheral tumor the surgeon should therefore be asked whether a segment would do, and by VATS a segmentectomy is a routine operation.

• Lobectomy and segmentectomy for lung cancer and for lung metastases from other cancers.
• Wedge resection of a nodule to find out what it is, with the pathologist reporting while you are still asleep.
• Bullectomy and pleurodesis for a collapsed lung that keeps recurring.
• Pleural biopsy, drainage and talc for fluid around the lung.
• Thymectomy for myasthenia gravis and thymic tumors, and removal of other masses in the mediastinum.
• Sympathectomy for severe hand sweating, and biopsy of lymph nodes for lymphoma or sarcoidosis.

Who is a candidate, and who is not?

• The CT scan of the chest with images, and the PET-CT report and images if one has been done.
• The biopsy or bronchoscopy report.
• Lung function tests, above all FEV1 and DLCO, plus the result of any exercise test you have had, since these three numbers decide the operation more than anything else in the file.
• A recent ECG. An echocardiogram if you have heart disease.
• A full list of medicines, and your smoking history in pack-years, since the anesthetist and the surgeon each read it differently.

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Fitness for surgery

Lung function decides more than age.

Spirometry and the gas transfer test predict how much breathing reserve you will have once a lobe is gone, and when the numbers are borderline an exercise test measures oxygen uptake directly. Patients with poor exercise capacity were long refused surgery, and the keyhole approach has moved that line. In a European database of 1,684 lobectomy patients, those with a low oxygen uptake who had open surgery died at more than twice the rate of those with good uptake, 6.7 against 2.8 percent, while after VATS the low-uptake group did no worse than the rest. The surgeons who reported it wrote that the finding challenges the traditional criteria of operability when the keyhole technique is used. A patient turned down for surgery elsewhere on lung function grounds is one of the patients who should send a file.

When a keyhole operation becomes an open one

A few operations in every hundred are converted to a thoracotomy during surgery, above all for scarring that hides the vessels, and sometimes for bleeding. Conversion is a safety decision and not a failure. It is discussed at consent, and the anesthetic and the preparation are the same either way, so nothing about the day changes except the incision you wake up with.

What is the hospital stay like?

Plan on ten to fourteen days in Istanbul. Two or three days of tests before surgery, four to six nights in hospital, and a week nearby before the flight home.

The day before surgery brings the final blood tests, the anesthetic consultation and teaching with a physiotherapist, who shows you the breathing exercises and the walking routine you will start the evening of the operation. A lobectomy takes two to three hours. You wake in a recovery area and go to a monitored bed on the ward the same day. A night in intensive care is reserved for those with heart or lung disease. You sit out of bed on the first evening. You walk the corridor on the first morning, with a nerve block or an epidural for the first two days and tablets afterward. The chest drain comes out when the air leak stops and the X-ray shows the lung fully expanded, between day two and day four in the main, and discharge follows a day later. Pathology on the lobe and the lymph nodes takes five to seven working days and decides whether chemotherapy is advised afterward. One relative can stay in the room throughout, and should, since the first two nights are the hardest and a familiar voice at three in the morning does more than any drug for the fear that breathlessness brings.

What are the risks, and what does recovery involve?

Among 2,562 matched patients, 26 percent had a complication after VATS lobectomy and 35 percent after open lobectomy. Operative deaths were the same.

Society of Thoracic Surgeons database, Journal of Thoracic and Cardiovascular Surgery, 2010

What decides the cost, and what about the trip?

The operation is priced by its extent, since a wedge resection, a segmentectomy and a lobectomy with lymph node dissection are three different amounts of work. The stapler cartridges, of which a lobectomy uses several and each is single-use. Nights in hospital, with intensive care nights at a higher rate. The pre-operative work-up, where a PET-CT, a brain MRI, lung function tests and an exercise test are each separate items. Pathology, including the immune and molecular tests on a cancer that decide later drug treatment. Then complications. A prolonged air leak can add a week. Your own health, since heart disease, diabetes, poor lung function and blood thinners each add consultations and monitoring.

Packages vary. Those published by hospitals in Istanbul for VATS lobectomy include the surgery and anesthesia, between four and eleven hospital nights, staplers in some, and airport transfers, and they leave the PET-CT, the brain MRI, the lung function tests and the hotel outside. Three things separate quotes. The number of nights, whether staplers and pathology sit inside the figure, and what a week of extra drainage would cost.

Your own figure follows the free review of your scans.

One coordinator from the international patients team is assigned from your first message and stays with you until you fly. The team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreting in other languages on request, and an interpreter attends the consultation, the anesthetic assessment and consent. An invitation letter naming the hospital and the treating surgeon is sent about ten days before travel. The international patients office arranges the airport transfer and the hotel for you and a companion for the nights outside the hospital, and your room on the ward has a companion bed, so one relative can stay for the whole admission. Halal, vegetarian and diabetic meals come from the hospital kitchen, a prayer room is on site, and a request for a female doctor is passed to the department and met wherever the rota allows.

Back home, the coordinator stays reachable on the same WhatsApp number. The pathology report and the surgeon's letter go to your own doctor and oncologist, and where the report calls for chemotherapy afterward, that is arranged at home from the surgeon's letter, since the drug treatment lasts months and gains nothing from being far from home. Go to a local emergency department the same day for fever, sudden breathlessness, chest pain, coughing up blood, or redness and discharge at a wound.

Flying needs one rule.

Wait at least a week after the drain comes out, and have a chest X-ray on the day before you fly that shows no air in the chest. A pocket of air that expands at altitude can collapse the lung, so airlines apply that rule and so do we. Sit on the aisle. Walk every hour. Carry the discharge summary in hand luggage.

VATS surgery FAQ