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Supine Positioning for Bilateral VATS: Pediatric Surgery Difficult...
With Dr. Mark McCollum · hosted by Dr. Todd Ponsky
Chapter 1 of 4 · Case-Based Learning
Case presentation
Case Presentation: Bilateral VATS in Supine Position
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Patient selection for supine bilateral VATS should include procedures with low morbidity and very well-defined pathology such that you won't encounter any surprises.
Bilateral thoracic sympathectomies for hyperhidrosis can be performed in 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 and applicable for low-risk pleural-based lesion cases, superficial wedge resections, or biopsies.
If there's a high risk of conversion or difficulty with exposure, traditional decubitus position is preferred over supine.
Bilateral phrenic nerve stimulators for patients with central hyperventilation syndrome is a good candidate for supine bilateral VATS because the phrenic nerve is quite anterior.
A double-lumen tube was used with positive pressure in the chest being worked on, providing great exposure.
Mechanical pleurodesis was performed from about the 5th rib intercostal space up to the apex, circumferentially, and was as easy as the standard decubitus approach.
Parietal pleurectomy is fairly easy once you get into the space underneath the parietal pleura and is a far more effective way to seal the pleural cavity than mechanical pleurodesis.
Recurrences have been seen after mechanical pleurodesis, but no recurrences have occurred after pleurectomy in one surgeon's experience.
Blood patch technique is very effective for pleurodesis, and blood should not be suctioned out during the procedure.
Blebs are not just a one-point-in-time thing but relate to lung anatomy and overstretch, so removing one bleb does not prevent another from forming in a few months.
Blebs are congenital and do not form over time at age 16; they become problematic during growth in the preteens.
In certain congenital problems, blebs can be present all over the chest, with the largest ones at the apex assumed to be the ones that burst, but blebs may exist that cannot be seen or identified.
Pleurectomy and talc pleurodesis are very painful postoperatively, and re-operating in a chest that has had talc is extremely difficult due to the entire lung being frozen.
Mechanical pleurodesis works effectively by causing only the apex of the lung to adhere, which may be sufficient to prevent tension pneumothorax without freezing the entire chest.
In the presented case, the area where the previous bleb had spontaneously erupted was well adhered to the apex of the chest when the right side was started.
Parietal pleurectomy, once started, is hard to stop because it strips away easily, and postoperative pain is manageable with modern analgesics.
Lateral decubitus positioning was adopted from the transition from open thoracotomy to VATS but may add unnecessary morbidity including brachial plexus injury and decubitus ulcers.
The presented case involved a 17-year-old male with asthma presenting 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, followed by a small left spontaneous pneumothorax that resolved with observation.
Bilateral VATS with bilateral apical bleb resections and mechanical pleurodesis was performed in supine position with single sterile preparation, reducing operative time.
Port placement for the right side 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.
Pleurodesis may not be necessary after bleb resection because the cause of pneumothorax is blebs in the apex of the lung, and removing the blebs should prevent recurrent pneumothorax.
A prospective randomized trial comparing blebectomy with pleurodesis versus blebectomy without pleurodesis could determine if there is a higher incidence of recurrence without pleurodesis.
Pleurectomy is incredibly painful postoperatively.
Patients receiving talc pleurodesis had more postoperative pain compared to mechanical pleurodesis in one surgeon's anecdotal experience.