Video-assisted thoracoscopic surgery (VATS)

Video-assisted thoracoscopic surgery, or VATS, is a type of keyhole surgery used to diagnose and treat conditions in your chest. Instead of one large cut, your surgeon works through a few small incisions, guided by a tiny camera called a thoracoscope that sends live images to a screen.

What conditions does it treat?

VATS can be used to diagnose or treat a wide range of chest conditions, including:

• Lung cancer, including removing part or all of an affected lung
• A build-up of fluid around the lung (pleural effusion) or a collapsed lung (pneumothorax)
• Lung infections, air-filled pockets in the lung tissue (bullae), or scar tissue over the surface of the lung
• Taking a tissue sample (biopsy) to help diagnose cancer or another chest condition
• Conditions affecting the oesophagus, the thymus gland, or lymph nodes in the chest
• Occasionally, certain heart procedures, such as some valve repairs.

Your thoracic or cardiothoracic surgeon, a specialist trained in chest surgery, will advise whether VATS is suitable for your particular condition.

What are the benefits of having VATS?

Compared with open chest surgery, VATS is generally linked to less pain, a shorter hospital stay, less scarring, a lower risk of infection, and a quicker return to daily activities.

Because it's less physically demanding on the body, it can also be a safer option for people who are older or too frail for a full open operation.

A clinical study led by consultants at a specialist UK heart and lung centre, known as the VIOLET study, found that VATS reduced pain, lowered complication rates, and led to a quicker recovery compared with open surgery.

Are there different types of surgical approach?

VATS can be done through several small incisions, usually 2 to 4, or through a single incision in a 'single-port' or 'uniport' approach. Some centres also offer a robotic-assisted version, where the surgeon controls robotic arms while viewing the thoracoscope's images.

Not every operation can be completed this way. More extensive procedures, such as removing a whole lung, removing lymph nodes, or treating a long-standing infection, sometimes need full open surgery (a thoracotomy) instead.

Because of this, your surgeon may ask you to consent to both approaches, so they can switch to open surgery during the operation if it turns out to be clinically necessary.

What happens before the operation?

Before VATS, you'll usually have a set of tests to help your surgical team plan the operation and check you're fit for surgery:

• Blood tests, a heart tracing (ECG), and sometimes an exercise or stress test
• Imaging such as a chest X-ray, CT scan, or PET scan, and breathing (pulmonary function) tests
• Stopping certain medicines, such as blood thinners, if your surgeon advises this
• Stopping smoking beforehand, with support available if you'd like it
• Staying reasonably active where you can, since this helps strengthen your lungs before surgery
• Fasting from a set time before your operation, and arranging for someone to take you home afterwards.

What happens during the procedure?

VATS is carried out under general anaesthetic, so you're fully asleep, and it typically takes around 2 to 3 hours depending on complexity. In general, it follows these steps:

1. A breathing tube is placed after you're asleep, allowing each lung to be managed separately – the lung on the operated side may be temporarily deflated to give your surgeon room to work
2. You're positioned on your side for the operation
3. Your surgeon makes several small incisions between your ribs, or sometimes just one for a single-port approach
4. The thoracoscope is inserted through one incision, sending live video images of your chest to a screen
5. Surgical instruments are inserted through the other incisions and used, guided by the video images, to examine, sample, or remove tissue, fluid or air as needed
6. A temporary chest drain is put in place, and the incisions are closed, usually with stitches or staples.

What does recovery look like?

Most people spend anywhere from 1 night to around 5 days in hospital, and occasionally go home the same day, depending on how they're recovering.

Your chest drain usually stays in for 24 to 48 hours, sometimes longer if there's more air or fluid to clear, and your team will encourage deep breathing exercises and short regular walks to support your lungs and help prevent complications such as blood clots.

Before you go home, your chest drain is removed and you'll be given guidance on caring for your wound, along with any pain relief or other medicines you need. Walking regularly, and avoiding driving and heavy lifting for the period your surgeon advises, supports a smooth recovery.

Recovery time depends on the specific procedure. Many people feel back to normal within about 2 weeks, though more complex operations can take up to around 8 weeks, and it's best to avoid heavy lifting or strenuous exercise for the first 3 to 4 weeks.

Some centres also offer a cryotherapy add-on during surgery, which can provide pain relief for several months afterwards.

What are the risks and complications?

VATS has lower complication rates than open chest surgery, but as with any operation on the chest, there are risks to be aware of, including:

• Bleeding, both during and after the operation
• Infection, either in the wound or within the chest
• An ongoing air leak from the lung, or fluid continuing to drain longer than expected
• A collapsed lung (pneumothorax) or areas of lung that don't fully re-inflate (atelectasis)
• Chest infection or pneumonia
• Heart rhythm problems (arrhythmias) or, rarely, a heart attack
• Blood clots, which can occasionally lead to a stroke
• Nerve damage, which may be temporary or, rarely, permanent
• Low blood oxygen levels, or damage to nearby organs, glands or blood vessels
• Complications related to the general anaesthetic

Your surgical team will talk through your individual risk, which depends on factors such as your age, overall health, and the specific procedure you're having.