Open thoracic surgery: video-assisted thoracoscopic surgery (VATS) conversion to thoracotomy

Video-assisted thoracoscopic surgery (VATS) approaches are becoming a mainstream technique within the discipline of thoracic surgery. Just as valuable however is to consider when VATS should not be considered, and even more important, when a case that began as VATS should be converted to thoracotomy, and if so, then how. Today the only documented absolute contraindication to VATS is the inability to achieve adequate visualization of the hemithorax. Patients who cannot tolerate single lung ventilation and situations in which lung isolation is not possible typically are not amenable to thoracoscopic approaches. Relative contraindications to VATS include: bronchoplastic procedures, chest wall deformities limiting visualization, large lesions that limit visibility and would ultimately require a large incision and rib spreading for extraction, central/hilar lesions requiring proximal and/or intrapericardial dissection, dense adhesions requiring decortication, calcified hilar adenopathy, neoadjuvant chemotherapy or radiation with challenging dissection, or extensive chest wall involvement. Given the amply available technology, surgeons may often choose to perform an intra-operative VATS exploration prior to thoracotomy. In such a setting, this should not be considered a conversion. Instead we offer the term “adjunctive VATS” to clarify the distinction. Surgeons often begin with a thoracoscopic port placed in the anterior axillary line anywhere in the 8th–9th intercostal space and ultimately utilize that incision as the site for chest tube insertion at the end of the procedure. This is distinctively different from aborting a planned VATS procedure and performing a thoracotomy. Published rates of conversion from VATS to thoracotomy vary. Reasons for conversion can be classified as: intraoperative complications, technical challenges, anatomic problems and oncologic conditions. As important as the technique of conversion, is the ability to make a timely and systematic decision to abort a VATS procedure. Surgeons must be aware that a conversion from VATS to thoracotomy does not represent surgical failure. There are essentially two types of conversions: planned and emergent. Based on the type of conversion, the approach to thoracotomy can differ. Once the decision to convert to VATS is made important principles and technical consideration need to be followed. The core tenant of these is the completion of a safe and oncologically sound operation.