Thoracoscopy vs Thoracotomy: What is the evidence?

Thoracoscopic, or video-assisted thoracoscopic surgery (VATS) is in an earlier phase of development in veterinary medicine compared to laparoscopy and this slower development mirrors it’s development in human medicine where minimally invasive thoracic interventions only started to emerge in the early 1990’s. VATS procedures are complex and require the collaboration of a number of different specialists to be successful. The anesthesia alone is complicated and with the majority of veterinary procedures being performed in the absence of a board-certified anesthesiologist an inability to perform techniques such as one-lung ventilation may be the single most significant deterrent to more routine use of advanced thoracoscopic procedures.

Because of this delay in widespread adoption of VATS procedures in clinical veterinary practice the evidence base for the procedures that have been described in clinical series is not there is extensive form yet. One study evaluated the difference between an open and a VATS approach in a canine pericardectomy model. In this report, the VATS approach was associated with lower post-operative pain scores in the post-operative period as well as higher blood glucose and cortisol concentrations in the thoracotomy group. Rescue analgesics were used with greater frequency in the thoracotomy group and fewer complications were observed in the VATS group. A recent clinical study has documented the results of VATS lung lobectomy in 22 canine patients with primary lung lobe tumors compared to a population that underwent thoracotomy for the same reason. The authors were able to demonstrate that the VATS approach was feasible and not associated with significantly greater morbidity but were not able to demonstrate apparent advantages in the length of hospital stay, ICU time or indwelling thoracic drain time. Importantly in this study completeness of resection was equivalent between the two approaches with only one dog in each group being resected with incomplete margins. In this study, no attempt was made to evaluate post-operative pain, discomfort or activity between groups. Additionally, outcome measures were not indexed to any clinical benchmarks and significant confounders caused by the decisions of different managing clinicians may have influenced outcomes. Future studies are required in this area to investigate in a prospective fashion the effects of these interventions versus their traditional open counterparts as well as the effectiveness of surgical staging of the various thoracic malignancies that we see in veterinary medicine. While management of tracheobronchial lymph node disease has been evaluated in an experimental study and small numbers of clinical cases this important component of management requires further investigation.  [...]