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History and principles of VATS: How to get access and working space in VATS procedures
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History
The necessity for thoracoscopy appeared as a way to treat the adhesions that limited the success of artificial pneumothorax in the treatment of pulmonary tuberculosis. The first thoracoscopy, using a modified cystoscope, was performed by H. C. Jacobaeus, a professor of medicine, not surgery, in Stockholm, publishing in 1910. He then published reports of series of 1,000 or more cases in spite of a significant incidence of complications. Its use declined rapidly after the introduction of streptomycin in 1945, becoming then confined to relatively minor diagnostic procedures except in a few European centers. The advent of video-assisted thoracoscopes and the development of ancillary instruments has allowed a new development of thoracoscopic surgery in the seventies.
In veterinary surgery, development of thoracoscopic surgery followed the one of laparoscopic surgery under the guidance of several pioneers, and became lately standard of care for a good number of intra-thoracic procedures like biopsies and pericardectomies. More recently, the combined use of mini-approaches and mini-invasive techniques even widened the indications of thoracoscopy as represented by the current acronym of VATS (Video-Assisted Thoracic Surgery)
In the abdomen, the working space is generally obtained by insufflating Co2 in the abdominal cavity. Doing this, the diaphragm is being pushed cranially, the abdominal wall is being dilated and the abdominal organs, including large vessels are being moderately compressed. Although 15 mm Hg is usually accepted as a limit before side effects of capnoperitoneum can occur, our current studies show that above 6 mm Hg the intra-abdominal volume, i.e, the working space offered to the surgeons, does not increase proportionally to the rise in pressure. This is the reason why most surgeons currently agree to work at more limited pressure. Alternatively, gasless laparoscopy has been developed to circumvent the physiological changes of capnoperitoneum, but is so far hardly used. [...]
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