Video – Assisted Thoracoscopic Spine Surgery (VATS) for Scoliosis

Article written by John Czerwein MD, Alok Sharan MD, Terry Amaral MD, Vishal Sarwahi MD

Surgery for scoliosis has seen dramatic progress in the methods of treatment. The surgical incision is most commonly performed posteriorly, on the back of the spine, but there are specific circumstances when an incision is needed to approach the front of the spine (anterior approach). Historically, anterior surgery was performed through an open thoracotomy. This required a large incision through the chest wall and chest cavity. Technological advances have allowed spine surgeons to perform these same procedures through small incisions in the chest wall using video technology with small cameras as well as endoscopic instruments. This article will review the technique of thorascopic surgery, the uses of this new technology, as well as its most common indications.

Thoracoscopic Approach
Video assisted thoracoscopy requires a surgical team that should include an experienced anesthesiologist, an "access" surgeon (thoracic or general surgeon), the spine surgeon, and an experienced scrub nurse. The patient is either positioned on their side or on their stomach, depending on the surgeon’s preference and operative plan. Typically, four 1-inch incisions are made through which various instruments are passed: one for the thoracoscope (video camera), one for the retractor, one for suction, and one for other surgical instruments. To make the exposure easier for the surgeon, the anesthesiologist usually deflates one of the lungs (single lung ventilation). Using this approach the typical steps involved in anterior spinal surgery are performed. This includes intervertebral disc removal, bone grafting, and sometimes instrumentation. At the end of the procedure, the incisions are typically closed with an absorbable suture and the deflated lung is reinflated. Post-operatively, bracing may or may not be used. The patient usually has restricted activities for the first several months. Usually by one year, the patient is able to return to full activities.

Indications
Video assisted thoracoscopic spine surgery (VATS) is typically used in those conditions in which a thoracotomy would be needed. This may include patients with idiopathic scoliosis who have large thoracic curve ≥80 degrees, diminished curve flexibility (rigid curves), and patients that are skeletally immature (adolescents). Instances when a thorascopic procedure would not be indicated include: severe scoliosis when the spine is nearly touching the chest wall; a patient in whom a previous thoracotomy was performed and in whom lung scarring might make the thorascopic approach more difficult; or in a patient in whom adequate single-lung ventilation would not be tolerated.

Advantages vs. Disadvantages
With any surgery, there are advantages and disadvantages with newer techniques. Advantages of VATS include: smaller incisions, no spreading open of the chest wall, less muscle cutting/scarring, minimal open/closing time, cosmetically appealing, and improved visualization of the spine secondary to camera magnification. Disadvantages include: the need for additional training and experience to become efficient, risk of bleeding requiring a thoracotomy, and the need for single lung ventilation for adequate visualization, which requires an experienced anesthesiologist.

Conclusions
When discussing with your surgeon about whether or not VATS surgery is appropriate for you or your relative, it is important to ask your surgeon how experienced he is with endoscopic techniques and whether the benefits outweigh the risks in your particular case. Your surgeon and the entire surgical team should be experienced in this procedure. In the appropriate setting, video-assisted thorascopic spine surgery for scoliosis should be considered an attractive alternative to the conventional open thoracotomy.