VATS stands for video-assisted thoracoscopic surgery, a minimally invasive technique for operating inside the chest. Instead of opening the ribcage with a large cut, surgeons work through a few small incisions (typically 2 to 5 centimeters each) and guide their instruments using a tiny camera that displays a live video feed on a monitor. It’s used to diagnose and treat a wide range of lung and chest conditions, from biopsies to full cancer operations.
How the Procedure Works
A standard VATS procedure uses three or four small incisions arranged in a triangular pattern on the side of your chest. One incision serves as the camera port, while the others allow the surgeon to insert instruments like graspers, scissors, cautery tools, and staplers. The camera, called a thoracoscope, is a thin fiber-optic scope that gives the surgical team a magnified, high-definition view of the inside of the chest cavity on a video screen.
During surgery, only one lung is ventilated. The anesthesia team uses a special breathing tube that can inflate and deflate each lung independently, which collapses the lung on the surgical side and gives the surgeon room to work. You’re positioned lying on your side with the arm on the operative side raised overhead. No ribs are spread or cut, which is a major distinction from traditional open chest surgery (thoracotomy).
Why VATS Is Performed
VATS is used for both diagnostic and therapeutic purposes across a broad range of chest conditions. Common reasons include:
- Lung cancer: removing a lobe of the lung or a smaller wedge of tissue
- Lung biopsy: taking tissue samples to diagnose infections, inflammation, or suspicious growths
- Pneumothorax: treating a collapsed lung, especially recurrent cases
- Pleural effusion: draining fluid that has collected around the lungs
- Mediastinal tumors: removing growths in the space between the lungs
For early-stage lung cancer in particular, VATS lobectomy (removing an entire lobe) has become the preferred approach at many surgical centers, offering comparable cancer outcomes to open surgery with less physical trauma.
VATS vs. Open Chest Surgery
The main advantage of VATS over a traditional thoracotomy is reduced surgical trauma. A thoracotomy requires a single incision that can stretch 15 to 20 centimeters, along with spreading or cutting ribs to access the chest. VATS incisions are a fraction of that size, which translates to less blood loss, less muscle damage, and a faster return to normal activity.
One study comparing chronic pain after both approaches found that 25% of VATS patients still had pain six months after surgery, compared to 33% of thoracotomy patients. While the difference didn’t reach statistical significance in that particular trial (due to a small sample size), the trend consistently favors VATS for pain outcomes. Acute postoperative pain also tends to be lower, and since early pain intensity is linked to the risk of developing chronic pain, the smaller incisions appear to offer a meaningful long-term benefit.
What to Expect Before Surgery
Preparation for VATS typically involves several steps in the weeks leading up to your procedure. Your surgical team will order imaging, which may include a chest X-ray, CT scan, or PET scan depending on the reason for surgery. Pulmonary function tests measure how well your lungs are working, and blood tests and an electrocardiogram check your overall fitness for anesthesia.
If you smoke, you’ll be asked to stop well before the procedure. You may also be given a handheld breathing device called a spirometer and asked to practice deep breathing exercises daily. Blood-thinning medications generally need to be paused ahead of time. As with most surgeries, you’ll follow fasting instructions the night before.
Recovery and Hospital Stay
After VATS, a chest tube is placed through one of the incision sites to drain air and fluid from the chest cavity. This tube typically stays in for two to three days, though the exact timing depends on how quickly any air leak resolves and how much fluid is draining. The standard removal criteria include no air leak and fluid output below about 200 milliliters in a 24-hour period.
The median hospital stay after a VATS lobectomy is around five days, with more than half of patients staying five days or longer. Simpler procedures like biopsies or wedge resections often allow discharge sooner, sometimes within one to two days. Once home, most people can resume light daily activities within a week or two, though full recovery from a lobectomy takes several weeks. You’ll likely have follow-up imaging and gradually return to exercise over the course of one to two months.
Complications and Conversion Rates
The overall complication rate for VATS is relatively low. In a study of early-stage lung cancer patients, 10.6% experienced a postoperative complication. The most common was a prolonged air leak, occurring in about 5% of cases. Other less frequent issues included a partially collapsed lung after tube removal, abnormal heart rhythms, and a type of lymphatic fluid leak called chylothorax, each occurring in roughly 1% of patients.
About 10% of VATS procedures end up being converted to an open thoracotomy during the operation. This is not considered a failure but a safety measure. The most common reasons for converting are bleeding or vascular injury (28% of conversions), difficulty dissecting lymph nodes (26%), and scar tissue or adhesions binding structures together (19%). These conversions are rarely emergencies. Surgeons typically recognize the need to convert and do so in a controlled, planned fashion.
Who May Not Be a Candidate
Not everyone is eligible for a VATS approach. The most common disqualifying factor is the inability to tolerate having one lung deflated during surgery, which is essential for the surgeon to have a clear working space. Patients with severely compromised lung function on the opposite side may not safely tolerate this.
For cancer operations, tumors that have grown into the chest wall, invaded major blood vessels, or spread extensively to lymph nodes generally require open surgery. Very large or centrally located tumors sitting deep in the hilum (where the major airways and vessels enter the lung) can also make a VATS approach technically impractical. Dense calcified scar tissue around the hilum, sometimes caused by past fungal infections like histoplasmosis, is another factor that complicates the minimally invasive route. Prior chemotherapy or radiation to the chest area may also make the tissues more difficult to work with, though experienced surgeons increasingly manage these cases thoracoscopically on a case-by-case basis.