Open thoracic surgery: video-assisted thoracoscopic surgery (VATS) conversion to thoracotomy
Bibliographic record
Abstract
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.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.017 | 0.005 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".