Video-assisted thoracoscopic surgery, known as VATS, is a minimally invasive technique used to diagnose and treat problems inside the chest. Instead of opening the chest through a large incision, surgeons work through one to four small cuts between the ribs, using a tiny camera to guide them. It has become one of the most common approaches to chest surgery, offering less pain and faster recovery than traditional open procedures.
How VATS Works
During the procedure, you’re placed under general anesthesia and positioned on your side. A breathing tube designed to ventilate only one lung is inserted so the surgeon can work on the other lung while it’s deflated. Through small incisions in the chest wall, the surgeon inserts a thoracoscope, a thin tube with a camera on its tip, along with specialized surgical instruments. The camera sends a live video feed to a monitor in the operating room, giving the surgeon a magnified view of the chest cavity.
Most VATS procedures use three to four incisions, though some surgeons perform the surgery through just two ports or even a single incision. The main working incision, called the utility incision, is typically 4 to 5 centimeters long and placed at the fifth rib space. The additional ports are smaller and used for the camera and secondary instruments. This is a significant difference from open thoracotomy, which requires an incision of 15 to 20 centimeters and spreading of the ribs.
What VATS Can Treat
VATS is used for a wide range of diagnostic and therapeutic procedures in the chest. On the diagnostic side, surgeons use it to take tissue samples from the lung, lymph nodes, or the lining of the chest cavity (the pleura). These biopsies help identify infections, inflammatory conditions, and cancers.
For treatment, VATS is commonly used to:
- Remove part of a lung (wedge resection or lobectomy), often for early-stage lung cancer or suspicious nodules
- Drain fluid buildup around the lungs, a condition called pleural effusion
- Treat collapsed lung (pneumothorax) by repairing air leaks or removing damaged tissue
- Remove tumors or masses in the space between the lungs
- Address infections such as empyema, where pus collects in the chest cavity
VATS lobectomy, the removal of an entire lobe of the lung, has become the preferred surgical approach for early-stage non-small cell lung cancer when the tumor’s size and location allow it.
VATS vs. Open Thoracotomy
The key advantage of VATS over traditional open surgery is the reduced trauma to the chest wall. Open thoracotomy requires cutting through muscle and spreading the ribs apart, which causes significant postoperative pain and a longer recovery. VATS avoids rib spreading entirely, and the smaller incisions mean less muscle damage.
Research comparing the two approaches for lung cancer surgery found that VATS is associated with less postoperative pain, less blood loss during surgery, shorter hospital stays, and better quality of life for the first year after surgery. These benefits make VATS the preferred approach when it’s technically feasible.
That said, not every case can be completed through VATS. About 11% of VATS procedures need to be converted to open thoracotomy during the operation, typically because of bleeding that’s difficult to control through small incisions or because the surgery can’t safely progress. Surgeons plan for this possibility, and conversion is considered a safe decision rather than a complication.
What to Expect During Recovery
After VATS, you’ll wake up with one or more chest tubes in place. These thin plastic tubes drain air and fluid from the chest cavity while the lung re-expands and heals. The tubes are typically removed once there’s been no air leak for 6 to 12 hours and fluid drainage drops below about 450 to 500 milliliters over 24 hours. For many patients, this means the chest tube comes out on the first day after surgery. In some cases with minimal drainage, it can even be removed the same day.
Hospital stays after VATS vary depending on what was done. A simple biopsy or drainage procedure might mean just one or two nights. A lobectomy for lung cancer usually requires three to five days. By comparison, the same operation done through open thoracotomy often adds extra days in the hospital.
Pain after VATS is generally more manageable than after open surgery because the intercostal nerves running along the ribs are less likely to be damaged when fewer and smaller ports are used. Surgeons often use nerve blocks near the spine or along the back muscles to control pain in the first few days, rather than the epidural catheters more commonly needed after open procedures. You can expect soreness at the incision sites and some discomfort with deep breathing or coughing for the first few weeks.
Preparing for the Procedure
Preparation for VATS follows the general pattern for any surgery under general anesthesia. You’ll need to fast, typically nothing to eat or drink after midnight the night before. If you smoke, your surgical team will strongly encourage you to stop as far in advance as possible, since smoking impairs lung healing and increases the risk of complications. Pre-operative testing usually includes blood work, imaging of the chest (CT scan), and sometimes breathing tests to assess your lung function, especially if part of the lung will be removed.
Certain medications, particularly blood thinners, may need to be stopped days before surgery. Your surgeon’s office will give you specific instructions about which medications to hold and when.
After You Go Home
Most people return to light daily activities within one to two weeks after VATS, though this depends heavily on the extent of the surgery. Lifting heavy objects and vigorous exercise are typically restricted for four to six weeks. Deep breathing exercises and gentle walking are encouraged almost immediately, since keeping the remaining lung tissue fully expanded reduces the risk of pneumonia.
You should expect some fatigue that improves gradually over weeks. If a lobe of the lung was removed, your remaining lung tissue compensates over time, and most people return to their previous activity level within a few months. The small incision scars from VATS fade significantly compared to the long scar left by open thoracotomy.