VATS

•Choose the side you plan to biopsy eg R side
•Left side down, lateral position
•No need to break the bed
•Lower border of the scapula is the land mark for thoracotomy to access the lung (classically the thoracotomy is done 2 finger breaths under the scapular).
•Place the first 12 mm port into the high anterior axillary line, corresponding to the lower border of the scapula. If an open thoracotomy needs to be done this port incision can be extended around to follow the rib back below the scapula. This port will become the position for the anterior/apical chest tube. Place the skin incision (horizontal) anterior and lower to the planned entry into the chest wall, so that the apical ICC can be angulated this way and remain in place.
•The lower anterior 12mm port should be placed below and lateral to the first port, corresponding to the mid-to-posterior axillary line, roughly 2 rib spaces below. Place the skin incision along the same rib space a bit anterior so that the ICC can be placed on the angle and sit postero-lateral.
•These 2 ports tend to be more constant so that they correspond to 2 ICC (some will only need 1 ICC). The 3rd port can be placed under vision once the area to be biopsy has been visualised and the appropriate site planned. For example the 3rd port can be placed posteriorly to triangulate the position of the ports.
•Wedge resect with stapler, remove the sample through the ports.
•Close the unused ports in two layers using Vicryl and nylon.
•For the ICC site place a mersilene horizontal matress suture and then the ICC and wrap the Mersilene around the ICC and secure it

•Post Op:
•Check CXR in recovery
•Place the ICC on 20 mmHg of suction
•Keep the ICC in till no air leak for 24 hours