VATS Instrument Set: Video-Assisted Thoracoscopic Surgery Guide

That last row is the one that dictates the tray. When the surgeon’s hand cannot enter the chest, every atraumatic manoeuvre a hand performs — cradling a lobe, feeling a nodule, spreading a fissure — has to be reproduced by a tip at the end of a 400 mm shaft. VATS instruments are designed backwards from that constraint.

What makes a thoracic instrument different

Laparoscopic instruments are frequently substituted into thoracic cases and mostly work. Mostly is the problem.

The chest is a fixed bony box. There is no insufflation-created working space to expand into, and the intercostal space through which everything passes is 10 to 20 mm wide and bounded by a neurovascular bundle you must not lever against. Three consequences follow:

Length. Thoracic working lengths run 300 mm to 450 mm against the laparoscopic standard of 330 mm, because the target — a hilum, an upper lobe apex — sits further from the port than most abdominal targets sit from theirs.

Curvature. Many VATS instruments are curved or double-curved rather than straight. In single-port surgery, where every instrument enters through one 30 to 40 mm incision, straight instruments collide inside the chest wall. Curved shafts let three instruments and a scope fan out from a single entry.

Jaw geometry. Lung parenchyma tears under point loading. Thoracic graspers use long, broad, low-pressure jaws — ring and oval patterns rather than the fine toothed graspers of abdominal work.

Ports are the other structural difference. Many VATS surgeons work without rigid trocars entirely, using a soft wound protector so instruments pass directly through the intercostal space. This reduces intercostal nerve compression, which is the main driver of chronic post-thoracotomy pain, and it means instrument shafts contact tissue directly and must be smooth along their whole length.

The core VATS instrument set

Optics and access

• Thoracoscope — 10 mm and 5 mm, 30° and 0°. The 30° is the working scope; it lets the camera assistant look up at the apex and down into the fissure without moving the port. High-definition or 4K, with a light cable rated for the output.
• Port set — flexible or rigid, 5 mm, 10 mm, 12 mm. A 12 mm port is required for most endoscopic staplers.
• Soft tissue retractor / wound protector — the utility incision, typically 30 to 40 mm in the fourth or fifth intercostal space.
• Camera holder or robotic scope arm where available.

Graspers

The heart of the set, and where most substitution errors happen.

Blunt-tipped graspers, ring forceps and suction are the three instruments in most continuous use across a VATS case. If a set is being built to a budget, those are the three to over-specify.

Dissection

• Curved dissector (right-angle) — the single most important dissecting instrument in a lobectomy. Passing behind a pulmonary artery branch to encircle it is what this instrument exists for. Available in a range of tip radii; a fine tip is safer around arterial adventitia.
• Endoscopic Metzenbaum scissors — 5 mm, curved, rotatable, monopolar-capable.
• Hook cautery — L-hook or spatula for fissure and mediastinal pleura.
• Energy device — ultrasonic or advanced bipolar, for lymphatic and small vessel sealing.
• Peanut / swab holder — endoscopic sponge stick for blunt dissection and for the first response to bleeding.

Stapling and specimen

• Endoscopic linear stapler with articulating head, in vascular (2.0–2.5 mm), parenchymal (3.5–3.8 mm) and bronchial (4.8 mm) reload heights. Reload selection by tissue thickness is not a preference.
• Specimen retrieval bag — never deliver a tumour specimen unbagged through the utility incision.
• Clip appliers — 5 mm and 10 mm, for lymphatics and small branches.

Nodal dissection and closure

• Long thoracic dissecting forceps and a nodal grasper for stations 7, 4R and the inferior stations.
• Endoscopic needle holder for bronchial or vascular repair.
• Long knot pusher.
• Rib approximator and chest drain instruments, kept on the trolley regardless of approach.

The conversion tray

Every VATS list runs with an open thoracotomy set in the room, unopened, immediately available.

This is not a formality. A pulmonary artery branch avulsion converts a routine lobectomy into a two-minute emergency, and the sequence — sponge stick on the bleeding point, convert, control — depends on a rib spreader being reachable rather than being fetched. The conversion set is the standard thoracotomy set: Finochietto rib spreader, long Metzenbaum and Mayo scissors, Duval and Allis clamps, Satinsky and Cooley vascular clamps, periosteal elevator, rib shears, and rib approximator.

Two operational points that get missed. The conversion set must be counted as part of the case even if never opened, and the theatre team should be able to state where it is without looking.

Port placement decides which instruments you need

Instrument selection is downstream of geometry, and the geometry is set before the first incision.

The patient is in full lateral decubitus with the table flexed to open the intercostal spaces. In conventional multiport technique the camera port goes low — seventh or eighth space, mid-axillary line — so the scope looks up at the hilum rather than across it, and the utility incision goes in the fourth or fifth space anteriorly, over the target structures. A posterior port completes the triangle.

Two rules follow from that layout and both have instrument consequences.

First, the camera and the working instruments should not share an axis. If they do, the instrument tip approaches the target directly away from the viewer and depth perception on a 2D monitor collapses. A 30° scope partially compensates, which is why it is the default rather than the 0°.

Second, the distance from port to target sets the working length. A lower lobe basal segment approached from an eighth-space camera port is a very different reach from an apical segment approached from the same port. This is why thoracic sets carry the same instrument in two lengths rather than one compromise length, and why buying a single 330 mm set and hoping is the most common false economy in a new thoracic service.

There is also a rib-levering problem that no instrument design fully solves. The intercostal space is narrow and the surgeon is tempted to use the rib as a fulcrum to gain angle. That force is transmitted to the intercostal nerve — the dominant source of chronic post-thoracic pain — and simultaneously to the instrument’s jaw alignment through a 400 mm lever arm. Soft wound protectors and correctly chosen instrument curves exist largely to remove the temptation.

Single-use and reusable in the same tray

A thoracic set is a hybrid, and pretending otherwise leads to poor budgeting.

Staplers and their reloads, specimen bags, energy device handpieces beyond their reprocessing limit, and most clip cartridges are single-use. Graspers, dissectors, scissors, needle holders, scopes and ports are reusable. In practice the disposable line dominates the per-case cost of a VATS lobectomy while the reusable line dominates the capital cost — which means the two are usually approved by different people on different budgets, and the reusable side is where the quality decision actually gets made.

The economics favour reusable instruments in any unit doing meaningful volume, but only if reprocessing capacity exists. A modular thoracic instrument requires disassembly, lumen brushing, flushing, ultrasonic treatment and drying on every cycle. A unit that buys reusable instruments without funding the CSSD workload gets neither the saving nor a clean instrument; it gets instruments that fail early and a sterility problem it cannot see. Where reprocessing capacity is genuinely constrained, the honest answer is a smaller reusable core and more disposables, not a large reusable set processed badly.

Instrument lifespan tracking belongs in the same decision. A grasper rated for a nominal number of cycles by a manufacturer is a starting assumption, not a guarantee; actual life depends on levering forces, ultrasonic exposure and handling. Sets should be tracked by tray and inspected on a defined interval rather than replaced on complaint, an approach covered in our guide to hospital instrument inventory management.

Uniportal VATS changes the instrument requirement

Single-port VATS is now routine for lobectomy in many high-volume units, and it is not simply multiport surgery with fewer holes.

Through one 30 to 40 mm incision the scope and every instrument enter in parallel rather than triangulating. Instruments therefore need to be:

1. Curved or double-curved, so the shafts diverge inside the chest and the handles diverge outside it.
2. Longer — 400 mm and above is common, because instruments approach the target obliquely rather than head-on.
3. Slim in the handle, since three hands are working at one incision.
4. Available in mirrored left and right curves, so the surgeon is not fighting a curve that fights back.

A unit moving from multiport to uniportal that keeps the old tray will find the technique harder than it is. This is one of the few cases where the instruments genuinely gate the technique.

Materials and construction

Shafts are AISI 304 or 316L for corrosion resistance; jaws and working elements are hardened martensitic 420 where grip and edge retention govern. Insulated monopolar instruments carry a coating over the entire shaft and a 4 mm luer lock flushing port at the proximal end.

Modularity is the specification decision that pays for itself. A three-part instrument — handle, outer sheath, insert — lets a worn insert be replaced without discarding a handle, and, more importantly, opens the shaft lumen for brushing and flushing. On a 400 mm shaft, a lumen you cannot open is a lumen you cannot verify as clean.

Two failure modes dominate in service. Insulation breach, where a pinhole in the shaft coating delivers current to whatever the shaft touches — inside a chest that may be the pericardium or the phrenic nerve, and the injury is out of the camera’s view. Insulation should be tested, not just looked at. Jaw misalignment from the long lever arm: a 400 mm shaft magnifies any handle force applied off-axis, and levering against a rib is exactly that force.

Reprocessing a thoracic set

Long, narrow lumens are the whole reprocessing problem.

Disassemble modular instruments completely before cleaning — every time, not when convenient. Flush every lumen with enzymatic solution using a syringe on the luer port, then brush with a correctly sized long channel brush; a brush that does not contact the lumen wall along its length is doing nothing. Ultrasonic cleaning follows, with lumens submerged and filled so cavitation reaches the internal surface, then a final rinse in purified water. Residual chloride from ordinary tap water in a stainless lumen is a classic pitting corrosion mechanism, discussed further in our guide to instrument rust and staining.

Dry lumens with medical air. Lubricate hinges with a steam-permeable instrument milk, never with mineral oil, which forms a barrier steam cannot penetrate. Then sterilise disassembled — a modular instrument sterilised assembled has an unvalidated interface between the sheath and insert.

General cleaning chemistry selection is covered in our enzymatic cleaner guide, and it applies directly here: protein left in a 3 mm channel is not removed by any downstream step.

The inspection interval

Thoracic instruments accumulate damage in ways that are invisible in a tray and obvious in a chest. A defensible inspection routine checks five things on every reusable instrument, at a defined interval rather than on complaint:

1. Insulation integrity on every monopolar shaft, by insulation tester rather than visual inspection. A pinhole is not visible and its consequences are out of camera view.
2. Jaw alignment, closed against a light along the full jaw length. Any daylight means point contact.
3. Jaw grip, tested on a latex or silicone strip. A grasper that slips on a test strip will slip on a lobe.
4. Shaft straightness, rolled on a flat surface. A bowed 400 mm shaft binds inside a port and transmits that binding to the tip.
5. Lumen patency and cleanliness, by flushing and, periodically, by borescope on the instruments that permit it.

Instruments failing any of the five go to repair, not back to the tray. The failure that matters most is the first one, because it is the only one that injures a patient silently.

Building the set

A first VATS tray does not need to be comprehensive, and buying somebody else’s complete list is the usual expensive mistake. Start with a 30° scope, a soft wound protector, two ring or oval lung graspers, a fine curved right-angle dissector, endoscopic Metzenbaum scissors, a hook cautery, a suction-irrigation device and an endoscopic sponge stick. Add nodal instruments once the unit is doing formal lymphadenectomy, and buy curved uniportal instruments only when the technique actually changes.

Fizza Surgical manufactures reusable thoracoscopic and open thoracic instruments in Sialkot under ISO 13485, in AISI 304, 316L and 420, in working lengths to 450 mm and in modular three-part construction. Browse the surgical instruments catalogue, review OEM and custom manufacturing for pattern-specific requirements, or see our certifications.