The lateral decubitus position is the easiest approach to perform VATS, but as laparotomy or sternotomy requires different patient positioning, the surgeon should eliminate diaphragmatic or pericardiac lesions before. In practice, we mainly recommend lateral position for delayed thoracoscopic exploration.

The supine position (Fig. 21.1) makes the VATS slightly more difficult, but this setting allows accesses in all directions as and when required. Elevate the injured chest with a cushion, with the arm folded over the head. If necessary, tilt the operating table up to 30° in order to improve the exposure. Should you need to proceed through a sternotomy or a laparotomy, you just have to remove the cushion and replace the arm in abduction.

Two or three trocars (10 mm, sometimes 5 mm), one 10 mm 0° optical (a 30° optical may facilitate the visualization of chest wall lesions), one irrigation-suction cannula, bipolar diathermy forceps, coagulating scissors, lung grasping forceps (Duval type = endoscopic or open surgery forceps), and endostaplers Ethicon® or Covidien®, straight or articulated with purple reloads

Use 10 mm ports as it allows you to swap the optical from one site to another.

Avoid placing the first port in the wound as it may reactivate bleeding.

The first port site depends on the place of the wound; in most cases, you should place the first port at the level of the inferior angle of the scapula, posterior to the midaxillary line around the fifth intercostal space. It may then be necessary to aspirate blood pouring throughout the port before inserting the optical if the thorax has not been drained before. The inspection immediately focuses on the internal orifice(s) of the chest wound and on adjacent lung lesions. A second port should rapidly follow, either through the seventh or eighth intercostal space, the previous drain orifice, or through the wound itself (Fig. 21.1). Drain the hemothorax under direct vision, swapping instruments if necessary to achieve a systematic and meticulous inspection. A third port disposed in an appropriate triangulation will allow the insertion of a retractor or forceps and careful mobilization of the lung.