With two to four surgeons, an endoscopic tower, an instrument table, and one or two electrosurgical units, as well as anesthesia personnel and equipment, a considerable logistical challenge is present during most minimally invasive surgical procedures. Although many human centers now operate in custom-designed minimally invasive procedure suites, where ceiling-mounted booms house most of the required components used in these procedures, these facilities are not widely available in veterinary medicine. Integrated minimally invasive surgery suites often have the advantage of incorporating multiple viewing screens, allowing surgeons and surgical assistants to maintain a straight viewing angle to the area of interest and on to the viewing screen. The ability to always maintain this direct line of vision is key to maintaining good hand–eye control. Because only one viewing screen is available in most ORs and is generally located on top of the endoscopic tower, the position of the tower is key.

Proper patient positioning is critical to success in thoracoscopic surgery to allow gravity to aid in visualization and organ retraction during surgery. In general, patients are positioned one of three ways for thoracoscopic interventions: lateral, dorsal, or sternal recumbency. Broadly speaking, procedures that are usually approached by an open intercostal thoracotomy are approached thoracoscopically in lateral recumbency with intercostally placed telescope and instrument ports. Open procedures performed by median sternotomy are usually positioned in dorsal recumbency for thoracoscopy using a paraxiphoid telescope portal. Sternal recumbency has been used exclusively for performance of thoracic duct ligation at this time but may be used for other procedures in the future.¹

For patients in lateral recumbency, the forelimbs are pulled in a cranial direction and secured to allow access to the most cranial intercostal spaces if required. The hindlimbs are tied caudally. Straps or 2-inch medical tape can be used to secure the patient to the surgical table to avoid any patient movement during table tilting. The entire lateral thorax (cranially to the scapula) and cranial half of the abdomen are surgically clipped from the ventral midline to close to the dorsal midline. The entire abdomen can be clipped if any ancillary abdominal procedures are planned during the procedure. This entire clipped area is aseptically prepared for surgery.

For procedures performed in dorsal recumbency, the forelimbs are retracted cranially using limb ties to allow access to the cranial intercostal spaces if required. The hindlimbs are more loosely tied caudally. Sandbags or a vacuum-based surgical positioning device can be used to secure the patient from rolling off the table. Devices that would be placed high up on the thoracic wall are discouraged because they may interfere with surgeon movement during instrument and telescope manipulation. A strap or length of 2-inch surgical tape can be used to strap across the abdomen and lower neck area to provide additional stabilization. This is especially important to avoid patient movement or falling off the operating table in cases where lateral table tilting or Trendelenburg or reverse Trendelenburg positioning may be used intraoperatively. The patient is clipped for surgery widely from the midneck area to the umbilicus caudally or even farther if any access to the abdominal cavity is required for adjunctive procedures. Laterally, the surgical clip should extend up to the dorsal third of the thoracic wall. This entire area is aseptically prepared for surgery.

For procedures in sternal recumbency (see Chapter 3636 for further details), positioning devices have been placed under the pubis to stabilize the pelvis and ensure that the abdomen is suspended, allowing gravity-induced ventral positioning of the organs away from the mediastinal root.¹ For this position, wide clipping of the hair from near the ventral midline to the dorsal midline and from the scapular spine to the mid-abdominal region is advised. Some authors have also used a bilateral thoracoscopic approach for access to the thoracic cavity for optimal viewing of the thoracic duct for ligation (see Chapter 36). If bilateral access is performed, similar clipping and aseptic preparation are performed bilaterally.

Just as in laparoscopy, access to the thoracic cavity for thoracoscopic procedures needs to be obtained in a safe and efficient manner. This can be achieved in a number of different ways. The advantages and disadvantages to these different techniques have not been well evaluated in human or veterinary medicine, so the choice of which technique to use is currently largely down to surgeon preference and may be influenced by the available equipment. In all cases, it is advised that a blunt-tipped trocar or trocarless cannula is used for initial establishment of telescope access in all cases.