The Feasibility and Advantages of Subxiphoid Uniportal Video-Assisted Thoracoscopic Surgery in Pulmonary Lobectomy

Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach

INTRODUCTION

The present study reports the first clinical experience with subcostal uniportal VATS (suVATS) compared with the conventional lateral uniportal VATS (luVATS) approach.

PATIENTS AND METHODS

All patients who underwent suVATS between January 2019 and April 2020 were included. Patients who had undergone luVATS for similar indications were included as the control group. The data were prospectively and retrospectively analysed.

RESULTS

The suVATS group included 38 patients with a mean age of 61 (30-83) years. The luVATS group included 33 patients (mean age, 69 years; range: 46-89 years). An intercostal block was performed intraoperatively in the luVATS group. Local infiltration under anaesthesia was performed around the incision in the suVATS group. The duration of the surgery was significantly longer in the suVATS group. However, the chest tube treatment and hospital stay duration were significantly shorter in the suVATS group. The routinely recorded Visual Analogue Scale scores on the first post-operative day and the day of discharge were significantly lower in the suVATS group.

CONCLUSION

Subcostal uniportal VATS enables a shorter drainage treatment duration and hospital stay and significantly reduces post-operative pain. Thus, a faster patient recovery can be achieved.

Transareolar Video-Assisted Thoracoscopic Surgery in Females: A Novel Incision for Pulmonary Ground Glass Nodule Resection

Purpose: Uniportal video-assisted thoracoscopic surgery (VATS) is recognized for its minimally invasive nature, widely adopted globally. However, the evident scarring it leaves often triggers psychological apprehension and resistance to surgery. Transareolar incision, known for its superior cosmetic outcome with no visible scars, poses challenges in women due to the risk of mammary gland damage. In this report, we present successful pulmonary ground glass nodule (GGN) resection using transareolar VATS in female patients, aiming to address these concerns. Materials and Methods: We retrospectively analyzed the clinical data of 35 female patients who underwent GGN resection through transareolar VATS between August 2020 and March 2022. Results: There were no serious complications or perioperative deaths in this cohort of 35 female patients undergoing GGN resection through transareolar VATS. The operations, including local resection or segmentectomy, had an average duration of 70.1 ± 26.4 minutes, with a tube duration of 4.7 ± 2.1 days and a hospitalization time of 7.2 ± 2.3 days. The surgical approach varied, with 21 cases using transareolar uniport, 8 cases assisted by a 3-mm tiny port, and 6 cases converted to two-port VATS. Scar outcomes varied, with 21 cases showing no scar, 8 cases displaying a microscar, and 6 cases presenting a dominant scar of 1.7 ± 0.5 cm. Postoperative pain scores at 1 week and 1 month were 1.9 ± 0.9 and 1.0 ± 0.9, respectively, and the wound numbness occurred in 2.86% (1/35) of cases. Regarding breast complications, 2 patients suffered delayed healing of the incision. No damage and inflammation of glands were detected by breast B-mode ultrasonography. Conclusions: The transareolar incision emerges as a novel approach for VATS in female patients, offering advantages in terms of pain management and cosmetic outcomes.

Clinical applications of minimally invasive uniportal video-assisted thoracic surgery

BACKGROUND

In recent years, the field of minimally invasive thoracic surgery has experienced significant advancements driven by improvements in video-assisted thoracoscopic surgery (VATS) techniques and surgical instruments. These advances have given rise to uniportal VATS as a new area of exploration in minimally invasive thoracic surgery. This technique presents several potential advantages, including reduced access trauma, less postoperative pain, improved cosmesis, fewer complications, shorter hospital stays, and faster rehabilitation, ultimately leading to an improvement in patient quality of life.

PURPOSE

This article reviews the evolutionary history of minimally invasive thoracic surgery, highlights novel techniques, explores possible applications and obtained results, and discusses future prospects of uniportal VATS.

CONCLUSION

Experienced thoracic surgeons have demonstrated the capacity to perform uniportal VATS with a high level of safety and efficacy. Further studies are necessary to assess its long-term efficacy, address limitations, and enhance clinical decision-making for optimal treatment of thoracic conditions.

Experience of a modified chest tube suture-fixation technique in uniportal thoracoscopic pulmonary resection

OBJECTIVE

This study aimed to explore the feasibility and advantages of a modified chest tube suture-fixation technique in uniportal video-assisted thoracic surgery for pulmonary resection.

METHODS

A retrospective analysis was conducted on 116 patients who underwent uniportal video-assisted thoracic surgery (U-VATS) for lung diseases in Zhengzhou People's Hospital between October 2019 and October 2021. Patients were stratified into two groups based on the applied suture-fixation methods, i.e., 72 patients in the active group and 44 patients in the control group. The two groups were subsequently compared in the terms of gender, age, operation method, indwelling time of chest tube, postoperative pain score, chest tube removal time, wound healing grade, length of hospital stay, incision healing grade, and patient satisfaction.

RESULTS

There was no significant difference between the two groups in terms of gender, age, operation method, indwelling time of chest tube, postoperative pain score, and length of hospital stay (P = 0.167, 0.185, 0.085, 0.051, 0.927, and 0.362, respectively). However, the chest tube removal time, incision healing grade, and incision scar satisfaction in the active group were significantly better compared with those of the control group (P = < 0.001, 0.033, and < 0.001, respectively).

CONCLUSION

In summary, the new suture-fixation approach can minimize the number of stitches, and time necessary for chest tube removal process, and avoid the pain experienced when removing the drainage tube. This method is more feasible, has better incision conditions, and provides a convenient tube removal, making it more suitable to patients.

Comparison of short-term results of subxiphoid and conventional video-assisted thoracoscopic surgery in diagnostic wedge resections

BACKGROUND

This study aimed to compare early results in patients who underwent subxiphoid wedge resection with those operated on using a multiportal approach.

METHODS

We retrospectively evaluated 151 patients who underwent diagnostic wedge resection for suspected interstitial lung disease. Patients who underwent wedge resection via subxiphoid video-assisted thoracoscopic surgery and conventional video-assisted thoracoscopic surgery were compared.

RESULTS

The study included 90 men (59.6%) and 61 women (40.4%) with a mean age of 54.8 ± 12 years. Of these, 127 patients underwent conventional video-assisted thoracoscopic surgery and 24 patients underwent subxiphoid video-assisted thoracoscopic surgery. Postoperative complications occurred in 13 patients (8.6%), with no significant difference according to surgical technique. Sex was a significant factor in the rate of complications (12.2% in men vs. 3.2% in women). There was no intraoperative mortality; the 30-day mortality rate was 4% (n = 6). Five nonsurviving patients were in the conventional video-assisted thoracoscopic surgery group and 1 was in the subxiphoid video-assisted thoracoscopic surgery group (p = 0.95).

CONCLUSION

The results of this study indicate that the subxiphoid approach reduced procedure time and length of hospital stay in the early period, while there was no significant difference between the techniques in terms of complications or mortality. Based on these findings, we conclude that surgical outcomes were as successful with the subxiphoid approach as with conventional video-assisted thoracoscopic surgery.

Sublobar Resections

Sublobar resections are commonly performed operations that have seen an increase in applicability. The sublobar approach, comprising segmentectomy and wedge resections, can provide lung preservation and thus is better tolerated in select patients in comparison to lobectomy. These operations are offered for a variety of benign and malignant lesions. Understanding the indications and technical aspects of these approaches is paramount as improvements in lung cancer screening protocols and the imaging modalities has led to an increase in the detection of early-stage cancer. In this article, we discuss the anatomy, indications, technical approaches, and outcomes for sublobar resection.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Simultaneous Comparison of Subxiphoid and Intercostal Wound Pain in the Same Patients Following Thoracoscopic Surgery

There is a lack of data comparing postoperative pain after subxiphoid and intercostal video-assisted thoracoscopic surgery (VATS). Pain is an individual’s subjective experience and, therefore, difficult to compare between different individuals subjected to either procedure. This study assessed reported pain at six postoperative time points in the same patients receiving both subxiphoid and intercostal incisions for thoracic disease. Data from 44 patients who received simultaneous combined intercostal and subxiphoid VATS were retrospectively analyzed from August 2019 to July 2021. All patients received the same length of subxiphoid and intercostal incisions with or without drain placements. A numerical pain rating scale was administered on postoperative days (POD)-1, POD-2, POD-Discharge, POD-30, POD-90, and POD-180. Bilateral uniportal VATS was performed in 11 patients, and unilateral multiportal VATS was performed in 33 patients. In the unilateral VATS group, there were no differences in pain reported for both incisions in the early postoperative period. However, in the bilateral VATS group, subxiphoid wounds resulted in significantly higher pain scores on POD-1, POD-2, and POD-Discharge (p = 0.0003, 0.001, and 0.03, respectively). Higher late (3 and 6 months) postoperative pain was associated with intercostal incisions in both groups, as previously reported, whereas higher early (day 1, 2, and discharge) postoperative pain was more associated with subxiphoid incisions than intercostal incisions in the bilateral VATS group.

Computerized Tomography Image Features under the Reconstruction Algorithm in the Evaluation of the Effect of Ropivacaine Combined with Dexamethasone and Dexmedetomidine on Assisted Thoracoscopic Lobectomy

This research was aimed to study CT image features based on the backprojection filtering reconstruction algorithm and evaluate the effect of ropivacaine combined with dexamethasone and dexmedetomidine on assisted thoracoscopic lobectomy to provide reference for clinical diagnosis. A total of 110 patients undergoing laparoscopic resection were selected as the study subjects. Anesthesia induction and nerve block were performed with ropivacaine combined with dexamethasone and dexmedetomidine before surgery, and chest CT scan was performed. The backprojection image reconstruction algorithm was constructed and applied to patient CT images for reconstruction processing. The results showed that when the overlapping step size was 16 and the block size was 32 × 32, the running time of the algorithm was the shortest. The resolution and sharpness of reconstructed images were better than the Fourier transform analytical method and iterative reconstruction algorithm. The detection rates of lung nodules smaller than 6 mm and 6–30 mm (92.35% and 95.44%) were significantly higher than those of the Fourier transform analytical method and iterative reconstruction algorithm (90.98% and 87.53%; 88.32% and 90.87%) (P < 0.05). After anesthesia induction and lobectomy with ropivacaine combined with dexamethasone and dexmedetomidine, the visual analogue scale (VAS) decreased with postoperative time. The VAS score decreased to a lower level (1.76 ± 0.54) after five days. In summary, ropivacaine combined with dexamethasone and dexmedetomidine had better sedation and analgesia effects in patients with thoracoscopic lobectomy. CT images based on backprojection reconstruction algorithm had a high recognition accuracy for lung lesions.

Internet of Things-Based Ultrasound-Guided Erector Spinae Plane Block Combined with Edaravone Anesthesia in Thoracoscopic Lobectomy

This paper aimed to study the application value of Internet of Things (IoT) edge computing algorithm-based ultrasound-guided erector spinae plane block combined with edaravone anesthesia in thoracoscopic lobectomy. A total of 110 patients undergoing thoracoscopic resection were selected as subjects. The patients were anesthetized with erector spinae plane block combined with edaravone before surgery and underwent chest ultrasound scan. IoT edge computing algorithm was constructed and applied to ultrasound images of patients to enhance and denoise the images. It was found that, in different mixed noise mixtures (Gaussian noise 10% + speckle noise 90%; Gaussian noise 30% + speckle noise 70%), the edge computing algorithm can still maintain the edge information of the output image, showing better performance on edge information detection and denoising compared with the Prewitt and Canny operator. In addition, visual analog scale (VAS) scores decreased with postoperative time after edaravone anesthesia induction and erector spinae plane block lobectomy and reached the lowest level after five days. In short, erector spinae plane block combined with edaravone showed good sedative and analgesic effects on patients undergoing thoracoscopic lobectomy. Ultrasound images processed by IoT edge computing algorithm showed high accuracy in the identification of lung lesions, which was worth applying to clinical diagnosis.

Subxifoid versus transthoracic thoracoscopic lobectomy: Results of a retrospective analysis before and after matching analysis

Background

Here, we report our initial experience with subxifoid video‐assisted thoracoscopic surgery (SVATS) lobectomy for the management of primary lung cancer, and compared the outcomes of SVATS with those of conventional transthoracic VATS (CVATS) lobectomies to validate its feasibility and usefulness.

Methods

The clinical data of consecutive patients undergoing VATS lobectomy via SVATS or CVATS for lung cancer were retrospectively compared. The endpoints were to evaluate the statistical differences in surgical results, postoperative pain (measured with visual analog scale [VAS] scores at 8 hours, Day 1, Day 2, Day 3, at discharge, one month and three months after surgery) and paresthesia (measured at one‐ month, and three months after surgery). The two groups were compared before and after matching analysis.

Results

Our study population included 223 patients: 84 in the SVATS and 139 in the CVATS group. The two groups were not comparable for sex (P = 0.001), preoperative comorbidity as cardiopathy (P = 0.007), BMI value (P = 0.003), left‐sided procedure (P = 0.04), tumor stage (P = 0.04), and tumor size (P = 0.002). These differences were overcome by propensity score matching (PSM) analysis that yielded two well‐matched groups which included 61 patients in each group. Surgical outcomes including blood loss, hospital stay and complications were similar before and after matching analysis, but SVATS compared to CVATS was associated with longer operative time before (159 ± 13 vs. 126 ± 6.3, P < 0.0001), and after matching analysis (161 ± 23 vs. 119 ± 8.3; P < 0.0001) and significant reduction of postoperative pain during the different time‐points (P < 0.001), and paresthesia at one (P = 0.001), and three months (P < 0.0001).

Conclusions

SVATS lobectomy is a feasible and safe strategy with surgical outcomes similar to CVATS lobectomy but with less postoperative pain and paresthesia.

Key points

Significant findings of the study

Subxifoid thoracoscopic lobectomy is a feasible and safe procedure, with potential benefits in terms of postoperative pain and paresthesia compared to conventional thoracoscopic lobectomy

Our results showed that surgical outcomes including blood loss, hospital stay, morbidity and mortality are similar but subxifoid thoracoscopy was associated with significant reduction of postoperative pain and paresthesia.

What this study adds

Subxifoid thoracoscopy is a safe procedure; compared to conventional transthoracic thoracoscopy, it avoids intercostal incisions, and spares nerve trauma, resulting in a reduction of postoperative pain and paresthesia.

Subxiphoid versus intercostal video-assisted thoracic surgery for lung resection: a meta-analysis

INTRODUCTION

To systematically evaluate the safety and advantages of subxiphoid approach video-assisted thoracic surgery (SA-VATS) compared with intercostal approach video-assisted thoracic surgery (IA-VATS) for lung resection, we conducted a meta-analysis of the current literature.

MATERIAL AND METHODS

The literature search was conducted in PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure. RevMan 5.3 software was used to perform this meta-analysis.

RESULTS

Eleven studies involving 934 patients were included. Compared with patients in the IA-VATS group, those in the SA-VATS group had lower pain scores on the day of the operation and at 24 h, 48 h and 72 h after the operation (p < .001) and suffered from less postoperative paraesthesia at the first, third and sixth months after the operation (p < .001). Moreover, there was no statistically significant difference between the two groups regarding postoperative complications, intraoperative blood loss, length of hospital stay, drainage amount, or chest tube duration. However, SA-VATS had a longer operative time (p < .001).

CONCLUSIONS

SA-VATS is a safe surgical technique and has superior postoperative outcomes over IA-VATS for lung resection in terms of acute postoperative pain and chronic postoperative paraesthesia.

Uniportal subxiphoid bilateral removal of self-introduced thoracic foreign bodies

This is a report of a 31-year-old male refugee, who was admitted to Intensive Therapy Unit after being found in severe chest pain after escaping extreme torture from his home country. He was found to have four nails in his thorax. These were removed using a subxiphoid video-assisted thorascopic surgery (VATS) technique. This technique allowed excellent visualization of the right, left and anterior mediastinal part of the chest and therefore preventing damage or injury to surrounding structures. This was particularly useful in a complex case such as this. By avoiding an intercoastal incision and intercostal manipulation, our patient had limited pain post-procedure facilitating an earlier aggressive mobilization program with potential benefit in terms of improved lung expansion, reduction of atelectasis and lung infections. With the right training, the technical challenges of using the technique should be overcome and thus the benefits of subxiphoid VATS will be offered to a larger portion of thoracic surgical patients.