Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy

The Efficacy of Continuous Serratus Anterior and Erector Spinae Plane Blocks vs Intercostal Nerve Block in Uniportal-Vats Surgery: A Propensity-Matched Prospective Trial

BACKGROUND

To evaluate the analgesic efficacy of continuous erector spinae plane block(c-ESPB) and serratus anterior plane block(c-SAPB) versus the intercostal nerve block (ICNB) in Uniportal-VATS in terms of pain control, drug consumption, and complications.

METHODS

Ninety-three consecutive patients, undergone one of the three peripheral nerve blocks after Uniportal-VATS, were prospectively enrolled. A 1:1 propensity score matching was used to minimize bias.

RESULTS

C-ESPB and c-SAPB groups had no difference in morphine request upon awakening compared to ICNB. A higher VAS-score was recorded in c-ESPB compared to ICNB in the first 12 h after surgery. A significantly lower consumption of paracetamol in II postoperative day (p.o.d.) and tramadol in I and II p.o.d. was recorded in the c-ESPB group compared to the ICNB group. A higher dynamic VAS score was recorded at 24 h and 48 h in the ICNB group compared to the c-SAPB. No difference was found in safety, VAS-score and drug consumption between c-ESPB and c-SAPB at any given time, except for a higher tramadol request in c-SAPB in II p.o.d.

CONCLUSIONS

C-ESPB and c-SAPB appear to have the same safety and analgesic efficacy when compared between them and to ICNB in Uniportal-VATS approach. C-ESPB showed a delayed onset of analgesic effect and a lower postoperative drug consumption compared to ICNB.

Radicality and safety of mediastinal lymphadenectomy in lung resection: a comparative analysis of uniportal thoracoscopic, multiportal thoracoscopic, and thoracotomy approaches

BACKGROUND

Lung cancer poses a significant challenge with high mortality rates. Minimally invasive surgical approaches, including the uniportal thoracoscopic technique, offer potential benefits in terms of recovery and patient compliance. This study focuses on evaluating the radicality of mediastinal lymphadenectomy during uniportal thoracoscopic lung resection, specifically assessing the reachability of established lymphatic stations.

METHODS

A comparative study was conducted at the University Hospital Ostrava from January 2015 to July 2022, focusing on the evaluation of radicality in mediastinal lymphadenectomy across three patient subgroups: uniportal thoracoscopic approach, multiportal thoracoscopic approach, and thoracotomy approach. The study implemented the routine identification and excision of 8 lymph node stations from the respective hemithorax to assess the radicality of lymph node harvesting.

RESULTS

A total of 428 patients were enrolled and evaluated. No significant differences were observed in the number of lymph nodes removed between the subgroups. The mean number of lymph nodes removed was 6.50 in the left hemithorax and 6.49 in the right hemithorax. The 30-day postoperative morbidity rate for the entire patient population was 27.3%, with 17.5% experiencing minor complications and 6.5% experiencing major complications. Statistically significant differences were observed in major complications between the uniportal approach and the thoracotomy approach (3.5% vs 12.0%, p = 0.002). The overall mortality rate in the study population was 3%, with a statistically significant difference in mortality between the uniportal and multiportal approaches (1.0% vs 6.4%, p = 0.020).

CONCLUSIONS

The uniportal approach demonstrated comparable accessibility and lymph node yield to multiportal and thoracotomy techniques. It is equivalent to established methods in terms of postoperative complications, with fewer major complications compared to thoracotomy. While our study indicates a potential for lower mortality following uniportal lung resection in comparison to multiportal lung resection, and demonstrates comparable outcomes to thoracotomy, it is important to approach these findings cautiously and refrain from drawing definitive conclusions.

Safety and feasibility of preferential manual bronchoplasty in 2-3 cm single-port video-assisted thoracoscopic lobectomy

BACKGROUND

This retrospective study aimed to compare preferential manual bronchoplasty (PMB) and mechanical stapler closure (MSC) of the bronchial stump after 2-3 cm single-port (SP) video-assisted thoracoscopic surgery (VATS) lobectomy in patients with pathological T1 (pT1) stage lung cancer.

METHODS

Between January 2019 and March 2022, patients with pulmonary neoplasms who underwent 2-3 cm SP VATS lobectomy were retrospectively screened. After propensity-matched analysis, we compared perioperative outcomes and analyzed the safety and feasibility of PMB and MSC of the bronchial stump while performing VATS lobectomy.

RESULTS

In this study, 280 and 832 patients were enrolled in the PMB and MSC groups, respectively. Propensity score matching produced 280 pairs. The operation time was shorter in the PMB group, whereas the average number of lymph nodes dissected was higher in the PMB group. The conversion rate was significantly lower in the PMB group. The following were similar between the PMB and MSC groups, respectively: average blood loss volume, postoperative hospital stay, and chest tube removal time. Postoperatively, the incidence of atelectasis was significantly higher in the MSC group. As per subgroup analyses, PMB was associated with a shorter operation time in left and right upper lobectomies. Particularly in left upper lobectomy, PMB had more lymph node dissections and less conversion to open and postoperative atelectasis.

CONCLUSIONS

In comparison with MSC of the bronchial stump, PMB showed better safety and feasibility in 2-3 cm SP VATS left and right superior lobectomies in patients with pT1 stage lung cancer.

Incorporation of an intercostal catheter into a multimodal analgesic strategy for uniportal video-assisted thoracoscopic surgery: a feasibility study

Background

Well-controlled postoperative pain is essential for early recovery after uniportal video-assisted thoracoscopic surgery (UVATS). Conventional analgesia like opioids and thoracic epidural anaesthesia have been associated with hypotension and urinary retention. Intercostal catheters are a regional analgesic alternative that can be inserted during UVATS to avoid these adverse effects. This feasibility study aims to evaluate the postoperative pain scores and analgesic requirements with incorporation of an intercostal catheter into a multimodal analgesic strategy for UVATS.

Methods

In this observational study, 26 consecutive patients who underwent UVATS were administered a multilevel intercostal block and oral paracetamol. All of these patients received 0.2% ropivacaine continuously at 4 ml/h via an intercostal catheter at the level of the incision. Rescue analgesia including etoricoxib, gabapentin and opioids were prescribed using a pain ladder approach. Postoperative pain scores and analgesic usage were assessed. The secondary outcomes were postoperative complications, days to ambulation and length of stay.

Results

No technical difficulties were encountered during placement of the intercostal catheter. There was only one case of peri-catheter leakage. Mean pain score was 0.31 (range 0–2) on post-operative day 1 and was 0.00 by post-operative day 5. 16 patients (61.6%) required only oral rescue analgesia. The number of patients who required rescue non-opioids only increased from 1 in the first 7 months to 8 in the next 7 months. There were no cases of hypotension or urinary retention. Median time to ambulation was 1 day (range 1–2). Mean post-operative length of stay was 4.17 ± 2.50 days.

Conclusions

Incorporation of an intercostal catheter into a multimodal analgesia strategy for UVATS is feasible and may provide adequate pain control with decreased opioid usage.

Modified 2-cm super single port vs. the traditional 3-cm single port for video-assisted thoracoscopic surgery lobectomy

PURPOSES

We introduce a novel 2-cm single port designed to minimize intercostal muscle and nerve damage in video-assisted thoracoscopic surgery (VATS) lobectomy, and compared it with the 3-cm traditional single port.

METHODS

We analyzed, retrospectively, the clinical data, safety, convenience, incision complications, and postoperative pain and numbness in 81 patients who underwent either modified (n = 42) or traditional (n = 39) single-port VATS lobectomy.

RESULTS

The preoperative variables were comparable between both single-port VATS lobectomy groups after matching. There were no serious complications and there was no mortality in either group. There were no remarkable differences between the groups in intraoperative blood loss, chest tube duration, lymph node dissection, or postoperative complications. The modified single-port group had a longer operation time (p < 0.05), but the static and dynamic postoperative VAS scores and incisional numbness were better in the modified single-port group (p < 0.05). The modified single-port group also had an obvious advantage in incision seepage, healing, and appearance.

CONCLUSIONS

Our 2-cm modified single port for lobectomy is safe and effective, and results in less postoperative pain and incisional numbness than the 3-cm traditional single port.

Lobectomy with high-position single-intercostal two-port video-assisted thoracoscope for non-small cell lung cancer is a safe and effective surgical procedure

Background

High-position single-intercostal two-port video-assisted thoracic surgery (VATS) technique has been used for thoracic diseases. It can effectively avoid postoperative chronic pain compared with the traditional three-port VATS. This study aimed to evaluate the safety and efficacy of high-position single-intercostal two-port video-assisted thoracoscopic lobectomy.

Methods

From June 2014 to December 2018, a total of 474 patients in our hospital with non-small cell lung cancer (NSCLC) underwent lobectomy with a high-position single-intercostal two-port video-assisted thoracoscope. A retrospective study of these patients was conducted, and follow-up was performed to analyze the patients' 3- and 5-year survival rates.

Results

Of the total number of patients, 27.6%, 41.4%, and 31% underwent surgery between the third, fourth, and fifth intercostals, respectively. During the operation, 31 patients were converted to open surgery or three-port thoracoscopic surgery. The average surgical time was 160.9±44.9 min, the average postoperative hospital stay was 5.6±3.4 days, the incidence of postoperative complications was 7.2%, and the average number of lymph nodes resected was 13.6±5.3. The 3-year overall survival (OS) rate of IA1, IA2, IA3, IB, IIA, IIB and IIIA was 99.0%, 98.6%, 96.3%, 91.2%, 85.7%, 66.7%, and 60.8%, respectively. Meanwhile, the 5-year OS rate of IA1, IA2, IA3, IB, and IIIA was 99.0%, 94.5%, 87.5%, 85.5%, and 43.3%, respectively.

Conclusions

Lobectomy with a high-position single-intercostal two-port video-assisted thoracoscope for NSCLC is a safe and effective surgical procedure.

Modified left subsuperior segmentectomy via 2-cm uniportal video-assisted thoracoscopic surgery

Independent subsuperior segmentectomy (S*) via uniportal video-assisted thoracoscopic surgery (VATS) has rarely been reported. We describe our modified technique of performing simplified left subsuperior segmentectomy for a lung nodule, via 2-cm uniportal VATS. The uniportal approach was different from the traditional approach made by blunt separation into the thorax without electrocautery. Our modified technique minimizes damage to the intercostal nerves and muscles. We also simplified the subsuperior segmentectomy procedure according to the findings of three-dimensional (3D) computed tomography angiography and bronchography. Combining these two techniques achieves a new more minimally invasive method for subsuperior segmentectomy.

Serratus anterior plane block or thoracic paravertebral block for postoperative pain treatment after uniportal video-assisted thoracoscopic surgery: a retrospective propensity-matched study

Background

Reports of postoperative pain treatment after uniportal video-assisted thoracoscopic surgery are limited. Thoracic paravertebral block and serratus anterior plane block have been described recently in pain management after thoracic surgery. A comparison between these two blocks for postoperative analgesia after uniportal video-assisted thoracoscopic surgery has not been previously reported. The aim of this study was to compare the analgesic benefits of serratus plane block and thoracic paravertebral block after uniportal video-assisted thoracoscopic surgery and examined the two block types for noninferiority.

Methods

From December 2015 to May 2018, a total of 636 relevant records of patients who underwent uniportal video-assisted thoracoscopic surgery under general anaesthesia alone or with the addition of serratus plane block or thoracic paravertebral block performed preoperatively were identified. A propensity-matched analysis incorporating preoperative variables was used to compare the efficacy of postoperative analgesia in three groups.

Results

Overall, 123 patients were identified for analysis. Propensity score matching resulted in 41 patients in each group. The visual analogue scale scores were significantly lower in the serratus plane block group and the thoracic paravertebral block group than in the control group at the 1st, 2nd, 4th, and 6th postoperative hours. Cumulative opioid consumption was significantly lower in the serratus plane and thoracic paravertebral block groups than in the control group at 6 hrs (18.3±3.1 mg, 18.7±3.9 mg vs 21.5±4.4 mg; P=0.001) and 24 hrs (43.4±7.3 mg, 42.5±7.7 mg vs 49.3±8.8 mg; P<0.001) postoperatively. The serratus plane block group was noninferior to the thoracic paravertebral block group on pain score and opioid consumption.

Conclusion

The addition of single-injection serratus plane or thoracic paravertebral block is associated with early analgesic benefits in patients undergoing uniportal video-assisted thoracoscopic surgery, including a reduction in the postoperative opioid consumption and pain scores. Serratus plane block is as effective as thoracic paravertebral block for reducing postoperative pain.

Uniportal Lung Cancer Surgery: State of the Evidence

BACKGROUND

Uniportal video-assisted thoracic surgery (VATS) has generated much attention in recent years, but questions remain regarding the adequacy of evidence to support its use in lung cancer surgery. This review aims to explore what the currently published literature suggests the role of the uniportal approach may be and to critically appraise that literature.

METHODS

A systematic review was conducted using the Ovid Medline database to identify articles related to uniportal VATS. Articles were selected for review on the basis of ability to provide original clinical data on the role of uniportal VATS for lung cancer surgery.

RESULTS

The literature search revealed that only some publications on uniportal VATS provided original clinical data. Twenty-two articles were selected for review, including 9 case series and 13 comparative studies. No concerns about the safety of the uniportal VATS were noted. Some but not all comparative studies provided data suggesting that uniportal VATS may hold advantages over multiportal VATS in some simple clinical outcomes (such as reduced lengths of stay and postoperative pain). However, the quantity and quality of evidence thus far are limited.

CONCLUSIONS

It remains premature to declare superiority for uniportal VATS in lung cancer surgery. A higher level of evidence is needed, especially in investigating objective benefits and treatment efficacy of the single-incision approach.

Management of intra-operative major bleeding during single-port video-assisted thoracoscopic anatomic resection: two-center experience

BACKGROUND

Our objective is to report on two centers' experience of intra-operative management of major vascular injury during single-port video-assisted thoracoscopic (SPVATS) anatomic resections, including bleeding control techniques, incidence, results, and risk factor analysis.

METHODS

Consecutive patients (n = 442) who received SPVATS anatomic lung resections in two centers were enrolled. The different clinical parameters studied included age, previous thoracic surgery, obesity (BMI > 30), tumor location, neoadjuvant therapy, and pleural symphysis. In addition, peri-operative outcomes were compared between the groups, with or without vessel injury.

RESULTS

There were no intra-operative deaths in our study. Overall major bleeding incidence was 4.5%, whereby 70% of major bleeding episodes could be managed with SPVATS techniques. In order to determine risk factors possibly related to intra-operative bleeding, we used case control matching to homogenize our study population. After case control matching, pleural symphysis was significantly related in the univariate (p = 0.005, Odds ratio 4.415, 95% CI 1.424-13.685) and multivariate analysis (p = 0.006, Odds ratio 4.926, 95% CI 1.577-15.384). Operative time (p < 0.001), blood loss (p < 0.001), and post-operative hospital stay (p = 0.012) were longer in patients with major vascular injury. There were no differences in 30-day mortality and 90-day morbidity.

CONCLUSIONS

In summary, major intra-operative bleeding episodes during SPVATS anatomic lung resections are acceptable and most such bleeding episodes can be safely managed with SPVATS techniques.

Uniportal video-assisted thoracoscopic right upper lobectomy and systemic mediastinal lymph nodes dissection

Along with the progresses that have been made in techniques and instruments, uniportal video-assisted thoracoscopic surgery (VATS) became more and more popular. Here, we present the operation video of a 52-year-old female with early stage lung cancer in the right upper lobe (RUL), who underwent uniportal VATS right upper lobectomy and systemic mediastinal lymph nodes dissection performed by our team. The video demonstrated the Uniportal VATS techniques of hilar anatomy, bronchus and blood vessel separation, mediastinal lymph node areas exploration and en-bloc dissection. Once the vision angle is properly adapted, techniques and instruments are mastered, and the patients are well selected, uniportal VATS approach can be an alternative to the conventional VATS for early stage lung cancer.

Muscle sparing lateral thoracotomy: the standard incision for thoracic procedures

Lateral thoracotomy is a versatile approach with many variations and is currently the most widely used incision in thoracic surgery. In the current article we are presenting the muscle-sparing lateral thoracotomy in the lateral decubitus position which we consider to be the “standard” for lateral thoracotomies. Indications, surgical technique and pitfalls are described alongside our experience with thoracic drainage. Although there is no consensus regarding the name of this incision, some authors call it “axillary thoracotomy” while others call it a “modified lateral thoracotomy”, they all agree on one aspect – the importance of muscle sparing – which makes it the go-to thoracotomy for both small and large procedures involving the lung. Lateral muscle sparing thoracotomy allows for good exposure of the pulmonary hilum, fissures, apex and diaphragm. The approach is easy and quick to perform while at the same time ensuring faster postoperative recovery by sparing the latissimus dorsi muscle, better cosmetics and lower postoperative pain score when compared to the posterolateral or classical lateral thoracotomies.

The feasibility and advantage of uniportal video-assisted thoracoscopic surgery (VATS) in pulmonary lobectomy

Background

Ongoing improvements in technique and instruments for video-assisted thoracoscopic surgery (VATS) have made minimally-invasive uniportal VATS lobectomy a reality. However, the outcomes of the procedure are still under investigation, and at present, uniportal VATS lobectomy is performed infrequently at most hospitals. We have therefore reviewed our outcomes with this procedure in an attempt to validate its safety, efficacy, and feasibility.

Methods

We retrospectively analyzed and compared perioperative data for patients who underwent uniportal, two-port, and traditional three-port VATS lobectomy between January 2015 and December 2015 at our hospital.

Results

Among 257 patients who had successful VATS lobectomy during the study period, 73 underwent uniportal VATS, 86 underwent two-port VATS, and 98 underwent traditional three-port VATS. There were no surgical or 30-day postoperative mortalities, and no significant differences in operative times, blood loss, number of lymph nodes retrieved and nodal stations explored, drainage times, length of hospital stay, or postoperative complications among the three groups. The visual analogue scale (VAS) pain scores were significantly lower in the uniportal VATS group after surgery (P < 0.05).

Conclusions

Uniportal VATS lobectomy is a safe and feasible surgical procedure that is associated with decreased surgical trauma and less postoperative pain compared to traditional VATS. Further long term follow-up analyses in large numbers of patients are ongoing.

Uniportal video-assisted thoracoscopic lobectomy for lung cancer

Great advances have been made in the multi-port video-assisted thoracoscopic surgery lobectomy in the recent two decades. However, only five years passed a more minimally surgery, namely uniportal video-assisted thoracoscopic lobectomy, was launched. Accumulating experience and exploration are being performed in most of the medical centres and hence we summarize the experience of uniportal video-assisted thoracoscopic lobectomy in our operation group.

Single-port thoracoscopic surgery for pneumothorax under two-lung ventilation with carbon dioxide insufflation

BACKGROUND

The development of single-port thoracoscopic surgery and two-lung ventilation reduced the invasiveness of minor thoracic surgery. This study aimed to evaluate the feasibility and safety of single-port thoracoscopic bleb resection for primary spontaneous pneumothorax using two-lung ventilation with carbon dioxide insufflation.

METHODS

Between February 2009 and May 2014, 130 patients underwent single-port thoracoscopic bleb resection under two-lung ventilation with carbon dioxide insufflation. Access was gained using a commercial multiple-access single port through a 2.5-cm incision; carbon dioxide gas was insufflated through a port channel. A 5-mm thoracoscope, articulating endoscopic devices, and flexible endoscopic staplers were introduced through a multiple-access single port for bulla resection.

RESULTS

The mean time from endotracheal intubation to incision was 29.2±7.8 minutes, the mean operative time was 30.9±8.2 minutes, and the mean total anesthetic time was 75.5±14.4 minutes. There were no anesthesia-related complications or wound problems. The chest drain was removed after a mean of 3.7±1.4 days and patients were discharged without complications 4.8±1.5 days from the operative day. During a mean 7.5±10.1 months of follow-up, there were five recurrences (3.8%) in operated thorax.

CONCLUSIONS

The anesthetic strategy of single-lumen intubation with carbon dioxide gas insufflation can be a safe and feasible option for single-port thoracoscopic bulla resection as it represents the least invasive surgical option with the potential advantages of reducing operative time and one-lung ventilation-related complications without diminishing surgical outcomes.

Single port VATS: recent developments in Asia

Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.

Reasons not to perform uniportal VATS lobectomy

The uniportal video assisted thoracic surgery (VATS) approach to lung lobectomy has generated phenomenal interest in recent years. It promises to offer patients less morbidity and faster recovery, even when compared to conventional multiportal VATS. However, critics of the uniportal VATS approach may raise concerns about whether this most minimally invasive surgical approach for lung surgery may compromise safety and treatment efficacy. This debate has great potential importance not only in determining how patients are operated on, but in understanding how 'success' is gauged in major pulmonary surgery. This article explores both sides of this debate, drawing on the experience of how clinical research in multiportal VATS evolved over the years. Systematic generation of clinical evidence with progressively increasing sophistication is required to fairly evaluate the uniportal VATS approach. A review of the current literature suggests that there remain many large gaps in the evidence surrounding uniportal VATS. Hence, at the present time, the reasons voiced by critics as to why uniportal VATS should not be performed should not be lightly dismissed. Instead, it behoves surgeons on both sides of the debate to continue to generate good clinical evidence to resolve it.

Thoracoscopic Lobectomy for Non-small Cell Lung Cancer

Lobectomy is the gold standard treatment in operable patients with surgically resectable non-small cell lung cancer. Thoracoscopic lobectomy has emerged as an option for surgeons facile with the technique. Video-assisted thoracoscopic surgery (VATS) is used for a variety of indications, but its efficacy as a reliable oncologic procedure makes it appealing in the treatment of non-small cell lung cancer. Fewer postoperative complications and decreased postoperative pain associated with VATS procedures can lead to shorter lengths of stay and lower overall costs. Thoracoscopic surgery continues to evolve, and uniportal, robot-assisted, and awake thoracoscopic procedures have all shown promising results.

Feasibility of Subxiphoid Anatomic Pulmonary Lobectomy in a Canine Model

Purpose. Transthoracic thoracoscopic approach is the gold standard in surgical treatment for thoracic disease. However, it is associated with significant chronic postoperative wound discomfort. Currently, limited data are available regarding the subxiphoid approach to the thoracic cavity. The present study is aimed to evaluate the performance of a subxiphoid anatomic pulmonary lobectomy (SAPL) in a canine model. Methods. The SAPL procedure was performed in 10 beagle dogs using a 3-cm incision over the xiphoid process. After thoracic exploration, SAPL was performed under flexible bronchoscopy guidance. The pulmonary vessel was divided with Ligasure and secured with a suture ligature. The bronchus was divided with endostapler. Surgical outcomes were evaluated by the success of SAPL and operative complications. Results. SAPL was successfully completed in 9 animals. One animal required conventional thoracotomy to resuture the pulmonary artery stump. Another animal encountered small middle lobe laceration after SAPL and died at 8 days postoperation due to respiratory distress. Conclusion. Subxiphoid anatomic pulmonary lobectomy is technically feasible. Refinement of endoscopic instruments combined with more research evidences may facilitate the development of subxiphoid platform in thoracic surgery.

[Uniportal VATS: a sublimation of micro-invasive lung cancer resection]

以电视胸腔镜手术（video-assisted thoracic surgery, VATS）为代表的微创手术已成为肺癌切除的主流。传统多孔VATS（包括四孔、三孔及两孔）已覆盖了几乎所有肺癌切除方式。然而，如何使肺癌的切除更加微创始终是胸外科医师的不懈追求。单孔VATS只需一个切口完成手术，与传统多孔VATS相比，能最大程度地减轻胸壁损伤，在减轻术后切口疼痛和胸壁感觉异常方面有明显的优势。近年来，单孔VATS已开始应用于肺癌的切除，并取得不错的临床效果。本文就单孔VATS肺癌切除的进展进行简要小结，单孔VATS是微创肺癌切除的再次升华。

Multiinstitutional analysis of single-port video-assisted thoracoscopic anatomical resection for primary lung cancer

BACKGROUND

Multiinstitutional analysis of single-port video-assisted thoracic surgery (VATS) for anatomic pulmonary resection is rare. This study aimed to address the technical feasibility and applicability of single-port video-assisted anatomical resection for primary lung cancer.

METHODS

A total of 121 patients with primary lung cancer undergoing single-port video-assisted anatomical resection between 2011 and 2014 in 4 hospitals were included. The clinicopathologic variables and perioperative outcomes were collected and analyzed retrospectively.

RESULTS

Single-port VATS segmentectomies and lobectomies were performed in 24 (19.8%) and 97 (80.2%) patients, respectively. One hundred seven of 121 (88.4%) patients had adenocarcinoma and 93 of 121 (76.9%) had pathologic stage I lung cancer. The average operative time and estimated blood loss was 198.8 ± 65.4 minutes and 99.1 ± 147.6 mL, respectively. The conversion and complication rates were 2.5% (3 of 121 cases) and 14.0% (17 of 121 cases), respectively. There was no surgical mortality, and the average length of hospital stay was 6.6 ± 2.6 days. The mean resected lymph node was 22.6 ± 12.0. We also identified patient age of 60 years or more, male sex, and tumor size greater than 3 cm as unfavorable perioperative outcome predictors after single-port video-assisted anatomical pulmonary resection.

CONCLUSIONS

This first multiinstitutional single-port VATS study demonstrated that anatomical resection for primary lung cancer can be safely and effectively completed through a single-port VATS approach in hospitals experienced in VATS techniques.

Uniportal video-assisted thoracoscopic lobectomy: an alternative to conventional thoracoscopic lobectomy in lung cancer surgery?

OBJECTIVES

Although the standard video-assisted thoracoscopic surgery (VATS) approach is generally performed through two to four incisions, uniportal VATS pulmonary resection has recently been reported to be a promising, less invasive alternative. To evaluate the adequacy of uniportal VATS lobectomy as an alternative to conventional VATS lobectomy in lung cancer, we analysed and compared the outcomes of uniportal and conventional VATS lobectomies.

METHODS

Retrospective observational data for patients who underwent VATS lobectomy at Samsung Medical Center between January 2013 and February 2014 due to a diagnosis of lung cancer were collected. Perioperative factors such as operative time, postoperative chest tube duration, postoperative hospital stay, complication rate, conversion rate, reoperation rate and mortality were compared between the uniportal and conventional VATS groups.

RESULTS

A total of 90 uniportal VATS lobectomies and 60 conventional VATS lobectomies were attempted. Fifty-eight (64.5%) cases were completed as uniportal VATS lobectomies, and 51 (85%) cases as conventional VATS lobectomies. There were 32 (35.5%) conversions of uniportal VATS lobectomy cases, including four conversions to three-port VATS, 18 to two-port VATS and 10 to open thoracotomy. No differences in postoperative complications, postoperative 30-day mortality or reoperation rate were noted between the two groups. There was no difference in operative time, number of removed lymph nodes, chest tube duration or length of postoperative hospital stay between the uniportal VATS group and conventional VATS group.

CONCLUSIONS

The similar perioperative results of uniportal VATS lobectomy compared with conventional VATS lobectomy suggest that uniportal VATS is a viable alternative approach to the conventional VATS approach in selected patients, especially in patients with early peripheral lung cancer with good anatomy and in good general condition.

Uniportal video assisted thoracoscopic lobectomy: primary experience from an Eastern center

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy is an emerging technique for the surgical resection of non-small cell lung cancer (NSCLC). Besides its wide debates on safety and efficacy throughout the world, there were few report on uniportal VATS from the Eastern countries. In this article, we summarized our primary experience on uniportal VATS lobectomy in an Eastern center.

METHODS

From October 2013 till February 2014, 54 consecutive uniportal VATS lobectomy were performed in the Department of Thoracic Surgery, Zhongshan Hospital of Fudan University. Patients' clinical features and operative details were recorded. Post-operatively, the morbidity and mortality were recorded to analyze the safety and efficacy of uniportal VATS lobectomy for NSCLCs.

RESULTS

Among the 54 planned uniportal VATS lobectomy, there was one conversion to mini-thoracotomy due to lymph node sticking. Extra ports were required in two patients. The uniportal VATS lobectomy was achieved in 51 out of 54 patients (94.4%). The average operation duration was 122.2±37.5 min (90-160 min). The average volume of estimated blood loss during the operation was 88.8±47.1 mL (50-200 mL). The mean chest tube duration and hospital stay were 3.2±1.9 days and 4.6±2.0 days, respectively. There was no postoperative mortality in this study. Two patients suffered from prolonged air leakage (5 and 7 days), and one atrial fibrillation was observed in this cohort.

CONCLUSIONS

Based on our primary experience, uniportal VATS lobectomy is a safe and effective procedure for the surgical resection of NSCLCs. The surgical refinements and instrumental improvements would facilitate the technique. Further studies based on larger population are required to determine its benefits towards patients with NSCLCs.

The feasibility of single-incision video-assisted thoracoscopic major pulmonary resection performed by surgeons experienced with a two-incision technique

OBJECTIVES

This study evaluated the safety and feasibility of a single-incision video-assisted thoracoscopic surgery (VATS) major pulmonary resection performed by surgeons experienced with the two-incision technique.

METHODS

Consecutive patients who underwent single-incision VATS major pulmonary resection from March 2012 to May 2013 were included. The fifth intercostal space was incised (3-5 cm) at the anterior or posterior axillary line according to the tumour location.

RESULTS

In total, 60 patients (39 men, 21 women; median age, 61 years; interquartile range, 53-69 years) were included in this study. Malignant lung disease was diagnosed preoperatively in 56 patients (93%) and benign disease in 4 (7%) patients. Lobectomy was performed in the majority of patients (n = 55), bilobectomy in 1, sleeve lobectomy in 1 and segmentectomy in 3. Four patients (7%) required a second incision, and conversion to thoracotomy was required in 2 (3%). In 50 lung cancer cases completed using a single-incision technique, the median surgical duration was 145 min (interquartile range, 90-182 min), and the total number of dissected lymph nodes per patient was 22 (interquartile range, 10-28 min). The chest tube was removed 5 days (interquartile range, 3-6 days) postoperatively, and there were no cases involving major perioperative morbidity or mortality.

CONCLUSIONS

Single-incision VATS major pulmonary resection is feasible, and following a two-incision technique learning period, may yield results similar to those obtained with conventional VATS lobectomy.

Modern impact of video assisted thoracic surgery

With advancement in technology, experience and training over the last two decades, video assisted thoracic surgery (VATS) has become widely accepted and utilized all over the world. VATS started as a diagnostic tool in the early 1990s, technique of VATS lobectomy evolved and became safer over the next 10-15 years and now it is being used for more advanced and hybrid operations. VATS has contributed to the development of minimally invasive surgical interventions for other thoracic disorders like mediastinal tumors and esophageal cancer as well. This article looks at the advantages of VATS, technique advancements and its applications in other thoracic operations and its influence on the present and future of thoracic surgery.

Flexible videoscope for thoracoscopic lobectomy: evolution of uniportal technique

BACKGROUND

Over the years reducing the number of ports during Video-assisted thoracic surgery (VATS) has allowed to accomplish pulmonary lobectomy with a single incision. Endoscopic view and instruments maneuvers issues could be improved by using flexible endoscope. We report our experience of fifteen uniportal VATS (UVATS) using a flexible thoracoscope.

METHODS

A single incision of about 4-5 cm long was performed at the 5th intercostal space along the anterior axillary line. No additional skin incisions were made. A flexible videoscope and multiple VATS instruments were simultaneously inserted into the uniport. Pulmonary lobectomy with systematic mediastinal lymph node dissection was performed. Verbal pain scores were registered using the visual analog scale from 0 to 10 at the first post-operative day.

RESULTS

No post-operative complications or hospital mortality were recorded. Mean operative time was 112.6 min (range 70-200) and mean postoperative hospital stay 3.2 days (range 2-6). Mean pain score was 0.5 (range 0-2).

CONCLUSIONS

Single-incision VATS lobectomy using a flexible thoracoscope is a feasible and safe approach.

Uniportal complete video-assisted thoracoscopic lobectomy with systematic lymphadenectomy

Video-assisted thoracoscopic surgery (VATS) has permeated our thoracic surgical practice and now will develop in depth towards a next level of minimally invasive surgery (MIS). Irrespective of generation gaps and diversified perception within thoracic community, more and more surgical teams are adapting to the uniportal lobectomy. This video demonstrates a case undergoing uniportal VATS lobectomy with systematic lymphadenectomy for lung cancer. We here describe our technique for uniportal approach by using a combination of double-jointed and endoscopic instruments to combat the four major obstacles: (I) interference of the thoracoscope, stapler and the instrumentation in and out of the thoracic cavity? (II) whether the field of vision is enough or not without the other 1-3 ports to improve the exposure? (III) the optimal stapler introduction angle especially for upper and middle lobes resection? (IV) more importantly, the oncologic validity of uniportal procedures as well as the reduction of postoperative morbidity? We believe, uniportal VATS lobectomy with systematic lymphadenectomy is technically safe and feasible and alternative approach to conventional thoracoscopic lobectomy in lung cancer treatment. The issues of patient acceptability, the cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future through multi-institution randomized controlled trials and long-term follow-up.