The Geometric and Ergonomic Appeal of Uniportal Video-Assisted Thoracic Surgery

Ergonomic Assessment of Robotic versus Thoracoscopic Thymectomy

Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.

Uniportal video-assisted thoracoscopic carinal resections: technical aspects and outcomes

OBJECTIVES

Important benefits in uniportal video-assisted thoracoscopic surgery (VATS) for lung cancer have recently been achieved. However, the use of this technique for complex sleeve procedures is limited. We describe the technical aspects of and patient outcomes following carinal resections using uniportal VATS.

METHODS

Since 2015, 16 sleeve carinal resections, including 11 right pneumonectomies, 4 right upper lobectomies and 1 lung-sparing carinal resection, have been performed at the Regional Clinic Hospital, Tyumen, Russia.

RESULTS

The mean surgical time was 215.9 ± 67.2 min (range 125-340 min). The mean blood loss volume was 256.3 ± 284.5 ml (range 50-1200 ml). There was 1 case of conversion to thoracotomy. The morbidity rate was 25%, and the mortality rate was 0%. The median overall survival was 38.6 ± 3.5 months.

CONCLUSIONS

The use of uniportal VATS for carinal resections in certain patients allows for radical resections with low rates of morbidity and mortality.

Standardized surgical technique for uniportal video-assisted thoracoscopic lobectomy

SUMMARY

Uniportal video-assisted thoracoscopic surgery may be the approach for any thoracic procedure, from minor resections to complex reconstructive surgery. However, anatomical lobectomy represents its most common and clinically proven usage. A wide variety of information about uniportal video-assisted thoracoscopic lobectomies can be found in the literature and multimedia sources. This article focuses on updating the surgical technique and includes important aspects such as the geometric approach, anaesthesia considerations, operating room set-up, tips about the incision, instrumentation management and the operative technique to perform the 5 lobectomies. The following issues are explained for each lobectomy: anatomical considerations, surgical steps and technical advice. Medical illustrations and videos are included to clarify the text with the goal of describing a standard surgical practice.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Uniportal versus multiportal video-assisted thoracic surgery for lung cancer

Background

Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients.

Methods

We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting.

Results

The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008).

Conclusions

We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.

Devising the guidelines: the concept of uniportal video-assisted thoracic surgery-instrumentation and operatory room staff

In the last years, uniportal video-assisted thoracic surgery (VATS) has been gaining more and more popularity, becoming a common procedure in several thoracic centers all over the world not only for minor procedures but also for major and complex cases. This technique combines the advantages of the less invasiveness with the oncological principles of open surgery. A standardization of the different peri- and intraoperative steps can help in the establishment and development of this technique. The aim of this paper is to set the basic steps for operating room set-up and instrumentation for starting or improving a uniportal VATS program in thoracic surgery centers.

Learning curve of uniportal video-assisted lobectomy: analysis of 15-month experience in a single center

Background

Uniportal video-assisted thoracoscopic (U-VATS) lobectomy has been becoming the technique of choice in an increasing number of centers. The aim of our study was to review our experience, evaluating the learning curve of U-VATS for lung lobectomy and outcomes.

Methods

The prospectively collected clinical data of 43 consecutive patients, undergone U-VATS lobectomy from June 2016 to September 2017, were reviewed. The cumulative sum analysis was applied for defining the completion of learning curve (CLC), evaluating the relationship between operative time and the consecutive number of operations.

Results

The mean operative time of Uniportal VATS lobectomy was 179.93±43.41 min. According to the cumulative sum analysis, the CLC was reached after 25 patients. Using the cut-off of 25 patients, the whole populations was divided in group A (first 25 patients of the experience) and group B (the last 18 patients). The mean operative time in group B was significantly shorter than in group A (164.00±24.46 vs. 191.40±50.45 min, respectively, P=0.04). There were no differences in demographic characteristics, number of removed lymph nodes, chest tube duration, and hospital stay among the two groups. The number of conversions was higher in group A (4 vs. 0; P=0.07), as the number of major complications, like reoperations for bleeding (2 vs. 0; P=0.22). There was no postoperative 30-day-related death.

Conclusions

U-VATS lobectomy seems to be a quite safe and feasible procedure, with a steep learning curve and low complication rate, if performed by experienced surgeons after proper training.

Application of a three-dimensional video system in the training for uniportal thoracoscopic surgery

Background

Three-dimensional (3D) video systems offer better depth perception and are associated with improved performance during endoscopic or robotic surgery. We compared the impact of a 3D video system with a two-dimensional (2D) video system on a simulation program for uniportal thoracoscopic surgery.

Methods

We launched an endoscopic simulation program for uniportal surgery using a 3D high-definition video system for training surgeons and medical students. This program included three basic surgical skills: (I) peg transfer, (II) passing a needle through a 3-mm hole, and (III) suturing on a tailor-made skin model. We evaluated the impact of 3D vision during simulation for uniportal surgery in each task. Overall, 113 trainees (85 surgeons in training and 28 medical students) who had not experienced a 3D video system were registered in the program. The three surgical simulation skills were evaluated under 2D and 3D video systems.

Results

The 3D video system allowed for shorter procedural times [92 participants (80.0%) in task 1, 102 (86.4%) in task 2, and 88 (74.6%) in task 3] and improved performance. Moreover, 65 s in task 1, 145 s in task 2, and 32 s in task 3 were shortened using the 3D video system. Post-simulation survey revealed improved depth perception (n=71, 60.2%) and handling of instruments on the uniportal surgical module (n=39, 33.1%) as advantages of the 3D video system during simulation. Sixty (50.8%) trainees were not negatively affected by the use of the 3D glasses; however, 53 (44.9%) felt eye discomfort during simulation.

Conclusions

We concluded that the 3D video system has potential advantages, such as improved procedure time and handling of instruments, during basic simulation of uniportal surgery for surgical trainees.