Early Experience with Single-Incision Thoracoscopic Surgery in the Pediatric Population

Uniportal Video-Assisted Thoracic Surgery in a Pediatric Hospital: Early Results and Review of the Literature

Background: Uniportal video-assisted thoracic surgery (U-VATS) is an implemented technique in adult surgery that may aid to extend offer the benefits of thoracoscopy to a wide number of pediatric patients. Materials and Methods: Consecutive cases treated between July 2019 and July 2021 were retrospectively analyzed. Simultaneously, a MEDLINE systematic search was conducted. Results: Twelve patients (median age 13 years, median weight 44.5 kg) underwent 4 major procedures (n = 2 lobectomy, n = 2 segmentectomy) and 11 minor procedures (n = 1 bronchogenic cyst resection, n = 4 apical wedge resections and pleurodesis for pneumothorax, n = 4 wedge resections for lung nodules, and n = 2 debridement for empyema). The median observed operative time was 77 minutes. We recorded one conversion to biportal VATS. No intraoperative complications or 30-day morbidity-mortality was reported. A rate of 40% adverse postoperative events was observed (Clavien-Dindo grade I-IVa). Visual analog scale for postoperative pain recorded a median value of 0 on days 1, 2, and 3. The systematic review provided 15 full-text articles reporting 76 pediatric interventions (4 major and 72 minor procedures); among them, 1 biportal conversion, 3 mild postoperative complications, and 1 redo surgery are presented. Conclusions: As emerged from the literature review, U-VATS remains scarcely adopted by pediatric surgeons. Its feasibility is supported by the four reported major lung resections plus the four cases added on by our series. Thanks to a more rapid learning curve over conventional VATS, the uniportal technique could be accessible to a wider number of centers.

The international experience of single-incision pediatric endosurgery: current state of the art

PURPOSE

As application and awareness of single-incision pediatric endosurgery (SIPES) are increasing, various techniques and indications have been independently described by select centers around the world. In order to facilitate a cooperative approach toward advancing and investigating the practice of SIPES, we conducted a survey among members of the International Pediatric Endosurgery Group (IPEG), asking them about their experience and attitudes toward single-incision endosurgery.

MATERIALS AND METHODS

After institutional review board approval, an invitation to participate in an online survey was sent to all IPEG members. Questions focused on demographic information, practice patterns, indications, and equipment used regarding SIPES.

RESULTS

Of the 560 contacted active IPEG members, 115 completed the survey (recall 21%). The respondents represented pediatric surgeons from 32 countries on six continents. Of respondents, 97% had heard of, while 71% had performed, SIPES. Reasons for not having performed SIPES included disbelief in benefit (59%), lack of proficiency (34%), and inadequate resources (28%). The most commonly performed SIPES procedures were appendectomy (85%), cholecystectomy (66%), splenectomy (42%), pyloromyotomy (35%), and intestinal surgery (13%), as well as Nissen fundoplication and gynecologic adnexal pathology (7%). The equipment and techniques utilized showed large variation and included some self-devised, innovative, low-resource approaches. Complications with SIPES reported by the survey participants included technical difficulties, wound infection, and prolonged operating time.

CONCLUSIONS

SIPES is being performed worldwide for a large spectrum of common indications in pediatric surgery. The equipment and techniques used vary with geographic location and resources. Some encountered complications are common to those seen with conventional minimally invasive surgery, whereas others may be SIPES-specific. Different respondents reported diverging views on pain, operating time, and cost.

The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study

BACKGROUND

Thoracoscopic surgery is a commonly used endoscopic surgical treatment approach in patients with primary spontaneous pneumothorax. The conventional thoracoscopic approach utilizes three or more small wounds for surgery. Currently, a single port approach is a potential alternative procedure in general thoracoscopic surgery. We investigated whether a single-port approach is suitable as a first-line endoscopic approach for all patients with primary spontaneous pneumothorax requiring surgery.

METHODS

From July 1st, 2008 to Dec 31, 2009, a total of 62 patients was included in this study. All the patients were admitted to our ward because they had surgical indications for surgery. Twenty-six patients underwent conventional three-port thoracoscopic surgery and thirty-six underwent single-port thoracoscopic surgery. All of the clinical data were analyzed retrospectively. Variables were compared and analyzed to determine the outcomes of the different surgical approaches.

RESULTS

The mean age of the 62 patients was 27.2 years. Forty-nine patients were men and thirteen patients were women. The mean time required for the operation was 61.6 minutes. There was one patient who had a recurrence in single-port group and 2 patients had a recurrence in three-port group during the period of follow-up. The average pain scores at 24 and 48 hrs after the operation were similar, but the pain scores at 72 hrs in the single-port group were better than the three-port group. There was no case that required conversion from a single-port to multiple wound approach in this study. There was no immediate postoperative recurrence. The follow-up duration was greater than 12 months.

CONCLUSION

This study showed that single-port thoracoscopic surgery is a feasible and reasonable first-line endoscopic approach in the surgical treatment of primary spontaneous pneumothorax.

Single-incision thoracoscopic surgery for primary spontaneous pneumothorax using the SILS port compared with conventional three-port surgery

BACKGROUND

Single-incision thoracoscopic surgery (SITS) is postulated to cause less incisional pain, less paresthesia, and less wound scarring than the conventional three-port approach. The difficulties performing the technique have prevented it from being widely accepted. This study shows how the authors overcame the difficulties by using the SILS port and proved it to be a safe and useful procedure for the treatment of primary spontaneous pneumothorax (PSP).

METHODS

The same surgeon operated on all the patients using the three-port technique (n = 13) and SITS (n = 27) under the same procedural and management policy. The two groups were retrospectively compared in terms of operation time, postoperative complications, hospital stay, pain score, residual paresthesia, satisfaction regarding the wound scar, and surgical material cost.

RESULTS

The mean age, sex ratio, and previous pneumothorax episodes were similar between the two groups. The uniport and three-port groups did not differ statistically in terms of mean operation time (74.6 ± 22.8 vs 72.4 ± 20.2 min; p = 0.77), hospital stay (2.3 ± 0.7 vs 2.5 ± 0.8 days; p = 0.72), visual analog pain scale (on the day of surgery: 4.1 ± 1.7 vs 4.8 ± 2.2, p = 0.26; on day 1: 3.2 ± 1.4 vs 2.8 ± 1.4, p = 0.33; on day 2: 2.7 ± 1.0 vs 2.6 ± 1.1, p = 0.61), or total surgical material cost (US$1,810 ± $320 vs $1,741 ± $329; p = 0.58). However, the uniport group had a lower incidence of paresthesia than the three-port group (33.3 vs 76.9%; p = 0.01) and showed a higher satisfaction rate regarding wound scarring (70.4 vs 30.7%; p = 0.03).

CONCLUSIONS

Compared with the three-port approach, SITS using the SILS port in PSP patients proved to be a safe and feasible procedure that can be clinically implemented without additional economic burden or operation time. Additionally, SITS showed better cosmesis with minimized neurologic sequelae, which contributed to higher satisfaction among patients. Progress in uniport instruments and surgical experience will lead to wider applications of SITS.