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

What's new in thoracic oncology

Many changes have occurred in the field of thoracic surgery over the last several years. In this review, we will discuss new diagnostic techniques for lung cancer, innovations in surgery, and major updates on latest treatment options including immunotherapy. All these have significantly started to change our approach toward the management of lung cancer and have great potential to improve the lives of our patients afflicted with this disease.

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.

Feasibility and safety of uniportal thoracoscopy for chronic pulmonary aspergillosis

Surgery plays a crucial role in the treatment of patients with chronic pulmonary aspergillosis (CPA). However, there is currently limited information available regarding the use of uniportal thoracoscopy (Uni-VATS) in CPA patients. To address this gap, we conducted a retrospective analysis of surgical procedures performed at a single center, aiming to demonstrate the feasibility and safety of Uni-VATS for patients with CPA. We collected basic information and surgical data from patients who underwent surgery for CPA at our hospital between January 2018 and June 2022. All patients received voriconazole antifungal medication for 3-6 months post-surgery and were monitored for a minimum of 6 months. A total of 110 patients, comprising 59 cases in the traditional open chest incision group and 51 cases in the Uni-VATS group, met the inclusion criteria. Among those who underwent surgery, 70% were male (77/110). The median age (IQR) of all enrolled patients was 55 (46-62) years. There were no statistically significant differences in general information, such as age, sex, comorbidities, BMI, FEV1, FVC, clinical symptoms, location of the disease, and duration of voriconazole antifungal medication, between the OS group and the Uni-VATS group (p > 0.05). The postoperative complication rates were 40.7% (24/59) for the traditional open chest incision group and 17.6% (9/51) for the Uni-VATS group. Through univariate analysis, we identified sex and operative approach as risk factors for postoperative complications. Multivariate logistic analysis confirmed that male and OS procedures were the independent risk factors for postoperative complications. There were statistically significant differences in operative time, intraoperative blood loss volume, postoperative drainage volume, pain scores, postoperative drainage tube removal time, postoperative hospital stay time between the OS group and the Uni-VATS group (p < 0.05). Uni-VATS is a feasible and safe surgical procedure for patients with CPA, and we recommend it as a preferred option for selected patients with CPA.

Meta-analysis comparing the perioperative efficacy of single-port versus two and multi-port video-assisted thoracoscopic surgical anatomical lung resection for lung cancer

BACKGROUND

As a new surgical procedure for non-small cell lung cancer, single-port video-assisted thoracoscopic surgery (VATS) has lately gained popularity; nevertheless, it is unknown if single-port VATS offers any advantages over multi-portal. The study aims to assess the different impacts of using single-port VATS versus 2-port or multi-port VATS such as operation and drainage time, blood loss volume, number of resected lymph nodes, and hospital stay in lung cancer patients.

METHODS

Inclusion criteria included studies from different languages that compare single-port against 2 or multi-port VATS. The outcomes of these studies were analyzed using a random-effect model and it was used to calculate the mean difference with 95 percent confidence intervals to quantify the impact of different surgical techniques on clinical parameters.

RESULTS

Single or Uni-portal video-assisted thoracoscopic surgery results in significantly lower drainage time after surgery compared with 2-port (P = .03) and multi-port (P < .001) VATS. In contrast to the resection of lymph nodes, there was no significant difference between uni-port and 2-port (P = .49) or multiport (P = .29) VATS. While operation time, blood loss, complications, and hospital stay were significantly lower in uni-port compared with multi-port VATS (P = .04, P = .002, P < .001, respectively), but not with 2-port VATS (P = .44, 0.06, P = .13). There were no significant differences between uni-port and multi-port VATS regarding conversion rate, mortality, and staging.

CONCLUSION

Single or Uni-portal video-assisted thoracoscopic surgery has high efficacy and lower side effects compared with multi-port regarding the perioperative outcomes. Two-port VATS has similar results with uni-port in several parameters.

The concept of broad exposure facilitates uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection

Background

Systematic lymph node dissection is an important part of radical resection for lung cancer. Insufficient incision of the mediastinal pleura results in a tapered or tunnel-like operation surface, which increases the difficulty of uniportal video-assisted thoracoscopic mediastinal lymph node dissection. The objective of this study was to report our concept of broad exposure and investigate the efficacy and safety of this concept in uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection.

Methods

We retrospectively analyzed the clinical data of the 204 non-small cell lung cancer patients who underwent uniportal video-assisted thoracoscopic surgery for anatomical lobectomy and systematic lymph node dissection following the concept of broad exposure. SPSS 23.0 software was used for statistical analysis.

Results

All operations were completed under uniportal video-assisted thoracoscopic surgery following the concept of broad exposure. The median surgery time was 102 (range, 76–285) minutes and the median blood loss was 50 (range, 20–900) milliliters. The median chest tube duration time was 2 (range, 1–6) days, the median postoperative hospital duration time was 5 (range, 4–10) days. The median number of dissected lymph node stations and dissected lymph nodes were 8 (range,6–9) and 15(range,12–19), respectively. The median number of dissected mediastinal lymph nodes stations and dissected mediastinal lymph nodes were 5(range,3–6) and 11(range,10–15), respectively. The up-staging rate of N staging was 6.86%. The postoperative complication rate was 10.29% and there was no perioperative death.

Conclusions

According to our results, it’s effective and safe to perform uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection following the concept of broad exposure. This new concept not only emphasizes sufficient exposure, but also focuses on protection of important tissues.

Modified technique of closing the port site after multiport thoracoscopic surgery using the shingled suture technique: a single centre experience

Background

Due to improvements in operative techniques and medical equipment, video-assisted thoracoscopic surgery has become a mainstay of thoracic surgery. Nevertheless, in multiport thoracoscopic surgery, there have been no substantial advances related to the improvement of the esthetics of the site of the chest tube kept for postoperative drainage of intrathoracic fluid and decompression of air leak after thoracoscopic surgery. Leakage of fluid and air around the site of the chest tube can be extremely bothersome to patients.

Methods

From March 2019 to April 2020, we used a modified technique of closing the port site in 67 patients and the traditional method in 51 patients undergoing multiport thoracoscopic surgery due to lung disease or mediastinal disease. We recorded patients’ age, gender, body mass index, surgical method, postoperative drainage time, and postoperative complications.The NRS pain scale was used to score the pain in each patient on the day of extubation.The PSAS and the OSAS were used for the assessment of scars one month after surgery.

Results

In the modified technique group, only one patient (1.49%) had pleural effusion leakage, compared with five patients (9.80%) in the traditional method group (P < 0.05). There were no significant differences in the pain of extubating and wound dehiscence between the two groups. However,the incidence rates of wound dehiscence in the modified technique group were lower than in the traditional method group. There were no post-removal pneumothorax and wound infection in either of the groups. Significant differences in the PSAS and OSAS were observed between the groups,where the modified technique group was superior to the traditional method group.

Conclusions

The modified technique of port site closure is a leak-proof method of fixation of the chest tube after multiport thoracoscopic surgery. Moreover, it is effective and preserves the esthetic appearance of the skin.

Patient-Reported Outcomes of Video-Assisted Thoracoscopic Surgery Versus Thoracotomy for Locally Advanced Lung Cancer: A Longitudinal Cohort Study

BACKGROUND

The effects of video-assisted thoracoscopic surgery (VATS) and traditional thoracotomy with respect to patient-reported outcomes (PROs) have only been assessed for early-stage lung cancer. This study was a longitudinal PRO assessment to compare the effects of these surgeries for locally advanced (stage II and III) lung cancer from the patients' perspective.

METHODS

We investigated lung cancer patients from a previous prospective, multicentre study. Longitudinal data of clinical characteristics and PROs were collected. PROs were obtained preoperatively, daily in the hospital postoperatively, and weekly up to 4 weeks after discharge or the beginning of postoperative adjuvant therapy. Symptoms and impact on daily functioning and quality of life (QOL) were assessed by using the MD Anderson Symptom Inventory for lung cancer and a single-item QOL scale. Trajectories of PROs over the investigation period were compared.

RESULTS

Overall, 117 primary lung cancer patients (stage II or III), including 63 and 54 patients who underwent VATS and traditional thoracotomy, respectively, were included. During postoperative hospitalization, VATS patients reported milder disturbed sleep (p = 0.048), drowsiness (p = 0.008), and interference with activity (p = 0.001), as well as better work ability (p < 0.0001), walking ability (p < 0.0001), and life enjoyment (p = 0.004). Post-discharge, VATS patients had less distress (p = 0.039), milder pain (p = 0.006), better work ability (p = 0.001), and better QOL (p = 0.047).

CONCLUSIONS

Locally advanced lung cancer patients who underwent VATS had lower postoperative symptom burden, less daily function interference, and better QOL than those who underwent thoracotomy.

Uniportal Versus Multiportal Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: An Updated Meta-analysis

OBJECTIVE

We reviewed the available literature on patients with lung cancer undergoing either uniportal (UVATS) or multiport video-assisted thoracoscopic surgery (MVATS).

METHODS

Original research studies that evaluated perioperative and long-term outcomes of UVATS versus MVATS were identified, from January 1990 to April 2020. The perioperative, along with the oncologic and long-term survival outcomes, were calculated according to either a fixed or a random effect model, appropriately. The Q statistics and I2 statistic were used to test for heterogeneity among the studies.

RESULTS

Twenty studies were included, incorporating a total of 1,469 patients treated with UVATS and 3,231 treated with MVATS. The incidence of complications was lower in patients treated with UVATS [OR: 0.76 (95% CI 0.62, 0.93); p = 0.008]. The chest tube duration was significantly lower in the UVATS group (WMD: - 0.63 [95% CI - 1.03, - 0.23]; p = 0.002). Length of hospital stay (L.O.S.) was also lower in the UVATS patient group (WMD: - 0.54 [- 0.94, - 0.13]; p = 0.009), along with postoperative pain [WMD: - 0.57 (95% CI - 0.97, - 0.18); p = 0.004]. No significant differences were found regarding the mean operative time (M.O.T.), mean blood loss, the number of resected lymph nodes, the 30-day mortality, along with the survival at 1 and 3 years postoperatively.

CONCLUSIONS

The present meta-analysis indicates that UVATS is associated with enhanced outcomes in patients undergoing surgery for lung cancer. Well-designed, randomized studies, comparing UVATS to MVATS, are necessary to further assess their long-term clinical outcomes.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery for Intrathoracic Diseases: Initial Results in Vietnam

OBJECTIVE

Nonintubated uniportal video-assisted thoracoscopic surgery (VATS) is a recent controversial procedure in many countries. Hence, the authors would like to present the experience in performing this approach and evaluate its initial results in the treatment, particularly, of intrathoracic diseases in Vietnam.

METHODS

A prospective, descriptive study was conducted on 17 patients with intrathoracic diseases treated with nonintubated uniportal VATS from February to July 2019. Preoperative, intraoperative, and postoperative parameters were gathered and analyzed by SPSS Statistics, Version 18.0.

RESULTS

Patients had an average age of 49.2 ± 20.5 (range 6 to 71) years. Regarding operative indications and methods, there were 3 ground glass opacity (17.6%) and 1 bullous lung disease receiving wedge resection (5.9%); 8 mediastinal tumors (47.1%) having resection, and 5 non-small-cell lung cancers receiving lobectomy combined with node dissection (29.4%). The average operative time and pleural drainage time were 108.6 ± 28.17 min (range 60 to 160) and 3.7 ± 1.18 days (range 2 to 8), respectively. The average hospitalization time was 4.9 ± 1.76 (range 3 to 12) days. No mortalities or major complications were recorded postoperatively.

CONCLUSIONS

Nonintubated uniportal VATS is a safe and considerable surgical choice for appropriate intrathoracic conditions.

Uniportal versus multiportal thoracoscopic lobectomy: Ergonomic evaluation and perioperative outcomes from a randomized and controlled trial

BACKGROUND

To compare perioperative outcomes and surgeon physical and mental stress when performing lobectomy through uniportal and multiportal video-assisted thoracoscopic surgery (VATS) on patients with non-small-cell lung cancer (NSCLC).

METHODS

Patients aged 41 to 73 years with resectable NSCLC were randomly assigned via a computer-generated randomisation sequence to receive either uniportal VATS (UVATS) or multiportal VATS (MVATS) lobectomy and lymphadenectomy between December 2015 and October 2016. Overall, we randomly assigned 35 patients to the UVATS and 34 to the MVATS group. Patients and the investigators undertaking interventions, assessing short-term outcomes, performing ergonomic evaluations, and analyzing data were not masked to group assignment.

RESULTS

Patient demographics of the 2 groups were comparable. The ergonomic evaluation considered eye blink rate and the NASA Task Load Index (NASA-TLX), better results were observed in UVATS than in MVATS. The operative time, number of lymph nodes harvested, chest tube duration, length of hospital stay, and lung function were not significantly different between the groups. Compared with MVATS lobectomy, UVATS lobectomy was associated with less intraoperative blood loss and less volume of total drainage in the 24 hours. No conversion, no reoperation, and no in-hospital mortality occurred in either group.

CONCLUSIONS

UVATS lobectomy is a safe and programmable technique with some better perioperative outcomes and ergonomic results than MVATS. Further studies based on large numbers of patients and with long-term follow-up are required to confirm its benefits towards patients.

TRIAL REGISTRATION

ClinicalTrials.gov ID:NCT02462356. Registered May 27, 2015.

Uniportal video-assisted thoracic surgery for the treatment of lung cancer: a consensus report from Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS) and Chinese Association of Thoracic Surgeons (CATS)

Uniportal video-assisted thoracoscopic surgery (UniVATS) has been widely adopted in China, where several ultra-high volume thoracic surgical and training centers are located. The objective of this consensus from Chinese experts was to summarize the current application and give reference for the future development of UniVATS in the treatment of lung cancer. A panel of 41 experts from 21 Chinese hospitals was invited to join this project. The Delphi method was used in this consensus consisting of two rounds of voting. The questionnaire was based on the current clinical evidence. Forty (97.6%) experts completed the 2 rounds of questionnaires. The experts’ experience was relatively similar. We defined the UniVATS as monitor-dependent surgery, no use of rib-spreading and single incision less than 4 cm. Tumor with stage of T1–T3 and N0–N2 is considered amenable to UniVATS. Other consensus was reached on several points outlining the safety and feasibility, surgical skills, learning curve, short-term and long-term outcomes for lung cancer, and current application of subxiphoid and nonintubated UniVATS approach. This consensus statement represents a collective agreement among Chinese experts to suggest that UniVATS is an effective alternative to multi-portal approach, although high-level evidence is expected in the future. Some agreements can be referred in the training of young surgeons.

Uniportal versus multiportal video-assisted thoracoscopic anatomical resection for NSCLC: a meta-analysis

Background

Uniportal video-assisted thoracoscopic surgery (U-VATS) has recently emerged as an alternative procedure for non-small cell lung cancer (NSCLC); however, whether U-VATS has advantages over multiportal VATS (M-VATS) remains unknown.

Methods

We performed a systematic review of two databases (Pubmed and Web of Science) to search comparative studies of U-VATS and M-VATS anatomical pulmonary resection for NSCLC. Operative time, blood loss, number of resected lymph nodes, drainage duration, length of postoperative stay, pain in postoperative day 1(POD1) and conversion rates were retrieved to estimate the comparison of outcomes. A subgroup analysis stratified by study type (propensity-matched analysis and randomized-controlled trial versus non-propensity matched analysis) was performed.

Result

A total of 20 studies with 4142 patients were included in this meta-analysis. U-VATS was performed on 1869 patients, whereas the other 2173 patients underwent M-VATS. This meta-analysis showed that there was no significant difference in operative time (U-VATS: 146.48 ± 55.07 min versus M-VATS: 171.70 ± 79.40 min, P = 0.81), blood loss (74.49 ± 109.03 mL versus 95.48 ± 133.67 mL, P = 0.18), resected lymph nodes (17.28 ± 9.46 versus 18.31 ± 10.17, P = 0.62), conversion rate (6.18% versus 4.34%, P = 0.14), drainage duration (3.90 ± 2.94 days versus 4.44 ± 3.12 days, p = 0.09), length of postoperative stay (6.16 ± 4.40 days versus 6.45 ± 4.80 days, P = 0.22), and pain in POD1 (3.94 ± 1.68 versus 3.59 ± 2.76, p = 0.07). Subgroup analysis showed the value of PSM and RCT group consistency with overall value.

Conclusion

This up-to-date meta-analysis shows that the perioperative outcomes of U-VATS and M-VATS anatomical pulmonary resection are equivalent. In addition, the differences in long-term outcomes of these two approaches are still unclear. Thoracic surgeons should pay more emphasize on providing high-quality and personalized surgical care for patients, to improve the survival ultimately.

Video-assisted thoracoscopy for lung cancer: who is the future of thoracic surgery?

As the computer processing technique and display technology evolved dramatically, the surgical approach to early-stage non-small cell lung cancer (NSCLC) has made a rapid progress within the past few years. Currently, the gold standard for NSCLC is lobectomy. After the introduction of video-assisted thoracoscopic surgery (VATS), lung resection can now be conducted mini-invasively, enabling better prognosis for patients and better operation condition for surgeons. At the very beginning, the conventional two-dimensional (2D) system enabled operators to have a closer, magnified and illuminated view inside the body cavity than open thoracotomy. With the introduction of the glasses-assisted three-dimensional (3D) and glasses-free 3D display system, multiple viewing angles were further enhanced, thus a more stable, easier to master and less invasive video-assisted thoracoscopic surgery (VATS) appeared. However, given that the standard VATS is associated with limited maneuverability and stereoscopy, it restricts the availability in more advanced cases. Hopefully, most of the limitations of standard VATS can be overcome with the robotic-assisted thoracic surgery (RATS). The RATS system consists of a remote console and a robotic unit with 3 or 4 arms that can duplicate surgeons’ movements. Also, it provides a magnified, 3D and high definition (HD) operation field to surgeons, allowing them to perform more complicated procedures. Apart from these, some new technologies are also invented in combination with the existing surgery system to solve difficult problems. It is hoped that the higher costs of innovative surgical technique can be offset by the better patient outcomes and improved benefits in cost-effectiveness.

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.

[Comparison of the Clinical Effect of Uniportal Video-assisted Thoracoscopic Lobectomy and Biportal Video-assisted Thoracoscopic Lobectomy in the Treatment of Lung Cancer]

背景与目的

近年来单孔胸腔镜肺癌根治术逐渐兴起，作为一种新的手术方式，其可行性及安全性尚未得到普遍认可。本研究拟探讨单孔胸腔镜肺癌根治术在治疗Ⅰ期至部分Ⅲa期肺癌病例中的可行性及安全性。

方法

回顾性分析苏州大学附属第一医院胸外科同一治疗组在2018年5月-2019年3月连续进行的胸腔镜肺癌根治术患者的临床资料。排除部分不符合要求的病例后，根据手术方式分为单孔组（55例）和单操作孔组（87例），共142例。分析两组患者的临床数据，进行统计学分析。

结果

142例患者均行肺叶切除+淋巴结清扫术，术后顺利出院，未有围手术期死亡。单孔组和单操作孔组比较，年龄、肿瘤位置、术后病理类型、肿瘤大小、肿瘤的病理性原发灶-淋巴结-转移（pathological tumor-node-metastasis, pTNM）分期的差异均无统计学意义（P > 0.05）。单孔组手术时间更短[(167.65±43.85) min vs (181.71±51.28) min]，术中出血量更少[(57.45±50.19) mL vs (87.47±132.54) mL]，术后引流管留置时间[(4.82±2.82) d vs (5.84±3.43) d]及术后住院天数[(6.91±3.88) d vs (7.74±3.87) d]更短，但差异无统计学意义（P > 0.05）。单孔组的术后总引流量显著低于单操作孔组[(1, 064.82±776.38) mL vs (1, 658.71±1, 722.38) mL]，术后24 h及72 h视觉疼痛评分明显更低[（4.73±0.73）分vs（5.25±0.74）分；（2.16±0.71）分vs（2.55±0.86）分]，差异有统计学意义（P < 0.05）。

结论

在Ⅰ期至部分Ⅲa期肺癌病例中，单孔胸腔镜肺癌根治术安全可行。

Pathologic features and clinical course of a non-functioning primary pulmonary paraganglioma: A case report

Introduction

Paragangliomas (PGGL) are rare neuroendocrine tumors arising from non-epithelial extra-adrenal chromaffin cells. They have been described in different sites: abdomen, pelvis, head, neck and thorax. Incidence is very low, occurring in less than 2–8/million per year. PGGL's of the lung are extremely rare, they have a slow growth and present as painless lesions. Biopsy is the method of choice for diagnosis and prognosis.

Presentation of case

This is a 70-year-old woman with chronic cough, with a CT-scan showing a 3.3-cm mass in the left lower lobe. After video-assisted thoracic surgery, histologic findings confirmed a non-functioning pulmonary paraganglioma. We present the clinical, radiological, pathological findings and clinical course.

Discussion

Primary pulmonary PGGL's are extremely rare neuroendocrine tumors with low-grade malignancy, difficult to distinguish from other pulmonary tumors relying only on imaging techniques. In this case, PGGL presented as an incidentaloma during the evaluation of chronic cough. After histological diagnosis, genetic testing are ideally performed to identify somatic or germline mutations that may condition a higher risk of malignancy and metastasis.

Conclusion

PGGL's must be considered when other diagnoses are unlikely due to immunohistochemistry findings. Larger studies in this field are needed to determine the risk factors for its development and to determine which populations have the greatest potential for malignant transformation

•

Paragangliomas are rare neuroendocrine tumors derived from non-epithelial extra-adrenal chromaffin cells.

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Paragangliomas from the lung are rare, they have a slow growth and present as non-painful lesions.

•

Complete surgical resection is the diagnostic method of choice for solitary primary pulmonary paragangliomas.

•

Genetic testing is important to identify somatic or germline mutations.

Uniportal versus multiportal video-assisted thoracoscopic surgery in the treatment of lung cancer: a Canadian single-centre retrospective study

Background

Observational studies comparing uniportal and multiportal video-assisted thoracoscopic surgery (VATS) in the treatment of lung cancer have produced conflicting results. We present a Canadian study comparing clinical outcomes of uniportal and multiportal VATS in the treatment of lung cancer.

Methods

A retrospective study evaluating patients who underwent multiportal (2012–2014) or uniportal (2014–2016) VATS lobectomies, segmentectomies and wedge resections for lung cancer. Clinical outcomes measured included patient demographics, tumour factors, operative factors, length of hospital stay, postoperative complications, analgesic use, pain scores and mortality. Descriptive statistics were used to compare the 2 groups.

Results

Of 185 patients, 65 underwent uniportal and 63 underwent multiportal VATS resection. Patients were similar in terms of their baseline demographics, comorbidies and cancer characteristics. Median operative time was 184 and 185 minutes in the uniportal and multiportal groups, respectively. There were 5 conversions to thoracotomy in the uniportal group and 1 in the multiportal group. Similar lymph node retrieval (median 7 v. 5 nodes) and positive margin rates (6.2% v. 4.8%) were seen in the 2 groups. Median length of stay was 2 days (interquartile range [IQR] 1–3) and 3 days (IQR 2–4) in the uniportal and multiportal groups, respectively. Rates of postoperative complications were similar in the 2 groups (16.9% v. 19.0%, p = 0.76). Patient-controlled analgesia use and pain scores did not differ between the groups.

Conclusion

Adoption of uniportal VATS appears to be feasible and safe, without compromising oncologic principles or increasing intraoperative resource utilization. Larger, prospective studies can help confirm these findings.

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.

Complete Uniportal Thoracoscopic Anatomic Lung Resection With Systematic Mediastinal Lymphadenectomy for Non-Small Cell Lung Cancer: Personal Experience of 326 Cases

BACKGROUND

With its growing popularity and potential outcome, complete uniportal thoracoscopic (CUT) surgery has been used in the treatment of thoracic diseases. This study aimed to summarize a personal experience of CUT anatomic lung resection with systematic mediastinal lymphadenectomy (CUT-ALR-SML) for non-small cell lung cancer (NSCLC) and to evaluate the feasibility and safety of CUT-ALR-SML in our institute.

MATERIALS AND METHODS

A total of 326 patients with NSCLC were chosen to undergo CUT-ALR-SML in our institute from August 2013 to July 2018. Data such as clinicopathologic characteristics and perioperative outcomes were reviewed in this article.

RESULTS

For the 326 cases of ALR, the specific procedures and the corresponding number of cases were as follows: segmentectomy, 90; lobectomy, 218; sleeve lobectomy, 9; ipsilateral lobe combined with segment resected synchronously (i-L+S), 6; and pneumonectomy, 3. A total of 31 cases required conversion to open surgery, and 4 cases were converted to multiportal thoracoscopic surgery. All patients underwent SML. The average mediastinal lymph node stations and mediastinal lymph nodes dissected under CUT-ALR-SML were 3.3±1.4 and 9.6±8.4, respectively. Approximately 99.7% of the patients acquired free resection margins. A total of 42 (12.9%) patients suffered from postoperative complications, and 1 patient died of pneumonia during the perioperative period.

CONCLUSIONS

Complete uniportal ALR, particularly for segmentectomy and lobectomy is safe and feasible with low complication rates and excellent free resection margin rates. SML during complete uniportal thoracoscopic surgery adequately assesses the N2 lymph node. However, further studies need to be conducted to evaluate the role of CUT-ALR-SML in the treatment of NSCLC.

Feasibility and safety of reduced-port video-assisted thoracoscopic surgery using a needle scope for pulmonary lobectomy- retrospective study

Background

This study aimed to determine the usefulness and limitations of videoassisted thoracoscopic (VATS) lobectomy using one-window and puncture method (1WPM).

Methods

This study involved 14 patients who underwent lobectomy using the 1WPM at our institute from 2008 to 2017.

Results

The study patients comprised of 3 men and 11 women with a median age of 10.5 years (range, 0-72 years). There were eight cases in children younger than 18 years old and the youngest patient was 9 days old. The diagnoses were congenital pulmonary cystic disease (n = 7), primary lung cancer (n = 4), metastatic lung tumor (n = 1), and others (n = 2). The 1WPM was successful in 9 of 14 patients (64.3%) and, in 5 cases (35.7%), needed conversion to either two-window method (TWM) using additional port (n = 3) or open thoracotomy (n = 2). The causes for conversion were need for additional bronchoplasty or lymph node dissection (n = 3), failure of one-lung ventilation (n = 1), and presence of a small thoracic cavity that made the procedure extremely difficult (n = 1). In the group that was successfully treated with 1WPM, the median values were as follows: operation time, 193 min (range, 112-480 min); blood loss, 0 ml (range, 0-90 ml); drainage duration, 1 day (range, 1-4 days); and postoperative hospital stay, 7 days (range, 4-13 days).

Conclusions

Lobectomy by 1WPM can be safely performed and has good postoperative course and this procedure can be applicable and effective in small infants.

•

This study describes the novel VATS lobectomy method: the one-window and puncture method (1WPM).

•

1WPM is performed using 2–3 cm single incisions and a needle scope for intrathoracic access from other points.

•

This retrospective study involved 14 patients who underwent lobectomy using the 1WPM.

•

VATS lobectomy using 1WPM can be safely applied from adult cases to new born cases.

Systematic mediastinal lymph node dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic lobectomy for lung cancer

BACKGROUND

To evaluate the systematic mediastinal lymph node (LN) dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic surgery (UVATS).

METHODS

Patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic surgery (VATS) and systematic mediastinal LN dissection between January 2015 and January 2017 were retrospectively reviewed. We categorized the patients into two groups according to the different surgical approaches. Patients' clinical data were collected and compared. The index of estimated benefit from LN dissection was used to evaluate the therapeutic value of LN dissection for each station.

RESULTS

A total of 453 patients underwent VATS, including 197 patients in the UVATS group and 256 patients in the triportal VATS (TVATS) group. There were no significant differences in the 1-, 2- and 3-year survival rates of these two groups (P > 0.05). There were no statistically significant differences in the operative time, numbers and stations of LNs, numbers and stations of N2 LNs, conversion rate or postoperative complications. The UVATS group had less intraoperative blood loss, a shorter duration of hospital stay, less chest tube drainage and a shorter duration of chest tube drainage than the TVATS group (P < 0.05). The conversion rates in the UVATS and TVATS groups were 5.1% and 4.3%, respectively, and the difference was not significant. The same degree of LN sampling was achieved in both groups.

CONCLUSION

UVATS permits the same degree of LN sampling as TVATS without a difference in the conversion rate.

Modified marionette technique for uniportal video-assisted thoracic surgery: a case report

Background

The current state of thoracoscopic technology allows less invasive surgical procedures and requires fewer ports and incisions. Totally video-assisted thoracic surgery with a single port has emerged as the least invasive thoracoscopic approach.

However, uniportal video-assisted thoracic surgery brings about considerable difficulties, necessitating the development of skillful techniques as well as specific surgical devices. In such situations as dense pleural adhesion and anatomical abnormality, it may be more burdensome, necessitating the conversion to conventional multiportal video-assisted thoracic surgery or even to thoracotomy. To troubleshoot these situations, we herein propose the use of additional technique which could support to sustain the confident operative field for uniportal video-assisted thoracic surgery. This procedure also provides the same cosmetic outcomes as uniportal video-assisted thoracic surgery.

Case presentation

A previously healthy, 77-year-old female was referred to our hospital, with a lung adenocarcinoma measuring 28 mm in the right upper lobe. Uniportal video-assisted thoracoscopic surgery was planned to resect the tumor. During operation, we found the incomplete interlobar fissure between the upper and the middle lobe and the abnormal lobulation of the upper lobe. Therefore, the modified marionette technique was introduced to make the procedure safer and easier. This technique proposed herein consists of employing the untethered gripping forceps to retract the lung, not requiring additional traumatic trocars. The postoperative course was uneventful and the patient `was discharged in 1 week after a modified uniportal video-assisted thoracic surgery for the right upper lobectomy.

Conclusions

The modified marionette technique produced sufficient operative views to attain uniportal video-assisted thoracic surgery safely in this case, rendering operative conversion unnecessary.

Uniportal video-assisted thoracic surgery could reduce postoperative thorax drainage for lung cancer patients

BACKGROUND

Uniportal video-assisted thoracic surgery (VATS) has undergone significant development in recent years, yet its usefulness and value in the treatment of lung cancer remains controversial. We investigated the effect of uniportal VATS surgery for reducing postoperative thorax drainage in lung cancer patients.

METHODS

The data of primary lung cancer patients who underwent VATS anatomical lung resection at the China National Cancer Center by a single surgeon were retrospectively collected. After propensity score matched analysis, 492 patients (246 uniportal VATS, 246 multiportal VATS) were included in the study. The clinicopathologic and surgery-related features, including drainage volume, were compared. Student's t and chi-square tests were used; all tests were two-sided.

RESULTS

Patients in the two groups had similar demographic and clinicopathological features. Patients who underwent uniportal VATS surgery had significantly lower postoperative thorax drainage (830.0 ± 666.0 mL vs. 1014.5 ± 616.9 mL, P = 0.002) and a comparatively lower rate of unplanned return to the operating room (0 vs. 0.8%; P = 0.156) than multiportal VATS patients. The surgical duration, blood loss, number of lymph nodes dissected, postoperative complications, and length of hospital stay were similar between the groups.

CONCLUSIONS

Uniportal VATS could reduce postoperative thorax drainage and the risk of unplanned return to the operating room for lung cancer patients. This study included the largest sample by a single surgeon and our results suggest the potential value of uniportal VATS for the faster recovery of lung cancer patients.

Ultrasonography for Detecting Adhesions: Aspirin Continuation for Lung Resection Patients

BACKGROUND/AIM

Aspirin reduces cardiovascular disease and/or stroke risks. However, perioperative aspirin use remains controversial. We assessed the efficacy of ultrasonography to facilitate video-assisted thoracic surgery (VATS). We analyzed the perioperative management of patients using aspirin and its association with bleeding events during lung cancer surgery.

PATIENTS AND METHODS

A total of 38 patients who underwent VATS after continuing or discontinuing aspirin were examined. Ultrasound was performed preoperatively to evaluate the pleural adhesions. Fisher's exact test was used to analyze correlations between the two groups.

RESULTS

Dense adhesions were found at VATS ports using ultrasonography (accuracy: 100%). No differences were detected in bleeding, thrombotic events, or operative times between the aspirin and non-aspirin groups. There were differences in bleeding (p=0.009) and operative times (p=0.021) between the dense adhesion and non-dense adhesion groups.

CONCLUSION

Preoperative detection of pleural adhesions using ultrasonography was useful in selecting pulmonary resection patients who continued aspirin perioperatively.

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.

Uniportal versus multiport video-assisted thoracoscopic surgery for anatomical lung resections: a glance at a dilemma

Introduction

As the number of operations performed by videothoracoscopy is increasing, there is also a tendency to decrease the number of port incisions. Apart from the reduced number of surgical incisions, there are a few reports and systematic reviews that demonstrate some potential advantages of the uniportal video-assisted thoracoscopic surgery, but the impact of the reduced incisions in the clinical setting still remains uncertain.

Aim

To compare uniportal video-assisted thoracoscopic surgery to multiport video-assisted thoracoscopic surgery for anatomical lung resections in patients with malignant and benign lung diseases.

Material and methods

From August 2010 to April 2016, a total of 102 patients with malignant and benign lung diseases underwent videothoracoscopic lobar and sublobar lung resections in our department. Comorbidities, tumor stage, tumor localization, mortality, operative time, pain visual analogue scale, length of hospital stay, perioperative blood loss, duration and amount of postoperative drainage and air leak, number of harvested lymph nodes and complication rates were analyzed.

Results

No significant difference was found in the duration of chest tube drainage, pain visual analogue scale score, length of hospital stay, perioperative blood loss, amount of postoperative drainage, number of harvested lymph nodes or complication rate. There was no surgical mortality in either of the two groups. However, operative time was shorter (189 min vs. 256 min, p < 0.005) in the multiport group than in the uniportal group.

Conclusions

Compared with the uniportal approach, the multiport approach is associated with a significantly shorter operative time in our study.

Comparison of survival between lung cancer patients receiving single or multiple-incision thoracoscopic surgery

Background

The effect of single-incision thoracoscopic surgery for lung cancer on long-term survival is unknown and no studies have investigated whether there are differences in survival between single and multiple incision approaches. We aimed to compare long-term overall survival and disease-free survival of patients who underwent single-incision thoracoscopic surgery with those who received multiple-incision thoracoscopic surgery for lung cancer.

Methods

We retrospectively analyzed 532 patients with lung cancer who underwent either single-incision (n=150) or multiple-incision thoracoscopic resection (n=382) during the period January 2000 to December 2014. Patients were matched on propensity score at a 1:2 ratio to estimate the effect of treatment on long-term and disease-free survival. Overall survival and disease-free survival were assessed using the Kaplan-Meier method, the log-rank test and Cox proportional-hazards regression.

Results

Propensity matching resulted in 138 patients in the single-incision group and 276 patients in the multiple-incision group. The matched patients in the single-incision group had a significantly better 5-year overall survival than those in the multiple-incision group (P=0.027). Disease-free survival was similar between the two groups before and after matching. The number of chest wall incisions did not influence overall survival or disease-free survival.

Conclusions

The long-term outcomes of single-incision thoracoscopic surgery are comparable to those of multiple-incision thoracoscopic surgery for lung cancer.

Single-incision versus multiport video-assisted thoracoscopic surgery in the treatment of lung cancer: a systematic review and meta-analysis

OBJECTIVES

Recent studies compared single-incision thoracoscopic surgery (SITS) with more widely used conventional multiport video-assisted thoracoscopic surgery in the treatment of lung cancer. To establish the safety and feasible of SITS in the treatment of lung cancer, we conducted this systematic review and meta-analysis.

METHODS

Eleven studies were identified from the databases of PubMed, Cochrane Library, SpringerLink, and ScienceDirect. The randomized controlled trials (RCTs) and non-randomized studies evaluated the outcomes of SITS compared with multiport video-assisted thoracoscopic surgery in the treatment of lung cancer were included for analysis. Odds ratio (OR, used to compare dichotomous variables) and weight mean difference (WMD, used to compare continuous variables) were calculated with 95% confidence intervals (CIs) based on intention-to-treat analysis.

RESULTS

Eleven studies including 1314 patients were included for analysis. Our analysis showed that the operative time, blood loss amount, mean duration of chest tube, lymph nodes retrieved were similar between two approaches, the SITS pulmonary resection might be associated with shorter hospital stay (p = .008) and lower complication rate (p = .009) when compared with conventional multiport video-assisted thoracoscopic surgery approaches.

CONCLUSIONS

In selected patients SITS is safe, feasible and may be considered an alternative to multiport VATS.

Uniport versus multiport video-assisted thoracoscopic surgery in the perioperative treatment of patients with T1-3N0M0 non-small cell lung cancer: a systematic review and meta-analysis

Background

Uniport video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive approach for the treatment of non-small cell lung cancer (NSCLC). However, whether uniport VATS has more potential advantages over multiport VATS remains controversial. This meta-analysis aimed to compare the perioperative efficacy of uniport and multiport VATS for T1-3N0M0 NSCLC.

Methods

An electronic and manual search of literature published before 1st October 2017 was conducted using PubMed, Embase, Web of Science, and the Wiley Online library. The effective values of dichotomous variables or continuous variables were estimated by odds ratios (OR) or by standardized mean differences (SMD) with 95% confidence intervals (CIs) respectively.

Results

Eleven relevant observational studies were included for meta-analysis. Results demonstrated that patients in the uniport group had a significant reduction in the duration of postoperative drainage (uniport: 4.39±2.48 vs. multiport: 4.99±3.24 days; P=0.003), bleeding volume (97.7±60.0 vs. 116.7±99.7 mL; P=0.006), length of hospital stay (6.3±2.4 vs. 7.0±3.6 days; P<0.001), VAS of postoperative pain (2.53±0.73 vs. 4.22±0.71, P=0.02) and in the overall rate of complications (14.5% vs. 17.5%; P=0.008). There were no significant differences between the two treatment groups with regards to mortality, operative time, the number of dissected lymph nodes or the conversion rate.

Conclusions

Uniport VATS might have represent a preferable option for the treatment of T1-3N0M0 NSCLC, due to its superior perioperative efficacy.

A word of caution-when uniportal VATS should not be done

Uniportal VATS (U-VATS) is gaining more and more popularity. Herein, we discuss the current status of adoption of the technique and-from a "laggard's" point of view-some situations when the use of U-VATS should be reconsidered. As we all do lack scientific evidence for the superiority of one minimally invasive approach over the other, these situations reflect a gut feeling rather than solid arguments. The article should raise awareness of currently discussed issues with minimally invasive approaches. Finally, it highlights the need for randomized controlled trials, if we really want to rank minimally invasive accesses.

Are There Contraindications for Uniportal Video-Assisted Thoracic Surgery?

Allowing oneself to indulge in illusory superiority when it comes to uniportal video-assisted thoracic surgery (VATS) can harm patients and the specialty. It is important for every VATS surgeon to remain vigilant. One must be clear about the absolute and relative contraindications for VATS: those conditions that should deter from even attempting a uniportal approach. Once the operation is started, one must also bear in mind those situations that should prompt one to convert. Only by first safeguarding patients in this way can the aspiring uniportal VATS surgeon go on to safely master the approach and explore its benefits.

Uniportal video-assisted thoracoscopic surgery in hemothorax

The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.

Transfection with Livin and Survivin shRNA inhibits the growth and proliferation of non‑small cell lung cancer cells

Lung cancer is reported to be a major public health issue worldwide and the overall prognosis of patients remains poor. The expression levels of Livin and Survivin, of the inhibitors of apoptosis (IAP) family, are associated with prognostic significance in the majority of solid tumors. Therefore, in the presents study, short hairpin (sh)RNA expression vectors inhibiting the Livin and Survivin genes were constructed to examine the effects of the transfection of Livin shRNA and/or Survivin shRNA on the biological functions of tumor cells. The transfection efficiency was measured using fluorescence reverse transcription‑quantitative polymerase chain reaction and western blot analyses. The cell growth inhibition ratio was measured using a CCK assay. Cell apoptosis following transfection and in tumor tissues were measured using a TUNEL assay, and a cancer xenograft model was used to investigate the effect of Livin shRNA and/or Survivin shRNA on tumor growth. The results indicated that the mRNA and protein expression levels were suppressed following the transfection of Livin and Survivin shRNA into tumor cells (P<0.05, compared with control group). The growth of tumor cells in vivo and in vitro was significantly inhibited following transfection with Livin and Survivin shRNA, compared with that in the other groups (P<0.05). Taken together, the transfection of cells with Livin and Survivin inhibited tumor growth in vivo and in vitro, with the co‑transfection of Livin and Survivin shRNA showing increased efficiency, compared with transfection of either the Livin vector or Survivin vector alone. The combined inhibition of Livin and Survivin may be a promising multitargeted gene therapeutic strategy in cancer treatment.

Advantages and disadvantages of single incision VATS in major anatomical resection for lung cancer

Safety and feasibility of lung resections by single incision thoracoscopy have been confirmed in large number of studies. As proponents claim its lesser invasive nature caused by lacking of additional intercostal port(s), opponents question the outcome measures of the approach especially in oncological manner. Since there is no major discussion regarding the superiority of video-assisted thoracoscopic surgery (VATS) on lung resections over the open technique in the surgical management of lung cancer today, advantage and disadvantage of single incision VATS lung resections was reviewed with the comparison of standard, multi-port VATS approach in this article. Overall, results of comparative studies confirm that single incision and multiportal thoracoscopy are similar, or single incision thoracoscopy has more advantages in the lung resection for lung cancer. Currently, the main disadvantage of single incision approach is the lacking of long-term oncological results.

Uniportal video-assisted thoracoscopic surgery left upper lobectomy and systematic lymph node dissection with fused fissure

As surgical proficiency and the development of medical techniques have improved, uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a minimally invasive alternative in the surgical management of lung cancer. The spectrum of uniportal VATS indications is now almost equal to that of conventional VATS. Recent decades have witnessed the emergence of numerous uniportal VATS techniques. A significant proportion of these have to be converted into a multiport approach and even open thoracotomy due to the difficulty of managing the upper lobe vein and bronchus, particularly for the technically challenging left upper lobectomy. Although many successfully uniportal VATS left upper lobectomies have been reported, their procedures were modularized without describing refined techniques or operative improvements. This report describes a patient who was clinically diagnosed with stage IB (T2aN0M0) primary lung cancer of the left upper lobe (LUL), and who underwent left upper lobectomy and systematic lymph node dissection. During the operation, the placement of a single incision was readjusted to obtain optimal angulation; the versatile electrocautery hook and curved suction tube were used in conjunction with each other; accessible, cost-effective modified instruments were used; and new operative tricks were created; in addition, the operative sequence was alternated and the nerves were preserved to ensure a smooth procedure, improve efficiency, embody tumor-free operation and ensure safety. These are all good ideas that are worth disseminating.

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.

Modular Uniportal Video-Assisted Thoracoscopic Lobectomy and Lymphadenectomy: A Novel Pattern of Endoscopic Lung Cancer Resection

BACKGROUND

Since the development of the uniportal video-assisted thoracoscopic surgery (VATS) technique, the use of uniportal VATS has become increasingly popular for the surgical resection of non-small cell lung cancer (NSCLC). The objective of this study is to introduce a novel modularly designed surgical pattern for uniportal VATS for lung cancer resection and to investigate the safety, feasibility, and efficacy of this novel method.

MATERIALS AND METHODS

The clinical data of NSCLC patients who underwent a curative uniportal VATS lobectomy between March 2015 and April 2016, including via the modular pattern (MP) and the conventional pattern (CP), were retrospectively collected and analyzed. Perioperative and postoperative parameters, including the operation duration, estimated intraoperative blood loss, rate of conversion to thoracotomy, lymph node dissection number, and postoperative complications, were compared between the two groups.

RESULTS

A total of 321 patients were identified, among whom 221 underwent MP uniportal VATS lobectomy and 100 were treated via CP uniportal VATS lobectomy. Patients in the MP group experienced a shorter operation duration (135.58 ± 47.16 minutes versus 148.86 ± 42.53 minutes, P = .017) and less estimated intraoperative blood loss (75.20 ± 37.99 mL versus 89.50 ± 41.11 mL, P = .003) than patients in the CP group. No significant difference was observed in the intraoperative conversion rate (2.7% versus 5.0%, P = .477), total number of lymph nodes dissected (24.67 ± 7.73 versus 25.34 ± 7.62, P = .471), postoperative drainage duration (4.86 ± 1.96 days versus 4.78 ± 2.10 days, P = .755), length of stay (9.60 ± 2.93 days versus 9.97 ± 2.80 days, P = .286), or incidence of postoperative complications between the two groups. No postoperative deaths occurred.

CONCLUSIONS

MP uniportal VATS lobectomy combined with mediastinal lymphadenectomy appears to be a safe and feasible technique for the treatment of NSCLC. The use of this technique can reduce the operation duration and intraoperative blood loss.

Clinical innovations in minimally invasive surgery in Korea

Over the past decade, the surgical approach to treating thoracic disease has shifted to minimally invasive surgery. Without compromising the outcomes, this approach may lead to fewer resections and fewer incisions for those resections. Video-assisted thoracoscopic surgery (VATS) is a recent but major advancement that has become an established approach for major thoracic surgery. More recently, robotic surgery has been gaining recognition because it can overcome the limitations of VATS and encourage a minimally invasive approach. Indications and applications of many other innovative surgical techniques and strategies to improve overall survival have expanded rapidly. In this article, we do not represent all thoracic surgeries occurring in Korea and do not reflect the large active centers in the country. However, as one of the most innovative and active Korean centers for thoracic surgery and research, we reviewed our procedures and programs for thoracic surgery.

A propensity matched comparison of effects between video assisted thoracoscopic single-port, two-port and three-port pulmonary resection on lung cancer

BACKGROUND

To summarize our experiences of single-port, two-port vs. three-port VATS pulmonary resection for lung cancer patients.

METHODS

Data of consecutive 1,553 patients who underwent video assisted thoracoscopic surgery (VATS) pulmonary resection for lung cancer in the Department of Thoracic Surgery of Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between November 2014 and January 2016 were prospectively collected and analyzed. A propensity-matched analysis was used to compare the short-term outcomes of lung cancer patients who received VATS single-port, two-port and three-port pulmonary resection.

RESULTS

There were 716 males and 837 females. The mean age was 58.90 years (range, 25-82 years) and the conversion rate was 2.7% (42/1,553) in this cohort. After propensity score matching, there were 207 patients in single-port and two-port group, and 680 patients in three-port group. Propensity-matched analysis demonstrated that there were no significant differences in duration of operation (129 vs. 131 min, P=0.689), intra-operative blood loss (63 vs. 70 mL, P=0.175), number of dissected lymph nodes (12 vs. 13, P=0.074), total hospital expense (﹩9,928 vs. ﹩9,956, P=0.884) and cost of operation (﹩536 vs. ﹩535, P=0.879) between VATS single-port, two-port and conventional three-port pulmonary resection groups. There was no significant difference in the complication rate between two groups (5.3% vs. 4.7%, P=0.220). However, compared with three-port group, patients who underwent single port and two-port experienced shorter postoperative length of stay (6.24 vs. 5.61 d, P=0.033), shorter duration of chest tube (4.92 vs. 4.25 d, P=0.008), and decreased volume of drainage (926 vs. 791 d, P=0.003).

CONCLUSIONS

The short term outcomes between VATS single-port, two-port and conventional three-port groups for the surgical treatment of lung cancer were comparable. However, compared with three-port VATS pulmonary resection, single-port and two-port were associated with shorter postoperative length of stay, shorter duration of chest tube, and decreased volume of drainage.

Modified uniportal video-assisted thoracoscopic surgery (VATS)

Video-assisted thoracoscopic surgery (VATS) for resectable lung cancer patients has been frequently used in the past decades. The potential beneficial advantages and safety of VATS has been shown in large patient series and meta-analyses. The strategy of limiting access to one incision in one intercostal space (uniportal VATS) has been adopted by some thoracic surgeons in recent years. We have described a modified uniportal VATS technique with its potential advantages. Modified uniportal VATS potentially offers better exposure, beneficial opportunities for education and improved comfort for the thoracic surgery team in clinical usage.

Transition from multiple port to single port video-assisted thoracoscopic anatomic pulmonary resection: early experience and comparison of perioperative outcomes

BACKGROUND

Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches.

METHODS

Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery.

RESULTS

Over 12 months, 50 S-VATS procedures were completed by one surgeon and compared to an equal number of VATS patients. The groups were similar in age, gender, BMI, comorbidity, tumor size and pulmonary function. There was no statistically significant difference in operative time. All tumors were completely resected (R0) and the median number of lymph nodes evaluated pathologically was equivalent {S-VATS=7 [4-10]; VATS=7 [4-10]; P=0.92}. There was no significant difference in conversion rate {S-VATS=2 (4%); VATS=1 (2%); P=0.56}. The median length of stay was similar in both groups {S-VATS=4 [3-7]; VATS=4 [3-7]; P=0.99}. There was no mortality and no significant difference in the rate of major complications {S-VATS=10/50 [20%]; VATS=5/50 [10%]; P=0.26}. There was no difference in patient reported pain as measured by a visual analog scale at 24 hours {S-VATS=4 [2-5]; VATS=4 [3-5]; P=0.63}.

CONCLUSIONS

Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required. Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Uniportal video-assisted thoracic (VATS) lobectomy

Uniportal video assisted thoracic surgery (VATS) has become one of the most exciting new developments in minimally invasive thoracic surgery in recent years. While the debate over its purported advantages continues, this chapter instead focuses on the technical aspects of performing a lobectomy via the uniportal approach. Using clear medical illustrations to show how each step is performed, the key tips and tricks are laid out for the beginner hoping to learn the technique.

Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative to the conventional multiportal approach in the treatment of lung cancer. The benefits of this uniportal technique have not yet been characterized in patients undergoing VATS lobectomy. This meta-analysis aimed to compare the clinical outcomes of uniportal and multiportal VATS lobectomy for patients with lung cancer.

METHODS

A systematic review was conducted using seven electronic databases. Endpoints for analysis included perioperative mortality and morbidity, operative time, length of hospital stay, perioperative blood loss, duration of postoperative drainage and rates of conversion to open thoracotomy.

RESULTS

Eight relevant observational studies were identified and included for meta-analysis. Results demonstrated a statistically significant reduction in the overall rate of complications, length of hospital stay and duration of postoperative drainage for patients who underwent uniportal VATS lobectomy. There were no significant differences between the two treatment groups in regard to mortality, operative time, perioperative blood loss and rate of conversion to open thoracotomy.

CONCLUSIONS

The present meta-analysis demonstrated favourable outcomes for uniportal VATS lobectomy in the treatment of lung cancer compared to the conventional multiportal approach. However, long-term follow-up data is still needed to further characterize the benefits of the uniportal approach.

Single-stage bilateral pulmonary resections by video-assisted thoracic surgery for multiple small nodules

BACKGROUND

Surgical treatment is thought to be the most effective strategy for multiple small nodules. However, in general, one-stage bilateral resection is not recommended due to its highly invasive nature.

METHODS

Clinical records of patients undergoing one-stage bilateral resections of multiple pulmonary nodules between January 2009 and September 2014 in a single institution were retrospectively reviewed.

RESULTS

Simultaneous bilateral pulmonary resection by conventional video-assisted thoracic surgery (VATS) was undertaken in 29 patients. Ground glass opacity (GGO) accounted for 71.9% (46/64) of total lesions, including 26 pure GGO and 20 mixed GGO lesions. One case underwent bilateral lobectomy that was complicated by postoperative dyspnea. Lobar-sublobar (L/SL) resection and bilateral sublobar resection (SL-SL) were conducted in 16 and 12 cases, respectively, and most of these cases had uneventful postoperative courses. There was no significant difference with regard to postoperative complications (P=0.703), duration of use of chest drains (P=0.485), between one- and two-stage groups. Mean postoperative follow-up in cases of primary lung cancer was 31.4 (range, 10-51) months. There was neither recurrence nor deaths at final follow-up.

CONCLUSIONS

Single-stage bilateral surgery in selected cases with synchronous bilateral multiple nodules (SBMNs) is feasible and associated with satisfactory outcomes.