Posterior uniportal video-assisted thoracoscopic surgery for anatomical lung resections

Single-Injection Midpoint Transverse Process-to- Pleura Block Versus Thoracic Paravertebral Block for Postoperative Analgesia After Uniportal Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial

OBJECTIVES

The effect of midpoint transverse process-to-pleura block (MTPB) is unclear. The authors compared the analgesic characteristics of MTPB with those of thoracic paravertebral nerve block (TPVB) in patients undergoing uniportal video-assisted thoracoscopic surgery (uVATS) and examined the 2 types of blocks for noninferiority.

DESIGN

A randomized, controlled trial.

SETTING

A single-institution, university hospital.

PARTICIPANTS

The study comprised 82 patients between 18 and 75 years of age. Eighty-one patients were included for final analysis.

INTERVENTIONS

Patients were randomly allocated to either the MTPB group (Group M) or the TPVB group (Group P).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the mean difference in the postoperative visual analog scale (VAS) score between Group M and Group P at rest and at 12 hours. The secondary outcomes included VAS scores during rest and coughing, nerve block performance, intraoperative consumption of anesthetics and vasoactive medication, time at first use of patient-controlled intravenous analgesia (PCIA), number of uses of PCIA, consumption of sufentanil in PCIA, and side effects. The mean difference in VAS score in the MTPB and TPVB group at rest and 12 hours postoperatively was 0.5 (95% confidence interval, -0.26 to 0.36). There was no significant difference in the time at first use of PCIA, which was 12 (10, 12) hours and 11 (10, 12) hours in Group M and Group P, respectively. The depth of puncture was shallower, and the time to perform block was shorter in Group M compared with Group P (p < 0.001).

CONCLUSIONS

The analgesic effect of single-level-injection MTPB is noninferior to that of TPVB in patients undergoing uVATS. The target point of the needle in MTPB is shallower and farther away from the pleura compared with TPVB. For these reasons, it is quicker and safer and, thus, may be preferable.

Research on the application of uniportal video-assisted thoracoscopic segmental resection of the lung in elderly patients with non-small cell lung cancer aged over 65 years

Introduction

The literature regarding the application of uniportal video-assisted thoracoscopic segmental resection of the lung in patients aged over 65 years with non-small cell lung cancer (NSCLC) is sparse. This paper reports 175 cases of uniportal video-assisted thoracoscopic segmental resection of the lung performed at one center, of which 63 patients were over 65 years old.

Aim

To investigate the safety and feasibility of uniportal video-assisted thoracoscopic segmental resection of the lung in elderly patients aged over 65 years with NSCLC.

Material and methods

A retrospective analysis of 175 NSCLC patients who underwent uniport video-assisted thoracoscopic segmental resection of the lung in the center from August 2018 to August 2020 was conducted, and based on the age of 65 years, patients were divided into elderly and non-elderly groups. The general data and perioperative indicators of the two groups were compared.

Results

The procedures were completed in all patients without death or conversion to open surgery. In the general data of the two groups of patients, the prevalence of emphysema in the elderly group was significantly higher than that in the non-elderly group (p = 0.001). However, there was no statistically significant difference between the two groups in surgery time, intraoperative blood loss, thoracic drainage tube retention time, postoperative hospital stay, incision satisfaction, or postoperative complications (p > 0.05).

Conclusions

Uniportal video-assisted thoracoscopic segmental resection of the lung is feasible and safe in elderly patients with NSCLC aged over 65 years.

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.

Non-intercostal access for video-assisted thoracic surgery-analysis of technical advantages and disadvantages

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted method for the treatment of early-stage non-small-cell lung cancer (NSCLC). The standard VATS approach is an intercostal one which is often followed by postoperative pain due to injury of the intercostal nerve. The non-intercostal techniques of VATS include the subxiphoid, transcervical, transdiaphragmatic and transoral procedures.

Methods

The technical difficulty of operative management of the anatomical structures during VATS anatomical resection are compared for the intercostal, subxiphoid and transcervical approaches.

Results

Some operative steps have different range of difficulty, which are analyzed in detail.

Conclusions

The clearest advantages of the non-intercostal approaches include less postoperative pain and superradial bilateral mediastinal lymphadenectomy in case of the transcervical approach. However, the non-intercostal approaches are more technically demanding procedures, which therapeutic role has to be clarified in the future.

Posterior uniportal video-assisted thoracoscopic surgery for anatomical lung resections

Background

The acceptance of uniportal video-assisted thoracoscopic surgery (uVATS) for anatomical lung resections has been growing in recent years. This study presents the first case-series in the literature with posterior uVATS (puVATS) technique for specific anatomical lung resections.

Methods

The first 20 consecutive patients who underwent an anatomical lung resection by a single surgeon, by means of puVATS technique were evaluated in terms of pre-, peri- and post-operative results. A single incision of 3.5-4.5 cm was made posteriorly in the 6^th intercostal space at the so-called 'triangle of auscultation' to perform a resection of either a posterior segment of an upper lobe or a superior segment of a lower lobe for both lungs.

Results

There were 5 posterior segmentectomies and 3 apical segmentectomies of the right upper lobe and 6 apical segmentectomies of the left lower lobe. Moreover, there were 6 lobectomies, all except for one as an extension of initially planned "posterior" segmentectomy. There were no intraoperative complications. Median tumor size (IQR) was 1.65 cm (1.1-2.57 cm), while median incision size (IQR) was 3.5 cm (3.5-3.87 cm). Median operative time (IQR) was 160 minutes (142-178 minutes). Median number of removed lymph nodes (IQR) was 19 [15-20]. Four patients had postoperative complications: three had bronchitis and one developed heart failure, all of which resolved before patients were discharged. Median length of hospital stay (IQR) was 6 days (5-8 days).

Conclusions

puVATS approach for posterior lung segment resections, even for lobectomy if needed, seems to be feasible and safe. Exposure of the bronchovascular structures of the 'posterior segments' is better, and local and mediastinal lymphadenectomy seem to be easier with access directly in front of the incision and the lung, rather than behind it.