Uniportal VATS in Asia

Uniportal Video-Assisted Thoracoscopic Segmentectomy for Early-Stage Non-Small Cell Lung Cancer: Overview, Indications, and Techniques

Twenty years have passed since uniportal video-assisted thoracoscopic surgery (VATS) was first reported. Several reports have already proven the minimal invasiveness of uniportal VATS. In addition, two large clinical trials recently demonstrated the benefits of segmentectomy for small peripheral early-stage non-small cell lung cancer. Uniportal VATS segmentectomy is considered the most beneficial minimally invasive surgery for patients with early-stage lung cancer. However, a high level of skill and experience are required to achieve this goal. Only a few reports have discussed specific techniques, particularly for complex segmentectomies. In this Special Issue, we reviewed previous reports on uniportal VATS segmentectomy regarding the indications, instrument selection, marking of the tumor location, methods of intersegmental plane identification, and lymph node dissection, including our own techniques with video content.

Uniportal video-assisted thoracic surgery Roman experience-a report of the first 16-month Roman experience

Background

The acceptance of uniportal video-assisted thoracic surgery (U-VATS) for thoracic procedures has been growing worldwide. This study reports one of the widest Italian U-VATS experiences.

Methods

The prospectively collected data of 237 patients underwent a U-VATS procedure, between May 2016 and September 2017, were retrospectively reviewed. A wide range of procedures, like major and minor lung resections, esophageal surgery, pleural and mediastinal one, was performed. The main aim of the study was evaluating general outcomes in terms of safety and effectiveness, and analyzing short-term results of U-VATS approach.

Results

The mean age of population was 59.93±16.03 years. In 208 cases (85.3%) a U-VATS lung resection was performed, in 10 cases (4.1%) an esophagectomy or an esophageal diverticulectomy, in 15 (6.1%) a mediastinal procedure and in 11 (4.5%) a toilette for pleural empyema or removal of pleural lesions. The chest tube duration was 4.24±3.73 days and the postoperative hospital stay was 4.62±4.59 days. The intraoperative and thirty-day mortality were null. Mean level of pain in I postoperative day was 2.30±1.26 on VAS scale and the mean duration was of 1.54±1.21 days. In 93% of cases there was a resolution of pain after chest tube removal. Furthermore, the average level of cosmetic satisfaction was 2.73±0.49 (measured on a 0-3 scale).

Conclusions

According to our experience, U-VATS seems to be a safe and practicable mini-invasive technique, above all for surgeons who already have thoracoscopy experience or made proper training attending multilevel courses, hands-on conferences and wet-labs.

[To Explore Clinical Value of Single-port Video-assisted Thoracoscopic Surgery in Elderly Patients with Non-small Cell Lung Cancer: Lobectomy, Segmentectomy and Lobectomy vs Segmentectomy]

背景与目的

肺癌的发病率长期位于癌症之首。Ⅰ期、Ⅱ期和部分Ⅲ期非小细胞肺癌(non-small cell lung cancer, NSCLC)的主要治疗方式以手术为主，肺叶切除术与肺段切除术为两类较为常见的手术方式。电视辅助胸腔镜手术(video-assisted thoracoscopic surgery, VATS)已广泛应用于临床，单孔电视辅助胸腔镜(single-port video-assisted thoracoscopic surgery, SP VATS)在胸部外科手术中的应用也逐渐被国内外专家所认识和接受。随着社会高龄化程度逐渐加深，这类患者成为NSCLC诊疗的难点。本研究探讨并分析SP VATS肺叶切除术与肺段切除术在治疗高龄NSCLC患者中的临床应用价值。

方法

回顾性分析福建医科大学附属协和医院胸外科在2014年5月-2016年12月期间行SP VATS肺叶切除与肺段切除的417例患者资料。其中高龄患者139例(肺叶切除124例vs肺段切除15例)，非高龄患者278例(肺叶切除248例vs肺段切除30例)。分别比较高龄与非高龄患者行SPVATS肺叶或肺段切除术及高龄患者行肺叶、肺段切除术的围手术期及术后短期恢复情况。

结果

SP VATS肺叶切除和肺段切除的比较组中，除在术前合并症患病率上，高龄患者均高于非高龄患者(P < 0.05)，在其余比较项上无明显差异(P > 0.05)。在单孔胸腔镜肺叶切除和肺段切除的高龄患者比较中，可发现淋巴结清扫站数[(7.61±0.21)组vs (5.60±0.35)组]及数目[(20.39±0.97)枚vs(15.40±2.64)枚]，差异有统计学意义(P < 0.05)，而在年龄、术前合并症患病率、平均手术时间、术中失血量却无统计学差异(P > 0.05)。虽然在术后并发症发生率上肺叶切除和肺段切除的高龄患者无统计学差异(P > 0.05)，但是在术后房颤和双下肢静脉血栓发生率上却存在明显差异(P < 0.05)。在术后住院时间[(3.18±1.32)天vs (5.04±1.30)天]、胸管放置时间[(7.00±1.31)天vs (5.00±0.74)天]及总住院费用[(70.06±5.23)千元vs (61.20±5.22)千元]上，差异无统计学意义(P > 0.05)。

结论

高龄患者由于合并更多基础疾病，可能增加术后并发症的风险，但单孔胸腔镜肺叶及肺段切除术并不增加高龄患者的手术相关风险，且对合适的高龄病例行肺段切除可获得与肺叶切除相类似的短期疗效。

Uniportal video-assisted thoracoscopic segmentectomy

Uniportal video-assisted thoracoscopic surgery (VATS) segmentectomy is a technically more complex procedure than uniportal VATS lobectomy, since a detailed comprehension of the segmental anatomy is required. Anatomic sublobar resection can achieve outcomes equivalent to lobectomy in selected patients with stage IA non-small cell lung carcinoma (NSCLC). In this paper we describe our clinical experiences and introduce the technical details of uniportal VATS segmentectomy, including expertise advice ("tips and tricks") in patient selection, positioning and incisions and technical highlights of the most common types of segmentectomies. Uniportal VATS segmentectomy is a demanding technique, safe and feasible in selected patients with good results in the literature that seems to be an acceptable alternative to conventional VATS or open thoracotomy when the surgeon completed the training period and learning curve.

The development of uniportal video-assisted thoracoscopic surgery in São Paulo: from diagnosis to lobectomy

BACKGROUND

The use of uniportal video-assisted thoracoscopic surgery (VATS) has been increasing worldwide. Our main goal was to describe the evolution of uniportal surgery in the biggest private hospital in Latin America that is located in São Paulo, Brazil.

METHODS

This descriptive and retrospective study included patients who underwent uniportal VATS in the thoracic surgical department of Beneficencia Portuguesa Hospital, after being referred to our team to undergo the aforementioned procedure within the period from February 2012 to March 2016. Postoperative management and results were analyzed.

RESULTS

In the thoracic surgical department of Beneficencia Portuguesa Hospital, 454 uniportal VATS surgeries were performed. Of the patients, 287 (65.52%) were male and 151 (34.48%) were female, with a mean age of 57.48±23.4 years. In December 2015, we initiated anatomical pulmonary resections (lobectomies and segmentectomies). In the cases of uniportal lobectomies for lung cancer in the initial staging, lymphadenectomy was performed in all the patients, of whom 59 (87%) had at least seven lymph nodes included in the dissection and confirmed in the pathological anatomy report. Four of the uniportal lobectomy cases were converted to thoracotomy because of bleeding. One patient needed blood transfusion and vasoactive drug administration in the intensive care unit (ICU), and seven patients required pleural procedures (thoracentesis or pigtail catheter) after drainage removal. No operative or perioperative mortality related to the procedure occurred. The main hospital stay was 7.4±4.3 days.

CONCLUSIONS

The uniportal thoracic procedures performed by our surgical team in São Paulo represent a breakthrough in the surgical treatment of thoracic pathologies in Southeast Brazil and can be offered as a safe and first-choice VATS procedure in our institution.

Uniportal video-assisted thoracoscopic surgery, Argentinian experience

The acceptance of uniportal video-assisted thoracoscopic surgery (VATS) for minor and major thoracic procedures is growing in South America. This study presents the experience with uniportal VATS in Buenos Aires, Argentina. In a retrospective study, 181 patients were operated with uniportal VATS technique between December 2013 and October 2016. Uniportal procedures included minor and major procedures. Uniportal VATS were analyzed en terms of morbidity, mortality, conversion rate, hospital stay. A total of 181 patients were analyzed. 59% were males and 41% females. The mean age was 58.7. The uniportal VATS procedures included pneumothorax 30, interstitial lung 5, complicated pleural effusion 35, pleurectomy biopsy pleurodesis 40, pericardial effusion 10, mediastinal tumor (posterior) 5, wedge resection 30, anatomical segment resection 6, and lobectomy 20. There were 2 conversions in major resection procedures due to technical difficulties. There was 1 revision for postoperative hemothorax. The mean hospital stay was 4.9 days for the whole group. Uniportal VATS is a safe technique in thoracic surgery. Maintains the oncological principles of traditional open procedures. There are lower, few general complications, lower pain level, lower postoperative morbidity and mortality. Reduces surgical trauma, and reduces the postoperative hospital stay.

Laser resection of pulmonary nodule via uniportal thoracoscopic surgery

Uniportal video-assisted thoracic surgery (VATS) lung wedge resection usually requires three devices, thoracoscope, lung retracting instrument and an endo-stapler cutter to perform the procedure. With advances in miniaturization of the thoracoscope and lung retracting instruments, a major limitation to operating through a smaller uniportal incision has become the endo-stapler. We describe the surgical technique for uniportal VATS laser lung resection which uses a much narrower laser catheter device to replace the endo-stapler for resection. The new approach to limited lung resection can potentially reduce instrument fencing and the uniportal incision wound size, while achieving satisfactory hemostasis and pneumostasis.

Multiportal video-assisted thoracic surgery, uniportal video-assisted thoracic surgery and minimally invasive open chest surgery-selection criteria

Thoracic surgery started the path to minimally invasive surgery over a hundred years ago, with the first thoracoscopic procedure performed by Jacobeus in 1910. Interestingly, these first procedures were performed using a single port approach and were used for diagnostic and minor procedures only. For a long period of time, the progress for minimally invasive thoracic surgery was considerably slow until the early 90s, when video assisted thoracic surgery started to be used for major pulmonary resections. Since then, video-assisted thoracic surgery (VATS) had a widespread use around the world and an ongoing search for a less invasive procedures evolved into uniportal VATS. Now, thoracic surgeons have a variety of choices for minimally invasive thoracic surgery and must be trained in these approaches to keep up with the evolution of the specialty and be up to date with the recommended treatments for diseases needing surgical intervention. The approach chosen by each surgeon is a matter of preference, while keeping in mind certain characteristics specific to the pathology and patient to be treated, the level of training of the surgeon, and the healthcare resources available. As more evidence is collected, the choice for video-assisted procedures, which have currently been proven safe, effective, less invasive and, in general, show good results, will prevail.

Uniportal video-assisted thoracic surgery: the Middle East experience

BACKGROUND

The application of uniportal video-assisted thoracic surgery (VATS) for both minor and major thoracic procedures is gaining widespread use across the globe. Believing its advantages, both in superb surgical results and less morbidity, our center has the privilege to be one of the first centers in the Middle East to introduce this surgical technique into our standard practice. This study presents our initial experience using this technique in 192 procedures and demonstrates the results of postoperative pain level in a sample of 90 patients.

METHODS

In a retrospective study of prospectively collected data, 192 uniportal VATS procedures were analyzed between November 2013 and June 2016. The level of early post-operative pain (postoperative days 1-4) was analyzed in the first 90 cases between November 2013 and March 2015. Uniportal technique was used for a wide array of procedures: blebectomies, pleurectomies, wedge resections, anatomical major lung resections, mediastinal tumors, empyema drainage and decortications.

RESULTS

The mean age of patients was 49.6 years, and 72 patients were females (37%). Thirty-five (18.2%) patients underwent anatomical resections with conversion to thoracotomy in three patients (8%). Six (3%) patients had air leak >4 days. The average chest drain duration was 3.25 days. The average length of stay was 4.2 days. Postoperative pain level was low in the first 4 days following the surgery and 30 days mortality was 0%.

CONCLUSIONS

Uniportal VATS surgery is a safe and established technique with a minimal invasive thoracic surgery. Excellent results with minimal morbidity, short hospital stay and low postoperative pain are amongst its strong points. Thoracic surgeons experienced in thoracic surgical approaches can safely perform uniportal VATS.

A Matched Comparison Study of Uniportal Versus Triportal Thoracoscopic Lobectomy and Sublobectomy for Early-stage Nonsmall Cell Lung Cancer

Background:

Both uniportal and triportal thoracoscopic lobectomy and sublobectomy are feasible for early-stage non-small cell lung cancer (NSCLC). The aim of this study was to compare the perioperative outcomes of uniportal and triportal thoracoscopic lobectomy and sublobectomy for early-stage NSCLC.

Methods:

A total of 405 patients with lung lesions underwent thoracoscopic lobectomy or sublobectomy through a uniportal or triportal procedure in approximately 7-month period (From November 2014 to May 2015). A propensity-matched analysis, incorporating preoperative variables, was used to compare the short-term outcomes of patients who received uniportal or triportal thoracoscopic lobectomy and sublobectomy.

Results:

Fifty-eight patients underwent uniportal and 347 patients underwent triportal pulmonary resection. The conversion rate for uniportal and triportal procedure was 3.4% (2/58) and 2.3% (8/347), respectively. The complication rate for uniportal and triportal procedure was 10.3% and 9.5%, respectively. There was no perioperative death in either group. Most patients had early-stage NSCLC in both groups (uniportal: 45/47, 96%; triportal: 313/343, 91%). Propensity score-matching analysis demonstrated no significant differences in operation time, intraoperative blood loss, numbers of dissected lymph nodes, number of stations of lymph node dissected, duration of chest tube, and complication rate between uniportal and triportal group for early-stage NSCLC. However, the duration of postoperative hospitalization was longer in the uniportal group (6.83 ± 4.17 vs. 5.42 ± 1.86 d, P = 0.036) compared with the triportal group.

Conclusions:

Uniportal thoracoscopic lobectomy and sublobectomy is safe and feasible, with comparable short-term outcomes with triportal thoracoscopic pulmonary resection. Uniportal lobectomy and sublobectomy lead to similar cure rate as triportal lobectomy and sublobectomy for early NSCLC.

Image-guided techniques for localizing pulmonary nodules in thoracoscopic surgery

Low-dose computed tomography (LDCT) screening has increased the detection rate for small pulmonary nodules with ground-glass opacity (GGO) in the peripheral lung parenchyma. Minimally invasive thoracoscopic surgery for these lung nodules is challenging for thoracic surgeons, and image-guided preoperative localization is mandatory for their successful resection. Image-guided localization methods primarily include two imaging tools: computed tomography (CT) and bronchoscopy. These different methods may use different localized materials, including hookwires, dyes, microcoils, fiducial markers, contrast media, and radiotracers. Ultrasonography and near-infrared imaging are also used for intraoperative localization of lung lesions. In this article, we review different localization techniques and discuss their indications and limitations.

Recent clinical innovations in thoracic surgery in Hong Kong

The concept of personalized medicine, which aims to provide patients with targeted therapies while greatly reducing surgical trauma, is gaining popularity among Asian clinicians. Single port video-assisted thoracic surgery (VATS) has rapidly gained popularity in Hong Kong for major lung resections, despite bringing new challenges such as interference between surgical instruments and insertion of the optical source through a single incision. Novel types of endocutters and thoracoscopes can help reduce the difficulties commonly encountered during single-port VATS. Our region has been the testing ground and has led the development of many of these innovations. Performing VATS, in particular single-port VATS in hybrid operating theatre helps to localise small pulmonary lesions with real-time images, thus increasing surgical accuracy and pushes the boundaries in treating subcentimeter diseases. Such approach may be assisted by use of electromagnetic navigational bronchoscopy in the same setting. In addition, sublobar resection can also be more individualised according to pathologic tumour subtype that require rapid intraoperative diagnostic test to guide appropriate surgical therapy. A focus on technology and innovation for large tumours that require chest wall resection and reconstructions have also been on going, with new materials and prostheses that may be tailored to each individual needs. The current paper reviews the literature pertaining to the above topics and discusses recent related innovations in Hong Kong, highlighting the study results and future perspectives.

Modular 3-cm uniportal video-assisted thoracoscopic left upper lobectomy with systemic lymphadenectomy

Uniportal video-assisted thoracoscopic lobectomy for non-small-cell lung cancer is accepted worldwide, with incisions ranging from 4 to 6 cm. We believed in less invasive and more precise that uniportal video-assisted thoracoscopic lobectomy could be. Therefore, we performed modular uniportal thoracoscopic lobectomy with systemic lymphadenectomy on left upper lobe using a 3-cm-diameter port. And the modular surgical route was arranged in seven modules. Anesthesia, patient positioning and instruments play an important role in the surgery. From October 2014 to June 2015, 96 patients underwent this modular surgery and all patient were discharged uneventfully with no postoperative deaths. Compared with multi-port VATS, the operation time were longer than multiport video-assisted thoracoscopic surgery (VATS) (164.70±12.50 vs. 160.70±11.60 min, P>0.05), and the mean lymphadenectomy station was 6.00±0.77, and the mean lymphadenectomy number was 17.58±5.33. There is no significant difference on lymphadenectomy. Thus, modular uniportal video-assisted thoracoscopic lobectomy with systemic lymphadenectomy on left upper lobe using a 3-cm-diameter port is a safe, feasible, and less painful technique for select patients with lung disease.

Learning curve and subxiphoid lung resections most common technical issues

BACKGROUND

Subxiphoid uniportal video-assisted thoracic surgery (SVATS) for major lung resections is a new approach. Clinical evidence is lacking. The aim of this article is to describe the learning curve of the 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision, and with the lessons learned from this early experience in SVATS and from the experience with transthoracic uniportal VATS we sought to compile "tips and tricks" for managing the multiple intraoperative technical difficulties that can arise during the SVATS and help to set the recommendations for a SVATS program.

METHODS

We describe the learning curve of the first 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision From September 2014 with early-stage non-small cell lung carcinoma (NSCLC) and benign disease. We examine the rate of conversion and the operating time comparing group one (first 100 cases) with group two (subsequent 100 cases).

RESULTS

Of the 200 consecutive selected cases (72 males, 128 females) with a mean age of 57.4±9 years, underwent either uniportal subxiphoid lobectomy or segmentectomy 136 were lobectomies and 64 were segmental resections The mean operating time was 170±45 mins; the average and after the case 86 the rate of the operating time appears to be similar. The conversion rate decrease from 13% in group one to 8% in group two.

CONCLUSIONS

There is a gradual reduction in the operating time and rate conversion with increasing experience. Lessons from our initial experience in the learning curve period in SVATS helps to create this trouble shooting guide that offers "tips and tricks" to both avoid and manage numerous intra-operative technical difficulties that commonly arise during the SVATS initial experience.

Recent developments in video-assisted thoracoscopic surgery for pulmonary nodule management

In the modern era when screening and early surveillance of pulmonary nodules is increasing in importance, the management of the pulmonary nodule represents a different challenge to thoracic surgeons. The difficulty lies in the merging of sound surgical and oncological principles with more minimally invasive and appropriate lung sparing surgery. Furthermore, the intra-operative identification and surgical management of small and sometimes multi-focal pulmonary lesions remain challenging. There have been many developments and innovations in the field of video-assisted thoracoscopic surgery (VATS) to cater for the demands from increasing incidence of pulmonary nodules with associated paradigm shift in their surgical management. Recently, uniportal VATS and non-intubated VATS represent an even less invasive alternative to the conventional multiport VATS. The emergence of image guided VATS, hybrid operating theatre and fluorescence thoracoscopy have all contributed to improved precision of VATS lung resection, and are becoming important adjuncts to lung sparing surgery. In this chapter, some of these recent developments in VATS with emphasize on their importance in surgical management of the pulmonary nodule will be discussed.

Uniportal video-assisted thoracoscopic surgery: safety, efficacy and learning curve during the first 250 cases in Quebec, Canada

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) using a single incision (uniportal) may result in better pain control, earlier mobilization and shorter hospital stays. Here, we review the safety and efficiency of our initial experience with uniportal VATS and evaluate our learning curve.

METHODS

We conducted a retrospective review of uniportal VATS using a prospectively maintained departmental database and analyzed patients who had undergone a lung anatomic resection separately from patients who underwent other resections. To assess the learning curve, we compared the first 10 months of the study period with the second 10 months.

RESULTS

From January 2014 to August 2015, 250 patients underwent intended uniportal VATS, including 180 lung anatomic resections (72%) and 70 other resections (28%). Lung anatomic resection was successfully completed using uniportal VATS in 153 patients (85%), which comprised all the anatomic segmentectomies (29 patients), 80% (4 of 5) of the pneumonectomies and 82% (120 of 146) of the lobectomies attempted. The majority of lung anatomic resections that required conversion to thoracotomy occurred in the first half of our study period. Seventy patients underwent other uniportal VATS resections. Wedge resections were the most common of these procedures (25 patients, 35.7%). Although 24 of the 70 patients (34%) required the placement of additional ports, none required conversion to thoracotomy.

CONCLUSIONS

Uniportal VATS was safe and feasible for both standard and complex pulmonary resections. However, when used for pulmonary anatomic resections, uniportal VATS entails a steep learning curve.

The evolution of uniportal video assisted thoracic surgery in Costa Rica

Video-assisted thoracic surgery (VATS) has become one of the most important advances in thoracic surgery in this generation. It has evolved continuously into a less invasive approach, being uniportal VATS the last step in this evolution. Since the first uniportal VATS lobectomy was performed in La Coruña in 2010, the procedure has suffered and exponential growth that has allowed it to widespread around the world, expanding the indications from initially early stage lung cancer cases to complex advance cases nowadays. In Costa Rica, uniportal VATS started to be used for major pulmonary resection in June 2014, thanks to the tutoring from Dr. Gonzalez-Rivas. In our center, uniportal VATS is the standard approach for minimally invasive procedures, and major pulmonary resections had only been done through the single port approach. In order to evolve and progress in the experience of the procedure, and to expand the indications in which it was being performed, a "uniportal VATS master class" was held in Rafael Angel Calderón Guardia Hospital in San José, Costa Rica, from September 16 to September 18 2015. The master class was led by Dr. Diego Gonzalez-Rivas and it counted with the contribution of Dr. Li Wentao and Dr. Yang Yang, from Shanghai Pulmonary Hospital. The course attracted almost every thoracic surgeon in our country and participants also included anesthesiologists, pulmonologists, nurses and medical students. Three uniportal VATS were performed during the course, a left lower and a right upper lobectomy and a wedge resection that was the first non-intubated VATS procedure ever performed in our country.

Hybrid theatre and alternative localization techniques in conventional and single-port video-assisted thoracoscopic surgery

Management of pulmonary nodules in terms of diagnosis and intraoperative localization can be challenging, especially in the minimal invasive video-assisted thoracoscopic surgery (VATS) approach, and may be even more difficult with single port VATS with limited access. The ability to localize small lesions intraoperatively is particularly important for excisional biopsy for diagnostic frozen section, as well as to guide sublobar resection. Some of the common techniques to aid localization include preoperative percutaneous hookwire localization, colour dye or radio-dye labelling injection of the nodule or adjacent site to allowing visualization or detection by radioactive counter intraoperatively. The use of hybrid operating room (OR) for intraoperative localization of lung nodules was first reported in 2013, and was called image guided VATS (iVATS). Subsequently, we have expanded the iVATS application for single port VATS major lung resection of small or ground-glass opacity lesions. By performing an on-table cone-beam CT scan, real-time and accurate assessment of the pulmonary lesion can be made, which can aid the localization process. Other types of physical or colour marker that can be deployed percutaneously in the hybrid OR immediate before surgery can enhance haptic feedback and sensitivity of digital palpation, as well as provide a radiopaque nidus for radiological confirmation. In the past decade, the electromagnetic navigation bronchoscopy (ENB) technology had developed into a useful adjunct technology for the localization of peripheral lung nodules by injection of marking agent or deployment of fiducial to the lesion through the endobronchial route causing much lower marking agent diffusion and artefacts. Recently, the combination of hybrid OR and ENB for lung nodule localization and marking has further increased the accuracy and applicability of the technology. The article will be exploring the latest development of the above approaches to lung nodule localization, and discuss some of the techniques' advantages and flaws.

Single port VATS: recent developments in Asia

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

Single-port video-assisted thoracic surgery for early lung cancer: initial experience in Japan

BACKGROUND

Single-port video-assisted thoracic surgery (SPVATS) emerged several years ago as a new, minimally invasive surgery for diseases in the field of respiratory surgery, and is increasingly becoming a subject of interest for some thoracic surgeons in Europe and Asia. However, the adoption rate of this procedure in the United States and Japan remains low. We herein reviewed our experience of SPVATS for early lung cancer in our center, and evaluated the safety and minimal invasiveness of this technique.

METHODS

We retrospectively analyzed patients who had undergone SPVATS for pathological stage I lung cancer in Nippon Medical School Chiba Hokusoh Hospital between September 2012 and October 2015. In SPVATS, an approximately 4-cm incision was made at the 4(th) or 5(th) intercostal space between the anterior and posterior axillary lines. A rib spreader was not used at the incision site, and surgical manipulation was performed very carefully in order to avoid contact between surgical instruments and the intercostal nerves. The same surgeon performed surgery on all patients, and analyzed laboratory data before and after surgery.

RESULTS

Eighty-four patients underwent anatomical lung resection for postoperative pathological stage I lung cancer. The mean wound length was 4.2 cm. Eighty-four patients underwent lobectomy and segmentectomy, respectively. The mean preoperative forced expiratory volume in 1 second (FEV1%) was 1.85%±0.36%. Our patients consisted of 49 men (58.3%) and 35 women (41.7%), with 64, 18, 1, and 1 having adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma, and small-cell lung cancer, respectively. The mean operative time was 175±21 min, operative blood loss 92±18 mL, and duration of drain placement 1.9±0.6 days. The duration of the postoperative hospital stay was 7.1±1.7 days, numeric rating scale (NRS) 1 week after surgery 2.8±0.6, and occurrence rate of allodynia 1 month after surgery 10.7%. No patient developed serious complications, and no deaths occurred within 30 days of surgery. Two patients (2.4%) were converted to open thoracotomy.

CONCLUSIONS

SPVATS is a safe and feasible technique, and is promising for next-generation thoracoscopic surgery. It may also reduce postoperative wound pain and contribute to improvements in the activities of daily living of patients.

[Place of thoracoscopy in the treatment of chest diseases: report of 104 cases]

Introduction

La thoracoscopie est l'exploration endoscopique de la cavité pleurale, des organes avoisinants (diaphragme, péricarde, médiastin) et du poumon. Le but de ce travail se veut d'abord didactique; décrivant la thoracoscopie, ses techniques ainsi que sa place dans la prise en charge de la pathologie thoracique (indications et perspectives thérapeutiques) et informatif en rapportant l'expérience de notre équipe.

Méthodes

Il s'agit d'une étude rétrospective intéressant 104 thoracoscopies à visée diagnostique et/ou thérapeutique réalisées au service de chirurgie thoracique du Centre Hospitalier Universitaire Hassan II de Fès, sur une période de 04 ans (Août 2008-décembre 2012). Nous avons exclu de notre étude les cas ayant bénéficié d'une médiastinoscopie ainsi que les cas ayant bénéficié d'une thoracoscopie dans le cadre des traumatismes fermés du thorax ou des plaies thoraciques.

Résultats

L’ âge moyen des patients est de 47 ans, avec des extrêmes allant de 18 à 80 ans, et une légère prédominance masculine à 54%. La thoracoscopie est d'ordre pleural chez 86 patients, pulmonaire chez 10 patients et médiastinale chez 8 patients. La thoracoscopie avait une indication à visée diagnostique chez 87 cas et thérapeutique chez 52 patients (talcage dans 45 cas, décortication pleuropulmonaire dans 2 cas, résection de kystepleuro-péricardique dans 2 cas, cure de pneumothorax dans 2 cas et une fenêtre péricardique). L’évolution post opératoire etait marquée par une amélioration clinico-radiologique chez 40 malades, 11 ont présenté une amélioration clinique seule, 6 ont présenté une persistance ou une récidive de l’épanchement.

Conclusion

La thoracoscopie représente un réel gain en matière de diagnostic de certaines pathologies intra-thoraciques. Son intérêt thérapeutique limité doit être éventuellement étendu grâce à la chirurgie thoracique vidéo assistée, qui est une technique récente fiable avec une limitation de la durée d'hospitalisation et de la morbidité.

Thoracic surgery: single-port video-assisted thoracoscopic lobectomy

Single-port video-assisted thoracoscopic surgery (VATS) has been increasingly applied in clinical settings in the past two years along with the improvements in both endoscopic instruments and surgical skills. Our center began to perform single-port VATS lobectomy in May 2014 and had performed this procedure in 121 patients till January 2015. The surgical incision (3.5-4.5 cm in length) was created in the 4(th) or 5(th) intercostal space at the anterior axillary line at the diseased side. The operator standed at the abdominal side of the patient and operated using the endoscopic instruments only. The surgical steps of single-port VATS lobectomy were same as those of the triple-port VATS lobectomy. There was no fixed mode in handling the three major structures of the pulmonary lobes, and the resection sequence can be scheduled based on the development status of pulmonary fissures and on the difficulties in dissecting the relevant structures. We believe the single-port VATS lobectomy is a safe and feasible procedure and warrants further clinical applications after finishing these surgeries.

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

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

Subxiphoid single-incision thoracoscopic surgery for bilateral primary spontaneous pneumothorax

It has been reported that single-incision thoracoscopic surgery can reduce postoperative pain without compromising the main surgical steps required for treating patients affected by primary spontaneous pneumothorax. However, all the reported thoracoscopic surgery cases with a single-incision procedure were via the intercostal route for unilateral pulmonary lesions. We present a novel single-incision thoracoscopic technique via a subxiphoid route to perform one-stage bilateral thoracoscopic surgery for bilateral spontaneous pneumothorax. Reduced postoperative pain, shorter operative time, and better cosmetic results are potential benefits of this technique in selected patients. The subxiphoid single-incision procedure may be indicated in patients with bilateral pulmonary lesions requiring surgical resections.

Uniportal video-assisted thoracoscopic lobectomy in the animal model

We introduce the training on uniportal video-assisted thoracoscopic (VATS) lobectomy in sheep. This animal model is helpful to learn the different view, the importance of lung exposure and the key points of the instrumentation. In this article we present three videos with the left upper lobectomy, the left lower lobectomy and the right upper lobectomy in the sheep.

Uniportal VATS: the first German experience

BACKGROUND

The acceptance of uniportal video-assisted thoracic surgery (VATS) for minor and major thoracic procedures is growing in Europe. This study presents the first experience with uniportal VATS in Germany.

METHODS

In a retrospective study of prospectively collected data, 56 uniportal VATS were analyzed between 06/2012 and 06/2014. The technique was used for diagnostic aims, pleurectomies, wedge resections, segmentectomies and major resections. All procedures were performed without rib spreading. Patients' demographic data, preoperative and postoperative management as well as results were analyzed.

RESULTS

A total of 42 patients (75%) were males. The mean age was 59.2±15 years. The uniportal VATS procedures included one or multiple wedge resections in 30 cases (53.6%), major resections in 9 cases (16.1%), anatomical segment resections in 6 cases (10.7%) and other indications in 11 cases (19.6%). The median operation time was 252, 114, 88 and 73 minutes for major resections, anatomical segment resections, wedge resections and other indications, respectively. There were three conversions in two cases of major resections and in one anatomical segmentectomy. The mean chest tube duration was 3.4±2.1 days. The mean hospital stay was 8.3±5.3 days for the whole group.

CONCLUSIONS

Uniportal VATS is a feasible and safe technique for various indications in thoracic surgery. The perioperative results are promising. It can be performed by thoracic surgeons experienced in the postero-lateral thoracotomy approach.

Single-port thoracic surgery: a new direction

Single-port video-assisted thoracic surgery (VATS) has slowly established itself as an alternate surgical approach for the treatment of an increasingly wide range of thoracic conditions. The potential benefits of fewer surgical incisions, better cosmesis, and less postoperative pain and paraesthesia have led to the technique’s popularity worldwide. The limited single small incision through which the surgeon has to operate poses challenges that are slowly being addressed by improvements in instrument design. Of note, instruments and video-camera systems that are narrower and angulated have made single-port VATS major lung resection easier to perform and learn. In the future, we may see the development of subcostal or embryonic natural orifice translumenal endoscopic surgery access, evolution in anaesthesia strategies, and cross-discipline imaging-assisted lesion localization for single-port VATS procedures.

Uniportal complete video-assisted thoracoscopic lobectomy with systematic lymphadenectomy

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

Single-port video-assisted thoracoscopic surgery for lung cancer

In 2004, novel results using pulmonary wedge resection executed through single-port video-assisted thoracoscopic surgery (VATS) was first described. Since that time, single-port VATS has been advocated for the treatment of a spectrum of thoracic diseases, especially lung cancer. Lung cancer remains one of the top three cancer-related deaths in Taiwan, and surgical resection remains the "gold standard" for early-stage lung cancer. Anatomical resections (including pneumonectomy, lobectomy, and segmentectomy) remain the primary types of lung cancer surgery, regardless of whether conventional open thoracotomy, or 4/3/2-ports VATS are used. In the past three years, several pioneers have reported their early experiences with single-port VATS lobectomy, segmentectomy, and pneumonectomy for lung cancer. Our goal was to appraise their findings and review the role of single-port VATS in the treatment of lung cancer. In addition, the current concept of mini-invasive surgery involves not only smaller resections (requiring only a few incisions), but also sub-lobar resection as segmentectomy. Therefore, our review will also address these issues.