Uniportal video-assisted thoracoscopic anatomic segmentectomy

Uniportal vs. multiportal thoracoscopic segmentectomy: a north American study

Background

Uniportal video-assisted thoracoscopic surgery (VATS) segmentectomy is gaining worldwide acceptance, but experience in North America is still limited. We report a North American multicenter comparison of uniportal vs. multiportal VATS segmentectomy.

Methods

We performed an institutional review board-exempt retrospective chart review on prospectively collected databases at two North American centers, from January 2012 to December 2020. We included all VATS segmentectomy patients and excluded emergent cases (n=1), patients with incomplete records (n=2), and segmentectomy performed in conjunction with another type of lung resection (n=1). We recorded patient demographics, perioperative data, 30-day postoperative complications and compared outcomes between cohorts. We provided descriptive statistics for each group. We calculated propensity score matching and paired patients 1:1. We defined P values less than 0.05 as statistically significant.

Results

We performed a total of 423 VATS segmentectomies, 181 uniportal (42.7%) vs. 242 multiportal (57.2%). Indications for surgery were primary lung cancer (n=339), metastatic (n=41), benign disease (n=40), and other (n=3). We staged 85.1% of patients preoperatively with positron emission tomography-computed tomography (PET-CT) scan according to National Comprehensive Cancer Network (NCCN) guidelines. Propensity score matching generated 156 patients on each group. Operating time was significantly lower in the uniportal group compared to multiportal (130 vs. 161 min respectively, P<0.001). We found no difference in estimated blood loss, Clavien-Dindo class III-IV complications, conversion to thoracotomy, R0 resection rate, nodal upstaging, hospital length of stay, 30-day readmission or mortality.

Conclusions

Our experience from two North American centers indicates that, in experienced hands, postoperative outcomes after uniportal and multiportal VATS segmentectomy are comparable.

The three steps method for uniportal video-assisted thoracoscopic right upper lobectomy

BACKGROUND

The uniportal video-assisted thoracoscopic right upper lobectomy (UVATRUL), as a common procedure for thoracic surgeons, is difficult to manipulate and has some inherent challenges. To solve both of problems, we summarized a series of techniques as the three steps method and investigated its feasibility on the patients of right upper lung cancer.

METHODS

Forty-eight patients with right upper lobe lung cancer who underwent the three steps method UVATRUL in our hospital from January 2020 to May 2022 were selected as the three steps method group. Forty-seven patients who underwent the traditional UVATRUL were selected as the traditional method group. The intraoperative condition and postoperative condition of the two groups were retrospectively analysed. Multiple linear regression analysis was carried out to analyze the relationship between positive results and surgical method.

RESULTS

All patients had successfully completed their surgeries. There was no significant difference between the two groups in respect of intraoperative blood loss, rate of conversion, day one thoracic drainage volume, chest tube indwelling time, incidence of postoperative complications, number of lymph node, and postoperative hospital stay (P > 0.05). Operative time of the three steps method group was significantly shorter than the traditional method group (P < 0.001), and number of reloads used was also significantly less than the traditional method group (P = 0.014). Multiple linear regression analysis showed that operative time (β = - 0.470, P < 0.001), and number of reloads (β = - 0.254, P = 0.007) correlated with surgical method.

CONCLUSION

Compared with the traditional UVATRUL, the three steps method trims the surgery procedures, shortens the operative time, and reduces the use of reloads which makes it an effective procedure for UVATRUL.

Anatomical segmentectomy under uniportal video-assisted thoracoscopic surgery for early staged non-small cell lung cancer: a case report

Background

Anatomical segmentectomy has become more and more universal in thoracic surgery because of the increasing detection of pulmonary nodules with ground-glass opacity (GGO), most of which proved early staged non-small cell lung cancer (NSCLC) postoperative. With the advantage of preservation of normal lung tissues, segmentectomy may be performed by surgeons when computed tomography (CT) scan shows pure GGO or multiple GGOs appearing. Especially when the patients with poor cardiopulmonary function or severe comorbidities or in the circumstance of bilateral pulmonary GGOs, segmentectomy can provide opportunities to radically resect all lesions. With the development of minimally invasive surgery technology, uniportal video-assisted thoracoscopic surgery (VATS) has become the regular operative route in many medical centers because it can provide less access trauma, less stress response, less pain, shorter hospital stays, and a lower postoperative complication rate and corresponds well with the idea of "minimally invasive". However, all of the procedures must be performed in one tiny portal, so uniportal VATS anatomical segmentectomy not only needs the skill and patience of surgeons but the effective cooperation of assistants, nurses and anesthetists, and plenty of details must be paid special attention.

Case Description

Here we present a video of a patient undergoing S¹ segmentectomy of right upper lobectomy (RUL) under uniportal VATS. The chief complaints of the patients was that two pure GGOs in the bilateral upper lobe were found by physical examination for 26 months and he had no symptoms. We performed S¹ segmentectomy of RUL under uniportal first time and performed trisegmentectomy of left upper lobectomy (LUL) 3 months later. With routinely follow-up, no evidence of relapse and metastasis disease was found.

Conclusions

We think anatomical segmentectomy under uniportal VATS can be a feasible and safe procedure that reduces trauma and has equivalent oncology outcomes to lobectomy in early-stage lung cancer but need a more experienced medical center to perform.

Keywords

Uniportal video-assisted thoracoscopic surgery (uniportal VATS); segmentectomy; non-small cell lung cancer (NSCLC); case report.

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Subxiphoid uniportal thoracoscopic pulmonary segmentectomy for stage I non-small cell lung cancer: Feasibility, quality of life and financial worthiness

Background

Subxiphoid uniportal video‐assisted thoracoscopic surgery (SVATS) is more technically challenging than intercostal uniportal video‐assisted thoracoscopic surgery (UVATS), especially in more complex procedures such as segmentectomy. We therefore aimed to investigate the worthiness of undertaking the more demanding subxiphoid approach in patients who had undergone anatomical segmentectomy for stage IA non‐small cell lung cancer (NSCLC).

Methods

A total of 491 patients were included in our study who had undergone anatomical segmentectomy for stage IA non‐small cell lung cancer from September 2014 to April 2018. They were divided into two groups; 278 patients in the UVATS group and 213 patients in the SVATS group. Different perioperative variables, postoperative pain, quality of life and cost were analyzed and compared between both groups.

Results

The SVATS group showed a significantly longer operative time (P = 0.007) and more operative blood loss than the intercostal group (P = 0.004). There was no significant difference between both groups regarding postoperative drainage, duration of chest tube, postoperative hospital stay, operative conversion or postoperative complications. The SVATS group showed a significantly lower pain score postoperatively (P < 0.001). In addition, the SVATS group showed a significantly better postoperative quality of life score along the first postoperative year (P < 0.001). UVATS segmentectomy appeared to be significantly cheaper than SVATS segmentectomy (P < 0.001).

Conclusions

SVATS segmentectomy for stage IA lung cancer is a safe procedure that is worth proceeding with as it is associated with better postoperative pain and better quality of life in the first postoperative year. Further studies are recommended to evaluate the actual cost‐effectiveness of SVATS segmentectomy.

Key points

• Significant findings of the study

Subxiphoid uniportal approach for pulmonary segmentectomy is safe and feasible approach. It has better postoperative pain and better quality of life than the uniportal intercostal approach; however, it is more expensive.

• What this study adds

Subxiphoid uniportal approach for pulmonary segmentectomy gives a better quality of life in Chinese patients than the intercostal approach; however, it is more expensive.

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.

Uniportal video-assisted thoracoscopic S8 segmentectomy and S1a subsegmentectomy for synchronous multiple primary lung cancers

With the increasing incidence of synchronous multiple primary lung cancers (SMPLC), difficulties in diagnosis and decision making for treating patients with SMPLC can result in clinical dilemmas for clinicians. To simplify the diagnostic and treatment course, the less-invasive technique of video-assisted thoracic surgery (VATS) segmentectomy and subsegmentectomy can be selected preferentially. However, segmentectomy and subsegmentectomy are technically more sophisticated compared to lobectomy, and they involve the identification of the nodule locations, confirmation of the targeted structures and ensuring the surgical margin. Here, we describe the performance of uniportal VATS segmentectomy and subsegmentectomy technique in a patient with SMPLC in the right upper lobe with the assistance of three-dimensional (3D) navigation. We detected the intersegmental planes using infrared thoracoscopy with an intravenous injection of indocyanine green (ICG). The patient was discharged with no complication. We think that uniportal VATS segmentectomy is a feasible alternative and technically safe for treating patients with SMPLC.

Situs inversus uniportal video-assisted thoracoscopic right anatomic segmentectomy S1-S2 and S6

Situs inversus totalis (SIT) is an extremely rare condition where the major organs are reversed or mirrored from their usual positions. There are few reports in the literature describing thoracoscopic major surgery in patients with this unusual anomaly. Here we report a 48-year old female with two small early stage lung cancer lesions located in the apicoposterior segment of the right upper lobe and in the dorsal segment of the right lower lobe. The patient underwent a uniportal approach through a 3 cm incision and combined anatomic segmentectomies in the upper and lower lobes. The postoperative course was uneventful. This is the first report of an anatomic segmentectomy in a patient with a situs inversus condition.

[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。

First International Symposium, Uniportal VATS-International Course Uniportal VATS, Buenos Aires, Argentina

This is a report of the first three days Uniportal VATS International Meeting. The conference included oral presentations at the Universidad Catolica Argentina (UCA), on the first day. Live Surgery from Shanghai Pulmonary Hospital, Tongji University, China, and Clinica San Camilo. Bs As, Argentina on the second day and a Wet lab in Fundación Triada Mininvasiva, Fatima Pilar on the final day.

Physiopathology aspects of anatomical video-assisted thoracic surgery resections: current status and prospects of development

Pulmonary lobectomy remains the gold standard therapy for early-stage lung cancer. With the spread of video-assisted thoracic surgery (VATS), surgeons began using this approach also to perform lobectomies, becoming progressively widespread worldwide. However some early-stage lung cancer patients are of questionable eligibility for open lobectomy being considered at high-risk to develop postoperative complications due to compromised pulmonary function or cardiopulmonary reserve. Herein we evaluate pathophysiology of VATS, focusing on: the correlation between the traditional predictors of outcome and overall complications, the current status of different VATS approaches and the role of VATS segmentectomy in high-risk patients, unable to tolerate lobectomy for their compromised cardiopulmonary reserve.

Uniportal lobectomy and segmentectomy-is it for all?

Technological advances have markedly transformed the philosophy of thoracic surgery in the current era, with notable improvements in patient outcomes with video-assisted thoracoscopic surgery (VATS). More recently, innovations in uniportal VATS approaches have been promising, although robust data on their efficacy is limited. Nonetheless, the lessons learned from experience with the 2-port and 3-port VATS lobectomy and segmentectomy can be applied to further improve the efficacy of uniportal approaches, in terms of achieving oncologic efficacy and improving patient outcomes. This perspective reviews contemporary outcomes of uniportal lobectomy and segmentectomy, highlights our institutional experience, and examines future directions and challenges pertaining to widespread adoption of this innovative technique.

Evaluation of surgical approaches to anatomical segmentectomies: the transition to minimal invasive surgery improves hospital outcomes

Background

We aim to evaluate the transition process from open to video-assisted thoracoscopic surgery (VATS) anatomical segmentectomies in a regional thoracic surgical unit.

Methods

In a retrospective study from January 2013 to December 2015, we identified all anatomical segmentectomies performed in our unit. Pre, peri and postoperative data were compared between the three years (2013, 2014 and 2015) and according to operative approach. Thoracotomy after VATS intraoperative biopsy was considered a conversion for the purposes of the study.

Results

A total of 86 consecutive cases [56 females and 30 males, median age 70 years (range, 43 to 83 years); median FEV1 of 78% predicted (range, 41% to 126%)] were included. There was a significant change in the surgical approach with time. Fifty-two cases underwent VATS (73% via single-port) and 34 open surgeries, including nine conversions. There were no postoperative deaths in the VATS group and one in the open group. Operative outcomes were similar over time with no haemorrhagic events, equivalent R1 resection and nodal stations explored in all lymph node positive patients. In node negative cases however, open surgery was associated with more extensive mediastinal exploration. Patients in 2015 had a shorter hospital stay in comparison to those in previous years [median 4 days (range, 1-15 days) vs. median 6 days (range, 3-27 days), P=0.01]. There were no differences in the incidence of complications or readmissions to hospital over time.

Conclusions

The transition over a short period of time from open to single-port VATS segmentectomy has allowed us to significantly reduce postoperative hospital stay without compromising operative or postoperative outcomes.

VATS segmentectomy: past, present, and future

Video-assisted thoracoscopic surgery (VATS) has gradually been implemented in thoracic surgery, and the VATS approach has now been extended to technically challenging procedures, such as segmentectomy. The definition of VATS segmentectomy is changing over time, and the repertoire of segmentectomy is getting wider with increasing reports on atypical segmentectomy. VATS segmentectomy bears surgical, oncological, and technical advantages; however, there are still areas of controversy, particularly regarding oncological outcomes. The indication of VATS segmentectomy is diverse and is used for treating lung cancer, metastatic lung tumors, or a variety of nonmalignant diseases. It is particularly valuable for the lung-sparing resection of deeply located small nodules or repeated surgery for multiple lung lesions. VATS segmentectomy requires a thorough analysis of segmental anatomy and a tailored preoperative planning with the assessment of surgical margins. Technical challenges include intraoperative navigation, methods to identify and dissect the intersegmental plane, and the prevention of air leakage. This review will discuss the present state of VATS segmentectomy, with a focus on past studies, current indications and techniques, and future view.

Needlescopic-assisted uniportal video-assisted thoracoscopic pulmonary anatomical segmentectomy

BACKGROUND

Pulmonary segmentectomy can be an oncologic equivalent of lobectomy for small non-small cell lung cancer. Uniportal video-assisted thoracoscopic surgery (VATS) has recently showed favorable surgical outcomes, but remains technical demanding, especially in a complex procedure like anatomic segmentectomy. This manuscript demonstrates the surgical techniques for uniportal VATS segmentectomies with the assistance of additional needlescopic instruments.

METHODS

Data of 22 consecutive patients who underwent 24 needlescopic-assisted uniportal VATS segmentectomies between December 2016 and June 2017 was analyzed.

RESULTS

There were 12 uni-segmentectomies, 10 bi-segmentectomies, and 2 tri-segmentectomies. The mean operation time was 178.3 minutes. The mean duration of chest tube drainage was 5.2 days, and the mean duration of hospital stay was 7.4 days. There were two episodes of major bleeding and one case that required conversion to lobectomy.

CONCLUSIONS

Under the assistance of additional needlescopic instruments, segmentectomy can be performed more easily and safely with uniportal VATS.

Anatomic thoracoscopic segmentectomy for early-stage lung cancer

Over the past 20 years, there have been significant advancements in thoracoscopic surgical techniques as well as in lung cancer screening protocols, which have identified greater numbers of smaller lung tumors (<2 cm) that are more frequently operable and curable. These advancements have led to new interest in the thoracoscopic (VATS) approach to segmentectomy. This article will discuss the outcomes and technical considerations associated with VATS segmentectomy.

VATS segmentectomy: an underused option?

It is well known that the "gold standard" procedure for surgically resectable early-stage non-small cell lung cancer (NSCLC), is pulmonary lobectomy. Even though sublobar resections (SLR), particularly segmentectomy, seem attractive as an alternative to lobectomy in early stage lung cancers, they are still debated procedures. The aim of this study is to answer to the question: "Is VATS lung segmentectomy an underused option?" To obtain an answer to this query, the authors carried out a review of the "state of the art" as follows: (I) performing a non-systematic review of the literature; (II) analyzing the review articles published; (III) looking at the ongoing studies, the results of which have not yet published; (IV) scanning the technical aspect of lung segmentectomy. After completing the multi-step revision, we can conclude that there is a lack of evidence about the oncological value of segmentectomy in early stage NSCLC. Although VATS segmentectomy is feasible and performed by many thoracic surgeons, it's currently not yet world-wide adopted. Among the trials now being recruited in some countries and, aimed to clarify the role of SLR in the treatment of early stage lung cancer, a European prospective randomized study is advocated to implement the scientific knowledge on this issue.

Uniportal video-assisted thoracoscopic right upper posterior segmentectomy with systematic mediastinal lymphadenectomy

Uniportal video-assisted thoracoscopic surgery (VATS) has now evolved into a sophisticated technique that can be used in some of the most complex thoracic procedures; however, this approach to segmentectomy is not standardized, and the surgical procedure varies between surgeons. Here, we describe the use of our uniportal VATS procedure during right upper posterior segmentectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed. The patient has recovered well after surgery. We believe that uniportal VATS segmentectomy is a technically safe and feasible alternative approach to conventional thoracoscopic techniques for treating lung cancer.

Uniportal video-assisted thoracoscopic combined segmentectomy for lung cancer with incomplete fissure

This video clip demonstrated a performance of uniportal video-assisted thoracoscopic surgery combined segmentectomy. The patient had a potential invasive nodule located near the bifurcation of right bronchus, 3-dimensional reconstruction image showed the fissure between posterior segment of upper lobe and superior segment of lower lobe was incomplete. An up-to-down approach was applied in this operation with the en bloc resection of the two segments. Pathological report was adenocarcinoma with negative margin (TNM stage: T1aN0M0).

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.

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.

Uniportal video-assisted thoracoscopic right upper lobectomy with systematic lymphadenectomy

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has been reported to be a promising, less invasive alternative with potentially better cosmesis and less postoperative pain and paraesthesia. Although uniportal VATS has now evolved into a sophisticated technique capable of performing some of the most complex thoracic procedures, this approach to lobectomy is not standardized, and the surgical procedure still varies between surgeons. Here, we describe our uniportal VATS procedure during right upper lobectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed to remove lymph nodes from the 2(nd), 3(rd), 4(th), 7(th), 8(th), and 9(th) groups. Although there are some details that are different compared to the conventional VATS approach, as experience with uniportal VATS has grown, this approach is a viable alternative approach for lobectomy in selected patients.

Uniportal video-assisted thoracic surgery for left upper lobe: single-direction lobectomy with systematic lymphadenectomy

A 62-year-old female was admitted to our hospital after computed tomography (CT) revealed a 2.5 cm × 2.1 cm mass in the left upper lobe. PET/CT scan diagnosed as malignant lesion with no signs of metastasis. Under general anesthesia, the patient was placed in right lateral decubitus position. A 4cm incision was made in the 4th intercostal space with plastic protector. The camera was placed in the upper part of the incision and the instruments were inserted below the camera. Left upper lobectomy along with systematic lymphadenectomy was performed. Total surgical time was 135 min and estimated blood loss was 70 mL. The chest tube was removed on the 2nd postoperative day and the patient was discharged on the 3rd postoperative day with no complication. This uniportal VATS single-direction lobectomy for the left upper lobe is feasible and amplifies the concept of thoracotomy-like minimally invasive surgery.

[Evolution and Development Trend of Lung Cancer Surgical Incision]

微创、安全以及无瘤原则，是影响肺癌外科手术切口选择的最重要因素，从现有经验来看，把握手术指征，选择恰当的切口，掌握微创手术技巧，各种微创全胸腔镜手术均是安全可靠的切口入路，但如果术中无法满足安全或无瘤原则，应果断更改为开胸手术；开胸手术入路仍是肺癌外科治疗的基石，特别是应用于中央型病灶以及复杂肺癌外科手术。单孔VATS技术与3D胸腔镜、经自然孔道内镜技术、虚拟现实可视化技术以及机器人VATS技术的结合，是肺癌外科手术切口未来发展的方向。

[Development, Application Details, and Prospects of Uni-VATS on Lung Cancer Radical Operation under the Concept of "Precise Medical Treatment"]

单孔电视胸腔镜手术（uni-portal uideo-assisted thoracic surgery, Uni-VATS）的推广，是近年微创胸外科最重大的进展之一。随着腔镜下成像设备、切割缝合器械及电分离器械的改进，单孔VATS的应用范围已从最初的肺组织活检术逐渐扩大到解剖性肺叶/段切除、全肺切除、支气管/血管袖式吻合。多中心大量报道已证实：单孔VATS行肺叶切除安全、可行，清扫纵隔淋巴结的组数及总数均不低于传统多孔VATS，在疼痛、创伤及术后恢复方面也有积极的结果。虽然暂未得到多中心、大样本的临床数据如5年生存率，但有序地逐步开展单孔VATS仍是微创胸外科未来发展的重要方向。本文将围绕单孔VATS的原理及具体操作细节，结合肺癌根治术的基本操作理念进行讨论及综述，以期为单孔VATS的有序、规范化开展提出思考和探索。

Comparison of treatment outcomes between single-port video-assisted thoracoscopic anatomic segmentectomy and lobectomy for non-small cell lung cancer of early-stage: a retrospective observational study

BACKGROUND

There are few reports of single-port video-assisted thoracoscopic surgery (S-VATS) anatomic segmentectomy and S-VATS lobectomy for early-stage non-small cell lung cancer (NSCLC) and no comparisons between them have yet been reported. Therefore, the aim of this study was to compare the safety and efficacy of S-VATS anatomic segmentectomy and S-VATS lobectomy for early-stage NSCLC.

METHODS

In this retrospective observational study, the outcomes of 79 consecutive patients who had undergone S-VATS anatomic segmentectomy (32 patients) or S-VATS lobectomy (47 patients) for early-stage NSCLC from April 2014 to June 2015 were examined. The operation time, intraoperative blood loss, numbers of dissected lymph nodes and mediastinal nodal stations, numbers of staples used, postoperative drainage volume and duration, duration of hospital stay, costs, postoperative complications, local recurrence, and survival were compared between these two groups.

RESULTS

The postoperative drainage volume was smaller and the postoperative drainage duration shorter in the S-VATS segmentectomy than the lobectomy group (P<0.05). There were no significant differences in operation time, intraoperative blood loss, number of staples used, number and stations of dissected mediastinal lymph nodes, duration of hospital stay, costs, or postoperative complications. At the time of writing, no deaths or local recurrences had occurred in either group.

CONCLUSIONS

S-VATS segmentectomy is as safe and effective as S-VATS lobectomy. Patients who undergo S-VATS segmentectomy seem to recover faster.

Management of bleeding from an abnormally located S6 arterial branch in a common origin with S2 branch during live surgery

In 24^th/03/2016 we organized the first uniportal video-assisted thoracic surgery (VATS) live surgery workshop in Jerusalem at our institution with our special guest Dr. Diego Gonzalez-Rivas, more than 30 participants attended this workshop from Israeli and the Palestinian territories (cardiothoracic and vascular surgeons, general surgeons, anesthesiologists and nurses). During the workshop Dr. Gonzalez operated two complex cases while the first case was an anatomical S1 segmentectomy, the second case (the one which we are reporting in this paper) was bilobectomy of right middle and lower lobes, during this case a profuse bleeding appeared while introducing the stapler in the interlobar fissure, the source of this bleeding was an abnormally located arterial branch, however the bleeding managed perfectly by Dr. Gonzalez-Rivas, although this surgery kept all of us in a state, all the attendees were happy to see the way how this bleeding managed and everybody was satisfied with the final result.

Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3)

The video-assisted thoracoscopic surgery (VATS) approach for combined lobectomy and segmentectomy in the same lung is an infrequent procedure, rarely reported in the literature. Currently, Most of the surgeons still use 2-3 thoracic incisions for thoracoscopic anatomic resections. However, the uniportal approach is gaining worldwide acceptance in the recent years. The main advances of uniportal VATS during the last years are related to improvements in surgical technique by implementing new technology. The experience acquired with the uniportal technique allows expert uniportal VATS surgeons to explore new approaches in order to minimize even more the surgical invasiveness. Recently the aim to avoid the intercostal nerve damage created by the transthoracic incision has led to the creation of a novel procedure entitled uniportal VATS subxiphoid approach. Here we report the first case of a lobectomy combined with anatomic segmentectomy performed through a uniportal subxiphoid approach.

Global development and current evidence of uniportal thoracoscopic surgery

In the era of video-assisted thoracoscopic surgery (VATS), uniportal and single incision thoracoscopic surgeries are gaining popularity. The spectrum of uniportal VATS indications is now almost equal to that of conventional VATS. For example, successful uniportal sleeve lobectomy, rib segmental resection, and management of intraoperative bleeding have all been reported. According to published data in the English-language literature, more than 9,545 uniportal VATS have been performed to date, including 1,293 lobectomies, 1,024 procedures for pneumothorax, and 6,845 sympathectomies. Of the 192 articles discussing this topic, 35 were conducted in Spain, and there were an increasing number of publications from China, Korea, and other Asian countries. There were 41 technical and review articles, all of which provided an excellent foundation of surgical concept and skill learning. The benefits of uniportal VATS include better surgical geometry and cosmetics. Regarding postoperative outcomes, thirteen out of the 15 articles reviewed showed that uniportal VATS has similar or superior outcomes to conventional VATS. Most studies demonstrated that uniportal VATS produced less postoperative pain and paresthesia. In conclusion, uniportal VATS can produce excellent operative outcome, which is becoming a mature surgical approach in thoracic disease, supported by fast-accumulating and abundant experience.

The uni-portal video-assisted thoracic surgery: achievements and potentials

Described for the first time in 2004 for performing minor lung resection, during the following ten years a growing scientific evidence supported the spread and evolution of the uni-portal video-assisted thoracic surgery (VATS). This novel approach, performed using a single thoracic incision, requires a change of perspective in relation to traditional VATS, offering on the other hand a great versatility for numerous surgical procedures. The present work reviews the literature inherent to the uni-portal VATS with the aim of highlighting the principles of this technique, the fields of application, the obtained results and the future perspectives.

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.

A 3.5-cm Single-Incision VATS Anatomical Segmentectomy for Lung Cancer

The results of several pulmonary resections using a uniportal approach have been published. However, there are no reports of uniportal thoracoscopic anatomic segmentectomy in Japan. We have a fundamental belief in "reduced-port surgery" and therefore routinely perform uniportal thoracoscopic surgery for patients with pneumothorax. This report describes a successful case of uniportal thoracoscopic anatomic segmentectomy through a 3.5-cm incision in a 76-year-old woman with primary lung cancer. The patient was pathologically diagnosed with multiple primary adenocarcinomas stage IA (T1aN0M0). Postoperatively, no analgesics were needed. The operative procedure is described in detail and includes technical tips such as the pulley method, extra-vessel exposure, the shaft-on-shaft technique, one-hand encircling, and one-hand exposure. The selection criteria for uniportal thoracoscopic segmentectomy limit its use.

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.

Open, thoracoscopic and robotic segmentectomy for lung cancer

While lobectomy is the standard procedure for early stage lung cancer, the role of sublobar resection is currently under investigation for selected patients with small tumors. In this review, studies reporting outcomes on open, thoracoscopic and robotic segmentectomy were analyzed. In patients with stage I lung cancer, with tumors <2 cm in diameter and within segmental anatomic boundaries, segmentectomy appears to have equivalent rates of morbidity, recurrence and survival when compared to lobectomy. Segmentectomy also resulted in greater preservation of lung function and exercise capacity than lobectomy. It appears reasonable to consider segmentectomy for patients with stage I lung cancer (particularly in air-containing tumors with ground glass opacities) where tumors are <2 cm in diameter and acceptable segmental margins are obtainable, especially in patients with advanced age, poor performance status, or poor cardiopulmonary reserve. The results of two ongoing randomized controlled trials (CALGB 140503 and JCOG0802/WJOG4607L) and additional well-designed studies on open, thoracoscopic, and robotic segmentectomy will be important for clarifying the role of segmentectomy for lung cancer.