Single incision video-assisted thoracoscopic anatomic segmentectomy

Current role of uniportal video-assisted thoracic surgery for lung cancer treatment

The use of video-assisted thoracic surgery (VATS) as an approach for early-stage lung cancer treatment has revealed benefits compared to open surgery by minimizing trauma to the patients. This trend has brought the evolution of VATS to less and less invasive methods, eventually leading to the development of Uniportal VATS (UniVATS) technique. This new approach has shown to be resourceful, proving its feasibility even for complex oncological procedures. Furthermore, data is starting to express some benefits over multiport VATS, thus spurring on its development towards newer and more complex procedures. It is also been adopted by the surgical community achieving fast evolution and worldwide diffusion. Here, we review the evolution of UniVATS, its current state of evidence, some basic technical aspects, the present role it has in lung cancer treatment and the ongoing development of the technique.

RELEVANCE FOR PATIENTS

This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.

Learning curve of uniportal video-assisted lobectomy: analysis of 15-month experience in a single center

Background

Uniportal video-assisted thoracoscopic (U-VATS) lobectomy has been becoming the technique of choice in an increasing number of centers. The aim of our study was to review our experience, evaluating the learning curve of U-VATS for lung lobectomy and outcomes.

Methods

The prospectively collected clinical data of 43 consecutive patients, undergone U-VATS lobectomy from June 2016 to September 2017, were reviewed. The cumulative sum analysis was applied for defining the completion of learning curve (CLC), evaluating the relationship between operative time and the consecutive number of operations.

Results

The mean operative time of Uniportal VATS lobectomy was 179.93±43.41 min. According to the cumulative sum analysis, the CLC was reached after 25 patients. Using the cut-off of 25 patients, the whole populations was divided in group A (first 25 patients of the experience) and group B (the last 18 patients). The mean operative time in group B was significantly shorter than in group A (164.00±24.46 vs. 191.40±50.45 min, respectively, P=0.04). There were no differences in demographic characteristics, number of removed lymph nodes, chest tube duration, and hospital stay among the two groups. The number of conversions was higher in group A (4 vs. 0; P=0.07), as the number of major complications, like reoperations for bleeding (2 vs. 0; P=0.22). There was no postoperative 30-day-related death.

Conclusions

U-VATS lobectomy seems to be a quite safe and feasible procedure, with a steep learning curve and low complication rate, if performed by experienced surgeons after proper training.

Thoracoscopy: The past, the present and the future! A personal journey

Thoracoscopy, in my opinion, is underutilised in Africa, for a multiplicity of reasons. These include a lack of expertise, the perceived cost and difficulties in obtaining and maintaining equipment. The benefits, however, in improved surgery and decreased surgical pain and rapid return to productive work outweigh by far the so-called disadvantages. In my opinion, thorascopic techniques should be routine in all our academic departments. Our newly qualified thoracic surgeons should be trained in video-assisted thoracic surgery.

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).

Modified procedure of uniportal video-assisted thoracoscopic lobectomy with muscle sparing incision

BACKGROUND

To describe modified procedure for uniportal video-assisted thoracoscopic surgery (UVATS) lobectomy with a small, total muscle-sparing incision.

METHODS

Forty-eight UVATS leucotomy were attempted and successfully completed. A single incision of approximately 3 cm was made in an intercostal space along the anterior axillary line. Muscle-sparing technique was applied with this single-incision approach using muscle sparing technique.

RESULTS

Incision size was kept to a minimum, with a median of 3 cm. Mediastinal lymph node dissection was performed in all patients with malignancy. Overall median operative time was 1.3 hours. Median hospitalization was 13.5 days (range, 6-21 days). Morbidity rate was low at 3%. There were no other postoperative complications, mortality, or re-admissions.

CONCLUSIONS

Modified procedure of lobectomy with UVATS might be easy to operate with less surgical time and morbidity rate, muscle sparing technique might reduce post-operation pain.

Modified uniportal video-assisted thoracoscopic surgery (VATS)

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

Feasibility and learning curve of uniportal video-assisted thoracoscopic segmentectomy

BACKGROUND

Video-assisted thoracoscopic (VATS) segmentectomy is an acceptable alternative to lobectomy for treating early-stage lung cancer. Uniportal VATS segmentectomy is a challenging surgical procedure that has substantial technical difficulties and complications. In this study, we reviewed our experience of uniportal thoracoscopic segmentectomy and evaluated the feasibility and learning curve of this procedure.

METHODS

Retrospective observational data of 70 patients who underwent uniportal VATS segmentectomy between May 2014 and July 2015 were collected. Perioperative factors, such as demographic characteristics, operation time, blood loss, the number of dissected mediastinal lymph nodes and nodal stations, conversion rate to three-port VATS or thoracotomy, postoperative complications, duration of chest drainage, and postoperative hospital stay, were reviewed. Cumulative summative analysis and one-way ANOVA were used to identify the learning curve of uniportal thoracoscopic segmentectomy.

RESULTS

Forty cases were included in the study. The patients were equally divided into four groups according to the sequence of surgery. Twelve patients were men and the mean age was 53.7±8.3 years. The mean operation time was 174.2±51.5 minutes and mean blood loss was 81.9±57.4 mL. There were no differences in demographic characteristics, blood loss, number of removed lymph nodes, chest tube duration, and hospital stay among the groups. However, the operation time in group 4 was significantly shorter than that in groups 1-3 (P=0.012). The learning curve showed that after 33 patients, the operation time was less than the conventional average operation time. There was no conversion to three-port VATS, two-port VATS or open thoracotomy. Three patients had postoperative complications and all of them recovered after treatment. No patient needed reoperation. There was no postoperative 30-day-related death.

CONCLUSIONS

Uniportal thoracoscopic segmentectomy is a safe and feasible technique for treating small pulmonary lesions, with acceptable morbidity and mortality. This technique can be applied to an operation for segments that are technically difficult and anatomically variant. An experienced surgeon can achieve a relatively stable level after 33 cases.

Comparison of single port versus multiport thoracoscopic segmentectomy

BACKGROUNDS

Single-port thoracoscopic segmentectomy is a challenging option in the early stages of lung cancer. The purpose of this study was to determine the feasibility of single-port video-assisted thoracoscopic surgery (VATS) segmentectomy compared to conventional multi-port VATS.

METHODS

A total of 45 patients underwent pulmonary segmentectomy by video-assisted thoracoscopic surgery between March 2006 and October 2015. We analyzed the operative outcomes of segmentectomy by surgical approach (34 single-port versus 11 multi-port).

RESULTS

Twenty-three primary lung cancers (51.1%), 16 benign lung diseases (35.6%), and 6 secondary lung cancers (13.3%) were diagnosed and included in our study. In 29 malignancy cases (64.4%), the mean tumor size was 1.8±0.7 (range, 1-3.5) cm. Twenty patients (44.4%) underwent preoperative localization with hook-wire and radiocontrast. The most frequent operated segment was the left upper divisional segment (n=9, 30%). There was no significant difference in operation time (P=0.073), the number of dissected lymph nodes (P=0.310), intraoperative events (P=0.412), and the development of prolonged air leak (>5 days) (P=0.610) between the single-port and multi-port VATS segmentectomy groups. There was a reduction in postoperative morbidity (P<0.001) and hospital stay (P=0.029) in the single-port VATS group.

CONCLUSIONS

Single-port VATS segmentectomy for early lung cancer and benign lung disease, is a safe and feasible option for patients undergoing pulmonary segmentectomy.

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.

Techniques and difficulties dealing with hilar and interlobar benign lymphadenopathy in uniportal VATS

BACKGROUND

Surgical treatment of lung cancer has evolved to a minimally invasive approach and currently is recognized as an acceptable treatment for resectable non-small cell lung cancer (NSCLC). As the volume and complexity of cases has increased technical difficulties had arisen. Hilar and sublobar lymph nodes can represent a challenge for video-assisted thoracoscopic surgery (VATS) surgeons in order to complete a safe dissection of vascular and bronchial structures without complications or conversion. It is not unusual the patients with smoking history or benign infections in the past present with enlarged calcified nodes that are fused to the hilum, fissure and specially the bronchus which can lead to an accident during the procedure if the surgeon has no experience handling this issue. As the amount of surgeons carrying out VATS lobectomies grows it is very important for them to know what to do in this specific case so the completion of the procedure can be achieved safely.

METHODS

The coordination between the surgeon and the assistant is very important in order to carry out the procedure without discomfort positions and good visualization, the use of energy devices in expert hands can help considerably during the dissection of lymph nodes in the hilum and fissure reducing the bleeding, which provides a clean operative field. It is a necessary maneuver during the dissection to find the correct adventitial plane between the lymph node and the structure before passing it.

RESULTS

The videos in this article show the different maneuvers a VATS surgeon can implement when facing enlarged fussed lymph nodes in the hilum, fissure or mediastinum. Improving exposure, opening the fissure, using energy and carrying out the dissection through the correct plane are keys to complete the procedure successfully.

CONCLUSIONS

With growing experience in uniportal VATS and advances in surgical technology, enlarged or fussed lymph nodes are no longer a contraindication to complete a VATS lobectomy, experience VATS surgeons have a repertory of options in order to perform a safe and effective dissection.

A 2-cm single-incision thoracoscopic left upper division segmentectomy

BACKGROUND

A video-assisted thoracic surgery (VATS) sublobar resection for early lung malignancy has been applied recently in selected patients with the improvement in surgical technique.

METHODS

From 2012, we began VATS segmentectomy with 2-cm single incision in early lung cancer (T1a, tumor size <2 cm) and no lymph node metastasis with preoperative dual localization for lung lesion.

RESULTS

In the video clip, we performed a 2-cm single-incisional VATS segmentectomy for early lung cancer at left upper lobe upper divisional segment and lymph node dissection using a 5-mm thoracoscope, articulating or curved endoscopic devices. Dual localization for lung lesion could help to identify the specific location of lung lesion. The potential benefits of single-incisional VATS segmentectomy include less intercostal pain, better postoperative outcomes more over than less incisional scar.

CONCLUSIONS

A single-incision VATS segmentectomy might be a feasible option for the treatment of early lung cancer in selected patients.

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.