Uniportal and single-incision video-assisted thoracic surgery: the state of the art

Calvin S H Ng, Gaetano Rocco, Randolph H L Wong, Rainbow W H Lau, Simon C H Yu, Anthony P C Yim. 

Interact CardioVasc Thorac Surg(2014) 19 (4): 661-666.

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has evolved dramatically into a sophisticated technique capable of performing some of the most complex thoracic procedures. The idea of operating through fewer surgical incisions and, therefore, with potentially better cosmesis, less postoperative pain and paraesthesia, has led to uniportal VATS increasing in popularity worldwide. The uniportal approach demands instrument design to be better suited for operating with multiple instruments through a single small incision. Furthermore, the drive by surgeons and industry to develop novel, smaller, more specialized procedure-specific instruments for uniportal VATS to further allow reduction in incision size is relentless. Refinement of uniportal VATS instruments, angulated and narrower endostaplers, and improvements in video-camera systems, including 3D systems, and 120° articulating lens will make uniportal VATS major lung resection easier to perform and learn. In the future, we could see the development of subcostal or e-NOTES access, endorobotic arms that open and operate within the chest cavity, and cross-discipline imaging assistance for uniportal VATS procedures.

Single Port Video-Assisted Thoracic Surgery VasoView Sympathectomy for Palmar Hyperhidrosis

Rainbow Lau; Calvin Ng; Randolph Wong; Eugene Yeung; Micky Kwok; Innes Wan; Malcolm Underwood.

Chest. 2014;145(3_MeetingAbstracts):44A.

Video-assisted thoracic surgery (VATS) sympathectomy is the definitive therapy for primary palmar hyperhidrosis with high success rates and low recurrence. Classically, a 3-port bilateral VATS approach is utilized. We report our novel application and experience of single-port VATS sympathectomy with the VasoView® endoscopic vein harvesting devices.

Defeating the pores of Kohn

Ng CS, Lau RW, Lau KK, Underwood MJ, Yim AP.

Asian Cardiovascular and Thoracic Annals 2014 22: 102

Uniportal video-assisted thoracoscopic surgery for anatomical fissureless anterior segment resection (S3) of the right upper lobe followed by lymph node dissection.

Davor Stamenovic, MD, and Antje Messerschmidt, MD

Multimed Man Cardiothorac Surg. 2018 Jan 11;2018. doi: 10.1510/mmcts.2018.001.

Uniportal video-assisted thoracoscopic (UVATS) resections seem to offer real benefits over conventional surgery in terms of postoperative pain and better cosmetic results.  The procedure described in this tutorial, an anterior segment resection of the right upper lobe, is rarely performed, and fissureless resection of this segment by means of UVATS has, at time of writing, never been described in the literature.  Our patient was a 79-year-old female, admitted to our clinic for treatment of a solitary metachronous metastatic tumor of a colon carcinoma, located in the anterior segment of the right upper lobe. A fissureless anatomical anterior segment resection of the right upper lobe was conducted, followed by the radical lymph node dissection.  The postoperative course was event free and the patient was discharged on the 4th postoperative day. Fissureless VATS operations have an advantage compared to conventional operations in terms of reduced risk of prolonged air leak. Moreover, these operations take no longer to perform than conventional surgery and have no notable disadvantages, apart from the potential for using more staples.

Uniportal video-assisted thoracoscopic resection of anterior segment of the left upper lobe.

Stamenovic D¹, Messerschmidt A².

Multimed Man Cardiothorac Surg. 2018 Jan 11;2018. doi: 10.1510/mmcts.2018.002.

Anatomical segment resections are often technically more demanding than lobectomies. Anterior segment of the left upper lobe (S3) is usually removed within the standard resection of the upper three segments.    Our patient in this case was a 56-year-old with a known oropharyngeal carcinoma, otherwise amenable to curative treatment, who was admitted to our clinic with  a 1-cm nodule in the anterior segment of the left upper lobe.  Distant metastases were excluded, and a decision was made to proceed with a uniportal video-assisted thoracoscopic segmentectomy and lymphadenectomy. The procedure was successfully conducted without any adverse effects and the patient's postoperative course was uneventful.  The tumor was diagnosed as a primary solid 1-cm adenocarcinoma and the final stage was pT1aN0M0.

Subxiphoid uniportal video-assisted bilateral surgery: right upper lobectomy and left upper wedge resection S3.

Giraldo Ospina CF, et al. J Vis Surg. 2017.

Traditional approach of bilateral lesions usually involves bilateral approaches instead of classical thoracotomy or video-assisted thoracoscopic surgery (VATS) surgery, and often at two different times. During visit of Dr. Gonzalez Rivas at Master Class to Málaga, we performed right upper lobectomy and S3 wedge resection left upper lobe of a two synchronous bilateral lung lesions case with subxiphoid single incision approach. We are reporting the first case of a lobectomy combined with a wedge resection performed through an uniportal subxiphoid bilateral VATS in Spain.

Video-assisted thoracoscopic surgery lobectomy using “the caudal approach”: results and evolution

Giampiero Dolci, Alessio Campisi, Domenica Giunta, Stefano Congiu, Niccolò Daddi, Giacomo Murana, Andrea Dell’Amore

Background: Video-assisted thoracoscopic surgery (VATS) has become a common surgical approach in the diagnosis and treatment of lung and mediastinal diseases. In this study, we reported our current experience of thoracoscopic surgery using a new caudal position technique for anatomical lung resections and compared it with the standard anterior VATS technique.

Methods: From January 2016 to October 2017, 92 consecutive patients with lung cancer underwent VATS lobectomy. Among these, 34 patients were treated by conventional anterior three portal VATS lobectomy, and 58 patients were treated using the caudal three port VATS lobectomy. The mean operative time, conversion rate, hospital stay, post-operative drainage, reoperation, post operative pain were compared between each group.

Results: No differences between the two groups are showed in terms of surgical time, post-operative drainage, incidence of prolonged air leaks and post-operative pain.

Conclusions: The caudal approach to major pulmonary resection of thoracoscopic lobectomy results in a reliable and comfortable procedure for the surgeon. Once demonstrated the reliability of the VATS lobectomy with three accesses using the caudal position, we are starting to standardize biportal and uniportal VATS with the surgeon in the caudal position.

Thoracoscopic anatomic lung resections for cancer in patients with previous cardiac surgery

Alfonso Fiorelli, Dario Amore, Paolo Mendogni, Davide Tosi, Mario Nosotti, Mario Santini, Carlo Curcio

J Vis Surg. 2017 Dec 21;3:188. doi: 10.21037/jovs.2017.11.10. eCollection 2017.

We reported the feasibility of thoracoscopic anatomical resections for lung cancer in four consecutive patients undergoing previous cardiac surgeries as coronary artery by-pass graft (CABG) using left internal mammary artery (LIMA) graft (n=1), cardiac transplantation (n=2), and mitral valve replacement (n=1). A three-port approach was used in all patients but one where an uniportal approach was adopted. Lobectomy was carried out in two patients; left upper three-segmentectomy and upper bilobectomy in the other two. All procedures were successfully performed without needing conversion. No intra-operative, post-operative morbidity and mortality were recorded. At last follow-up, all patients were alive without recurrence but one who had cerebral metastasis. Thoracoscopic lung resection after cardiac surgery is a feasible but complex procedure that should be performed in centres having a cardiac surgery team ready to operate in case of cardiac complications.

Minimally invasive techniques in thymic surgery: a worldwide perspective

Hasan Fevzi Batirel

J Vis Surg. 2018 Jan 10;4:7. doi: 10.21037/jovs.2017.12.18. eCollection 2018

Minimally invasive surgical techniques are important in surgical management of thymic pathologies. Traditional access techniques are being replaced with minimally invasive techniques using multiportal or uniportal approach. Adoption of minimally invasive techniques for thymic malignancies has been slow due to long term recurrence concerns. Recent studies show that minimally invasive video-assisted thoracoscopic surgery (VATS) or robotic approach to early stage thymic malignancies are associated with less intraoperative bleeding, lower rate of respiratory complications, shorter chest tube duration and shorter hospital stay. Oncologic outcomes are at least equivalent to open approach. Minimally invasive approach for benign pathologies is widely applied. There are significant variations in VATS approaches for thymus, showing a multinational interest in the issue of minimizing trauma during thymectomy. Use of robotic technology is also popular, as the retrosternal area is a narrow anatomic space to manipulate conventional instruments. The evolution of minimally invasive surgery for thymus has been possible with contribution from centers all around the world. In the current practice, various approaches are being adopted and every surgeon should prefer a technique depending on surgical preference and experience.

The technique of VATS right pneumonectomy

Fernando Vannucci, Arthur Vieira, Paula A. Ugalde

J Vis Surg. 2018 Jan 15;4:11. doi: 10.21037/jovs.2017.12.01. eCollection 2018

Pneumonectomy has higher morbidity and mortality rate than any other anatomic lung resection. It is infrequently performed by VATS and mostly in high volume centers. The handling of central vessels with long instruments across very small incisions instead of palpation is the main cause of surgeon's discomfort and resistance to perform this radical type of resection. Published data on VATS pneumonectomy is still limited and based on case series. Nevertheless, the available series suggest that VATS pneumonectomy is at least equivalent to open pneumonectomy. Through a case presentation illustrated with surgical videos, we aim to describe the main technical features of a uniportal VATS right pneumonectomy for lung cancer. The clinical indications, contraindications, patient's preoperative evaluation and postoperative care will also be discussed.

Total Rib Resection Via Uniportal Thoracoscopic Approach.

Ilhan Ocakcioglu, Nezih Onur Ermerak, Mustafa Yuksel

Ann Thorac Surg. 2018 May 4. pii: S0003-4975(18)30585-X. doi: 10.1016/j.athoracsur.2018.03.082

Abstract

In this report, we present a case specifying the availability of uniportal thoracoscopic resection of a total rib safely without the need of conventional thoracotomy. The favorable outcome of this case suggests that uniportal thoracoscopic technique described here is safe and succesful approach for resection of costal lesions with good cosmetic results. To our knowledge; this is the first case reporting the entire rib resection via uniportal thoracoscopic approach.

Innovative surgical endoscopes in video-assisted thoracic surgery.

Truman Cheng, Calvin S. H. Ng, Zheng Li

Transaxillary uniportal video assisted thoracoscopic surgery for right upper lobectomy.

Yaxing Shen, Yong Zhang, Jianchao Sun, Jianying Gu, Yunfeng Yuan, Qun Wang

J Thorac Dis. 2018 Mar;10(3):E214-E217. doi: 10.21037/jtd.2018.02.86.

Abstract

Uniportal video-assisted thoracic surgery (VATS) was growing popular since its first introduction. Based on the conventional uniportal VATS, we modified the technique and introduced transaxillary uniportal VATS lobectomy in this case report. In March 2017, transaxillary uniportal VATS was firstly attempted on a patient suffering from right upper lobe lesion at the Department of Thoracic Surgery, Zhongshan Hospital, Fudan University. A 4-cm single incision was made at the fossa axillaris paralleled to the skin folds, to which a soft wound protector was applied to reach the third intercostal space along the anterior axillary line. The right upper lobectomy was performed through the transaxillary incision. The surgery was accomplished without conversion to thoracotomy or application of extra incision. The truncus anterior artery, the upper lobe bronchus and upper pulmonary vein was mobilized and dissected in order. The target lobe was removed through the fossa axillaris incision. The operation duration was 110 minutes with limited blood loss. The patient was discharged 3 days post-operatively. Transaxillary uniportal VATS lobectomy is safe and feasible, and the procedure showed cosmetic advantages. Further studies based on larger population are required to determine these findings.

Robotic-assisted thoracic surgery versus uniportal video-assisted thoracic surgery: is it a draw?

Sara Ricciardi, Carmelina Cristina Zirafa, Federico Davini, Franca Melfi

J Thorac Dis. 2018 Mar;10(3):1361-1363. doi: 10.21037/jtd.2018.03.94.

No abstract.

Uniportal VATS Lobectomy: Subxiphoid Approach.

Carvalheiro C,  Gallego-Poveda J, Gonzalez-Rivas D, Cruz J

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):141.

Abstract

INTRODUCTION: Interest in uniportal video-assisted thoracic surgery (VATS) is rapidly growing worldwide because it represents the surgical approach to the lung with the least possible trauma and in recent years the subxiphoid approach has been used in the field of thoracic surgery as it is associated with lesser pain because there is no intercostal nerve damage and it provides excellent cosmetic outcomes. This technique was recently introduced for major pulmonary resections and even bilateral approaches in selected patients.

METHODS: We present a case of a 66 years old male, former smoker (45 unit pack year) who had a thorax CT (computorized tomography) scan for worsening complaints of cough with sputum production. The CT scan revealed a right upper lobe nodule (16x14mm) with ground glass density and fissure retraction. The pulmonary function tests showed mild bronchial and bronchiolar obstruction. It was decided to undergo surgical treatment. The surgical approach was a subxiphoid uniportal lung resection.

RESULTS: The patient was positioned in a left lateral position with 60 degrees of inclination. The surgeon and scrub nurse were located in front of the patient and the assistant in the opposite side. A 3cm midline vertical incision was made below the sterno-costal triangle. The rectus abdominis was divided and the xiphoid process was partially resected. The right pleura was opened by finger dissection. The pericardial fatty tissue was removed and a soft tissue retractor was placed. A 10- mm, 30-degrees video camera and double articulated instruments combined with several specific longer VATS instruments were used through the same subxiphoid incision.It was performed a wedge resection and after the diagnosis of adenocarcinoma in the intraoperative histological examination, the patient underwent a right upper lobectomy and complete mediastinal lymphadenectomy by the same approach.The post-operative period was uneventful, the chest tube was removed in the third postoperative day. The pain control was excellent, with a maximum of pain grade 1 in the Visual Analogue Scale.The patient was discharged in the fourth postoperative day.

CONCLUSION: The subxiphoid approach is a variant of uniportal VATS approach without opening the intercostal space with its striking advantages in terms of pain control and cosmetics in selected patients. However, this technique has yet some limitations such as the control of major bleeding and the performance of a complete oncologic lymph node dissection related to its surgical complexity expected in emerging techniques. Further studies are necessary to certify the feasibility, safety and benefits of this approach

Uniportal Video-Assisted Thorascoscopic Surgery - The New Paradigm in the Surgical Treatment of Lung Cancer.

Fernandes P, Lareiro S, Vouga L, Guerra M, Miranda J

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):127.

Abstract

INTRODUCTION: The progressive development and improvement of minimally invasive approaches in the field of thoracic surgery allowed to establish video-assisted thoracoscopic (VATS) anatomic lung resections as the present technique of choice in the treatment of early stage lung cancer.

METHODS: The purpose of this study was to evaluate the surgical outcomes of patients who performed uniportal VATS anatomic lung resections for the treatment of primary lung cancer. The patients' demographics, approach and type of surgery, postoperative morbidity and mortality and overall survival were analyzed.

RESULTS: From December 2013 through September 2017, 173 patients underwent uniportal VATS anatomic lung resections for the treatment of lung cancer. Surgery was performed in 92 male and 81 female with a mean age of 63.5 years (range 19- 83 years). All surgeries began by a single- -port VATS approach, being necessary to add an extra port in 9 surgeries and conversion to mini-thoracotomy in 10 procedures (conversion rate of 5.8%) due to bleeding and/ or technical difficulties. All kinds of anatomic lung resection were performed: 154 lobectomies, which represents 89.0% of the procedures (93 upper lobectomies, 12 middle lobectomies and 49 lower lobectomies), 10 bilobectomies (5.8%) and 9 anatomic segmentectomies (5.2%). Mean lymph node stations dissected was 2.48 stations (range 1-8 stations). The mean surgical time was 112.2 minutes (range 40-245 minutes) and mean intra-operative drainage was 155.6ml (range 0-1400ml). Median hospitalization time was 5 days (range 2-28 days). There was no operative or 30-days mortality and the main complication observed was persistent air leakage in 38 patients (22.0%). Non-small-cell lung cancer (NSCLC) was the main histologic type of cancer (n=149; 86.1%), followed by carcinoid tumours (n=20; 11.6%) and other histologic type (n=4; 2.3%). The mean follow-up time was 15 months (range 0-45 months) and the overall survival was 94.5%.

CONCLUSION: We believe that uniportal VATS anatomic lung resection with systematic lymphadenectomy is technically safe and feasible and it is an alternative approach to thoracotomy or conventional thoracoscopic in the treatment of lung cancer. This approach has demonstrated to be reproducible, comprising all the advantages of a minimal invasive surgery, without jeopardizing the efficiency of the oncologic treatment. Therefore, we suggest that this technique could have a broader implementation and development in all national surgical centers. The issues of patient acceptability, cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future throughout multi-institution randomized controlled trials and long-term follow-up.

Three-year Experience on 477 Patients Undergoing Uniportal Video-Assisted Thoracoscopic Surgery.

Lareiro S, Fernandes P, Vouga L, Miranda J, Guerra M

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):136.

Abstract

INTRODUCTION: Uniportal video-assisted thoracic surgery (VATS) technique has been described both for diagnostic and therapeutic indications. Outcomes after uniportal VATS have never been reported in Portuguese large series. We review the safety and efficiency of our initial experience with uniportal VATS.

METHODS: In a retrospective study of prospectively collected data, 477 uniportal VATS procedures were analyzed between June 2014 and June 2017. All procedures were performed without rib spreading. Patients' demographic data, preoperative and postoperative management as well as results were analyzed.

RESULTS: The mean age of patients was 47,9 years (range, 10 to 86), and 155 (32,5%) patients were female. The uniportal VATS procedures included 156 (32,7%) anatomical major lung resections, 80 (16,8%) one or multiple wedge resections, 172 (36,1%) blebectomies and/ or pleurectomies, 24 (5%) mediastinal lesions, 16 (3,3%) empyema drainage and decortications and other indications in 29 (6,1%) cases. Median operative ime and surgical drainage for uniportal VATS for anatomical major lung resections was 95 minutes (range, 40 to 245) and 100 ml (range, 0 to 650), respectively. Conversion to either 2 or 3 port VATS or mini-thoracotomy was necessary in 7.1% of the surgeries, often due to adhesions, incomplete lung collapse or bleeding. The chest drain was removed after a median of 3 days (range, 0 to 34). Median hospital stay was 3 days (range, 1 to 41). Postoperative complication rate was 12,4% mainly due to prolonged air leak 8,4% (n=40). There was no perioperative mortality.

CONCLUSION: Uniportal VATS is a feasible and safe technique for various indications in thoracic surgery. The perioperative results are promising. Excellent results with minimal morbidity and short hospital stay are amongst its strong points. It can be performed by thoracic surgeons experienced in the postero-lateral thoracotomy approach.

Uniportal video-assisted thoracoscopic surgery following neoadjuvant chemotherapy for locally-advanced lung cancer.

Zhiqiang Yang, Chunbo Zhai

J Cardiothorac Surg. 2018 Apr 24;13(1):33. doi: 10.1186/s13019-018-0714-9.

Abstract

BACKGROUND: Several retrospective studies have confirmed that video-assisted thoracoscopic surgery (VATS) following neoadjuvant chemotherapy is a safe and feasible treatment for advanced non-small cell lung cancer patients. As a minimally invasive technique, VATS usually leads to better clinical outcomes and better compliance with adjuvant treatment than conventional thoracotomy. Uniportal VATS (U-VATS) as an alternative option to conventional multi-port VATS has attracted much attention recently because reduced number and size of incisions may help to decrease inflammatory response and reduce postoperative pain for patients. However, rarely studies have reported the application of U-VATS following neoadjuvant chemotherapy for the treatment of advanced lung cancer patients.

METHODS: A total of 29 lung cancer patients undergoing VATS following neoadjuvant chemotherapy were included in this study. The clinical data of these patients were retrospectively analyzed, including the preoperative neoadjuvant chemotherapy plan, surgical effect, postoperative complications, operation time, operative blood loss, number of lymph nodes dissected and postoperative mortality.

RESULTS: All patients underwent VATS following two cycles of neoadjuvant chemotherapy. Among these patients, 26 completed U-VATS, two were converted to triple-port VATS, and one was converted to open thoracotomy. The operation time ranged from 120 min to 300 min (mean: 160 ± 38.5 min); the operative blood loss was 50-500 ml (mean:167.8 ± 78.4 ml); the number of lymph nodes dissected was 16-28 (mean: 21.9 ± 3.7); the postoperative drainage time was 3-13 d (mean: 5.6 ± 1.9 d); and the postoperative hospital stay was 6-16 d (7.7 ± 1.9 d). Postoperative complications occurred in five (17.2%) patients, including three cases of respiratory infection, one case of air leakage (more than two weeks), and one case of wound infection. In addition, the 30- and 90-day postoperative mortality was zero.

CONCLUSION: U-VATS following neoadjuvant chemotherapy is feasible and safe for the treatment of advanced lung cancer patients.

Uniportal thoracoscopic resection of intralobar and extralobar pulmonary sequestration.

Andrea Dell’Amore, Domenica Giunta, Alessio Campisi, Stefano Congiu, Giampiero Dolci, Niccolò Antonino Barbera, Roberto Agosti, Francesco Buia

J Vis Surg. 2018 Mar 30;4:63. doi: 10.21037/jovs.2018.03.05. eCollection 2018.

Abstract

Pulmonary sequestration (PS) is a rare congenital malformation of the respiratory tract. Two main variants are described, the intralobar and the extralobar PS. Clinical manifestations vary from accidental findings to life threatening complications. Surgical resection is the definitive and indicated treatment of PS. The operation could be performed through an open thoracotomy or video-assisted thoracic surgery approach. We report the management of two patients with diagnosis of extralobar PS in the first case and intralobar PS in the second case. Both patients underwent uniportal video-assisted thoracic surgery resection of PS with success. In our experience, we confirm that uniportal video-assisted thoracic surgery is a safe and feasible approach for extralobar and intralobar PS.

Extended uniportal video-assisted thoracic surgery for lung cancer: is it feasible?

Iñigo Royo-Crespo, Arthur Vieira, Paula A. Ugalde

J Vis Surg. 2018 Mar 23;4:57. doi: 10.21037/jovs.2018.03.09. eCollection 2018.

Abstract: 

Since the first description of uniportal video-assisted thoracic surgery (U-VATS) (or single-port) lobectomy, several centers in Asia and Europe rapidly adopted this technique as a standard approach for treatment of early stage non-small cell lung cancer (NSCLC). Despite the controversies regarding feasibility and completeness of resection, thoracic surgeons in high volume centers keep pushing the limits to perform very complex procedures also known as “extended resections” through minimally invasive surgery. Published series and case reports confirm the viability of U-VATS in highly complex surgical cases such as pneumonectomy, chest wall resection and bronchoplasty, which require experience and technical ability to be performed through a 3–6 cm single incision. In this article, the authors would like to present several clinical indications of locally advanced NSCLC and the technical aspects to accomplish an extended resection through U-VATS.

Uniportal video-assisted removal of a right paratracheal pericardial cyst: an unusual location.

Andrea Dell’Amore, Alessio Campisi, Domenica Giunta, Stefano Congiu, Giampiero Dolci, Roberto Agosti

J Vis Surg. 2018 Mar 20;4:55. doi: 10.21037/jovs.2018.02.08. eCollection 2018.

Abstract

Cystic lesions of the pericardium are a rare entity. Generally, they are congenital and located in the cardiophrenic angle. The right paratracheal location is unusual and differential diagnosis in particular with bronchogenic cyst is difficult even when using magnetic resonance imaging (MRI). The surgical indication exists in case of symptomatic patients or huge mass with compression of nearby structures. Different surgical approaches have been reported in literature to treat mediastinal cysts. We report a case of uniportal thoracoscopic removal of an unusual located right paratracheal pericardial cyst.

Uniportal video-assisted thoracic surgery, and the uni-surgeon: new words for the contemporary world.

Marcello Migliore

J Vis Surg. 2018 Mar 7;4:45. doi: 10.21037/jovs.2018.02.11. eCollection 2018.

Abstract

Uniportal video-assisted thoracic surgery (U-VATS) is gaining popularity, and is currently performed by a team formed by one surgeon, one camera holder and one nurse. As expected, the new word "uni-surgeon" is becoming more and more common. In this article, using the example of thoracic surgery, I try briefly to analyze the pro and cons of the uniportal-single incision VATS and uni-surgeon in the modern world, and how uniportal surgery may bring a novel dimension to the future of surgery.

Single incision video-assisted thoracic surgery pneumonectomy for centrally located lung cancer.

Semih Halezero?lu

Future Oncol. 2018 Mar;14(6s):41-45. doi: 10.2217/fon-2017-0422.

Abstract

Increasing experience in single-incision video-assisted thoracoscopic (SIVATS) lung resections for lung cancer has made some sophisticated lung resections such as bronchial or vascular sleeve resections, chest wall resections and pneumonectomy possible. There are some case series published in medical literature about the feasibility and safety of multiportal video-assisted thoracic surgery pneumonectomy. However, in this prepubertal period of its evolution the literature data are still immature, and limited only to rare case reports or video presentations for SIVATS pneumonectomy for lung cancer. This article aims to discuss the technique, feasibility and place of SIVATS pneumonectomy in the management of non-small-cell lung cancer.

One hundred and fifty-six cases of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery: a 2-year learning experience.

Liang Duan Gening Jiang Yong Yang

Eur J Cardiothorac Surg. 2018 Apr 6. doi: 10.1093/ejcts/ezy142.

Abstract

OBJECTIVES: Our goal was to explore the outcome of the study and the feasibility for patients of the technique of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery (VATS).

METHODS: A total of 156 consecutive patients with lung lesions who received anatomical pulmonary segmentectomy by VATS between 2015 and 2016 in our hospital were enrolled. All the subjects had high-resolution, thin-section chest computed tomography (CT) examinations with 3-dimensional reconstruction, a pulmonary function test, abdominal ultrasonography, electrocardiogram and cardiac ultrasonography. The lung lesion was localized before the operation using CT reconstruction or a hookwire to plan the operative method.

RESULTS: Uniportal VATS pulmonary segmentectomy was successfully completed in 151 (96.8%) patients. Most cases involved the right apical and apical posterior segments and the left trisegment. Only 1 patient had a right middle interior segmentectomy, left upper apical anterior segmentectomy or a right lower posteriolateral segmentectomy, respectively. There were 26 cases of benign lesions (including 17 cases of atypical hyperplasia) and 130 cases of non-small-cell lung cancer. Operation time (146 ± 56 vs 113 ± 32 min), blood loss (63 ± 17 vs 54 ± 13 ml) and complication rates (13.5% vs 5.8%) were obviously lower in 2016 compared with 2015 (P < 0.01). In contrast, the preoperative hookwire localization rate was markedly higher in 2016 compared with 2015.

CONCLUSIONS: Uniportal VATS anatomical pulmonary segmentectomy is safe and feasible in clinical applications. Compared with the 2- or 3-port method, there were some technical difficulties in the early phase of the learning curve for uniportal VATS that were overcome through a period of practice.

Non-intubated uniportal video-assisted thoracoscopic surgery for carinal sleeve resection-is surgical process almost completed?

Dominik Herrmann, Jan Volmerig, Erich Hecker

J Thorac Dis. 2018 Jan;10(1):145-147. doi: 10.21037/jtd.2017.12.55.

Abstract

No abstract available

Uniportal Video-Assisted Thoracic Surgery for Pulmonary Hamartoma: Case Report.

Djakovi? Ž, Janevski Z

Acta Clin Croat. 2017 Dec;56(4):808-811. doi: 10.20471/acc.2017.56.04.32.

Abstract

Pulmonary hamartoma is the most common benign tumor of the lung. It accounts for 77% of all benign lung tumors but less than 1% of all lung tumors. Malignant alteration is -extremely rare. Surgical removal is therapy of choice. Uniportal video-assisted thoracic surgery is an easy-to-learn variant of video-assisted thoracic surgery. The approach is very similar to classic thoracotomy. Instruments for both classic and video-assisted thoracic surgery can be combined. A case is presented of a 44-year-old female patient with pulmonary hamartoma treated by uniportal video-assisted -thoracic surgery as a new method used for the first time at our department.

Uniportal Video-Assisted Thoracic Surgery for Pneumothorax: Real Alternative to Multiportal?

Alessandro Baisi, Federico Raveglia, Matilde De Simone, Ugo Cioffi

Ann Thorac Surg. 2018 Apr;105(4):1281. doi: 10.1016/j.athoracsur.2017.07.003.

No abstract.

Transcervical uniportal pulmonary lobectomy.

Marcin Zieli?ski, Tomasz Nabialek, Juliusz Pankowski

J Vis Surg. 2018 Feb 27;4:42. doi: 10.21037/jovs.2018.02.02. eCollection 2018.

Abstract

Background: The aim of the study is a description of surgical technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy.

Methods: We used a collar neck incision (transcervical) of an average length 5-8 centimeters. The manubrium of the sternum is elevated with a hook connected to the Zakopane II frame (Aesculap-Chifa, B. Braun, Nowy Tomy?l, Poland). The first step is a transcervical extended mediastinal lymphadenectomy (TEMLA), for improved staging and possible improved survival. The nodes removed during TEMLA undergo intraoperative imprint cytology examination. In case of no metastasis a uniportal VATS lobectomy through the neck follows. Ventilation of the operated lung is disconnected and the pleural cavity is entered by opening of the mediastinal pleura. Pleural adhesions, if present are managed with electrocautery. The branches of the pulmonary artery and vein are sequentially dissected and managed with endostaplers or vascular clips. The lobar bronchus and the fissures are divided with endostaplers and the resected lobe is removed in an endobag.

Results: There were 16 patients operated on in the period 1.2.2016-30.7.2016. There were two conversions-in one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. In the other patient undergoing right lower lobectomy there was a conversion to right thoracotomy because of the bleeding from the pulmonary artery. There was no mortality and complications occurred in three patients. The mean operative time was 245.6 min (range, 145-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 175.6 min (range, 75-295 min) for a lobectomy solely.

Conclusions: A uniportal transcervical VATS approach for pulmonary lobectomy combined with transcervical extended mediastinal lobectomy (TEMLA) provides an opportunity for radical pulmonary resection and superradical extensive mediastinal lymphadenectomy.

Micro-incision thoracoscopic treatment of primary spontaneous pneumothorax: the "loop" technique.

Alessio Campisi, Andrea Dell’Amore, Domenica Giunta, Stefano Congiu, Niccolò Daddi, Giampiero Dolci

J Vis Surg. 2018 Feb 10;4:35. doi: 10.21037/jovs.2018.02.01. eCollection 2018.

Abstract

Primary spontaneous pneumothorax has been defined as the disease of the 'young and healthy'. There are multiple possible therapies and in recent years, surgery has evolved towards the use of the uniportal thoracoscopic approach. The objective of our study is to describe and present an innovative approach to access to the thoracic cavity in patients with spontaneous pneumothorax. The surgery was performed using a single access of 20 mm at the level of the 8th intercostal space. For the isolation and suspension of any dystrophic area, we use a 'loop' of non-absorbable braided suture inserted through the IV intercostal space and successive wedge resection using an endoscopic 10 mm mechanical stapler. Using this access, we were able to visualize and dissect the pulmonary ligament and perform complete pleural abrasion. We had no complications. The operative time was 60 min, the chest tube was removed the 2th postoperative day and the patient was discharged the day after. The operation we propose permits the reduction of the dimension of the access to the thoracic cavity. We were able to resect blebs without problems, the recovery was excellent and no complications related to the procedure were reported.

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

Florian Augustin, Thomas Schmid

J Vis Surg. 2018 Feb 7;4:29. doi: 10.21037/jovs.2018.01.06. eCollection 2018.

Abstract

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

Which is the Best Minimal Invasive Approach for the Treatment of Spontaneous Pneumothorax? Uniport, Two, or Three Ports: A Prospective Randomized Trail.

Georg Thieme Verlag KG Stuttgart

Thorac Cardiovasc Surg. 2018 Feb 20. doi: 10.1055/s-0038-1629909. 

Abstract

OBJECTIVE:  Video-assisted thoracoscopic surgery (VATS) has become the standard treatment method for primary spontaneous pneumothorax. Concerns about lesser pain and better cosmesis led to the evolution of uniportal access. This study prospectively compared the results of the uniportal, two-port, and three-port thoracoscopic surgery.

MATERIAL AND METHODS:  One hundred and thirty-five patients were randomized into three groups according to the port numbers. The groups were compared regarding the operation time, hospital stay, amount of drainage, area of pleurectomy, complications, recurrences, and pain scores.

RESULTS:  Except for the amount of drainage (p = 0.03), no factors were found to be statistically significant. The overall recurrence rate was 5%. Although the first and second week pain scores were not statistically significant, the single-incision group patients had significantly less pain at 4, 24, and 72 hours (p < 0.05).

CONCLUSION:  The study indicated that uniportal VATS approach is less painful and has better cosmetic results, besides it is as efficient as two- or three-port VATS approach.

The state of uniportal video-assisted thoracoscopic surgery in North America: a survey of thoracic surgeons.

Ching Yeung, Sebastien Gilbert

J Vis Surg. 2018 Jan 18;4:19. doi: 10.21037/jovs.2018.01.03. eCollection 2018.

Abstract

Background: In recent years, there has been an exponential growth in the research and development of uniportal video-assisted thoracoscopic surgery (VATS). In the context of the 2017 Annual Asian Single-Port VATS Symposium held in Shanghai, China, we sought to describe current the state of uniportal VATS in North America and explore factors that could influence future adoption.

Methods: In March 2017, a five-question survey was distributed to North American Thoracic Surgeons in order to obtain their opinion regarding the uniportal VATS approach to pulmonary resection. Responses were summarized and statistical comparisons of categorical variables were performed using Fisher's exact test.

Results: The estimated response rate to the survey was 16.5% (99/600). The majority of respondents were experienced surgeons with 41.4% (41/99) having been in practice 11-20 years. The majority (70%; 69/99) of surgeons had never performed a uniportal VATS procedure. When surgeons were asked to state what could potentially convince them to adopt uniportal VATS, scientific evidence of superiority (86%; 85/99) and/or of superior ergonomics (39%; 39/99), attendance to focused conferences with a practical simulation component (38%; 38/99), and the availability of surgical proctorship (9%; 9/99) were the most commonly selected responses.

Conclusions: This survey is the first of its kind to provide a glimpse into the status of the uniportal VATS in North America. The responses suggest that there are few early adopters of this approach as compared to other parts of the world. The lack of perceived advantages to uniportal VATS and the need for more comparative evidence to other established approaches appear to be major obstacles to more widespread adoption in North America.

Uniportal non-intubated thoracic surgery.

Benedetta Bedetti, Davide Patrini, Luca Bertolaccini, Roberto Crisci, Piergiorgio Solli, Joachim Schmidt, Marco Scarci

J Vis Surg. 2018 Jan 18;4:18. doi: 10.21037/jovs.2017.12.09. eCollection 2018.

Abstract

Uniportal video-assisted thoracoscopic surgery (VATS) is the most advanced evolution of the minimally invasive technique, which allows often the possibility to include patients in enhanced recovery programs in order to optimize the therapeutic pathway, shorten the length of stay and reduce hospital costs. Non-intubated VATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax, which can provide a good lung isolation without the need of a double lumen tube. A survey between the members of the European Society of Thoracic Surgery (ESTS) showed that non-intubated VATS procedures are already performed by a large number of ESTS members for minor procedures. With the publication of new data and the spreading of uniportal VATS in many centers worldwide in the last decades, the application of the non-intubated technique in major procedure like anatomic resections is expected to grow. This technique can potentially be beneficial for high-risk patients but also could be used for the routine procedures as well, but more data are needed to establish the real benefit for these groups of patients.

Uniportal video-assisted thoracic lung segmentectomy with near infrared/indocyanine green intersegmental plane identification.

Elisa Meacci, Dania Nachira, Maria Teresa Congedo, Marco Chiappetta, Leonardo Petracca Ciavarella, Stefano Margaritora

J Vis Surg. 2018 Jan 18;4:17. doi: 10.21037/jovs.2017.12.16. eCollection 2018.

Abstract

In the era of lung cancer screening and early detection of lung lesions, pulmonary segmentectomy has gained wide acceptance between thoracic community reducing the need of lobectomy for diagnostic purpose and treatment in case of centrally located benign, multiple or undetermined lesions. In rigorously selected patients with stage I non-small cell lung cancer (NSCLC), segmentectomies seem to offer similar survival outcomes rather than lobectomies, but associated with a better conservation of lung function. However, segmentectomy is a more challenging procedure to be performed compared to lobectomy, especially by video-assisted thoracic surgery (VATS). Many difficulties could arise during video-assisted segmentectomy, making the procedure more demanding and stressful. Following the introduction of the near infrared (NIR)/indocyanine imaging system on standard endoscopic module, we decided to adopt peripheral intravenous injection of indocyanine green (ICG) to identify intersegmental plain during uniportal VATS lung segmentectomy. Our technique herein is widely illustrated.

Uniportal video-assisted thoracoscopic surgery (VATS) sleeve resections for non-small cell lung cancer patients: an observational prospective study and technique analysis.

Aris Koryllos, Erich Stoelben

J Vis Surg. 2018 Jan 17;4:16. doi: 10.21037/jovs.2017.12.22. eCollection 2018.

Abstract

Bronchus sleeve resection for operative treatment of non-small cell lung cancer (NSCLC) is a gold standard in modern thoracic surgery in cases of centrally located tumors or hilär lymph node metastases. Advanced instruments and growing surgical experience allowed surgeons to reduce the required incisions (from 3-port to uniportal) and to resect larger and more centrally located malignancies minimal invasively. It is a logical and expected advance in thoracic surgery that video-assisted thoracoscopic surgery (VATS) would be ultimately used also for complex bronchial resections. We therefore present in this study our early clinical results and technique of uniportal sleeve resections for patients with centrally located NSCLC or carcinoids. In the period 2015-2017, n:40 patients with NSCLC were found eligible for uniportal VATS sleeve resection in our institution. In two cases a thoracotomy conversion because of severe hilar scar tissue was necessary. In 38 cases a uniportal VATS sleeve resection could be completed. We believe that uniportal sleeve resections are the logical evolution of VATS allowing patients with locally advanced malignancies to have quicker recovery and reduced perioperative pain.

Subxiphoid uniportal video-assisted bilateral surgery: right upper lobectomy and left upper wedge resection S3.

Carlos Fernando Giraldo Ospina, Roberto Mongil Poce, Ricardo Arrabal Sánchez, Ricardo Medina Sánchez, Noelia Sánchez Martin, Diego Gonzalez Rivas

J Vis Surg. 2017 Dec 13;3:186. doi: 10.21037/jovs.2017.11.11. eCollection 2017.

Abstract

Traditional approach of bilateral lesions usually involves bilateral approaches instead of classical thoracotomy or video-assisted thoracoscopic surgery (VATS) surgery, and often at two different times. During visit of Dr. Gonzalez Rivas at Master Class to Málaga, we performed right upper lobectomy and S3 wedge resection left upper lobe of a two synchronous bilateral lung lesions case with subxiphoid single incision approach. We are reporting the first case of a lobectomy combined with a wedge resection performed through an uniportal subxiphoid bilateral VATS in Spain.

Uniportal video-assisted thoracoscopic resection of anterior segment of the left upper lobe.

Davor Stamenovic, and Antje Messerschmidt

Multimed Man Cardiothorac Surg. 2018 Jan 11;2018. doi: 10.1510/mmcts.2018.002.

Abstract

Anatomical segment resections are often technically more demanding than lobectomies. Anterior segment of the left upper lobe (S3) is usually removed within the standard resection of the upper three segments.    Our patient in this case was a 56-year-old with a known oropharyngeal carcinoma, otherwise amenable to curative treatment, who was admitted to our clinic with  a 1-cm nodule in the anterior segment of the left upper lobe.  Distant metastases were excluded, and a decision was made to proceed with a uniportal video-assisted thoracoscopic segmentectomy and lymphadenectomy. The procedure was successfully conducted without any adverse effects and the patient's postoperative course was uneventful.  The tumor was diagnosed as a primary solid 1-cm adenocarcinoma and the final stage was pT1aN0M0.

Uniportal video-assisted thoracoscopic surgery for anatomical fissureless anterior segment resection (S3) of the right upper lobe followed by lymph node dissection.

Davor Stamenovic, MD, and Antje Messerschmidt, MD

Multimed Man Cardiothorac Surg. 2018 Jan 11;2018. doi: 10.1510/mmcts.2018.001.

Abstract

Uniportal video-assisted thoracoscopic (UVATS) resections seem to offer real benefits over conventional surgery in terms of postoperative pain and better cosmetic results.  The procedure described in this tutorial, an anterior segment resection of the right upper lobe, is rarely performed, and fissureless resection of this segment by means of UVATS has, at time of writing, never been described in the literature.  Our patient was a 79-year-old female, admitted to our clinic for treatment of a solitary metachronous metastatic tumor of a colon carcinoma, located in the anterior segment of the right upper lobe. A fissureless anatomical anterior segment resection of the right upper lobe was conducted, followed by the radical lymph node dissection.  The postoperative course was event free and the patient was discharged on the 4th postoperative day. Fissureless VATS operations have an advantage compared to conventional operations in terms of reduced risk of prolonged air leak. Moreover, these operations take no longer to perform than conventional surgery and have no notable disadvantages, apart from the potential for using more staples.

Posterior uniportal video-assisted thoracoscopic surgery for anatomical lung resections.

Davor Stamenovic, Korkut Bostanci, Antje Messerschmidt

J Thorac Dis. 2017 Dec;9(12):5261-5266. doi: 10.21037/jtd.2017.11.64.

Abstract

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

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

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

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

Posterior uniportal video-assisted thoracoscopic surgery for anatomical lung resections.

Davor Stamenovic, Korkut Bostanci, Antje Messerschmidt

J Thorac Dis. 2017 Dec;9(12):5261-5266. doi: 10.21037/jtd.2017.11.64.

Abstract

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

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

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

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

Uniportal video-assisted thoracoscopic surgery in esophageal diseases: an introduction.

Toni Lerut

J Vis Surg. 2017 Dec 7;3:182. doi: 10.21037/jovs.2017.11.04. eCollection 2017.

Abstract

Esophagectomy followed by reconstruction is one of the most complex interventions in surgery of the alimentary tract. Over several decennia dedicated surgeons have realized a constant decrease in 30-day mortality being now well below 5% in expert hands. However quality of life after such intervention is often jeopardized by the high incidence of complications in particular pulmonary infections. The introduction and presently widespread use of total minimally invasive esophagectomy (MIE) has re resulted in a substantial decrease of these pulmonary complications along with a decrease of the need for ICU admission and a decrease of length of hospital stay. But still a non-negligible share of patients may suffer from, sometimes severe, posthoracotomy pain. A problem that is thought to be the result of the manipulation of instruments at the port sites causing damage to the intercostal nerves. The growing popularity of uniportal video-assisted thoracoscopic surgery (VATS) in particular in lung surgery claims to diminish this problem. Currently there is little experience in the use of uniportal VATS for esophagectomy which seems to be in part related to its higher degree of technical complexity. As a result there are no published data on the results but there are a few dedicated centers that are building up their experience. Their preliminary results seem to hold promising perspectives in relation to overcome the pain problem using a single small port site. Future will tell what the place will be of uniportal VATS versus other techniques e.g., robotic esophagectomy, endoscopic interventions on the esophagus and new emerging avenues in molecular biology.

Uniportal lobectomy and segmentectomy-is it for all?

Sameer A. Hirji, Stafford S. Balderson, Thomas A. D’Amico

J Vis Surg. 2017 Dec 7;3:180. doi: 10.21037/jovs.2017.11.09. eCollection 2017.

Abstract

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.

Subxiphoid uniportal VATS thymectomy.

Marcin Zieli?ski, Mariusz Rybak, Katarzyna Solarczyk-Bombik, Michal Wilkojc, Wojciech Czajkowski, Sylweriusz Kosinski, Edward Fryzlewicz, Tomasz Nabialek, Malgorzata Szolkowska, Juliusz Pankowski

J Vis Surg. 2017 Nov 17;3:171. doi: 10.21037/jovs.2017.09.13. eCollection 2017.

Abstract

Background: To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG).

Methods: Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed.

Results: There were four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity.

Conclusions: The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.

Uniportal subxiphoid video-assisted thoracoscopic approach for thymectomy: a case series.

Helen Weaver, Jason M. Ali, Lei Jiang, Chenlu Yang, Liang Wu, Gening Jiang, Giuseppe Aresu

J Vis Surg. 2017 Nov 17;3:169. doi: 10.21037/jovs.2017.10.16. eCollection 2017.

Abstract

Background: Minimally invasive techniques are becoming increasingly popular in thoracic surgery. Although median sternotomy is the traditional approach for thymectomy, video-assisted thoracoscopic surgery (VATS) approaches now predominate. This study reports a case series of the novel uniportal subxiphoid-VATS approach to extended thymectomy.

Methods: Over the period of study (October 2014-January 2017) 17 patients underwent uniportal subxiphoid-VATS extended thymectomy for a thymic nodule at the Shanghai Pulmonary Centre. Ten patients were female, and the mean age of the cohort was 55 years. The mean size of nodule was 23.6 mm.

Results: The mean operative duration was 2.5 hours, with one conversion to thoracotomy for bleeding. The mean operative blood loss was 115 mL. The median length of hospital stay was 4 days. There were no episodes of phrenic nerve palsies. The 30-day survival was 100%.

Conclusions: Uniportal subxiphoid-VATS is a feasible and safe surgical approach to extended thymectomy in selected patients, with good post-operative outcomes.

Bilateral uniportal video-assisted thoracic surgery segmentectomy S3: an unusual case.

Alonso José Oviedo Argueta, Sonia Raquelline Roque Cañas, Yuming Zhu, Diego Gonzalez-Rivas

J Vis Surg. 2017 Nov 11;3:168. doi: 10.21037/jovs.2017.10.13. eCollection 2017.

Abstract: 

When talking about lung cancer, it is important to recognize this as the first cause of death of neoplastic origin. The detection of this in early stages has made the emergence of ground glass opacity (GGO) more frequent due to the establishment of lung cancer screening programs, allowing the reduction of morbidity and mortality caused by the same and achieving a curative treatment of it. The management of multiple GGOs depends much on the characteristics of these, however, being multiple and contralateral should be considered surgical resection, always taking into account the stage of the dominant lesion. In this article, we present a case of a 60 years old woman with a bilateral GGO lesions located in segment 3 on both sides. A bilateral uniportal video-assisted thoracic surgery (VATS) anatomic segmentectomy S3 of both lesions was performed in a single stage surgery. The postoperative course of the patient was uneventful.

Uniportal video assisted thoracic surgery right main sparing lung bronchial resection: live surgery in Sao Paulo.

Rodrigo A. S. Sardenberg, Diego Gonzalez-Rivas

J Vis Surg. 2017 Nov 11;3:166. doi: 10.21037/jovs.2017.10.14. eCollection 2017.

Abstract: 

We report the first uniportal right main sparing bronchial resection in Brazil. The procedure was performed live at Hospital Alemão Oswaldo Cruz, São Paulo during the II Brazil uniportal video assisted thoracic surgery (VATS) advanced masterclass. Another uniportal VATS right upper lobectomy with bronchoplasty, uniportal VATS S6 left segmentectomy and a subxiphoid uniportal VATS mediastinal tumor, were performed as well. This VATS program was conducted in São Paulo for the first time in 2016. We hope to extend the course to other centers around the country in the next year.

Perspective on uniportal thoracic surgery: where do we stand and what is the future.

Marco Nardini, Rocco Bilancia, Joel Dunning

J Vis Surg. 2017 Nov 11;3:164. doi: 10.21037/jovs.2017.10.09. eCollection 2017.

Abstract

Uniportal video assisted thoracic surgery (U-VATS) is undoubtedly one of the recent most significant innovation in the field of pulmonary resection. The concept of a single incision, minimally invasive, thoracic procedure moved its first step in the late 90'. In more recent years we had several reports of uniportal surgery for major lung resection, complex surgery and also awake major pulmonary surgery. In this perspective we will try to understand the definitions, the potential benefit, its limitation and the future possible evolution of this relatively novel technique.

Unisurgeon' uniportal video-assisted thoracoscopic surgery lobectomy.

Diego Gonzalez-Rivas

J Vis Surg. 2017 Nov 7;3:163. doi: 10.21037/jovs.2017.10.07. eCollection 2017.

Abstract

The video-assisted thoracoscopic surgery (VATS) for major pulmonary resections has evolved in a period of only 7 years from 3-4 incisions to a single incision approach. However, Uniportal VATS approach is different from other forms of minimally invasive thoracic surgery, and the technique of lung exposure and stapler insertion through a single hole should be learned step by step. The main advances of uniportal VATS during the last years are related to improvements in surgical technique, evolving to a concept of "advanced VATS instrumentation", and implementation of new technology. One recent advance in uniportal VATS is the possibility of using a robotic or pneumatic articulated arm that holds the camera stable and no needs a surgical assistant. This is called "unisurgeon uniportal VATS" in where the surgeon has more freedom of movements and eliminates the fatigue of assistant holding the camera. We are still in the beginning of the "unisurgeon era" that probably will be more popular in the next coming years thanks to the Implementation of wireless cameras and graspers by means of magnetic control.

Uniportal sleeve lobectomy for lung cancer.

Dmitrii Sekhniaidze, Malik Agasiev, Tatyana Obuhova

J Vis Surg. 2017 Nov 7;3:159. doi: 10.21037/jovs.2017.08.17. eCollection 2017.

Abstract

Over the last years video-assisted thoracic surgery (VATS) has become more popular as it has a number of advantages comparing to the classical thoracotomy (less postoperative pain, reduced blood loss, cosmetic effect, etc.) A short time ago it was generally thought that it was impossible to make certain surgeries (including bronchoplasty) through single port approach. However, improvement of manual skills, more advanced stapling devices, tools and surgical needles have made it possible to perform surgeries practically of any extent observing the oncological principles of operational intervention.

A glance at the history of uniportal video-assisted thoracic surgery.

Tommaso Claudio Mineo, Vincenzo Ambrogi

J Vis Surg. 2017 Nov 7;3:157. doi: 10.21037/jovs.2017.10.11. eCollection 2017.

Abstract

In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.

Uniportal video-assisted thoracic surgery for esophageal cancer.

Hasan F. Batirel

J Vis Surg. 2017 Nov 6;3:156. doi: 10.21037/jovs.2017.09.14. eCollection 2017.

Abstract: Classical video-assisted thoracic surgery (VATS) approach to esophageal cancer uses four incisions. The rationale is to facilitate movement of the instruments and the esophagus and also suturing during placement of a purse-string suture for an intrathoracic anastomosis. Uniportal VATS (U-VATS) is challenge for surgeons, as you have to do an esophageal mobilization and anastomosis from a single 3–5 cm incision. The incision is placed either at the 5th or 6th intercostal space close to the posterior axillary line. Esophagus is mobilized en bloc with the subcarinal and periesophageal lymph nodes. The crucial parts are inclusion of subcarinal lymph node in the specimen, mobilization of the specimen from the left main bronchus and esophagogastric anastomosis. Esophagus is encircled with a thick penrose drain and retracted anterior and posteriorly during this dissection. Once the esophagus is completely mobilized, if an intrathoracic anastomosis is to be performed, gastric conduit is pulled inside the chest in correct orientation. A linear completely stapled side to side anastomosis is performed. A thick tissue endoscopic stapler is used for posterior and anterior wall. A single chest drain is placed and incision is closed. There are several intrathoracic anastomotic techniques. All of these techniques can be applied through a uniportal approach. Side to side completely stapled anastomosis is safe, fast and easy to perform. There is a single report on esophagectomy comparing uniportal and multiportal VATS approaches in esophageal cancer which showed comparable results in terms of duration of surgery, amount of bleeding, lymph node yield and leak rates. U-VATS for esophageal cancer is emerging as a new approach and the technique is feasible and certainly future studies will show if it is reproducible and provides a clinical advantage for the patient.

Nonintubated uniportal thoracoscopic wedge resection for early lung cancer.

Tung-Ming Tsai, Mong-Wei Lin, Hsao-Hsun Hsu, Jin-Shing Chen

J Vis Surg. 2017 Nov 6;3:155. doi: 10.21037/jovs.2017.08.21. eCollection 2017.

Abstract

Background: Minimal invasive surgery is current choice of treatment for lung cancer. Combined nonintubated anesthesia with uniportal thoracoscopic surgery is not well understood. Here, we report the experience of nonintubated uniportal thoracoscopic surgery in the treatment of primary non-small cell lung cancer (NSCLC).

Methods: From January 2014 to December 2015, we retrospectively reviewed 131 consecutive patients with primary NSCLC who underwent nonintubated uniportal thoracoscopic wedge resection and mediastinal lymph node dissection at a single medical center.

Results: Of the 131 patients, 110 (84%) received preoperative computed tomography-guided dye localization. Most of them were diagnosed with early stage invasive adenocarcinoma (N=112, 85.5%; pathological stage IA: 84.7%, N=111), and the mean size of the nodule was small (diameter: 0.85±0.40 cm). All section margins were free of malignancy. In total, 7 of the 131 patients (5.3%) had their treatment converted from uniportal to multi-portal video-assisted thoracoscopic surgery (VATS), and 1 (0.8%) had his treatment converted to endotracheal intubation with general anesthesia. The mean operation time was 91.1±32.6 minutes, and the postoperative complications included pneumonia (0.8%), prolonged air leaks (0.8%), and subcutaneous emphysema (1.5%).

Single incision extended video assisted transcervical thymectomy.

Marcello Migliore, Alessandra Criscione, Marco Nardini, Francesco Patti, Francesco Borrata

J Vis Surg. 2017 Oct 28;3:154. doi: 10.21037/jovs.2017.10.06. eCollection 2017.

Abstract: In the last 30 years the introduction of VATS in the surgical practice made possible to perform a wide range of thoracic operations including thymectomy. We describe our single incision video-assisted transcervical thymectomy (VATT) for non-thymomatous myasthenia gravis and/or small (<2 cm) intrathymic thymoma in 13 patients. The mean operation time was of 164 minutes (range; 45–275 minutes). The length of hospitalization was 3 days (range; 2–5 days). Decrease of symptoms was obtained in the entire group after a mean follow up of 79 months (range; 8–150 months); and two patients had a complete stable remission. In conclusion; single incision extended transcervical thymectomy (TT) is a safe and successful procedure which allows a complete excision of the anterior mediastinal fat.

Staged bronchial closure in uniportal video-assisted thoracoscopic anatomical resection for lung cancer with calcified lymph nodes.

Ying-Yuan Chen, Tzu-Hung Lin, Chao-Chun Chang, Wei-Li Huang, Yi-Ting Yen, Yau-Lin Tseng

J Vis Surg. 2017 Oct 28;3:149. doi: 10.21037/jovs.2017.08.16. eCollection 2017.

Abstract

Uniportal video-assisted thoracoscopic surgery (VATS) makes a breakthrough in these years. Even we have gained more experience and surgical skills of uniportal VATS, some elements, such as calcified perivascular lymph nodes, make the surgery challenging. In this series, we used staged bronchial closure (cut the bronchus first and then close it with stapler after dividing the pulmonary artery with calcified lymph node) as an approach for dealing with this challenging issue. Though the rate of intraoperative vessel injury is relatively high, we obtained ideal surgical outcome by using this technique in different lobes and segment of the lung.

Subxiphoid single incision thoracoscopic surgery approach for thymectomy: a case report.

Jay Karunanantham, Matthew Fok, Jason M. Ali, Adam Peryt, Aman Coonar, Giuseppe Aresu

J Vis Surg. 2017 Oct 27;3:147. doi: 10.21037/jovs.2017.10.03. eCollection 2017.

Abstract: 

Thoracic surgery is rapidly evolving with minimally invasive strategies now dominating. Thymectomy has traditionally been performed through a sternotomy, but more recently video-assisted thoracoscopic surgery (VATS) approaches have become increasingly popular. To further minimise surgical impact, the uniportal subxiphoid VATS technique has recently been described, using a muscle sparing incision that avoids intercostal nerve injury. A potential advantage that makes this approach particularly suited to thymectomy includes the ability to access both sides of the chest with a single incision. There is also the potential for reduced post-operative pain and chronic thoracostomy neuralgia. Here we describe the management of a patient with thymoma, reporting our procedure and technique for performing uniportal subxiphoid VATS thymectomy.

Subxiphoid approach for spontaneous bilateral pneumothorax: a case report.

Matthew Fok, Jay Karunanantham, Jason M. Ali, Serena Concina, Shruti Jayakumar, Adam Peryt, Aman Coonar, Giuseppe Aresu

J Vis Surg. 2017 Oct 27;3:146. doi: 10.21037/jovs.2017.10.02. eCollection 2017.

Abstract

The development of video-assisted thoracoscopic surgery (VATS) has contributed to reduced pain and improved recovery following thoracic surgery. However, pain remains a major issue. Patients with bilateral pulmonary pathology requiring operative intervention may have even more pain due to bilateral transthoracic incisions. The recently described uniportal subxiphoid VATS approach provides an opportunity to undertake bilateral thoracic surgery through a single incision that avoids the bilateral intercostal nerve damage caused by transthoracic incision and drainage. Here we report a case of a patient requiring bilateral bullectomy and pleurectomy for the management of pneumothorax that was performed successfully by the subxiphoid VATS approach.

Subxiphoid approach for a combined right upper lobectomy and thymectomy through a single incision.

Alonso José Oviedo Argueta, Sonia Raquelline Roque Cañas, Firas Abu Akar, Diego Gonzalez-Rivas

J Vis Surg. 2017 Aug 21;3:101. doi: 10.21037/jovs.2017.06.06. eCollection 2017.

Abstract

The subxiphoid uniportal video assisted thoracoscopic surgery (VATS) is a new interesting approach for the resection of anterior mediastinal masses and lung resections. For this reason in cases with both pathologies is an ideal approach to perform both procedures at the same time without multiple incisions. The evolution in the surgery of thymoma is getting less invasive, from the transsternal thymectomy to the minimally invasive Thoracic surgery improving the recovery of the patients and with satisfactory postoperative results, otherwise the anatomical view of the main structures and the recognition of the vascular anatomy, and his variants is feasible. In those cases with synchronic masses, the Subxiphoid approach is an ideal option in hands of experienced surgeons. In this video, we present the case of a right upper lobectomy and a thymectomy by subxiphoid approach in which the anatomical variations of the thymic artery are well recognized, and both procedures were completed without complications.

Uniportal video assisted thoracic surgery with 2 cm skin incision for right middle lobectomy with systematic lymphadenectomy.

Ruijun Liu, Qiang Tan, Jia Huang, Jiantao Li, Qingquan Luo

J Thorac Dis. 2017 Nov;9(11):4592-4596. doi: 10.21037/jtd.2017.10.40.

Abstract

Today, video-assisted thoracic surgery (VATS) was very popular and more and more common, which could be carried out at all levels of medical centers, most of which used multiple-ports VATS techniques. However, uniportal VATS was more difficult technique compared with multiple-ports VATS, and was not yet completely universal. Uniportal port VATS with 2 cm incision was more difficult surgery, and asked the surgeon to master more surgical techniques and good collaborations with each other, however, which not only could reduce the postoperative pain and skin numbness but supply cosmetology and psychological comfort for patients. To reduce unnecessary damage to patients, we minimized the incision to 2 cm. Therefore, we called it precise uniportal port VATS technique in our surgical center and introduced it here.

Spontaneous ventilation anesthesia combined with uniportal and tubeless thoracoscopic lung biopsy in selected patients with interstitial lung diseases.

Guilin Peng, Mengyang Liu Qun Luo, Hanzhang Chen, Weiqiang Yin, Wei Wang, Jun Huang, Yuan Qiu, Zhihua Guo, Lixia Liang, Qinglong Dong, Xin Xu, Jianxing He

J Thorac Dis. 2017 Nov;9(11):4494-4501. doi: 10.21037/jtd.2017.10.76.

Abstract

Background: The current guidelines emphasize the significant role of video-assisted thoracic surgical lung biopsy (VATS-LB) for a definite diagnosis of interstitial lung diseases (ILD), but they also encourage physicians to maintain the balance between the surgical benefits as well as risks. Both spontaneous ventilation video-assisted thoracic surgery (VATS) and uniportal VATS have emerged as remarkable progresses in VATS. We combined these two types of VATS and refined them to uniportal spontaneous ventilation VATS without urinary catheterization and chest tube drainage [uniportal and tubeless VATS (UT-VATS)] to perform LB in selected patients with ILD.

Methods: From January 2014 to May 2015, 43 patients were included in the study. The surgical data was retrospectively analyzed.

Results: The mean diffusion capacity for carbon monoxide (DLCO) of patients was 57.6%±13.0%, forced vital capacity (FVC) was 73.1%±17.0%. There was no 30-day mortality. No patient required a switch to intubated anesthesia. The mean age was 49.6±10.7 years. The general median operative duration was 22±5 minutes, with 25±3 minutes for multiple specimens and 15±2 minutes for single specimen, respectively. Intra-operative conversion to 2-portal VATS followed by chest tube drainage and urinary catheterization occurred in 3 (7.0%) patients due to extensive pleural adhesion, and postoperative chest tube insertion was documented in 1 (2.3%) patient due to subcutaneous emphysema. No postoperative mechanical ventilation was noted. Precise histopathological diagnosis was achieved in 38 (88.4%) patients.

Conclusions: Uniportal and tubeless thoracoscopic LB using spontaneous ventilation anesthesia can be considered a feasible and safe operation method for selected patients with ILD.

Uniportal video-assisted lobectomy through a posterior approach.

Francesco Paolo Caronia, Ettore Arrigo, Alfonso Fiorelli

J Thorac Dis. 2017 Oct;9(10):4057-4063. doi: 10.21037/jtd.2017.09.87.

Abstract

We propose a technique of uniportal VATS lobectomy using a posterior approach. The main differences of our technique versus standard anterior uniportal VATS are the following: (I) the surgical incision is performed in the auscultatory triangle instead of in the posterior axillary line and (II) the surgeon is placed posteriorly to the patient rather than anteriorly. For thoracic surgeons who are familiar with posterolateral thoracotomy, our technique allows to replicate the same maneuvers performed in the open approach. This strategy was applied with success in 19 consecutive patients for anatomical resection of neoplastic (n=17) and benign (n=2) diseases.

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

Veena Surendrakumar, Antonio E. Martin-Ucar, John G. Edwards, Jagan Rao, Laura Socci

J Thorac Dis. 2017 Oct;9(10):3896-3902. doi: 10.21037/jtd.2017.09.91.

Abstract

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.

Uniportal video-assisted thoracic surgery lobectomy in a patient with carcinoid tumor located at the orifice of the right lower lobe.

Semih Halezero?lu

J Thorac Dis. 2017 Sep;9(9):3288-3292. doi: 10.21037/jtd.2017.07.62.

Abstract

We present here a 47-year old male patient who had a typical carcinoid tumor located at the orifice of right lower lobe bronchus underwent uniportal thoracoscopic lower lobectomy following bronchoscopic removal of the endobronchial tumor. Tumor was seen by bronchoscopy to protrude out from the lower lobe into the intermediary bronchus obstructing the lower lobe completely and the middle lob partially. However, the origin of the endobronchial tumor was in the distal part of the lower lobe bronchus. In this case, open surgery could be an alternative to save the middle lobe by incising the lower lobe bronchus to pull out the endobronchial tumor first during thoracotomy. The other alternative could be a thoracoscopic lower bilobectomy for achieving a curative resection. In this patient, we performed sequential approaches at the same session as; bronchoscopic removal of the endobronchial tumor first, and then uniportal VATS lower lobectomy. Frozen section pathological analyses of bronchial stump of resected right lower lobe as well as the postoperative bronchoscopic biopsy confirmed a tumor-free margin. Patient was discharged on postoperative day four after an uneventful postoperative course.

Uniportal video-assisted thoracoscopic surgery left upper lobe trisegmentectomy using flexible tip 3D video scope.

Mathew Thomas

J Thorac Dis. 2017 Sep;9(9):3285-3287. doi: 10.21037/jtd.2017.07.61.

Abstract

A 69-year-old male patient with a history of melanoma and prostate cancer was found to have a 2.6 cm PET-avid, slowly enlarging, left upper lobe lung nodule that was suspicious for either metastasis or primary lung cancer. Due to the deep location of the nodule, a wedge resection was not recommended. A diagnostic and therapeutic uniportal video-assisted thoracoscopic surgery (U-VATS) left upper lobe trisegmentectomy was performed uneventfully. Final pathology confirmed the presence of metastasis from prostate cancer without lymph node involvement. His recovery was uneventful and he was discharged two days after surgery. In this video, we demonstrate our technique for left upper lobe lingula-sparing lobectomy (trisegmentectomy). More importantly, the video demonstrates that a thorough lymphadenectomy can be effectively performed during U-VATS lung resections.

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

Guofei Zhang, Zhijun Wu, Yimin Wu, Gang Shen, Ying Chai

J Thorac Dis. 2017 Sep;9(9):3280-3284. doi: 10.21037/jtd.2017.07.67.

Abstract

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.

Systemic tunnel dissection of mediastinal lymph nodes without clamping via uniportal video-assisted thoracoscopic surgery.

Jia-Tao Zhang, Song Dong, Xue-Ning Yang, Yi-Long Wu, Wen-Zhao Zhong

J Thorac Dis. 2017 Sep;9(9):3272-3274. doi: 10.21037/jtd.2017.07.66.

Abstract

Here we introduce a manual tunnel approach to remove the mediastinal lymph nodes and highlight the conception of non-clamping during dissection. We describe two cases of pulmonary malignancy performing a strategic lobectomy and systemic dissection of mediastinal lymph nodes via single port. The technique of tunnel dissection without clamping ensure to satisfy the requirement of oncology and clinical criteria. By efficiently specifying surgery procedure and improving dissection thoroughness, our approach should be implemented.

Left upper lobectomy and pulmonary angioplasty by uniportal video-assisted thoracic surgery.

Kaihua Tian, Ronghua Yang, Bin Han

J Thorac Dis. 2017 Sep;9(9):3269-3271. doi: 10.21037/jtd.2017.07.60.

Abstract

Diego Gonzalez-Rivas and his colleagues performed the first case for pulmonary major resection by the uniportal approach in 2010. In the following years, more and more expert surgeons developed the uniportal approach and even applied it to very complex cases. Many centers have showed that uniportal video-assisted thoracic surgery (VATS) lobectomy is a safe and feasible technique. The patient presented here is a complex case: The lingular segmental artery was invaded seriously by the tumor and it was difficult to divide it freely, and the pulmonary artery plasty was needed. Although this condition made the procedure some technically challenging, the case was performed successfully without any operative complications.

Single Versus Multi-Incisional Video-Assisted Thoracic Surgery: A Systematic Review and Meta-analysis.

, Rahouma Mohamed, Kamel Mohamed, Ghaly Galal, and Mohamed Abdelrahman

J Laparoendosc Adv Surg Tech A. 2018 Feb;28(2):174-185. doi: 10.1089/lap.2017.0446. Epub 2017 Nov 6.

Abstract

BACKGROUND: Video-Assisted Thoracic Surgery (VATS) is conventionally performed through multiple small incisions (C-VATS). Recent studies have reported encouraging results with the single-incision VATS (S-VATS) over the conventional technique. However, these studies were either small in size, unfocused, nonuniform, retrospective, lacking follow-up information, or focused on pain. We aim to validate previously reported results in a single large meta-analysis, including only the best evidence studies available.

METHODS: Systematic review of the PubMed archive was conducted to include only full English articles with Newcastle Ottawa Scale score ≥7. The primary outcome was the complications rate while secondary outcomes were operative time, resected lymph nodes (LNs), chest tube duration, estimated blood loss, length of postoperative stay (LOS), and postoperative pain on day 1 after surgery. Odds ratio and standard mean difference were used as effect estimates. Random model and leave-one-out analysis were used.

RESULTS: A total of 39 studies were included with 4635 patients (1686 S-VATS versus 2949 C-VATS). S-VATS has resulted in significantly less postoperative pain (P < .001), blood loss (P = .006), LOS (P < .001), and chest tube duration (P < .001). In lung cancer patients, the number of retrieved LNs was similar to that of C-VATS (P > .05). Subgroup comparison of the rate of complications between lung resections versus other intrathoracic procedures, lung cancer versus pneumothorax, and lung cancer versus other lung-only lesions did not show any significant differences between the groups.

CONCLUSION: Performing S-VATS technique has shown superior postoperative outcomes over the C-VATS technique in the treatment of thoracic disorders. Substantial benefit was confirmed in terms of less postoperative pain, blood loss, drainage time, and postoperative hospital stay.

Enhanced recovery after surgery using uniportal video-assisted thoracic surgery for lung cancer: A preliminary study.

Haitao Huang, Haitao Ma, and Shaomu Chen

Thorac Cancer. 2018 Jan;9(1):83-87. doi: 10.1111/1759-7714.12541. Epub 2017 Oct 31.

Abstract

BACKGROUND: This study investigated the clinical efficiency of enhanced recovery after surgery (ERAS) using uniportal video-assisted thoracoscopic surgery for lung cancer.

METHODS: The clinical data of 83 patients with early-stage non-small cell lung cancer (NSCLC) at the First Affiliated Hospital of Soochow University from January 2016 to February 2017 were retrospectively analyzed. ERAS was applied to 38 patients (ERAS group), while 45 patients received conventional surgical treatment (control group). The operative duration, number of lymph nodes retrieved, blood loss, visual analogue scale (VAS), postoperative duration of chest tube placement, length of hospital stay, and postoperative complications were compared between the groups.

RESULTS: Surgeries were conducted successfully in all patients, and no mortality occurred during the perioperative period. The ERAS group had better VAS on the third postoperative day, shorter chest tube duration, and shorter length of hospital stay (P < 0.05). No differences between the groups in terms of operative duration, number of lymph nodes retrieved, blood loss, VAS on the first postoperative day, or complication rate were found (P > 0.05).

CONCLUSIONS: ERAS using uniportal video-assisted thoracoscopic surgery for NSCLC patients is safe and practicable, and could also reduce the length of hospital stay.

Subxiphoid uniportal video-assisted thoracoscopic surgery for synchronous bilateral lung resection.

Yang, Xueying; Wang, Linlin

Postgrad Med. 2018 Jan;130(1):142-145. doi: 10.1080/00325481.2018.1398048. Epub 2017 Nov 6.

Abstract

OBJECTIVES: With advancements in medical imaging and current emphasis on regular physical examinations, multiple pulmonary lesions increasingly are being detected, including bilateral pulmonary lesions. Video-assisted thoracic surgery is an important method for treating such lesions. Most of video-assisted thoracic surgeries for bilateral pulmonary lesions were two separate operations. Herein, we report a novel technique of synchronous subxiphoid uniportal video-assisted thoracic surgery for bilateral pulmonary lesions.

METHODS: Synchronous bilateral lung resection procedures were performed through a single incision (~4 cm, subxiphoid).

RESULTS: This technique was used successfully in 11 patients with bilateral pulmonary lesions. There were no intraoperative deaths or mortality recorded at 30 days.

CONCLUSIONS: Our results show that the subxiphoid uniportal thoracoscopic procedure is a safe and feasible surgical procedure for synchronous bilateral lung resection with less surgical trauma, postoperative pain and better cosmetic results in qualifying patients. Further analysis is ongoing, involving a larger number of subjects.

Needlescopic-assisted uniportal video-assisted thoracoscopic pulmonary anatomical segmentectomy.

Shun-Mao Yang, Wen-Ting Wu, Yu-Hsuan Liu, Huan-Jang Ko

J Vis Surg. 2017 Sep 30;3:138. doi: 10.21037/jovs.2017.08.20. eCollection 2017.

Abstract

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.

Uniportal video-assisted thoracoscopic surgery in hemothorax.

Stefano Sanna, Luca Bertolaccini, Jury Brandolini, Desideria Argnani, Marta Mengozzi, Alessandro Pardolesi, Piergiorgio Solli

J Vis Surg. 2017 Sep 14;3:126. doi: 10.21037/jovs.2017.08.06. eCollection 2017.

Abstract

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

Nonintubated uniportal VATS pulmonary anatomical resections.

Carlos Galvez, Jose Navarro-Martinez, Sergio Bolufer, Francisco Lirio, Julio Sesma, Juan Manuel Corcoles

J Vis Surg. 2017 Sep 14;3:120. doi: 10.21037/jovs.2017.08.10. eCollection 2017.

Abstract

Nonintubated procedures have widely developed during the last years, thus nowadays major anatomical resections are performed in spontaneously breathing patients in some centers. In an attempt for combining less invasive surgical approaches with less aggressive anesthesia, nonintubated uniportal video-assisted thoracic surgery (VATS) lobectomies and segmentectomies have been proved feasible and safe, but there are no comparative trials and the evidence is still poor. A program in nonintubated uniportal major surgery should be started in highly experienced units, overcoming first a learning period performing minor procedures and a training program for the management of potential crisis situations when operating on these patients. A multidisciplinary approach including all the professionals in the operating room (OR), emergency protocols and a comprehensive knowledge of the special physiology of nonintubated surgery are mandatory. Some concerns about regional analgesia, vagal block for cough reflex control and oxygenation techniques, combined with some specific surgical tips can make safer these procedures. Specialists must remember an essential global concept: all the efforts are aimed at decreasing the invasiveness of the whole procedure in order to benefit patients' intraoperative status and postoperative recovery.

Uniportal non-intubated lung metastasectomy.

Tommaso Claudio Mineo, Francesco Sellitri, Eleonora Fabbi, Vincenzo Ambrogi

J Vis Surg. 2017 Sep 14;3:118. doi: 10.21037/jovs.2017.07.12. eCollection 2017.

Abstract

BACKGROUND: More than 15 years ago, we started a program of uniportal video-assisted thoracoscopies (VATS) lung metastasectomy in non-intubated local anesthesia. Hereby we present the short and long-term results of this combined surgical-anesthesiological technique.

METHODS: Between 2005 and 2015, 71 patients (37 men and 34 women) with pulmonary oligometastases, at the first episode, underwent uniportal VATS metastasectomy under non-intubated anesthesia.

RESULTS: Four patients (5.6%) required intubation for intolerance. Mean number of lesions resected per patient was 1.51. There was no mortality. The study group demonstrated a significant reduction of operative time from the beginning of the experience (P=0.001), good level of consciousness at Richmond scale and quality of recovery after both 24 and 48 hours. Median hospital stay was 3 days and major morbidity rate was 5.5%. Both disease-free survival and overall survival were similar to those achieved with intubated surgery.

CONCLUSIONS: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Long-term results were similar.

Uniportal video-assisted thoracoscopic surgery (VATS) technique is associated with decreased narcotic usage over traditional VATS lobectomy.

Scott Gregory Louis, William James Gibson, Chase Lynn King, Nirmal Kumar Veeramachaneni

J Vis Surg. 2017 Sep 14;3:117. doi: 10.21037/jovs.2017.08.05. eCollection 2017.

Abstract

BACKGROUND: Uniportal video-assisted thoracoscopic surgery (VATS) is gaining popularity internationally, but remains an uncommon practice in the United States. One proposed benefit is a decrease in narcotic usage and peri-operative pain when compared to traditional multiple incision VATS. The purpose of this study was to determine the post-operative narcotic usage between patients undergoing anatomic lobectomy via traditional VATS as compared to patients undergoing uniportal VATS.

METHODS: All consecutive patients undergoing anatomic lobectomy for presumed malignancy by a single surgeon at an academic medical institution were recorded between July 2013 and September 2015. Patients were excluded if they were narcotic dependent prior to the operation, if they had an epidural catheter placed, or if they were under 18 years of age. All narcotics were converted to oral morphine equivalents (OMEq) using standard formulas.

RESULTS: Data were collected on 84 patients. There was no difference between groups with regard to age, gender, tumor size, length of stay, or duration of post-operative thoracostomy. The groups had a similar rate of complications including post-operative atrial fibrillation and need for prolonged thoracostomy. Patients undergoing uniportal VATS had significantly lower narcotic usage in the recovery room, and on post-operative days 1 and 2. In addition, the total narcotic usage during their inpatient stay was significantly lower for patients undergoing uniportal VATS.

CONCLUSIONS: Uniportal VATS is a safe and effective strategy for the surgical management of benign and malignant lung disease. In patients undergoing anatomic lobectomy, there was an association with significantly less post-operative narcotic usage in patients undergoing uniportal VATS when compared to traditional VATS. This emerging technology may benefit patients by allowing less narcotic usage during their post-operative hospitalization.

Single-incision video-assisted thoracoscopic surgery left-lower lobe anterior segmentectomy (S8).

Carlos Galvez, Francisco Lirio, Julio Sesma, Benno Baschwitz, Sergio Bolufer

J Vis Surg. 2017 Aug 30;3:114. doi: 10.21037/jovs.2017.08.02. eCollection 2017.

Abstract

Unusual anatomical segmentectomies are technically demanding procedures that require a deep knowledge of intralobar anatomy and surgical skill. In the other hand, these procedures preserve more normal lung parenchyma for lesions located in specific anatomical segments, and are indicated for benign lesions, metastasis and also early stage adenocarcinomas without nodal involvement. A 32-year-old woman was diagnosed of a benign pneumocytoma in the anterior segment of the left-lower lobe (S8, LLL), so we performed a single-incision video-assisted thoracoscopic surgery (SI-VATS) anatomical S8 segmentectomy in 140 minutes under intercostal block. There were no intraoperative neither postoperative complications, the chest tube was removed at 24 hours and the patient discharged at 5th postoperative day with low pain on the visual analogue scale (VAS). Final pathologic exam reported a benign sclerosant pneumocytoma with free margins. The patient has recovered her normal activities at 3 months completely with radiological normal controls at 1 and 3 months.

Anaesthesiology for uniportal VATS: double lumen, single lumen and tubeless.

Ze-Rui Zhao, Rainbow W. H. Lau, Calvin S. H. Ng

J Vis Surg. 2017 Aug 21;3:108. doi: 10.21037/jovs.2017.07.05. eCollection 2017.

Abstract

The advent of one-lung ventilation (OLV) technique provides immobilized surgical field which is fundamental in minimally invasive thoracic surgery. Mainstem methods of achieving lung separation are either via a double-lumen endotracheal tube or placing a bronchial blocker (BB) through a single-lumen endotracheal tube. More recently, the use of non-intubated thoracic surgery (NITS) has been investigated intensively, attempting to minimise the complications that follow general anaesthesia. The aim of this review is to describe the mechanism of these techniques briefly and outlines the advantages and drawbacks of them with the comparison.

Uniportal video-assisted thoracic surgery for pneumothorax and blebs/bullae.

Luca Bertolaccini, Alessandro Pardolesi, Jury Brandolini, Piergiorgio Solli

J Vis Surg. 2017 Aug 21;3:107. doi: 10.21037/jovs.2017.07.04. eCollection 2017.

Abstract

The last British Society of Thoracic Surgeons guidelines of 2010 for the management of primary spontaneous pneumothorax (PSP) stated that, after the first recurrence, the treatment of PSP should be a surgical operation, like a bullectomy accompanying with a procedure for inducing pleural adhesions. Therefore, the surgical approach is considered the best treatment to minimise the risk of recurrence in patients who experienced a PSP. There is substantial evidence in the literature demonstrating that the minimally invasive approach should be preferred to the thoracotomic procedure since it can reduce the postoperative pain and it is associated with a faster recovery of the physical and working activity. The video-assisted thoracic surgery (VATS) approach has been shown to offer greater advantages about patient pain and respiratory function when compared to thoracotomic incisions. A single port or single incision or uniportal approach was developed as an alternative to the standard multi-port VATS. Uniportal technique has shown to be safe and efficient not only for pulmonary resections and biopsies but also for lobectomy. When used for PSP, the bullectomy/blebectomy and pleural abrasion/pleurectomy is performed through the single incision through which the chest drain is then inserted. In this perspective, evidence showed that the minimally invasive approach should be preferred, confirming the advantages in comparison with traditional techniques.

For which thoracic operation is U-VATS superior?

Kyoji Hirai, Yutaka Enomoto, Jitsuo Usuda

J Vis Surg. 2017 Aug 21;3:103. doi: 10.21037/jovs.2017.07.06. eCollection 2017.

Abstract

In this special issue, I review the types of thoracic surgery that uniportal video-assisted thoracic surgery (U-VATS) is most suited to.

Subxiphoid complex uniportal video-assisted major pulmonary resections.

Diego Gonzalez-Rivas, Francisco Lirio, Julio Sesma, Firas Abu Akar

J Vis Surg. 2017 Jul 26;3:93. doi: 10.21037/jovs.2017.06.02. eCollection 2017.

Abstract

In recent years, the search for a less invasive and thus, less painful approach has driven technical innovation in modern thoracic surgery. In this context, subxiphoid uniportal approach has emerged as an alternative to avoid intercostal space manipulation and decrease postoperative pain and intercostal nerve chronic impairment. Subxiphoid uniportal major lung resections have been safe and effective procedures when performed by experienced surgeons even in complex cases or unexpected intraoperative situations. We present six of these surgical scenarios such as big tumors, incomplete or absent fissures, hilar calcified lymph nodes, active bleeding and massive adhesions to show the feasibility of subxiphoid approach to manage even these conditions.

Unusual case of subxiphoid uniportal VATS right upper lobectomy in a patient with interrupted inferior vena cava with azygous continuation.

Firas Emad Abu Akar, Chenlu Yang, Yiming Zhou, Lei Lin, Diego Gonzalez-Rivas, Lei Jiang

J Vis Surg. 2017 Jul 26;3:92. doi: 10.21037/jovs.2017.06.08. eCollection 2017.

Abstract

Interrupted IVC (also known as Azygos continuation of the inferior vena cava) is a relatively uncommon congenital condition with prevalence 1.5% (0.2-3%) of the general population (Bass et al.). Although it's usually asymptomatic condition, splenic or cardiac abnormalities could be associated (Hardwick et al.). Incidental diagnosis during prenatal ultrasound screening or by routine imaging is the most common scenario. Special attention is required during right side thoracic procedures surgical resections in order to avoid scarifying the azygos vein that could lead to fatal results (Effler et al.). We herein report a video documented case of right upper lobectomy and mediastinal lymph node dissection for non-small cell carcinoma of lung in a patient who had interrupted hepatic segmental branch of the IVC. The procedure was performed via the subxiphoid uniportal VATS approach.

Uniportal anatomic combined unusual segmentectomies.

Diego González-Rivas, Francisco Lirio, Julio Sesma

J Vis Surg. 2017 Jul 26;3:91. doi: 10.21037/jovs.2017.05.12. eCollection 2017.

Abstract

Nowadays, sublobar anatomic resections are gaining momentum as a valid alternative for early stage lung cancer. Despite being technically demanding, anatomic segmentectomies can be performed by uniportal video-assisted thoracic surgery (VATS) approach to combine the benefits of minimally invasiveness with the maximum lung sparing. This procedure can be even more complex if a combined resection of multiple segments from different lobes has to be done. Here we report five cases of combined and unusual segmentectomies done by the same experienced surgeon in high volume institutions to show uniportal VATS is a feasible approach for these complex resections and to share an excellent educational resource.

First uniportal video assisted thoracic surgery masterclass in Ecuador.

John Barba-Pacheco, Gutenberg Navarro, Diego Gonzalez-Rivas, Fernando Polit, Pamela Wong, Fabrizio Nieto, Manuel Romero, Jaime Carrera, Jonathan Villacis, Martha J. Zambrano, Karina Bravo, Renee Velastegui, Freddy Rodríguez, Manuel Reyes, Silvia Cullacay, Ramiex Cercado, Sara Salvatierra

J Vis Surg. 2017 Jun 4;3:77. doi: 10.21037/jovs.2017.05.11. eCollection 2017.

Abstract

Currently video-assisted thoracic surgery (VATS) and the evolution Uniportal VATS have a worldwide acceptance and Ecuador is not exception when we decided invited to Dr. Diego Gonzalez-Rivas pioneer surgeon in the world of single-port video-assisted thoracoscopic procedures, with the aim to provide a faster recovery of the patients compared to those who received a conventional thoracotomy. We thanks the opportunity to present a report to the first Masterclass in Uniportal VATS with live surgery, performed on February 23rd to 24th of 2017 at the Luis Vernaza Hospital in Guayaquil-Ecuador. In addition to demonstrate the efficacy and safety of the uniportal VATS technique we presented a video of uniportal VATS left lower lobectomy performed by Dr. Diego Gonzalez-Rivas during the first uniportal masterclass in Guayaquil, Ecuador.

Uniportal bilateral video-assisted sequential thoracoscopic extended thymectomy.

Francesco Paolo Caronia, Ettore Arrigo, Sebastiano Trovato, Attilio Ignazio Lo Monte, Salvatore Cottone, Francesco Sgalambro, Mario Guglielmo, Antonio Volpicelli, Alfonso Fiorelli

J Vis Surg. 2017 May 11;3:69. doi: 10.21037/jovs.2017.03.29. eCollection 2017.

Abstract

Standard video-assisted thoracoscopic surgery has been reported as a minimally invasive approach alternative to sternotomy for management of myasthenia gravis (MG) associated with thymoma or thymic hyperplasia. Uniportal video-thoracoscopy is an evolution of standard multi-portal video-thoracoscopy for management of several thoracic diseases but its role for resecting mediastinal tumor remains under-evaluated. Herein, we describe our experience with bilateral uniportal thoracoscopic sequential extended thymectomy with case and video illustrations.

Uniportal video-assisted thoracoscopic surgery, Argentinian experience.

Gustavo Bondulich, Diego Gonzalez Rivas

J Vis Surg. 2017 May 4;3:60. doi: 10.21037/jovs.2017.03.21. eCollection 2017.

Abstract

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.

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

William Guido Guerrero, Diego González-Rivas

J Vis Surg. 2017 Apr 14;3:56. doi: 10.21037/jovs.2017.03.11. eCollection 2017.

Abstract

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.

Intra-pericardial double sleeve uniportal video-assisted thoracoscopic surgery left upper lobectomy.

Firas Abu Akar, Chenlu Yang, Lei Lin, Shi Jia Min, Lei Jiang

J Vis Surg. 2017 Apr 10;3:51. doi: 10.21037/jovs.2017.03.07. eCollection 2017.

Abstract

The importance of parenchymal tissue preservation during lung resections is well realized in thoracic surgery. Technical refinement and anatomic insight have expanded indications for parenchymal -sparing surgeries. In thoracic surgery, it's reasonable to avoid pneumonectomy whenever it's possible, although challenging and technically more demanding than standard anatomic pulmonary resection, bronchial and/or vascular resection of a circumferential portion (sleeve resections) is a justified procedure due to its benefits of avoiding the complications of pneumonectomy in addition to preservation of pulmonary tissue and functions. In The era of video assisted thoracoscopic surgery's revolution and with the improvement of the surgical instruments and surgeon's experience, reports on multiportal and uniportal sleeve and double sleeve resections published recently in the literature. Here we present a video documented case of the Intra-pericardial double sleeve left upper lobectomy that demonstrates our technique in performing this surgery via uniportal approach.

The Athens uniportal video-assisted thoracic surgery masterclass-an ambitious kickstarter.

Constantine Marios Soultanis, Diego Gonzalez Rivas, Konstantinos Konstantinidis, Konstantinos Siafakas

J Vis Surg. 2017 Apr 10;3:50. doi: 10.21037/jovs.2017.03.02. eCollection 2017.

Abstract

The shift from open to minimally invasive techniques in thoracic surgery has been dramatic during the past 10 years. Not only the feasibility, safety, reproducibility and oncologic efficacy of these techniques have been clearly demonstrated, but also their superiority concerning mortality, postoperative pain, postoperative quality of life and recovery. Thus, video-assisted thoracic surgery (VATS) is currently the procedure of choice for a wide variety of thoracic interventions, ranging from major pulmonary resections for lung cancer to thymectomy and mediastinal procedures, even to esophageal procedures. Amongst the various minimally invasive techniques, the uniportal or single incision VATS has recently gained great popularity. The concept of a single 2.5 cm incision, despite not being the technique's only advantage, through which major thoracic procedures can be carried out, seems to greatly appeal to surgeons throughout the globe. Appealing as it may be, the technique is also demanding, revealing the need for training. A well organised and structured, fee free training programme that has been running at the Shanghai Pulmonary Hospital for more than 2 years under the inspirational guidance of Dr. Gonzalez Rivas has undoubtedly skyrocketed the technique's adoption worldwide. Of equal significance towards the spread of the technique have proved to be the master classes, 2-day intensive tutorials, hosted by centres all over the world during which Dr Rivas outlines the principles of the technique before performing with the assistance of the local surgical team. We hereby reflect on the experience obtained following Riva's visit to our institution in Athens, Hellas (Greece) for a 2-day uniportal VATS master class, the first held in Hellas.

Teaching uniportal video-assisted thoracic surgery in Rome.

Elisa Meacci, Dania Nachira, Maria Teresa Congedo, Stefano Margaritora

J Vis Surg. 2017 Apr 10;3:49. doi: 10.21037/jovs.2017.02.11. eCollection 2017.

Abstract

Uniportal video-assisted thoracic surgery (VATS) has recently gained popularity as procedure for major lung resections, and actually seems to be the future of thoracic surgery. Uniportal VATS has shown to be feasible and safe as thoracotomy when a correct and appropriate learning curve is done. However, switching from open or triportal VATS to uniportal VATS approach requires a proper training and a consequent learning curve even among experienced thoracoscopic surgeons.

Non-intubated uniportal left-lower lobe upper segmentectomy (S6).

Carlos Galvez, Jose Navarro-Martinez, Sergio Bolufer, Julio Sesma, Francisco Lirio, Maria Galiana, Maria Jesus Rivera

J Vis Surg. 2017 Apr 10;3:48. doi: 10.21037/jovs.2017.03.12. eCollection 2017.

Abstract

Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures.

From full thoracotomy to uniportal video-assisted thoracic surgery: lessons learned.

Eliseo Passera, Gaetano Rocco

J Vis Surg. 2017 Mar 30;3:36. doi: 10.21037/jovs.2017.01.14. eCollection 2017.

Abstract

Over the last two decades, conventional video-assisted thoracic surgery (VATS) has established itself as the preferred approach for almost all thoracic surgical procedures. The procedure provides a safe and easy approach with undisputed patient benefit at a cost acceptable to the healthcare system all over the world, in large hospitals as well as underprivileged rural areas. VATS has effectively addressed the patients' right to less scarring, trauma (both of access and intrathoracic manipulation), medication, pain, hospitalization, and early return home and work. These improvements have been further stressed by the introduction of uniportal VATS (uniVATS). Single port surgery is a very exciting new modality in the field of minimal access surgery which aims at further reducing scars of standard vats and towards an hypothetical prospective of scarless surgery.

Technological aids in uniportal video-assisted thoracoscopic surgery.

Sonia Raquelline Roque Cañas, Alonso José Oviedo Argueta, Ching Feng Wu, Diego Gonzalez-Rivas

J Vis Surg. 2017 Mar 17;3:29. doi: 10.21037/jovs.2017.01.05. eCollection 2017.

Abstract

With the evolution of uniportal video-assisted thoracoscopic surgery (VATS), the technological aids have come to help skill surgeons to improve the results in thoracic surgery and feasible to perform a complex surgery. The technological aids are divided into three important groups, which make surgical steps easy to perform, besides reducing surgical time and surgical accidents in the hands of experienced surgeons. The groups are: (I) conventional thoracoscopic instruments; (II) sealing devices using in uniportal VATS; (III) high definition cameras, robotic arms prototype and the future robotic aids for uniportal VATS surgery. Uniportal VATS is an example of the continuing search for methods that aim to provide the patient a surgical cure of the disease with the lowest morbidity. That is the reason companies are creating more and new technologies, but the surgeon have to choose properly and to know how, when and where is the moment to use each new aids to avoid mistakes. The future of the thoracic surgery is based on evolution of surgical procedures and innovations to try to reduce even more the surgical and anesthetic trauma. This article summarizes the technological aids to improve and help a thoracoscopics surgeons perform a uniportal VATS feasible and safe.

Subxiphoid uniportal lobectomy.

Mohamed M. Moneer ElSaegh, Nur Aziah Ismail, Mohamed I. Mydin, Marco Nardini, Joel Dunning

J Vis Surg. 2017 Mar 8;3:24. doi: 10.21037/jovs.2016.12.05. eCollection 2017.

Abstract

Video-assisted thoracic surgery (VATS) surgery has seen an evolution from multiple ports to uniportal and finally subxiphoid uniportal recently. In traditional VATS surgery, the instruments and the thoracoscope enter the thoracic cavity through two to four operating ports on the lateral chest wall, which can cause chronic pain and chest wall numbness. However single-portal VATS surgery could potentially cause similar problems as the port is placed in between the ribs. In March 2015 Liu et al. reported a VATS bilateral pulmonary metastasectomy and right middle lobectomy via a subxiphoid uniportal technique. The advantage of the uniportal subxiphoid approach is the ability to use different size of instruments and freedom of movement as there is no limitation by the ribs. Post-operative pain typically experienced due to bruising of the intercostal nerves is also avoided in this approach. Shanghai Pulmonary hospital has taken VATS surgery to the next level with subxiphoid uniportal VATS (SVATS) lung resection, whereby this method is performed in large volumes of cases. Here we describe our experience of a uniportal subxiphoid VATS right middle lobectomy using the Shanghai technique, the first in the UK. A uniportal sub-xiphoid lobectomy was performed on a 62-year-old lifelong smoker male patient with a histological diagnosis of right middle lobe adenocarcinoma, measuring 1.5 cm and radiological staging of T1aN0M0. We have been performing microlobectomies in our institution (with the utility port placed in the subxiphoid region) which is technically similar to this approach. This is the first subxiphoid uniportal lobectomy performed in the UK. The operation was done successfully and the patient was discharged home 2 days later without any complications.

Magnetic anchoring guidance system in video-assisted thoracic surgery.

Agnese Giaccone, Piergiorgio Solli, Luca Bertolaccini

J Vis Surg. 2017 Feb 13;3:17. doi: 10.21037/jovs.2017.01.13. eCollection 2017.

Abstract

The magnetic anchoring guidance system (MAGS) is one of the most promising technological innovations in minimally invasive surgery and consists in two magnetic elements matched through the abdominal or thoracic wall. The internal magnet can be inserted into the abdominal or chest cavity through a small single incision and then moved into position by manipulating the external component. In addition to a video camera system, the inner magnetic platform can house remotely controlled surgical tools thus reducing instruments fencing, a serious inconvenience of the uniportal access. The latest prototypes are equipped with self-light-emitting diode (LED) illumination and a wireless antenna for signal transmission and device controlling, which allows bypassing the obstacle of wires crossing the field of view (FOV). Despite being originally designed for laparoscopic surgery, the MAGS seems to suit optimally the characteristics of the chest wall and might meet the specific demands of video-assisted thoracic surgery (VATS) surgery in terms of ergonomics, visualization and surgical performance; moreover, it involves less risks for the patients and an improved aesthetic outcome.

The Shanghai Pulmonary Hospital uniportal subxiphoid approach for lung segmentectomies.

Giuseppe Aresu, Helen Weaver, Liang Wu, Lei Lin, Gening Jiang, Lei Jiang

J Vis Surg. 2016 Dec 2;2:172. doi: 10.21037/jovs.2016.11.07. eCollection 2016.

Abstract

BACKGROUND: Lung segmentectomy may be considered an oncologic equivalent treatment to lobectomy for non-small cell lung cancer (NSCLC) sized 20 mm or smaller. Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) could further improve the surgical outcome reducing the surgical stress and completely avoiding the intercostal nerve injury. The aim of this manuscript is to illustrate the Shanghai Pulmonary Hospital surgical techniques for uniportal subxiphoid VATS (SVATS) segmentectomies.

METHODS: A total of 79 consecutive patients underwent 84 subxiphoid segmentectomies for malignant or benign pulmonary diseases between September 2014 and January 2016. We here illustrate the surgical techniques and the early results.

RESULTS: There were 45 segmentectomies in right-side group and 39 segmentectomies left-side group. The mean operation time was 2.38±0.77 hours, and mean operative blood loss was 126.09±136.17 mL. Nine segmentectomies (10.7%) had an intra-operative change of procedure and four were converted to thoracotomy, one had a lobectomy rather than a segmentectomy and four were converted to conventional VATS lobectomy. A total of 12 patients (15.1%) had postoperative complications, including 1 hematoma, 4 prolonged air-leaks and 8 arrhythmias.

CONCLUSIONS: In the presented series that included our learning curve period we have experienced relative low conversion rates and few post-operatively complications showing that, SVATS segmentectomy can be considered a safe procedure with a relative low rate early post-operative complication

Uniportal subxiphoid video-assisted thoracoscopic bilateral segmentectomy for synchronous bilateral lung adenocarcinomas.

Giuseppe Aresu, Helen Weaver, Liang Wu, Lei Lin, Sandro Sponga, Gening Jiang, Lei Jiang

J Vis Surg. 2016 Nov 30;2:170. doi: 10.21037/jovs.2016.11.02. eCollection 2016.

Abstract

Uniportal subxiphoid video assisted bilateral segmentectomy is a minimally invasive option for the treatment of synchronous bilateral lung lesions. Its advantages over conventional multiportal or uniportal video assisted thoracoscopic surgery include avoidance of damage to the intercostal neurovascular bundle and allowance of bilateral lesion resection as a combined procedure via a single incision. This article presents a case from our centre to describe our surgical technique for this procedure.

Uniportal video-assisted thoracic surgery Ivor Lewis esophagectomy.

Sekhniaidze Dmitrii, Agasiev Malik

J Vis Surg. 2016 Oct 20;2:163. doi: 10.21037/jovs.2016.10.01. eCollection 2016.

Abstract

Esophageal cancer is one of the most debilitating diseases, and treatment of patients with this medical condition is considered to be one of the most complicated problems in clinical oncology. The up-to-date tendency of bringing minimally-invasive surgeries into more widespread use makes it necessary to invent new techniques to solve some or other tasks including those accompanying esophageal diseases. This article shows our innovation minimally-invasive technique of Ivor Lewis esophagectomy.

Uniportal right upper video-assisted thoracoscopic surgery lobectomy: safe and feasible.

Valerio Perna, Juan A. Torrecilla, Angel F. Carvajal, Luís Carlos Mora, Orlando Gigirey, Paulo Cano, Silvia Perello, Rosa Diaz

J Vis Surg. 2016 Sep 19;2:160. doi: 10.21037/jovs.2016.09.04. eCollection 2016.

Abstract

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy is now well established and performed all around the world. We are going to share the surgical technique for uniportal VATS right upper lobectomy based on our experience. A 62-year-old patient underwent Uniportal VATS right upper lobectomy for a primary non-small cell lung cancer (NSCLC). Our patient had no perioperative complications and was then discharged to his home on postoperative day 4. The patient's pain was managed with a paravertebral catheter during the first 48 hours and then with oral analgesics. Pathology report: well-differentiated adenocarcinoma; the size of the tumour was 1 cm × 0.8 cm × 1 cm; all margins were negative for residual tumour. The patient did not require adjuvant radiation or chemotherapy. Uniportal VATS lobectomy is a safe and effective procedure providing a favourable clinical outcome in the patient.

Uniportal video-assisted thoracic surgery lobectomy using a novel perfused ex vivo simulation model.

Ruben Avila, Pablo Achurra, Rodrigo Tejos, Julian Varas, María Solovera, Patricio Salas

J Vis Surg. 2016 Sep 8;2:155. doi: 10.21037/jovs.2016.08.12. eCollection 2016.

Abstract

Simulation may provide a solution to acquire advanced skills in thoracic surgery, however to date there are no reports in the English literature about a perfused ex vivo model. We developed a low cost and hi fidelity model using an ex vivo in bloc heart and lung specimen from a swine. The swine was previously used in a non-thoracic experiment, so we extracted the lung and heart for this ex vivo based model to reduce animal use. The cost of the whole model is 70 USD and it can be reused many times changing the ex vivo tissue, so this model may help reduce the costs and animal use associated to this high complexity surgery.

Uniportal video-assisted thoracoscopic anatomic segmentectomy for small-sized lung cancer.

Guangsuo Wang, Zheng Wang, Xuefeng Sun, Tonghai Huang, Guanggui Ding

J Vis Surg. 2016 Sep 8;2:154. doi: 10.21037/jovs.2016.08.08. eCollection 2016.

Abstract

Increasing evidences prove video-assisted thoracic surgery (VATS) segmentectomy is accepted as a valid alternative to lobectomy esp. a greater number of small lung nodules have been detected. Uniportal VATS segmentectomy for small-sized lung cancer is more challenging not only for technical issues in simple or complex uniportal segmentectomy, but also considering oncological efficacy in terms of localization, safe margin, the extent of lymph node dissection and pathological analysis. In this work, we evaluated our evolving uniportal experience, the surgical technique and decision-making of uniportal VATS segmentectomy for small-sized lung cancer.

Uniportal video-assisted thoracic surgery for complicated pulmonary resections.

Ding-Pei Han, Jie Xiang, Run-Sen Jin, Yan-Xia Hu, He-Cheng Li

J Vis Surg. 2016 Sep 1;2:150. doi: 10.21037/jovs.2016.08.06. eCollection 2016.

Abstract

In the past 20 years, video-assisted thoracic surgery has made a great progress, from 4-ports to 2-ports, and eventually to this revolutionary approach-uniportal video-assisted thoracic surgery (VATS). It can share the same instruments, the same surgical principles, the same strategies of trouble-shooting and the same postoperative short-term outcomes with conventional VATS via the improvement of instruments and surgical skills. And it has already been safe to adopt uniportal VATS in complicated pulmonary resections. In this study, we shared five video clips about uniportal VATS for complicated pulmonary resections: sleeve resection, segmentectomy, pneumonectomy and angioplasty. We hope these video clips can be instrumental for young surgeons.

Single port video-assisted thoracoscopic thymectomy.

Benedetta Bedetti, Pierfiorgio Solli, David Lawrence, Nikolaos Panagiotopoulos, Martin Hayward, Marco Scarci

J Vis Surg. 2016 Sep 1;2:149. doi: 10.21037/jovs.2016.08.07. eCollection 2016.

Abstract

Over the past decade, video-assisted thoracic surgery (VATS) has started to replace median sternotomy for the resection of non-invasive anterior mediastinal masses, including thymoma. In fact, many studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for non-invasive thymomas as long as en bloc resection of the tumour is achieved. Classically three ports are used, but the current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paraesthesia, and length of hospitalization. Uniportal VATS thymectomy for non-invasive mediastinal tumour resection is proven to be a safe and reliable method. In this paper we describe and illustrate our technique for single port VATS thymectomy.

Improved Closure Technique for Uniportal Video-Assisted Thoracic Surgery: Double-Embedding Stitching Method.

Lufeng Zhao, MD, Wenshan Li, MD, Ying Chai, MD

Ann Thorac Surg. 2017 Nov;104(5):1760-1761. doi: 10.1016/j.athoracsur.2017.01.036.

Abstract:

We read the articles by Son and colleagues [1] and Yang and colleagues [2] with great interest. Both of them showed concern about peritubular leakage and cosmesis of the incision after uniportal video-assisted thoracic surgery (VATS). Son and colleagues [1] moved the incision site down to the rib surface and used nylon for tube fixation that is anchored through the subcutaneous suture, whereas Yang and colleagues [2] placed the drainage tube within the intercostal space above the incision. We found that Son and colleagues’ technique may cause additional operational inconvenience in some patients, whereas Yang and colleagues’ method may cause damage to two intercostal nerves.

Bilateral uniportal video-assisted thoracoscopic lung resections.

Firas Emad Abu Akar Hui Zheng Gaser Ali Xiaogang Zhao

Interact Cardiovasc Thorac Surg. 2017 Dec 1;25(6):1012-1013. doi: 10.1093/icvts/ivx181.

Abstract

The introduction of uniportal video-assisted thoracoscopic surgery into the field of minimally invasive thoracic surgery has its revolutionary effect by bringing the surgical trauma to the minimum. As a result, less postoperative pain and complications may be achieved through this technology. This may convince us as thoracic surgeons to become more liberal and to extend the indications of performing 'single-staged' bilateral video-assisted thoracoscopic surgery. Herein, we described our technique in bilateral pulmonary resections. A 32-year-old woman was admitted to our department with 3 small bilateral lesions. Two wedge resections were performed on the left side, followed by S6 segmentectomy on the right side.

Fast-Tracking Patients Through the Diagnostic and Therapeutic Pathways of Intrathoracic Conditions: The Role of Uniportal Video-Assisted Thoracic Surgery.

Mahmoud Ismail, Marc Swierzy, Dania Nachira, Jens C. Ruckert

Thorac Surg Clin. 2017 Nov;27(4):425-430. doi: 10.1016/j.thorsurg.2017.06.011.

Abstract

Fast-tracking patients in surgery has become standard in many hospitals. This allows for a shorter hospital stay and a complete organized pathway for treating patients. The operative trauma has an important role in the patient's recovery, as has the increasing use of minimally invasive procedures. In thoracic surgery, video-assisted thoracic surgery (VATS) procedures are aimed at reducing the operative trauma. One of the latest developments of VATS is represented by the uniportal approach, whose purpose is to reduce postoperative pain and morbidity. This article reviews the current literature and the authors' experience in combining uniportal VATS technique and fast-track surgery.

Training in Uniportal Video-Assisted Thoracic Surgery.

Alberto Sandri, Alan D.L. Sihoe, Michele Salati, Diego Conzalex-Rivas, Alessandro Brunelli

Thorac Surg Clin. 2017 Nov;27(4):417-423. doi: 10.1016/j.thorsurg.2017.06.010. Epub 2017 Aug 10.

Abstract

Interest in uniportal video-assisted thoracic surgery (VATS) is rapidly growing worldwide because it represents the surgical approach to the lung with the least possible trauma. Specific training in this surgical approach is crucial due to its technical implications, to perform it safely while upholding the required therapeutic radicality. Novel strategies, such as interactive learning technologies, simulators, high-volume preceptorships, and targeted proctorships, play important roles in the training for uniportal VATS which, ideally, should be standardized, governed, and credentialed by national and international surgical societies to ensure patient safety and academic responsibility.

Uniportal Video-Assisted Thoracic Surgery Esophagectomy.

Alberto Sandri, Alan D.L. Sihoe, Michele Salati, Diego Gonzalex-Rivas, Alessandro Brunelli

Thorac Surg Clin. 2017 Nov;27(4):407-415. doi: 10.1016/j.thorsurg.2017.06.009.

Abstract

Interest in uniportal video-assisted thoracic surgery (VATS) is rapidly growing worldwide because it represents the surgical approach to the lung with the least possible trauma. Specific training in this surgical approach is crucial due to its technical implications, to perform it safely while upholding the required therapeutic radicality. Novel strategies, such as interactive learning technologies, simulators, high-volume preceptorships, and targeted proctorships, play important roles in the training for uniportal VATS which, ideally, should be standardized, governed, and credentialed by national and international surgical societies to ensure patient safety and academic responsibility.

Nonintubated-Awake Anesthesia for Uniportal Video-Assisted Thoracic Surgery Procedures.

Hui Zheng, Xue-fei Mu, Ge-ning Jiang, Jia-an Ding, Yu-ming Zhu

Thorac Surg Clin. 2017 Nov;27(4):399-406. doi: 10.1016/j.thorsurg.2017.06.008.

Abstract

Nonintubated video-assisted thoracic surgery (VATS) strategies are gaining popularity. This review focuses on noninutbated VATS, and discusses advantages, indications, anesthetic techniques, and approaches to intraoperative crisis management. Advances in endoscopic, endovascular, and robotic techniques have expanded the range of surgical procedures that can be performed in a minimally invasive fashion. The nonintubated thoracoscopic approach has been adapted for use with major lung resections. The need for general anesthesia and endotracheal intubation has been reexamined, such that regional or epidural analgesia may be sufficient for cases where lung collapse can be accomplished with spontaneous ventilation and an open hemithorax.

Uniportal Video-Assisted Thoracoscopic Surgery Segmentectomy.

Thorac Surg Clin. 2017 Nov;27(4):387-398. doi: 10.1016/j.thorsurg.2017.06.007.

Abstract

This article addresses technical details of uniportal VATS segmentectomy by lung segments, suggesting available techniques for lesion localization and identification of the intersegmental plane. Long-term results and superiority have not yet been characterized in standard VATS for lung malignancy. Indications include almost all thoracic procedures currently performed by conventional multiport VATS. We review our experience and published literature on the feasibility of uniportal VATS segmentectomy.

Subxiphoid Uniportal Video-Assisted Thoracoscopic Surgery Procedure.

Takashi Suda

Thorac Surg Clin. 2017 Nov;27(4):381-386. doi: 10.1016/j.thorsurg.2017.06.006. Epub 2017 Aug 10.

Abstract

In recent years, the subxiphoid approach has been used to avoid intercostal nerve damage in the field of thoracic surgery. A subxiphoid single-port thymectomy does not require sternotomy; it is associated with lesser pain because there is no intercostal nerve damage; and it provides excellent cosmetic outcomes. Furthermore, in 2014, the author and colleagues reported synchronous resection of bilateral pulmonary metastases by bilateral lung-wedge resection for bilateral metastatic lung tumors with a single 3-cm subxiphoid incision. In this method, a bilateral lung-wedge resection is performed synchronously without an intercostal approach and, thus, does not cause intercostal nerve damage and excels in aesthetic outcomes.

Are There Contraindications for Uniportal Video-Assisted Thoracic Surgery?

Alan D.L. Sihoe

Thorac Surg Clin. 2017 Nov;27(4):373-380. doi: 10.1016/j.thorsurg.2017.06.005.

Abstract

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

Important Technical Details During Uniportal Video-Assisted Thoracoscopic Major Resections.

Diego Gonzalez-Rivas, Alan D.L. Sihoe

Thorac Surg Clin. 2017 Nov;27(4):357-372. doi: 10.1016/j.thorsurg.2017.06.004.

Abstract

Since it was first performed in 2010, lobectomy via a single port-uniportal video-assisted thoracoscopic surgery (VATS)-has become increasingly popular among surgeons. However, this most minimally invasive surgical approach requires a different skill set compared with even conventional multiportal VATS. For those beginning to learn uniportal VATS, the technical challenges can seem considerable. This article shares some tips and tricks from experienced uniportal VATS practitioners that will help those wishing to learn the approach, and covers the principles of operative setup and instrumentation as well as specific pointers on surgery for each lung lobe.

Hybrid Theater and Uniportal Video-Assisted Thoracic Surgery: The Perfect Match for Lung Nodule Localization.

Ze-Dui Zhao, Rainbow W.H. Lau, Calvin S.H. Ng

Thorac Surg Clin. 2017 Nov;27(4):347-355. doi: 10.1016/j.thorsurg.2017.06.003.

Abstract

Cone-beam computed tomography provides unparalleled real-time imaging of the patient within the hybrid theater, which can be used for simultaneously diagnosing and localizing small pulmonary lesions for resection. Hybrid theater can guide more precise placement of electromagnetic navigation bronchoscopy tools, thereby increasing the diagnostic yield in biopsy procedures while reducing diffusion artifact in dye marking for nodule localization. Furthermore, hook-wires implantation that is widely used to assist in lesion localization for uniportal thoracoscopic surgery can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite.

Management of Intraoperative Difficulties During Uniportal Video-Assisted Thoracoscopic Surgery.

Marco Scarci, Diego Gonzalez-Rivas, Jachim Schmidt, Benedetta Bedetti

Thorac Surg Clin. 2017 Nov;27(4):339-346. doi: 10.1016/j.thorsurg.2017.06.002. Epub 2017 Aug 10.

Abstract

The learning curve of the uniportal video-assisted thoracoscopic surgery (VATS) approach is linked to a larger rate of intraoperative complications, which can lead to an emergency conversion to thoracotomy. Despite technical advancements and the large number of surgical videos posted on specialized websites, live surgery events and experimental courses have significantly contributed to accelerate the learning and evolution of minimally invasive thoracic surgery. Bleeding and other complications are the most dreaded event for many VATS surgeons. This article analyzes possible major intraoperative complications during uniportal VATS and explains how to manage them effectively and safely.

The Geometric and Ergonomic Appeal of Uniportal Video-Assisted Thoracic Surgery.

Luca Bertolaccini, Gaetano Rocco, Alessandro Pardolesi, Piergiorgio Solli

Thorac Surg Clin. 2017 Nov;27(4):331-338. doi: 10.1016/j.thorsurg.2017.06.001.

Abstract

The geometric characteristics of uniportal video-assisted thoracic surgery (VATS) are known: one small incision without further dissection of the intercostal space with the simultaneous introduction of instruments to the thoracoscope through an ideal circular truncated cone, as wide as a surgeon's fingerbreadth. The perspective of the uniportal VATS approach realizes projective planes that preserves the depth of intraoperative visualization. The instruments, moving along this planes, enable the surgeon to bring the operative fulcrum inside the chest. Also, the uniportal VATS approach generate an ergonomic advantage during surgery.

Early outcomes of robotic versus uniportal video-assisted thoracic surgery for lung cancer: a propensity score-matched study.

Su Yang Wei Guo Xingshi Chen Han Wu Hecheng Li

Eur J Cardiothorac Surg. 2017 Aug 30. doi: 10.1093/ejcts/ezx310. 

Abstract

OBJECTIVES: Both robotic-assisted thoracic surgery (RATS) and uniportal video-assisted thoracic surgery (UVATS) are minimally invasive surgical techniques used for treatment of lung cancer. However, no research studies comparing early outcomes between RATS and UVATS have been reported.

METHODS: Non-small-cell lung cancer patients treated with RATS or UVATS at our institution from January 2015 to September 2016 were enrolled. Early outcomes were compared after propensity score-matched analysis using 4 factors: age, gender, tumour size and operative procedure.

RESULTS: A total of 153 patients were included in this study: 76 patients underwent RATS and 77 patients underwent UVATS. After propensity score-matched analysis, each group included 69 cases. The comparison of the 2 groups showed that there were no significant differences in operative time, postoperative hospital stay, chest tube duration, analgesic usage, complications or the number of resected lymph nodes. However, RATS caused less intraoperative blood loss ( P  = 0.037) and more dissected lymph node stations ( P  = 0.014).

CONCLUSIONS: Judging from the short-term outcomes, both RATS and UVATS are safe and feasible for non-small-cell lung cancer treatment. In particular, RATS is better able to reduce bleeding and complete lymphadenectomy than UVATS.

© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

eComment. Uniportal VATS: the great potential of the technique.

Dania Nachira Elisa Meacci Maria Teresa Congedo Stefano Margaritora

Interact Cardiovasc Thorac Surg. 2017 Jul 1;25(1):163. doi: 10.1093/icvts/ivx154.

Abstract

No abstract available

Dr. Sebastien Gilbert: more evidence is need for the promotion of uniportal VATS in North America.

Maxine Feng

J Thorac Dis. 2017 Jun;9(6):E579-E580. doi: 10.21037/jtd.2017.05.17.

Abstract

No abstract available

Uniportal video-assisted thoracoscopic thymectomy and resection of a giant thymoma in a patient witness of Jehova.

Diego Gonzalez-Rivas, Ching Feng Wu, Mercedes de la Torre

J Thorac Dis. 2017 Jun;9(6):E556-E559. doi: 10.21037/jtd.2017.05.06.

A rare case of a giant thymoma in a patient witness of Jehova treated by single port thoracoscopic resection is reported. A 78-year-old man with chest pain and mild dyspnea had been previously diagnosed with giant thymoma went to our hospital and asked for second opinion of operation. Computed tomography showed a 12.5 cm × 9.5 cm × 10 cm mass in the anterior mediastinum. Under the request of this patient, he is only willing to receive minimal invasive surgery without blood transfusion. Thirty-six hours after surgical resection, the patient safely discharged from our hospital without complication. Pathological diagnosis indicated a thymoma without capsular invasion, and a diagnosis of Masaoka stage I thymoma was made. Giant mediastinal thymoma is not rare, but how to perform minimal invasive surgery without complication and blood transfusion is a great challenge even for an experienced surgeon.

Uniportal video-assisted thoracoscopic right upper lobectomy and systemic mediastinal lymph nodes dissection

Jia He, Dongjie Ma, Shanqing Li

J Thorac Dis. 2017 Jun;9(6):1644-1647. doi: 10.21037/jtd.2017.05.26.

Abstract

Along with the progresses that have been made in techniques and instruments, uniportal video-assisted thoracoscopic surgery (VATS) became more and more popular. Here, we present the operation video of a 52-year-old female with early stage lung cancer in the right upper lobe (RUL), who underwent uniportal VATS right upper lobectomy and systemic mediastinal lymph nodes dissection performed by our team. The video demonstrated the Uniportal VATS techniques of hilar anatomy, bronchus and blood vessel separation, mediastinal lymph node areas exploration and en-bloc dissection. Once the vision angle is properly adapted, techniques and instruments are mastered, and the patients are well selected, uniportal VATS approach can be an alternative to the conventional VATS for early stage lung cancer.

Glove-Finger Extraction Technique in Uniportal Video-Assisted Thoracoscopic Surgery

Yu-Wei Liu, Dong-Lin Tsai, Hsien-Pin Li, Chia-Jung Lin, Jui-Ying Lee, Shah-Hwa Chou

J Laparoendosc Adv Surg Tech A. 2017 Aug;27(8):795-798. doi: 10.1089/lap.2017.0216. Epub 2017 Jun 28.

Uniportal video-assisted thoracoscopic surgery in tracheal tumour under spontaneous ventilation anaesthesia.

Minzhang Guo, Guilin Peng, Bing Wei, Jianxing He

Eur J Cardiothorac Surg. 2017 Aug 1;52(2):392-394. doi: 10.1093/ejcts/ezx076.

Abstract

We present an innovative method using uniportal video-assisted thoracoscopic surgery under spontaneous ventilation anaesthesia (SVA) to perform tracheal surgery in a 46-year-old man with distal tracheal squamous cell carcinoma. SVA offered better exposure of the surgical field and facilitated anastomosis following a single incision. Such simplification of the ventilation strategy and uniportal incision accelerated the postoperative recovery and reduced the side effects of conventional anaesthesia.

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

Ying Chen, Jun-Tao Lin, Song Dong, Xue-Ning Yang, Yi-Long Wu, Wen-Zhao Zhong

J Thorac Dis. 2017 May;9(5):1375-1381. doi: 10.21037/jtd.2017.04.07.

Abstract

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

Barbed suture material technique for wound closure and concomitant tube placement in uniportal VATS for pneumothorax.

Kyung Soo Kim

J Thorac Dis. 2017 May;9(5):1265-1272. doi: 10.21037/jtd.2017.03.163.

Abstract

BACKGROUND: Uniportal video-assisted thoracoscopic surgery (VATS) is an alternative modality for treatment of primary spontaneous pneumothorax (PSP) with its less invasiveness and acceptable surgical outcomes. However, a few reports have been introduced for wound management to achieve better cosmetic wound healing and for placement of the chest tube in uniportal VATS. Thus, we aimed to evaluate the feasibility of our novel method for wound closure and concomitant tube placement using continuous barbed suture material in uniportal VATS for PSP.

METHODS: Between July 2012 and December 2015, consecutive 31 patients (22 males) underwent uniportal VATS to treat PSP. Bilateral approaches were performed in four patients, thus total 35 cases were enrolled. We divided them into two groups with one group of 17 (48.5%) cases (group A), using barbed absorbable wound closure device for knotless continuous wound closure and subsequent chest tube anchoring, and the other group of 18 (51.4%) cases (group B), using conventional suture anchoring after skin closure using absorbable suture device. Postoperative surgical outcomes were compared to assess the feasibility of this technique.

RESULTS: Demographic data demonstrate no significant difference in both groups. There was no significant difference in length of hospital stay (3.7±1.2 vs. 4.1±1.2 days, P=0.267) and in median chest tube indwelling time (2.4±0.9 vs. 3.1±1.2 days, P=0.066), respectively. Operation time in group A was shorter than in group B but there was no significant difference (41.7±11.8 vs. 45.6±16.0 minutes, P=0.415). There was neither conversion to two or three port VATS in all cases. In group A, all chest tubes were removed with concomitant sealing the tube removal site by pulling the thread. Residual knots do not exist that stitch out procedure is not required. There was no wound complication in both groups during the median follow-up period of 18 months.

CONCLUSIONS: Knotless, barbed suture material technique for continuous wound closure with concomitant chest tube placement achieved equivocal outcomes in comparison to the conventional suture anchoring method. We suggest this simple technique for wound closure and easy tube removal with cosmetic wound healing in uniportal VATS for PSP.

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

Yixin Cai, Ying Han, Ni Zhang, Shengling Fu, Yu Deng, and Xiangning Fu.

J Laparoendosc Adv Surg Tech A. 2017 Dec;27(12):1230-1235. doi: 10.1089/lap.2017.0063. Epub 2017 May 31.

Abstract

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

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

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

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

Uniportal VATS for treatment of bullous lung disease.

Hussein Elkhayat, Mahmoud Sallam, Mohamed Farouk, Khaled Hussein, and Emad Zarief

Multimed Man Cardiothorac Surg. 2017 Apr 26;2017. doi: 10.1510/mmcts.2017.006.

Abstract

This tutorial shows the resection of a bulla by uniportal video assisted thoracoscopic surgery in bullous lung disease. This disease is a benign condition requiring treatment in cases of severe dyspnea, spontaneous secondary pneumothorax, repeated infection, hemoptysis, and an increase in bulla size. The uniportal VATS approach results in less pain, better cosmoses, and a quicker recovery for the patient.

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

Ding-Pei Han, Kai Chen, Ya-Jie Zhang, Dan-Nong He, He-Cheng Li

J Thorac Dis. 2017 Apr;9(4):1140-1143. doi: 10.21037/jtd.2017.03.78.

Abstract

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 thoracic surgery for major lung resections: pitfalls, tips and tricks.

Mahmoud Ismail, Marc Swierzy, Dania Nachira, Jens C. Rückert, Diego Gonzalez-Rivas

J Thorac Dis. 2017 Apr;9(4):885-897. doi: 10.21037/jtd.2017.02.04.

Abstract

Nearly six years since inception, uniportal video-assisted thoracic surgery (VATS) has become a growing part of major lung resections and has revolutionized the way thoracic surgeons treat pulmonary lesions. This technique is being touted for various benefits. It ensures direct visualization together with a better exposure of the lung and allows the chance of a digital palpation of the lesion through a small incision. Postoperative pain is reduced due to the involvement of only one intercostal space without rib spreading and muscle disruption. The comfort and aesthetics factors are improved significantly since the oncological principles and radicality of open surgery are restored. As the surgeons gain more experience in uniportal-VATS lobectomy, more complex cases can be managed by this technique. The objectives of this work are to set the basic steps for performing major lung resections (lobectomy, bilobectomy and pneumonectomy) by utilizing uniportal-VATS and to analyze some common pitfalls that thoracic surgeons face when practicing this technique and provide practical tips and tricks on how to avoid.

Uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA).

Marcin Zieli?ski, Mariusz Rybak, Katarzyna Solarczyk-Bombik, Michal Wilkojc, Wojciech Czajkowski, Sylweriusz Kosinski, Edward Fryzlewicz, Tomasz Nabialek, Juliusz Pankowski

J Thorac Dis. 2017 Apr;9(4):878-884. doi: 10.21037/jtd.2016.12.01.

Abstract

BACKGROUND: To present the technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA).

METHODS: Transcervical extended approach utilizes a typical a 5-8 centimeters collar incision in the neck. The critical technical point enabling a wide access to the chest is an elevation of the sternal manubrium with a special retractor (modified Rochard frame, Asculap-Chifa Company). A bilateral visualization of the laryngeal recurrent and vagus nerves is usually performed to avoid injury of these structures. The uniportal transcervical VATS lobectomy for NSCLC is preceded by TEMLA to enable optimal intraoperative staging of the mediastinal nodes and perform extensive bilateral lymphadenectomy, which theoretically might affect survival. VATS lobectomy is the next step after obtaining results of intraoperative examination of the nodes. Ventilation of the operated lung is disconnected and the mediastinal pleura is opened. Pleural adhesions are divided. The branches of the pulmonary artery and vein and the lobar bronchus are sequentially dissected and managed with endo staplers. The fissure is divided with endo stapler and the resected lobe is removed in endobag.

RESULTS: There were 9 patients operated on in the period 1.2.2016-30.7.2016. In one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. There was no mortality and complications occurred in 2 patients. The mean operative time was 258.1 min (200-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 168.1 min (110-295 min) for a lobectomy solely.

CONCLUSIONS: A uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with TEMLA provides an opportunity for radical pulmonary resection and super radical extensive mediastinal lymphadenectomy.

Uniportal video-assisted thoracic surgery: the Middle East experience.

Firas Abu Akar, Diego Gonzalez-Rivas, Mahmoud Ismail, Maher Deeb, Yefim Reichenshtein, Irith Hadas-Halpern, Rachel Tauber, Daniel Fink

J Thorac Dis. 2017 Apr;9(4):871-877. doi: 10.21037/jtd.2016.11.89.

Abstract

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.

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

Alexandre de Oliveira, Thais Amarante P. P. Couto

J Thorac Dis. 2017 Apr;9(4):865-870. doi: 10.21037/jtd.2016.10.79.

Abstract

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.

Single-staged uniportal VATS in the supine position for simultaneous bilateral primary spontaneous pneumothorax.

Kyung Soo Kim

J Cardiothorac Surg. 2017 May 15;12(1):25. doi: 10.1186/s13019-017-0591-7.

Abstract

BACKGROUND: Simultaneous bilateral primary spontaneous pneumothorax (SBPSP) is rare, but requires surgery on both sides, in patients with definite bilateral bullae to prevent life-threatening conditions. Recently, uniportal video-assisted thoracoscopic surgery (VATS) has been widely accepted as a less invasive technique for the treatment of pneumothorax. Thus, we introduced single-staged uniportal VATS technique in the supine position, for the management of two cases of SBPSP.

CASE PRESENTATION: A 17-year-old boy presented with bilateral spontaneous pneumothorax and he underwent single-staged uniportal VATS in the supine position. Single wide draping in consecutive bilateral approaches removes the needs of changing patients' position. Whole thoracoscopic procedure for wedge resection of bullae lesions was conducted without difficulty. The total operation time took 65 min and the patient discharged 3 days after the operation. The patient was followed for 24 months without recurrence of both sides. Another 18-year-old boy was admitted with bilateral spontaneous pneumothorax and single-staged uniportal VATS was also performed in the supine position. The total operation time took 79 min and the patient discharged on postoperative day 4. He was followed for 19 months without recurrence of both sides.

CONCLUSIONS: Single-staged uniportal VATS approach yielded satisfactory results from simplicity that not requires position change compared to conventional multi-ports VATS in the lateral position, and with better cosmetics. This technique is thought to be a feasible procedure in selective patients with SBPSP or with contralateral bullae for preventive role.

Laser resection of pulmonary nodule via uniportal thoracoscopic surgery.

Calvin S. H. Ng, Freddie Capili, Ze-Rui Zhao, Peter S. Y. Yu, Jacky Y. K. Ho, Rainbow W. H. Lau

J Thorac Dis. 2017 Mar;9(3):846-848. doi: 10.21037/jtd.2017.02.100.

Abstract

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.

The era of uniportal video-assisted thoracoscopic surgery.

Monica Pastina, Cecilia Menna, Claudio Andreetti, Mohsen Ibrahim

J Thorac Dis. 2017 Mar;9(3):462-465. doi: 10.21037/jtd.2017.02.97.

Abstract

No abstract available

Three Hundred Fifty-One Patients With Pneumothorax Undergoing Uniportal (Single Port) Video-Assisted Thoracic Surgery.

Hicham Masmoudi, Harry Etienne, Raphaelle Sylvestre, Diane Evrard, Raphael Ouede, Marielle Le Roux, Mihaela Giol, Jalal Assouad

Ann Thorac Surg. 2017 Jul;104(1):254-260. doi: 10.1016/j.athoracsur.2017.01.054. Epub 2017 Apr 12.

Abstract

BACKGROUND: Video-assisted thoracic surgery (VATS) is usually performed using three ports. Uniportal VATS has not yet been widely developed. We report our single institution experience in uniportal VATS for the surgical management of 351 patients with pneumothorax.

METHODS: Between November 2009 and February 2016, we conducted a study in 351 patients treated for pneumothorax using uniportal VATS. Resection of apical bullae associated with partial pleurectomy, pleural abrasion, or talc effusion was performed.

RESULTS: The mean age was 29.6 ± 10.1 years. Surgical indications were mainly persistence or recurrence of pneumothorax. Sixty-seven patients (19%) presented with complications. At the 30-day control, 60.1% of patients were asymptomatic; 85% of patients were satisfied with the single small scar. The recurrence rate was 3.6% at 24 ± 13 months.

CONCLUSIONS: Uniportal VATS is feasible, safe, and reproducible in the treatment of pneumothorax. Morbidity is similar to multiport VATS. The recurrence rate is comparable with best results after multiport VATS or thoracotomy. Patients were satisfied with the single small scar.

Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

New technique of diaphragmatic plication by means of uniportal video-assisted thoracoscopic surgery.

Davor Stamenovic

Interact Cardiovasc Thorac Surg. 2017 Jul 1;25(1):162-163. doi: 10.1093/icvts/ivx022.

Abstract

Diaphragmatic plication has been a well employed method for the treatment of diaphragmatic eventration and/or paralysis. Uniportal thoracoscopic procedures seem to offer substantial benefit in terms of postoperative pain and cosmesis with similar outcomes as other surgical techniques. A 60-year-old female patient was referred to our clinic for the surgical treatment of diaphragmatic eventration of an unknown cause. The patient was referred to our institution from another hospital, where she had undergone a femoro-popliteal and crural bypass which was unsuccessful, requiring amputation of her leg. Following surgery, she was unable to breath spontaneously without any specific reason. Cranial magnetic resonance imaging showed no pathology and the neurologists did not have a diagnosis for her comatose state. There was consensus in both hospitals that surgical plication of her elevated diaphragm might be the only option for respiratory improvement. We performed a double-lined diaphragmatic plication procedure by means of uniportal video-assisted thoracic surgery technique with CO2 insufflation using GelPort. Despite the time-consuming adhesiolysis and the need for lung suturing at the end of the procedure, the operative time was 120 min. Oxygenation remarkably improved after the operation, yet the patient remained in comatose state. She was referred back to the hospital where she had initially begun her therapy for further recovery.

Uniportal middle lobectomy after a previous right upper lobectomy.

Arthur Vieira, Paula Ugalde Figueroa

Interact Cardiovasc Thorac Surg. 2017 Mar 1;24(3):477-478. doi: 10.1093/icvts/ivw367.

Abstract

Video-assisted thoracoscopic surgery (VATS) using a 3.5 cm single incision (uniportal) may not only result in better pain control, earlier mobilization and shorter hospital stays, but can also provide safer and clear visualization to perform thoracoscopic dissection during complex surgeries. This is a case of a 55-year-old woman who underwent redo-thoracoscopy through uniportal approach for a middle-lobe lobectomy, after a previous right-upper lobectomy.

Uniportal Video-Assisted Thoracoscopic Surgery Resection of a Giant Midesophageal Diverticulum.

Francesco Paolo Caronia, Alfonso Fiorelli, Mario Santini, Attilio Ignazio Lo Monte

Ann Thorac Surg. 2017 Apr;103(4):e365-e367. doi: 10.1016/j.athoracsur.2016.09.054.

Uniportal video-assisted thoracic surgery colorectal lung metastasectomy in non-intubated anesthesia.

Vincenzo Ambrogi, Francesco Sellitri, Gianluca Perroni, Orazio Schillaci, Tommaso Claudio Mineo

J Thorac Dis. 2017 Feb;9(2):254-261. doi: 10.21037/jtd.2017.02.40.

Learning curve and established phase for uniportal VATS lobectomies: the Papworth experience.

Benedetta Bedetti, Luca Bertolaccini, Piergiorgio Solli, Marco Scarci

J Thorac Dis. 2017 Jan;9(1):138-142. doi: 10.21037/jtd.2017.01.03.

Non-intubated subxiphoid uniportal video-assisted thoracoscopic thymectomy using glasses-free 3D vision.

Long Jiang, Jun Liu, Wenlong Shao, Jingpei Li, Jianxing He

J Thorac Dis. 2016 Dec;8(12):E1602-E1604. doi: 10.21037/jtd.2016.12.48.

Abstract

Trans-sternal thymectomy has long been accepted as the standard surgical procedure for thymic masses. Recently, minimally invasive methods, such as video-assisted thoracoscopic surgery (VATS) and, even more recently, non-intubated anesthesia, have emerged. These methods provide advantages including reductions in surgical trauma, postoperative associated pain, and in regards to VATS, provide certain cosmetic benefits. Considering these advantages, we herein present a case of subxiphoid uniportal VATS for thymic mass using a glasses-free 3D thoracoscopic display system.

Safety and feasibility of uniportal video-assisted thoracoscopic surgery for locally advanced non-small cell lung cancer.

Junqiang Fan, Jie Yao, Qi Wang, Zhibo Chang

J Thorac Dis. 2016 Dec;8(12):3543-3550. doi: 10.21037/jtd.2016.12.12.

Abstract

BACKGROUND: Conventional video-assisted thoracoscopic surgery (VATS) lobectomy for locally advanced non-small cell lung cancer (NSCLC) is a feasible and safe surgery in high-volume centers with significant VATS experience. Uniportal VATS lobectomy has been recently been reported to be a promising, less invasive approach. The purpose of this study is to explore the safety and feasibility of uniportal video-assisted thoracoscopic surgery (U-VATS) for the treatment of patients with locally advanced NSCLC.

METHODS: From January 2013 to September 2015, a total of 132 patients with locally advanced NSCLC underwent U-VATS or open thoracotomy major pulmonary resections and standard mediastinal lymph node dissection. Patients were divided into two groups: (I) locally advanced NSCLC underwent U-VATS (U-VATS); (II) locally advanced NSCLC underwent open thoracotomy (open). A descriptive and retrospective study was performed, including the operative time, operative blood loss, postoperative chest tube duration, postoperative hospital stay, lymph node dissection, postoperative complications and postoperative recovery.

RESULTS: A total of 132 patients with locally advanced NSCLC were included in this study: 64 (U-VATS) vs. 68 (open) patients. The patient demographic data was similar in both groups. Median operative time (157.0 vs. 160.6) and median number of lymph nodes (35.5 vs. 32.5) were similar in both groups. Chest tube duration and hospital of stay were statistically shorter in U-VATS group while rate of complications were higher in open thoracotomy group. One patient died on the 55th postoperative day because of tumor metastasis and bronchopleural fistula. A higher percentage of patients who underwent UVATS resections were able to receive adjuvant therapy timely compared to the open group.

CONCLUSIONS: Uniportal VATS major pulmonary resections and mediastinal lymph node dissection is a safe and feasible procedure for the treatment of locally advanced NSCLC. Particularly it is suitable for the frail patients with locally advanced NSCLC who require comprehensive treatment.

The feasibility and advantage of uniportal video-assisted thoracoscopic surgery (VATS) in pulmonary lobectomy.

BMC Cancer. 2017 Jan 25;17(1):75. doi: 10.1186/s12885-017-3069-z.

Abstract

BACKGROUND: Ongoing improvements in technique and instruments for video-assisted thoracoscopic surgery (VATS) have made minimally-invasive uniportal VATS lobectomy a reality. However, the outcomes of the procedure are still under investigation, and at present, uniportal VATS lobectomy is performed infrequently at most hospitals. We have therefore reviewed our outcomes with this procedure in an attempt to validate its safety, efficacy, and feasibility.

METHODS: We retrospectively analyzed and compared perioperative data for patients who underwent uniportal, two-port, and traditional three-port VATS lobectomy between January 2015 and December 2015 at our hospital.

RESULTS: Among 257 patients who had successful VATS lobectomy during the study period, 73 underwent uniportal VATS, 86 underwent two-port VATS, and 98 underwent traditional three-port VATS. There were no surgical or 30-day postoperative mortalities, and no significant differences in operative times, blood loss, number of lymph nodes retrieved and nodal stations explored, drainage times, length of hospital stay, or postoperative complications among the three groups. The visual analogue scale (VAS) pain scores were significantly lower in the uniportal VATS group after surgery (P < 0.05).

CONCLUSIONS: Uniportal VATS lobectomy is a safe and feasible surgical procedure that is associated with decreased surgical trauma and less postoperative pain compared to traditional VATS. Further long term follow-up analyses in large numbers of patients are ongoing.

Uniportal thoracoscopic decortication for pleural empyema and the role of ultrasonographic preoperative staging.

Stefano Bongiolatti Luca Voltolini Sara Borgianni Roberto Borrelli Giorgia Tancredi Domenico ViggianoAlessandro Gonfiotti

Interact Cardiovasc Thorac Surg. 2017 Apr 1;24(4):560-566. doi: 10.1093/icvts/ivw423.

Abstract

Objectives: The surgical approach to chronic pleural empyema is still controversial. Video-assisted thoracic surgery (VATS) debridement and decortication has shown favourable outcomes, while the uniportal VATS (U-VATS) approach is still anecdotal. We report our experience with ultrasonographic (US) preoperative staging followed by U-VATS decortication for pleural empyema.

Methods: We performed a retrospective analysis of patients who underwent surgical treatment of stage II and stage III pleural empyema from 2012 to 2015. Pre-, intra- and postoperative data were investigated to evaluate outcomes including postoperative complications and disease recurrence. Results were analysed according to preoperative US appearance of pleural space (stages A-E) and surgical approach (thoracotomy vs U-VATS).

Results: We performed 30 (47%) uniportal thoracoscopic pleural decortication and 34 (53%) open decortication for empyema in stage II (40%) or III (60%) obtaining a complete debridement and decortication in all patients. In-hospital mortality was zero and overall morbidity was 29%. U-VATS was associated with lower blood loss (118 ±  80 ml vs 247  ±  140 ml P  < 0.001), lower chest tubes duration (5.6 ±  1.4 vs 10.6  ±  4.4 days P  < 0.001), shorter hospital stay (6.7  ±  1.9 vs 12.2  ± 4.7 days, P  < 0.001) and lower complications (10% vs 16%, P  < 0.001). Elevated US patterns (D-E) are associated with thoracotomy, higher blood loss, operative time and a significant incidence of complications.

Conclusions: Uniportal thoracoscopic decortication for pleural empyema is a safe and effective approach for selected patients based on a combination of clinical and imaging staging. US patterns well corresponded with intraoperative pleural findings and showed a prognostic value.

Posterior uniportal video-assisted thoracoscopic surgery for resection of the apical segment of the right lower lobe followed by completion lobectomy.

Davor Stamenovic, Antje Messerschmidt

Interact Cardiovasc Thorac Surg. 2017 Apr 1;24(4):644-645. doi: 10.1093/icvts/ivw405.

Abstract

Uniportal thoracoscopic resections offer less pain and better cosmetic results. They are usually performed through an antero-lateral incision. Posterior uniportal approach has not been described yet. A 65-year-old female was admitted to our clinic for the treatment of an adenocarcinoma, located in the apical segment of the right lower lobe. Owing to the ideal location and size, anatomical segment resection and radical lymphadenectomy was planned. Fissureless video-assisted thoracoscopic resection of the apical segment of the right lower lobe, using a uniportal posterior approach was performed, followed by mediastinal lymphadenectomy. However, resection margins showed microscopic presence of lepidic tumour on frozen section analysis, so we needed to proceed with a completion lower lobectomy. Postoperative course was event-free and the patient was discharged on the 4th postoperative day. The 1.8-cm large tumour was diagnosed to be primary lepidic (80%) and acinar (20%) adenocarcinoma and the final TNM was pT2aN0M0.

Uniportal video-assisted thoracoscopic lobectomy: An alternative surgical method for pulmonary carcinoma.

Fengwu Lin, Chuan Zhang, Qiang Zhang, Kunpeng Cheng, Yan Zhao

Pak J Med Sci. 2016 Sep-Oct;32(5):1283-1285.

Abstract

OBJECTIVES: To explore the effects and feasibility of single-port video-assisted thoracic surgery (VATS) on lobectomy for pulmonary carcinoma.

METHODS: A total of 67 patients were enrolled in this study, in which 21 patients were treated by single-port VATS (Sing-port Group) and 46 patients by double-port VATS (Double-port Group). Blood loss, duration of thoracic drainage, length of post-operative hospital stay and post-operative pain ratings were compared between the two groups.

RESULTS: No significant difference existed in blood loss, duration of thoracic drainage and length of postoperative hospital stay between the two groups. However, Post-operative pain was significantly reduced in Single-port Group compared to Double-port Group.

CONCLUSION: Single-port VATS was totally feasible with reduced post-operative pain and good looking appearance.

Bilateral single-port thoracoscopic extended thymectomy for management of thymoma and myasthenia gravis: case report.

J Cardiothorac Surg. 2016 Nov 22;11(1):153.

Abstract

BACKGROUND: Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Herein, we reported an extended resection of thymoma in a patient with myasthenia gravis through an uniportal bilateral thoracoscopic approach.

CASE PRESENTATION: A 74 years old woman with myasthenia gravis was referred to our attention for management of a 3.5 cm, well capsulate, thymoma. All laboratory and cardio-pulmonary tests were within normal; thus, she was scheduled for thymoma resection through an uniportal bilateral thoracoscopic approach. Under general anaesthesia and selective intubation, the patient was placed in a 60° right lateral decubitus. A 3 cm skin incision was performed in the fourth right intercostal space and, through that a 30° video-camera and working instruments were inserted without rib spreading. After complete dissection of the thymus and mediastinal fat, the contralateral pleura was opened, and, through that the specimen was pushed into the left pleural cavity. Then, the patient was placed in the left lateral decubitus. Similarly to the right side procedure, a 3-cm incision was performed in the fourth left intercostal space to complete thymic dissection and retrieve the specimen. No intraoperative and post-operative complications were found. The patient was discharged four days later. Pathological examination revealed a type A thymoma (Masaoka stage I). No recurrence was found at 18 months of follow-up CONCLUSIONS: Bilateral single-port thoracoscopy is an available procedure for management of thymoma associated with myasthenia gravis. The less post-operative pain, the reduction of hospital stay and the better esthetic results are all potential advantages of this approach over traditional technique. Obviously, our impression should be validated by larger studies in terms of long-term oncological outcomes.

Non-grasping en bloc mediastinal lymph node dissection through uniportal video-assisted thoracic surgery for lung cancer surgery.

Chengwu Liu, Lin Ma, Chenglin Guo, Lunxu Liu

J Thorac Dis. 2016 Oct;8(10):2956-2959.

Abstract

Uniportal video-assisted thoracic surgery (VATS) has been demonstrated to be feasible, safe, and effective for lung cancer surgery compared with traditional multi-portal VATS. However, complete mediastinal lymph node dissection (MLND) through uniportal VATS is still a difficult work due to more limited access, and most thoracic surgeons use strategies of grasping, accompanied with which are complicated instrumentation and mutual interference among them. To simplify the instrumentation and make MLND more comfortable, we developed the method of "non-grasping en bloc MLND" and applied it during uniportal VATS lung cancer surgery. Two main instruments (suction and energy devices) were developed with diversified use. And only the two instruments were used during MLND following the strategy of "non-grasping". This technique incorporates with several advantages, such as: simplified instrumentation, decreased risk of damages to lymph nodes, and en bloc dissection. Considering the limited access, this technique fits well with the uniportal procedure and truly interprets the concept of "less is more" during uniportal VATS MLND.

"Ipsilateral, high, single-hand, sideways"-Ruijin rule for camera assistant in uniportal video-assisted thoracoscopic surgery.

Taotao Gao, Jie Xiang, Runsen Jin, Yajie Zhang, Han Wu, Hecheng Li

J Thorac Dis. 2016 Oct;8(10):2952-2955.

Abstract

Camera assistant plays a very important role in uniportal video-assisted thoracoscopic surgery (VATS), who acts as the eye of the surgeon, providing the VATS team with a stable and clear operating view. Thus, a good assistant should cooperate with surgeon and manipulate the camera expertly, to ensure eye-hand coordination. We have performed more than 100 uniportal VATS in the Department Of Thoracic Surgery in Ruijin Hospital. Based on our experiences, we summarized the method of holding camera, known as "ipsilateral, high, single-hand, sideways", which largely improves the comfort and fluency of surgery.

Tubeless Uniportal Thoracoscopic Wedge Resection for Peripheral Lung Nodules.

Man-Ling Wang, Ming-Hui Hung, Hsao-Hsun Hsu, Ya-Jung Cheng, Jin-Shing Chen

Ann Thorac Surg. 2017 Feb;103(2):462-468. doi: 10.1016/j.athoracsur.2016.09.006. Epub 2016 Nov 16.

Abstract

BACKGROUND: Endotracheal intubation and chest tube drainage are considered mandatory for thoracoscopic pulmonary resection. The management of peripheral lung nodules by tubeless uniportal thoracoscopic surgical repair has not been reported previously.

METHODS: From October 2015 through January 2016, 30 consecutive patients with peripheral lung nodules underwent uniportal thoracoscopic wedge resection without endotracheal intubation and chest tube drainage (tubeless group). The clinical outcomes were compared with the outcomes in 30 consecutive patients with peripheral lung nodules who underwent uniportal thoracoscopic wedge resection with chest tube drainage from April through October 2015 (chest tube group).

RESULTS: The demographic, anesthetic, and operative characteristics of the patients were comparable in both groups. No major adverse events occurred after operation. A small residual pneumothorax was noted in 12 (40.0%) patients at 6 hours and day 1 and in 2 (6.6%) patients on day 14 in the tubeless group. No patient required reintervention or readmission to the hospital. Patients in the tubeless group had lower pain scale scores on postoperative day 1 (mean, 1.0 vs 1.5, p = 0.012) and shorter postoperative hospital stays (mean, 3.1 days vs 4.4 days, p = 0.011) than did those in the chest tube group.

CONCLUSIONS: Tubeless uniportal thoracoscopic wedge resection is feasible and safe and may be a less invasive alternative for treating selected patients with peripheral lung nodules.

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

Zhengcheng Liu, Rusong Yang, Feng Shao, Yanqing Pan

Ann Transl Med. 2016 Oct;4(19):367.

Abstract

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.

From biportal to uniportal video-assisted thoracoscopic anatomical lung resection: A single-institute experience.

Jia-Ming Chang; Kam-Hong Kam; Yi-Ting Yen; Wei-Li Huang; Wei Chen; Yau-Lin Tseng; Ming-Ho Wu; Wu-Wei Lai; Diego Gonzalez-Rivas

Medicine (Baltimore). 2016 Oct;95(40):e5097.

Abstract

Our study sought to review our experience from biportal to uniportal video-assisted thoracoscopic surgery (VATS) major lung resection. Lessons we learned from the evolution regarding technical aspects were also discussed.We retrospectively reviewed patients who underwent VATS lobectomy or segmentectomies in Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, during January 2012 and December 2014. Patient clinical profiles, surgical indications and procedures, postoperative course, and oncological parameters were analyzed and compared between the biportal and uniportal groups.A total of 121 patients were enrolled in this study with median follow-up of 19.5?±?11.6 months for all patients and 22.5?±?11.5 months for primary lung cancer patients. Operation time (146.1?±?31.9-158.7?±?40.5?minutes; P?=?0.077), chest drainage time (3.8?±?3.3-4.4?±?2.4 days; P?=?0.309), conversion to thoracotomy rate (2.2%-2.6%; P?=?0.889), and complication rate (15.6%-19.7%; P?=?0.564) were equal between the groups, whereas blood loss (96.7?±?193.2-263.6?±?367; P?=?0.006) was lower in the uniportal group. For lung cancer cases, there were no statistical differences in the histology, cancer staging, mediastinal lymph node dissection stations, numbers of dissected N1, N2, and overall lymph nodes between uniportal and biportal groups.Our preliminary data showed that uniportal VATS anatomical lung resection is as feasible, equally safe, and of comparative oncological clearance efficacy to biportal VATS.

From biportal to uniportal video-assisted thoracoscopic anatomical lung resection: A single-institute experience.

Jia-Ming Chang; Kam-Hong Kam; Yi-Ting Yen; Wei-Li Huang; Wei Chen; Yau-Lin Tseng; Ming-Ho Wu; Wu-Wei Lai; Diego Gonzalez-Rivas

Medicine (Baltimore). 2016 Oct;95(40):e5097.

Abstract

Our study sought to review our experience from biportal to uniportal video-assisted thoracoscopic surgery (VATS) major lung resection. Lessons we learned from the evolution regarding technical aspects were also discussed.We retrospectively reviewed patients who underwent VATS lobectomy or segmentectomies in Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, during January 2012 and December 2014. Patient clinical profiles, surgical indications and procedures, postoperative course, and oncological parameters were analyzed and compared between the biportal and uniportal groups.A total of 121 patients were enrolled in this study with median follow-up of 19.5?±?11.6 months for all patients and 22.5?±?11.5 months for primary lung cancer patients. Operation time (146.1?±?31.9-158.7?±?40.5?minutes; P?=?0.077), chest drainage time (3.8?±?3.3-4.4?±?2.4 days; P?=?0.309), conversion to thoracotomy rate (2.2%-2.6%; P?=?0.889), and complication rate (15.6%-19.7%; P?=?0.564) were equal between the groups, whereas blood loss (96.7?±?193.2-263.6?±?367; P?=?0.006) was lower in the uniportal group. For lung cancer cases, there were no statistical differences in the histology, cancer staging, mediastinal lymph node dissection stations, numbers of dissected N1, N2, and overall lymph nodes between uniportal and biportal groups.Our preliminary data showed that uniportal VATS anatomical lung resection is as feasible, equally safe, and of comparative oncological clearance efficacy to biportal VATS.

Awake uniportal video-assisted thoracic surgery for complications after pneumonectomy.

Marcello Migliore, Francesco Borrata, Marco Nardini, Alessandra Criscione, Damiano Calvo, Mariapia Gangemi & Francesco Scalieri

Future Oncol. 2016 Dec;12(23s):51-54. Epub 2016 Oct 17.

Abstract

Since 1998, we started a clinical program for awake video-assisted thoracic surgery in our unit using four-step local anesthesia and sedation. Throughout the years, we experienced several difficult cases, three of them had complications postpneumonectomy. The aim of this paper is to report these three cases.

Uniportal video-assisted thoracic surgery or single-incision video-assisted thoracic surgery for lung resection: clarifying definitions.

Marcello Migliore, Semih Halezeroglu, Laureano Molins, Dirk Van Raemdonck, Michael R Mueller, Federico Rea & Subroto Paul

Future Oncol. 2016 Dec;12(23s):5-7. Epub 2016 Oct 7.

Abstract

No abstract available

Single-port right upper lobe sleeve lobectomy for a typical carcinoid tumour.

Heron Andrade,  Philippe Joubert,  Arthur Vieira,  Paula Ugalde Figueroa

Interact Cardiovasc Thorac Surg. 2017 Feb 1;24(2):315-316. doi: 10.1093/icvts/ivw323.

Abstract

Pulmonary carcinoid tumours are well-differentiated neuroendocrine tumours with indolent behaviour; complete resection offers long-term survival. When centrally located, these tumours can be treated with lung-sparing procedures. We present a case of a centrally located typical carcinoid tumour treated with a minimally invasive, right upper lobe sleeve lobectomy using a single port.

Rethinking N2 disease in the era of uniportal video-assisted thoracic surgery.

Tom Treasure, Paul De Leyn

Future Oncol. 2016 Dec;12(23s):23-26. Epub 2016 Sep 19.

Abstract

Third Mediterranean Symposium on Thoracic Surgical Oncology, Catania, Italy, 21-22 April 2016 The primary justification for mediastinal lymphadenectomy is that it provides more complete nodal staging to help select best adjuvant treatments. There is a secondary argument that dissection of nodes might remove otherwise unrecognized nodal disease to increase the chance of cure. They have to be thought through again as patients look for less invasive treatments for their cancers such as videothoracoscopy and stereotactic radiotherapy. Evidence from analysis of Surveillance, Epidemiology and End Results data indicated that sampling or dissection can be performed adequately by surgeons using videothoracoscopy but stereotactic radiotherapy of its nature precludes intraoperative lymph node dissection and yet is being promoted as equivalent treatment. Consideration of these issues requires re-examination of the evidence that lymphadenectomy influences survival.

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

Mingxiang Feng, Miao Lin, Yaxin Shen, Hao Wang

J Thorac Dis. 2016 Aug;8(8):2281-3. doi: 10.21037/jtd.2016.06.64.

Abstract

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

Uniportal video-assisted thoracoscopic right upper lobectomy with systematic lymphadenectomy.

Gang Shen, Ying Chai, Lijian Huang, Maoying Yang, Guofei Zhang

J Thorac Dis. 2016 Aug;8(8):2275-80. doi: 10.21037/jtd.2016.05.07.

Abstract

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 right upper lobectomy with systemic lymphadenectomy.

Ding-Pei Han, Jie Xiang, He-Cheng Li, Jun-Biao Hang

J Thorac Dis. 2016 Aug;8(8):2272-4. doi: 10.21037/jtd.2016.05.01.

Abstract

This video demonstrated a performance of uniportal video-assisted thoracoscopic surgery (VATS) right upper lobectomy with systemic lymphadenectomy. The patient had a malignant mass in his right upper lobe. The operator took a posterior to anterior approach to dissection the right upper lobe, the adjacent structures were clearly demonstrated after the entire dissection of mediastinal lymph nodes. Postoperative pathological report suggested the stage of the tumor was T1bN0M0 (stage IA).

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

Qi Wang, Yi-Xin Cai, Yu Deng, Sheng-Ling Fu, Xiang-Ning Fu, Ni Zhang

J Thorac Dis. 2016 Aug;8(8):2264-8. doi: 10.21037/jtd.2016.03.15.

Abstract

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.

Left upper lobectomy and systematic lymph nodes dissection in enlarged pulmonary hilar lymph nodes in primary lung cancer patient by uniportal video-assisted thoracic surgery.

Jun-Qiang Fan, Jie Yao, Zhi-Bo Chang, Qi Wang

J Thorac Dis. 2016 Aug;8(8):2259-63. doi: 10.21037/jtd.2016.01.80.

Abstract

Uniportal video-assisted thoracic surgery (VATS) anatomical pulmonary resection, with only one small incision for surgery instruments and camera insertion, requires higher operative skills, especially in the cases of the enlarged pulmonary hilar lymph nodes. With improved technology and increased experiences in VATS lobectomy, uniportal VATS lobectomy has been applied in major medical centers recently. A 67-year-old male patient with left upper peripheral lung cancer and enlarged hilar lymph nodes underwent unipotal VATS lobectomy and systemic mediastinal lymph node dissection. The patient recovered uneventfully.

Uniportal video-assisted thoracic surgery left superior segmentectomy with systematic lymphadenectomy in the semiprone position.

Zongwu Lin, Junjie Xi, Songtao Xu, Qun Wang

J Thorac Dis. 2016 Aug;8(8):2256-8. doi: 10.21037/jtd.2016.01.82.

Abstract

A 63-year-old male was referred to our hospital with two existing lesions in bilateral lungs. Computed tomography (CT) showed a 15-mm ground-glass opacity (GGO) in the superior segment of left lower lung (S6) and a 5-mm GGO in the center of the right upper lobe. The preoperative clinical diagnosis was stage I primary lung cancer for the left lesion while the right lesion needed follow-up. Uniportal video-assisted thoracic surgery (VATS) left superior segmentectomy in the semiprone position was performed in this case and the right upper lobe was kept untouched. Frozen section examination confirmed the diagnosis of lung adenocarcinoma, and systematic lymphadenectomy with non-grasping en bloc dissection technique was then performed. A chest tube was placed at the posterior part of the incision through the dorsal thoracic cavity to the apex. The postoperative pathologic diagnosis was minimally invasive adenocarcinoma, staged T1aN0M0.

Fact checking in the history of uniportal video-assisted thoracoscopic surgery.

Gaetano Rocco

J Thorac Dis. 2016 Aug;8(8):1849-50. doi: 10.21037/jtd.2016.07.77.

Abstract

No abstract available

Comparative Study of Survival following Videothoracoscopic Lobectomy Procedures for Lung Cancer: Single- versus Multiple-port Approaches.

Borro JM, Regueiro F, Pértega S, Constenla M, Pita S.

Arch Bronconeumol. 2017 Apr;53(4):199-205. doi: 10.1016/j.arbres.2016.06.018. Epub 2016 Sep 7.

Abstract

INTRODUCTION: Video-assisted thoracoscopic surgery has become the technique of choice in the early stages of lung cancer in many centers although there is no evidence that all of the surgical approaches achieve the same long-term survival.

METHOD: We carried out a retrospective review of 276 VATS lobectomies performed in our department, analyzing age, sex, comorbidities, current smoker, FEV1 and FCV, surgical approach, TNM and pathological stage, histologic type, neoadjuvant or coadjuvant chemotherapy, relapse and metastasis time, with the main aim of evaluating the survival rate and disease-free time, especially with regard to the two/three versus single port approach.

RESULT: The one/four year global survival rate was 88.1 and 67.6% respectively. Bivariate analysis found that the variables associated with survival are comorbidity, histological type, stage, surgical approach and need for chemotherapy. When we independently analyzed the surgical approach, we found a lower survival rate in the single-port group vs. the two/three-port group (VATS). Stratifying by tumoral stage (stage I) and by tumor size (T2) survival was significantly lower for patients with single-port group in comparison to VATS approach. In the multivariate analysis, single-port group is associated with a higher risk of death (HR=1.78). In analyzing disease-free survival, differences were found in both cases in favor of two/three port VATS: p=.093 for local relapses and p=.091 for the development of metastasis.

CONCLUSIONS: These results challenge the use of the single port technique in malignant lung pathologies, suggesting the need for clinical trials in order to identify the role this technique may have in lung cancer surgery.

Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.

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

Simon C. Y. Chow, Calvin S. H. Ng

J Thorac Dis. 2016 Jul;8(Suppl 6):S509-16. doi: 10.21037/jtd.2016.03.18.

Abstract

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.

Easier Uniportal VATS Lobectomy Using a Clamp With a String and a U-shaped Direction Converter for Lung Traction.

Xiaogang Zhao, Gening Jiang, Chang Chen, Chenyang Dai, Yuming Zhu

Ann Thorac Surg. 2016 Sep;102(3):e265-e267. doi: 10.1016/j.athoracsur.2016.03.048

Abstract

Although uniportal video-assisted thoracoscopic surgery (UVATS) is associated with decreased pain and chest wall paresthesia, as well as better cosmesis, it has not been widely accepted by thoracic surgeons. This lack of acceptance is largely because instrument collisions are difficult to avoid when many instruments are crowded into a single incision. We designed a set of instruments, including a clamp with a string and a U-shaped direction converter for lung traction, to provide better exposure during UVATS for lobectomy without the need for an endograsper. By retracting from different directions and applying appropriate force on the lung hilum to keep the vessels and bronchus separated, we were able to reduce collisions among instruments and make UVATS for lobectomy easier.

The adoption of uniportal approach in Chile: the experience of a single surgical team from Valparaíso, Chile.

Cristian González Collao

J Vis Surg. 2016 Aug 24;2:147. doi: 10.21037/jovs.2016.08.04. eCollection 2016.

Abstract

Uniportal VATS lobectomy in Chile began in 2013, in an old and small provincial hospital in Valparaíso, the main port of Chile, a few months after two thoracic surgeons had a short stay in Hospital La Coruña with the inventor of the most revolutionary technique in thoracic surgery of the last time. Four years after the first visit of Dr. González Rivas to Chile to sharing his initial experience, and after the explosive development of this technique especially in Asia, ALAT organization invited him again to our country as a main speaker in its International Congress, focused largely in uniportal lobectomy. As expected, these thoracic surgeons could operate with their teacher, and make true the dream of any thoracic surgeon who began with a new kind of surgery: perform it in their hospital with its inventor and also their friend.

Subxiphoid uniportal lobectomy.

Peter Bjørn Licht

Eur J Cardiothorac Surg. 2016 Dec;50(6):1067. doi: 10.1093/ejcts/ezw221. Epub 2016 Aug 19.

Abstract

No abstract available

Learning curve of single-incision thoracoscopic surgery for primary spontaneous pneumothorax.

• Hee Chul Yang, 
• Sohee Kim
• Sungwon Yum
• Sukki Cho
• Kwhanmien Kim
• Sanghoon Jheon

Surg Endosc. 2017 Apr;31(4):1680-1687. doi: 10.1007/s00464-016-5158-5. Epub 2016 Aug 11.

Abstract

BACKGROUND: Single-incision thoracoscopic surgery (SITS) requires extensive time and practice to achieve satisfactory technical skills. The aim of this study was to evaluate the learning curves of SITS for primary spontaneous pneumothorax (PSP).

METHODS: This study included a total of 274 consecutive patients who underwent PSP surgery by a single operator between May 2011 and February 2014. During this period, SITS was applied as a routine approach. Learning curves were made by the cumulative sum (CUSUM) method using the number of cases and four surgical technique-related factors, including operation time, postoperative complication, non-SITS rate, and ipsilateral PSP recurrence.

RESULTS: Among the 274 patients, 16 patients who were presented with a previous 3-port wound scar or inadequate chest tube site before surgery were not eligible for SITS. Hence, SITS was attempted on 258 patients and performed successfully in 251 patients. For these successful SITS patients, the mean age was 22.9 ± 8.1 years, the mean operation time was 65.6 ± 22.2 min, the mean chest tube indwelling time was 1.5 ± 1.1 days, and the mean postoperative hospital stay was 1.7 ± 1.1 days. The mean operation time decreased from 84.0 to 47.6 min when a comparison was made between patients operated in the initial 6 months and the last 6 months of the study period. As revealed by the CUSUM technique, more than 50 % of the cases experienced an operation time of <70 min after the first 92 cases. After 57 cases, the postoperative complication rate was maintained at <5 %. The non-SITS rate was achieved to be lower than 5 % after 112 cases. The ipsilateral PSP recurrence rate was maintained at below 8 % after 102 cases.

CONCLUSIONS: Although PSP is the most applicable scenario for the beginner of SITS, at least 100 cases of experience are needed to achieve optimal technical level.

First non-intubated uniportal video-assisted pulmonary lobectomy in America.

Ricardo Buitrago, Adriana Serna, Diego González-Rivas, Rafael Beltrán, Carlos Mario Palacio, Pablo Parades, Julian Beltrán

J Vis Surg. 2016 Aug 16;2:144. doi: 10.21037/jovs.2016.08.01. eCollection 2016.

Abstract

The first video-assisted thoracic lobectomy in non-intubated patient in America was performed on 27th of September 2014 in Bogotá Colombia, The National Cancer Institute in Bogotá received Dr. Diego González-Rivas to make possible this kind of procedure in a 53-year-old man, with a history of papillary thyroid cancer treated with surgery and Iodine therapy, in whom two pulmonary nodules were found in the monitoring tomography. We resected the nodule located at the right upper lobe previously marked by scintigraphy, the other one required a lobectomy because it was a deep nodule with malignant radiologic appearance inside of the middle lobe. The procedure discoursed in a non-intubated patient without technical difficulties or complications, very short recovery time, minimum pain and a quiet and usual postoperative evolution. This procedure, the first reported in America was replicated after others with similar results in several countries thanks to the collaboration between surgeons, anesthesiologists, radiologists, nurses and therapists, because especially in such interventions teamwork is essential. We believe that given the benefits in terms of recovery for the patient and anesthetic time, we could go on replicating the experience in selected patients.