A single-trocar technique for minimally-invasive surgery of the chest

Comparison of postoperative analgesia by thoracoscopic-guided thoracic paravertebral block and thoracoscopic-guided intercostal nerve block in uniportal video-asssited thoracic surgery: a prospective randomized controlled trial

BACKGROUND

Thoracoscopic-guided thoracic paravertebral nerve block (TG-TPVB) and thoracoscopic-guided intercostal nerve block (TG-INB) are two postoperative analgesia technology for thoracic surgery. This study aims to compared the analgesic effect of TG-TPVB and TG-INB after uniportal video-asssited thoracic surgery (UniVATS).

METHODS

Fifty-eight patients were randomly allocated to the TG-TPVB group and the TG-INB group. The surgical time of nerve block, the visual analog scale (VAS) scores, the consumption of sufentanil and the number of patient-controlled intravenous analgesic (PCIA) presses within 24 h after surgery, the incidence of adverse reactions were compared between the two groups.

RESULTS

The VAS scores were significantly lower during rest and coughing at 2, 6, 12, and 24 h in the TG-TPVB group than in the TG-INB group (P < 0.05). The consumption of sufentanil and the number of PCIA presses within 24 h after surgery were significantly lower in the TG-TPVB group than in the TG-INB group (P < 0.001).The surgical time of nerve block was significantly shorter in the TG-TPVB group than in the TG-INB group (P < 0.001). The incidence of bleeding at the puncture point was lower in the TG-TPVB group than that in the TG-INB group (P < 0.05).

CONCLUSION

TG-TPVB demonstrated superior acute pain relieve after uniVATS, shorter surgical time and non-inferior adverse effects than TG-INB.

Large-bore Chest Tube Insertion: Seldinger Technique over Two Guidewires

Purpose

Large-bore chest tube insertion is commonly performed using the trocar technique and blunt dissection; however, large-bore chest tube can cause severe visceral injury due to penetration, which is a life-threatening complication. Conversely, small-bore chest tubes can be safely inserted using the Seldinger technique; however, small-bore chest tubes are prone to blockage, especially in empyema cases. Therefore, this study aimed to demonstrate large-bore chest tube insertion using the Seldinger technique over two guidewires following image-guided puncture.

Material and Methods

We started performing large-bore chest tube insertion using the Seldinger technique over two guidewires following image-guided puncture in February 2022. Demographic data and procedural details, such as chest tube size, dilator size, procedure time, and type of image-guided puncture, of patients who underwent this procedure between February 2022 and March 2023 were retrospectively reviewed. Technical success was defined as the successful drainage of the pleural cavity.

Results

This method was used for performing ten procedures in nine patients who presented with empyema, pneumothorax, and pulmonary fistula. The insertion of a large-bore chest tube with a size ranging from 18- to 24-French was successfully performed in all cases without any complications. The median procedure time was 17.5 (first quartile-third quartile, 13.5-28.0) min.

Conclusions

Large-bore chest tube insertion using the Seldinger technique over two guidewires may be used as an alternative to conventional methods.

Uniportal thoracoscopic bullectomy with improved parietal pleurectomy for primary spontaneous pneumothorax

INTRODUCTION

Parietal pleurectomy with bullectomy has been established as an effective method for preventing the recurrence of primary spontaneous pneumothorax (PSP). Our center introduced enhanced technical measures in uniportal thoracoscopic parietal pleurectomy with bullectomy for patients with PSP, aiming to document our initial experience and assess the procedure's effectiveness in preventing the recurrence of PSP.

METHODS

We analyzed the clinical data of 86 patients with PSP who underwent the improved uniportal thoracoscopic parietal pleurectomy with bullectomy between July 2019 and August 2022. During the procedure, the parietal pleura above the second intercostal space was stripped but not removed. Instead, it was retained in the thoracic cavity using a piece of pedunculated pleura. Subsequently, the stumps of the lung were covered by the preserved parietal pleura.

RESULTS

The results of the study showed that the mean operative time was 59.87 ± 16.93 min, and the postoperative drainage duration averaged 3.94 ± 2.17 days. The mean intraoperative blood loss was 24.33 ± 48.91 ml, and the mean postoperative drainage volume was 289.00 ± 170.03 ml. Prolonged air leakage for more than 5 days was observed in five patients (5.81%), but no other postoperative complications were recorded. During the follow-up, one patient (1.16%) experienced a recurrence of pneumothorax.

CONCLUSIONS

The perioperative results of bullectomy with the improved pleurectomy technique are deemed satisfactory. The various technical steps attempted at our center are found to be feasible and safe, and they may contribute to reducing the rates of recurrence in PSP.

Simultaneous resection of coexisting pulmonary and mediastinal lesions by video-assisted thoracic surgery: a case-series study

BACKGROUND

With the growing number of patients with coexisting pulmonary and mediastinal lesions detected, reports about simultaneous video-assisted thoracic surgery (VATS) for these concurrent diseases are still rare. To further explore the safety and effectiveness of simultaneous resection of pulmonary and mediastinal lesions by uniportal or biportal VATS, we retrospectively analyzed the clinical data of the largest series of cases to date.

METHODS

From July 2018 to July 2021, all patients whose pulmonary lesions and mediastinal tumors were resected simultaneously in our institution were retrospectively reviewed. Their demographic and clinical data were collected and analyzed.

RESULTS

A total of 54 patients were enrolled, of whom 44 underwent unilateral uniportal VATS, 3 underwent bilateral uniportal VATS and 7 underwent unilateral biportal VATS. Seven cases were converted to thoracotomy during surgery. For the remaining 47 patients with various demographic and clinical characteristics, most of the operations were completed within 3 h (n = 33, 70.2%) with blood loss of no more than 100 mL (n = 43, 91.5%). The duration of chest tube drainage was 5.66 ± 3.34 days, and the average daily volume was 196.90 ± 122.31 mL. Four cases of postoperative complications occurred during hospitalization. The length of postoperative hospital stay was 8.60 ± 3.63 days. No severe complications or deaths were observed during follow-up.

CONCLUSIONS

Uniportal and biportal VATS are safe and effective for simultaneous resection of selected coexisting pulmonary and mediastinal lesions, but the indications and operational details need more evaluation.

Comparison of Chronic Postsurgical Pain Between Single-Port and Multi-Port Video-Assisted Thoracoscopic Pulmonary Resection: A Prospective Study

Background  Little is known about the prevalence of chronic postsurgical pain (CPSP) among patients receiving single-port video-assisted thoracic surgery (SP-VATS) compared with those undergoing multi-port VATS (MP-VATS). This study aimed to compare the incidence of CPSP between SP-VATS and MP-VATS lung resection and assess how the pain affected the daily living activities of this patient population.

Methods  We prospectively collected data regarding the demographic features, clinical factors during surgery, the intensity of acute postoperative pain, and complications after surgery among patients receiving elective SP-VATS or MP-VATS lung resection at our institution between June 2015 and August 2018. At 3-, 6-, and 12-months following surgery, the patients were followed up through a telephonic interview. The Brief Pain Inventory-Short Form was adopted to assess the incidence, severity and location of the CPSP, analgesic consumption, as well as the interference of pain with daily activities.

Results  In total, 476 patients were screened for eligibility, 411 patients were followed up for 12 months and included in final analysis. Among these, 190 patients had undergone an SP-VATS pulmonary resection and 221 had an MP-VATS pulmonary resection. At both 3 and 6 months, the incidence of CPSP in the SP-VATS group was lower than that in the MP-VATS group (25.3 vs. 38.0%, p  = 0.006; 11.1 vs. 19.0%, p  = 0.026, respectively). At 12 months after surgery, the prevalence of CPSP was comparable between groups (4.7 vs, 9.0%, p  = 0.089). In addition, the SP-VATS technique alleviated pain interference with the daily living activities of patients with CPSP in several domains, including sleep, mood, and enjoyment of life compared with the MP-VATS technique. The two predictive factors for CPSP at postoperative 3 months were the MP-VATS technique (odds ratio [OR] = 1.792, p  = 0.019) and postoperative chemotherapy (OR = 1.718, p  = 0.033).

Conclusions  This study indicated that the SP-VATS technique reduced the prevalence of CPSP at 3- and 6-months post-pulmonary resection compared with the MP-VATS technique. The SP-VATS technique also significantly alleviated pain interference with the daily living activities of the patients.

Risk Factors for the Development of Intraoperative Hypoxia in Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery: A Retrospective Study from a Single Center

Background

Nonintubated video-assisted thoracic surgery (NIVATS) has been demonstrated to be safe and effective in patients. However, the risk factors for intraoperative hypoxia are unclear. This retrospective study aimed to identify the risk factors for the development of intraoperative hypoxia in patients undergoing NIVATS.

Material/Methods

The study included patients who underwent NIVATS between January 2011 and December 2018. Intraoperative hypoxia was defined as SpO₂ ≤93%. Risk factors for hypoxia were identified by binary logistic regression analysis, and the characteristic distribution of patients with and without hypoxia was elaborated.

Results

Of 2742 included patients, age, anesthesia method, the technical level of surgeons, stair-climbing ability, and type of thoracic procedure were associated with intraoperative hypoxia (P<0.05). The characteristics of patients with hypoxia were older age (P=0.011), higher body mass index and revised cardiac risk index level (P=0.033 and P=0.031), and lower composition of stair-climbing ≥22 m (P<0.001). These patients also had more anatomical lung surgery and mediastinal mass resection (P=0.033) and more epidural anesthesia (P=0.005). The surgeries were more likely to be performed by surgeons with less than 10 years of VATS training (P=0.009) and to have increased intraoperative maximum end-expiratory carbon dioxide partial pressure (P<0.001). These patients had a longer Intensive Care Unit stay (P<0.001), duration of chest-tube drainage (P=0.019), and postoperative hospitalization (P=0.003).

Conclusions

The current study suggests that old age and stair-climbing ability of patients, anesthesia method, thoracic procedures, and surgeon experience are risk factors for intraoperative hypoxia in patients undergoing NIVATS.

Surgical techniques and outcome analysis of uniportal video-assisted thoracic surgery complex sleeve lung resection: a 20 case-series study

Background

Our study aims to explore the feasibility of uniportal video-assisted complex sleeve lung resection and summarize the surgical techniques and clinical outcomes.

Methods

From June 2016 to April 2020, a total of 20 complex sleeve pulmonary and distal tracheal resections were performed by the single surgical team at the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. We defined cases as complex sleeve pulmonary resections if they required pulmonary segment sleeve resection, extended sleeve resection (lobectomy plus segmentectomy of the remaining lobe), sleeve pneumonectomy, lobectomy plus carinoplasty or neo-carina construction, pulmonary-sparing main bronchus resection plus carina reconstruction, and distal trachea resection with end to end anastomosis.

Results

The 20 cases comprised lung squamous cell carcinoma (n=11), lung adenocarcinoma (n=2), hamartoma (n=3), adenoid cystic carcinoma (n=2), carcinoid tumor (n=1), and pleomorphic carcinoma (n=1). The average blood loss during the operation was 250±126.17 mL (50–800 mL). The average operation time was 192.0±61.1 minutes. The average number of lymph node stations removed was 5.82±1.33, including station seven in all cases, and the median number of lymph nodes removed was 4.18±5.89. On the day of surgery, the drainage volume was 266±192.01 mL. The mean postoperative hospital stay was 5.37±1.86 days. Twelve of the 16 patients diagnosed with malignancy received postoperative chemotherapy. Granuloma formation at the anastomosis level led to stenosis in one case, and tumor recurrence occurred in one case. Broncho-esophageal fistula occurred in one patient after radiochemotherapy. The postoperative follow-up time was 15.6±10.7 months. The 30-day mortality was zero, and at one-year follow-up, only one patient had died of metastatic disease after the operation.

Conclusions

Uniportal video-assisted complex sleeve pulmonary resections are feasible when conducted by experienced teams.

Uniportal video-assisted thoracoscopic drainless sympathectomy for palmar and palmo-plantar hyperhidrosis: an institutional experience

Background

Primary hyperhidrosis (PH) still impacts negatively the patient’s quality of life (QoL). Progressively, it leads to poorer QoL regardless of gender. The endoscopic thoracic sympathectomy has been used safely and effectively for control of palmar hyperhidrosis, but it is still questionable in palmo-plantar type. We assessed the benefits of uniportal drainless thoracoscopic sympathectomy (UDTS) for palmo-plantar hyperhidrosis patients compared to palmar ones.

This prospective study comprised 213 consecutive patients with PH. They underwent bilateral simultaneous UDTS. We used the Hyperhidrosis Disease Severity Scale (HDSS) scoring system for assessment of QoL pre- and postoperatively. Follow-up was continued for 1-year that was aiming to detect the QoL improvement, recurrence, and compensatory hyperhidrosis (CH).

Results

All patients experienced immediate complete resolution of hyperhidrosis postoperatively. Recurrence was encountered in one patient during the first 6 months. All patients had improved QoL postoperatively, but at the end of 1-year follow-up, 2.8% of patients were still suffering moderate to severe impaired QoL. Mean hospital stay was 31.79 ± 17.5 h. We found significant longer hospital stay in palmar group than palmo-plantar group. There was no significant difference between both groups in neither operative time, recurrence, nor CH.

Conclusions

UDTS offers better QoL for patients with PH even the palmo-plantar type. The palmo-plantar type benefits similarly to the palmar type in terms of comparable postoperative QoL and CH incidence.

Imaging patterns of early stage lung cancer for the thoracic surgeon

In the modern era, thoracic surgeons are experiencing an increase interest in imaging patterns of early stage lung cancer due to the introduction of the ground glass opacity in clinical practice, and for the necessity to an accurate cancer localization to perform the appropriate type of resection. In this brief review we analyze the latest news regarding imaging patterns of early pulmonary nodules with special emphasis to ground glass opacity.

Minimally invasive approach to pneumothorax: Single port or two ports?

Background

This study aims to compare the effectiveness of single-port and two-port video-assisted thoracoscopic surgery in patients with pneumothorax.

Methods

Between June 2016 and December 2018, a total of 44 patients (39 males, 5 females; mean age 27.0±9.5 years; range, 15 to 60 years) who underwent video-assisted thoracoscopic surgery due to the spontaneous pneumothorax in our center were retrospectively evaluated. The study population was divided into two groups as the single-port (n=29) and two-port (n=15) procedure according to the number of port entries applied during the operation. Age, gender, number of days of drainage, length of hospitalization, number of days of air leak, the indication of operation, pneumothorax side, type of pneumothorax, duration of operation, and complications were compared between the groups.

Results

Twenty-two patients (50%) were operated on the right side and 22 patients (50%) on the left side. The mean operation time was 81.1±19.2 min, indicating no significant difference between the groups (p=0.053). No significant difference was observed in the number of days of drainage, the length of hospitalization, and number of days of air leak between the two groups. Complications developed in eight patients (27.6%) in the single-port group and five patients (33.3%) in the two-port group, indicating no significant difference between the groups (p=0.475).

Conclusion

Our study results show that video-assisted thoracoscopic surgery for the treatment of pneumothorax can be successfully performed via a single-port approach.

Nonintubated Uniportal Video-Assisted Thoracic Surgery for Chest Infections

Chest infection is a health care problem in many regions of the world, and pleural empyema is the most common type of surgical chest infection. In the past decennium, the introduction of nonintubated surgery and uniportal video-assisted thoracic surgery changed considerably surgical treatment of pleural empyema. Although the advantages seem evident, the need for randomized controlled trials is necessary to confirm the usefulness. Moreover, in the future, an education and training program for thoracic surgeons and anesthesiologists would allow increasing the number of awake surgical options in caring for patients with stages II to III empyema.

Uniportal VATS technique for primary spontaneous pneumothorax: An analysis of 46 cases

Objective

In the treatment of primary spontaneous pneumothorax (PSP), the influence of safety and applicability of uniportal video assisted thoracoscopic surgery (VATS) bullectomy/blebectomy and pleurectomy method were evaluated in 46 patients.

Methods

Between November 2010 and January 2019, 46 patients (36 males, 10 females; mean age 24.2 years; range 16-36 years) undergoing uniportal video thoracoscopic bullectomy/blebectomy and apical pleurectomy for primary spontaneous pneumothorax were evaluated retrospectively at Canakkale Onsekiz Mart University (COMU). One patient underwent surgery for the second time after three months for contralateral pneumothorax and counted as two different patients, hence forty seven operations were performed in total. The cases were evaluated in terms of age, gender, comorbidity, duration of hospital stay, histopathological diagnosis, postoperative morbidity and mortality.

Results

Right surgical intervention was performed in 20 cases (42.6%) and left surgical intervention in 27 cases (57.6%). A total of 15 (31.9%) surgical operations were performed during the first attack, 30 (63.8%) during the second attack and 2 (4.3%) during third and more attacks. There was prolonged air leakage in all patients operated during the first episode. All cases underwent wedge resection and pleurectomy with endoscopic stapes. None of the patients required thoracotomy. Postoperative drainage period was between 2-7 days (mean: 4.1) and the duration of hospitalization was between three to eight days. Postoperative pain and paraesthesia were observed in eight cases. Prolonged air leakage was observed in five cases.

Conclusion

With video thoracoscopic uniportal technique, not only lung biopsy and resection but also bullectomy/blebectomy and pleurectomy operations can be performed safely in the treatment of PSP. In view of this information, minimally invasive techniques are seen as more advantageous than conventional techniques.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Uniportal video-assisted thoracoscopy surgery in lung cancer: largest experience

Background

Uniportal video-assisted thoracoscopic surgery is one of the latest development in minimal invasive thoracic surgery. It is being increasing applied in various parts of the world for the treatment of lung cancer. Although the technique has become popular, there is a lack of largescale literature addressing the safety and oncological outcomes. We aimed to describe our experience, highlighting the short-term outcomes and oncological efficacy.

Methods

From July 2013 to December 2017, 441 uniportal video-assisted thoracoscopic procedures were carried out in patients with primary lung cancer and no metastatic disease. The male-to-female ratio was 240:201. The median age of the patients was 63 years (range10 to 85 years).

Results

The median number of mediastinal lymph node stations dissected and median number of mediastinal nodes were 5 and 14, respectively. Ten or more nodes were dissected in 93.1% of patients. All surgeries were complete R0 resection. Minor postoperative morbidity according to the Clavien-Dindo classification was 4%. Seven patients experienced major morbidity requiring intensive care management. There was no 30-day mortality.

Conclusion

Uniportal video-assisted thoracoscopic anatomical resection for lung cancer appears to have similar postoperative outcomes to multiport surgery in terms of short-term morbidity and oncological efficacy. Uniportal video-assisted thoracoscopic surgery can be offered as a standard of care for lung cancer surgery in centers with adequate surgical expertise. Long-term follow-up will be needed to establish the long-term oncological outcomes.

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

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.

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

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.

Extended uniportal bilateral sympathectomy

Hyperhidrosis affect 3% of the population and, despite benign nature of the disease, the individuals seek medical advice in order to improve their quality of life which can be severely compromised. The interruption of the sympathetic chain (sympathectomy) and of the nerve of Kuntz established its role as the definitive treatment of primary hyperhidrosis. In this manuscript, we present our extended uniportal technique with the aid of the video. Uniportal approach expresses all its benefit when applied for this procedure because there is no specimen to be retrieved and all the surgery is accomplished through a 1-2 cm port access.

Uniportal non-intubated thoracic surgery

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 thoracoscopic surgery in esophageal diseases: an introduction

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.

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

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.

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

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 non-intubated lung metastasectomy

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 in hemothorax

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.

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

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.

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

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.

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

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.

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

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 55^th 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.

1000 cases of tubeless video-assisted thoracic surgery at the Rome Tor Vergata University

In the early 2000s, the ‘Awake Thoracic Surgery Research Group’ at Tor Vergata University began a program of thoracic operations in awake nonintubated patients. To our knowledge this was the first program created with this specific purpose. Since then over 1000 tubeless operations have been carried out successfully, making this series one of the widest in the world. Both nononcologic and oncologic conditions were successively approached and major operations for lung cancer are now being performed. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance and economical costs. Failure rates due to patient's intolerance and open surgery conversion are progressively reducing. Tubeless thoracic surgery can be accomplished in a safe manner with effective results.

Safety of video-assisted thoracic surgery lobectomy for non-small-cell lung cancer in a low-volume unit

Several studies have demonstrated that for complex surgical procedures, surgeons who treat more patients have better outcomes than their lower-volume counterparts. The aim of this paper is to review the experience with video-assisted thoracic surgery (VATS) lobectomies in our small thoracic unit (group A), to understand whether our short-term results were different to the outcomes obtained by the same surgeon previously working in a high-volume unit (group B). 37 patients underwent VATS lobectomy. Hospital stay was on average 4.5 days (group A) versus 4.1 days (group B). Operative time and the number of ‘frozen sections’ were higher in group A. Hospital mortality was 0. VATS lobectomies are a safe approach in a low-volume unit formed by a single surgeon with a previous high-volume experience.

Awake uniportal video-assisted thoracic surgery for complications after pneumonectomy

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.

Videothoracoscopic resection for lung cancer: moving towards a "standard of care"

Videothoracic surgery for lung cancer is now an established practice but there is a division of opinion between surgeons whose aim is to spare all patients a thoracotomy and those who have not adopted videoscopic methods for routine lobectomy. The latter remain in the majority; most patients at present have a thoracotomy. Surgeons from Europe and America met in Catania, Sicily at the 3(rd) Mediterranean Symposium on Thoracic Surgical Oncology to explore the evidence and the routes to making videothoracoscopic surgery a standard of care. Evidence from one completed randomized controlled trial (RCT) and several propensity score matching studies indicate that less invasive surgery is at least as safe as thoracotomy. By the accepted standards of an oncological lobectomy which include clearance of the primary cancer and the intended lymphadenectomy or sampling, the operations are equivalent. Clinical effectiveness in achieving long-term cancer free survival is likely. However, the co-existance of videothoracoscopy has encouraged smaller non-muscle cutting incisions and the avoidance of rib spreading, narrowing whatever gap there may have been in terms of the patients' experience.

[Evolution and Development Trend of Lung Cancer Surgical Incision]

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

Uniportal thoracoscopic surgery: from medical thoracoscopy to non-intubated uniportal video-assisted major pulmonary resections

The development of thoracoscopy has more than one hundred years of history since Jacobaeus described the first procedure in 1910. He used the thoracoscope to lyse adhesions in tuberculosis patients. This technique was adopted throughout Europe in the early decades of the 20(th) century for minor and diagnostic procedures. It is only in the last two decades that interest in minimally invasive thoracic surgery was reintroduced by two key technological improvements: the development of better thoracoscopic cameras and the availability of endoscopic linear mechanical staplers. From these advances the first video-assisted thoracic surgery (VATS) major pulmonary resection was performed in 1992. In the following years, the progress of VATS was slow until studies showing clear benefits of VATS over open surgery started to be published. From that point on, the technique spread throughout the world and variations of the technique started to emerge. The information available on internet, live surgery events and experimental courses has contributed to the rapid learning of minimally invasive surgery during the last decade. While initially slow to catch on, the traditional multi-port approach has evolved into a uniportal approach that mimics open surgical vantage points while utilizing a non-rib-spreading single small incision. The early period of uniportal VATS development was focused on minor procedures until 2010 with the adoption of the technique for major pulmonary resections. Currently, experts in the technique are able to use uniportal VATS to encompass the most complex procedures such as bronchial sleeve, vascular reconstructions or carinal resections. In contrast, non-intubated and awake thoracic surgery techniques, described since the early history of thoracic surgery, peaked in the decades before the invention of the double lumen endotracheal tube and have failed to gain widespread acceptance following their re-emergence over a decade ago thanks to the improvements in VATS techniques.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Uniportal video assisted thoracic surgery: summary of experience, mini-review and perspectives

The uniportal-video assisted thoracic surgery (VATS) technique comprises operations which can be performed with skin incisions ranging from 2 to 8 cm and the manifest result of the introduction of the uniportal lobectomy had made possible to increase rapidly the number of published papers on this subject. Many of the large ensuing literature report incomplete historical information on uniportal VATS, and doubts exist about the indication of uniportal VATS for some thoracic oncologic pathologies. Known limitations have been overcome. On the other hand, the modern thoracic surgical team includes one surgeon, one assistant and a scrub nurse, and it is clear that the new generation of thoracic surgeons need to use the "less" used hand. The new technology which permitted the introduction of the uniportal VATS could influence the future need of thoracic surgeons worldwide.

Preliminary experience with video-assisted thoracic surgery lobectomy for lung malignancies: general considerations moving toward standard practice

As part of the Second Catania Symposium on Thoracic Oncology, as we started the experience with video-assisted thoracic surgery (VATS) lobectomy for lung malignancies, we reviewed our data and argued some comments in a more general discussion. Operated patients with non-small-cell lung cancer were divided in two groups and compared: VATS (collected in a prospective database) and open (historical group). Out of 74 patients, 31 in group A and 44 in group B. The majority of patients in group A were stage I–II. Mean operative time was shorter in group A. Postoperative hospital stay was shorter in group A. There was no mortality. VATS is effective and safe to perform pulmonary lobectomy in our unit, and it represents our preferred approach for early-stage lung cancer.

A hybrid single-trocar VATS technique for extracorporeal wedge biopsy of the lingula in patients with diffuse lung disease

Lung biopsy is the last option to obtain lung tissue for a precise diagnosis in patients with interstitial lung disease (ILD). Several surgical techniques have been reported. The successful application of a hybrid approach is herein reported. The procedure utilizes a single-trocar video-assisted thoracoscopic surgery technique to localize and withdraw the tip of the lingula outside the chest to perform a biopsy in the diagnosis of ILDs. The advantages of this technique over other commonly used methods have also been discussed.

Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease

OBJECTIVE

To assess the efficacy and the safety of a single-trocar technique for minimally invasive surgery of the chest in the management of multiple noncomplex thoracic diseases, a prospective study was performed and the results are presented.

METHODS

Between October 1998 and December 2001, 100 patients underwent video-assisted thoracic surgery through a single trocar. The patients were divided into 4 groups as follows: (1) benign, (2) malignant, (3) pleural effusion, and (4) empyema. The following data were analyzed: age, sex, forced vital capacity, forced expiratory volume in 1 second, percentage of the predicted forced expiratory volume in 1 second, type of anesthesia, anesthesia time, surgery time, intraoperative complications, morbidity, chest tube removal, hospital stay, and follow-up.

RESULTS

The patient population consisted of 64 men and 36 women with a mean age of 62 years (range 31-92 years). General anesthesia was used in 53 patients (25 double-lumen and 28 single-lumen tube) and local anesthesia and sedation in 47 patients. Talc pleurodesis was performed in 55 patients. Mean operative time was 65 +/- 37 minutes, 48 +/- 18 minutes for simple and 67 +/- 37 minutes (P =.004) for complex pleural effusion. Mean anesthesia time was 102 +/- 85 minutes. Chest tubes were removed after 5 +/- 2 days. Mean overall hospital stay was 6 +/- 3 days, 5 +/- 2 days for benign diseases, 7 +/- 3 days for malignant diseases, and 8 +/- 3 for empyema. Morbidity was present in 19 patients. Two patients had intraoperative bleeding; 1 required a mini-thoracotomy to control it. There was no hospital mortality. Three patients had wound infection, and no patient with malignant diseases had port site metastasis.

CONCLUSION

Video-assisted thoracic surgery through a single trocar is simple, effective, and beneficial for all patients in the diagnosis and treatment of noncomplex diseases of the chest. Furthermore, with this newest type of technologically advanced instrumentation it is possible to carry out simple intrathoracic procedures without using additional ports.

Four-step local anesthesia and sedation for thoracoscopic diagnosis and management of pleural diseases

STUDY OBJECTIVES

Most thoracic surgeons perform thoracoscopy under general anesthesia using a double-lumen endotracheal tube. We describe our own technique for performing thoracoscopy under local anesthesia and sedation.

DESIGN, SETTING, PATIENTS

Forty-five patients underwent the procedure under local anesthesia and sedation (mean age, 64 years; age range, 40 to 92 years). A known history of cancer was present in 12 patients. American Society of Anesthesiology score was I in 1 patient, II in 16 patients, III in 22 patients, IV in 5 patients, and V in 1 patient. Premedication was comprised of droperidol, 5 mg, and atropine, 0.5 mg, administered 20 min before the scheduled operating room time. Sedation was maintained by diazepam injection, 3 mg. Four-step local anesthesia in the planned intercostal space using 10 mL of ropivacaine, 7.5 mg/mL, was performed.

RESULTS

Mean operative time was 45.7 min (range, 20 to 90 min); mean time of anesthesia was 71.3 min (range, 30 to 150 min). Among patients with pleural effusion, 23 effusions were simple and 16 effusions were complex. Talc was administrated in 28 patients. Complications were intraoperative bleeding (one patient), hyperpyrexia (eight patients), and atrial fibrillation (two patients). The mean time for removal of the chest drain was 5.6 days (range, 2 to 13 days). Postoperative hospital stay was 6.4 days (range, 2 to 14 days). No hospital mortality occurred. Follow-up is complete in all patients (mean, 92.8 days; range, 31 to 270 days).

CONCLUSION

Four-step local anesthesia and sedation is a simple and effective method of performing a video-assisted thoracic procedure to diagnose and treat simple thoracic pathologies.