Management of Intraoperative Difficulties During Uniportal Video-Assisted Thoracoscopic Surgery

The safety and efficacy of additional chest tube placement in patients with prolonged air leaks after pulmonary resection: a propensity score-matched analysis

Background

This study evaluates the symptomatic management of prolonged pleural air leaks following pulmonary resection, assesses the efficacy and safety of chest tube placement, and introduces experiences with high-positioned chest tube insertion.

Methods

We retrospectively reviewed 84 patients with prolonged pleural air leaks after lung surgery at Ningbo No.2 Hospital from January 2022 to December 2023. These patients were divided into a conservative treatment group (Group A, n = 64) and a chest tube placement group (Group B, n = 20). The propensity score matching method was applied to balance confounders between the two groups, resulting in 12 matched pairs. The study compared the time to chest tube removal, average hospital stays time, postoperative drainage volume, and facial visual analog pain score between the two groups.

Results

The average hospital stays and chest tube removal time of patients in group B were significantly lower than those of patients in group A (8.00 ± 1.12 vs. 9.75 ± 1.60 days, P = 0.003, 6.92 ± 1.08 vs. 8.58 ± 1.67 days, P = 0.005, respectively). However, the mean facial visual analog pain score in group B was higher than that in group A (1.58 ± 0.58 vs. 1.00 ± 0.01, P = 0.020). There were no significant differences between the two groups in terms of postoperative drainage volume.

Conclusions

For patients with prolonged air leaks, additional chest tube placement postoperatively significantly reduces both hospitals stay duration and chest tube indwelling time compared to conservative treatment. This method may be a potential treatment measure for prolonged air leak in selected patients.

Uniportal video-assisted thoracic surgery for the treatment of lung cancer: a consensus report from Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS) and Chinese Association of Thoracic Surgeons (CATS)

Uniportal video-assisted thoracoscopic surgery (UniVATS) has been widely adopted in China, where several ultra-high volume thoracic surgical and training centers are located. The objective of this consensus from Chinese experts was to summarize the current application and give reference for the future development of UniVATS in the treatment of lung cancer. A panel of 41 experts from 21 Chinese hospitals was invited to join this project. The Delphi method was used in this consensus consisting of two rounds of voting. The questionnaire was based on the current clinical evidence. Forty (97.6%) experts completed the 2 rounds of questionnaires. The experts’ experience was relatively similar. We defined the UniVATS as monitor-dependent surgery, no use of rib-spreading and single incision less than 4 cm. Tumor with stage of T1–T3 and N0–N2 is considered amenable to UniVATS. Other consensus was reached on several points outlining the safety and feasibility, surgical skills, learning curve, short-term and long-term outcomes for lung cancer, and current application of subxiphoid and nonintubated UniVATS approach. This consensus statement represents a collective agreement among Chinese experts to suggest that UniVATS is an effective alternative to multi-portal approach, although high-level evidence is expected in the future. Some agreements can be referred in the training of young surgeons.

Management of calcified hilar lymph nodes during thoracoscopic lobectomies: avoidance of conversions

Background

Our objective in this paper is to introduce a new method for handling calcified hilar lymph nodes during lobectomies by video-assisted thoracoscopy that effectively avoids arterial injury and possible conversions.

Methods

The 12 cases in this study were initially evaluated as eligible and were subsequently scheduled for thoracoscopic lobectomies. However, calcification of the hilar lymph nodes was discovered during the operations, and its presence hampered the conventional process of pulmonary artery dissection. To avoid vessel injuries and subsequent massive bleeding, we developed two techniques specific to the position and exposure of the target vessels and nodes. The space between the bronchus and lymph nodes is exposed by sharp dissection ("scissor first") either before or after suturing the artery. These techniques are illustrated in detail.

Results

Seven male and five female patients participated in this study, with an average age of 72.5 years. We performed five right-upper lobectomies, three right-middle lobectomies, three right-lower lobectomies, and a left-lower lobectomy. Using this new technique, no conversions to thoracotomy occurred. The average operation time was 125 minutes, the mean blood loss was 275 mL, and no intra-operative massive bleeding occurred. Two patients experienced minor complications, one pulmonary infection and another postoperative subcutaneous emphysema.

Conclusions

The proposed "scissor first" technique provides an effective solution for the thoracoscopic management of calcified hilar lymph nodes, and is a safe and effective method for avoiding arterial injury and conversion.