Single-port video-assisted thoracoscopic mediastinal tumour resection

Ergonomic Assessment of Robotic versus Thoracoscopic Thymectomy

Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.

Transareolar uniportal thoracoscopic extended thymectomy for patients with myasthenia gravis

Background

Transareolar uniportal thoracoscopic extended thymectomy (TUTET) has not been previously reported. We attempted to assess the feasibility and safety of TUTET for male myasthenia gravis (MG) patients.

Patients and methods

From February 2013 to February 2020, 46 men with MG underwent TUTET. All patients were followed up for 12–84 months postoperatively by clinic visits or telephone/e-mail interviews.

Results

All surgeries were completed successfully, with an average operation time of 72.6 min. The mean length of transareolar uniportal incision was 3.0 ± 0.4 cm, and the mean postoperative cosmetic score was 3.1 ± 0.5 at discharge. Three months postoperatively, no patients had an apparent surgical scar on the chest wall or complained of postoperative pain. Substantial amelioration of the disease was achieved in a short period, and several benefits were clear. At the 1-year follow-up, all patients showed a good cosmetic effect and high satisfaction.

Conclusions

TUTET is an effective and safe way for men with MG. The uniportal incision is hidden in the areola with sound cosmetic effects. We believe that TUTET is an acceptable procedure for extended thymectomy.

Modified subcostal arch xiphoid thoracoscopic expanded thymectomy for thymic carcinoma: a case report and review of literature

Thymic neoplasms are a relatively uncommon tumor, with the anterior mediastinum being the most common. Median sternotomy is the procedure of choice for the treatment of thymomas. With the advent of thoracoscopy, an increasing number of countries are adopting the right thoracic approach for the treatment of thymomas, but there are still no clear surgical standards or modalities to treat thymic carcinoma. We propose a modified subxiphoid subcostal arch thoracoscopic enlarged thymectomy to treat thymic carcinoma based on various reviews. We have also reviewed the relevant literature on the subject of evidence-based medicine. The evaluation of CD70 in combination with CD5 and CD117 or preferentially expressed antigen in melanoma in combination with CD5 and CD117 may help to diagnose thymic squamous cell carcinoma (TSCC) more accurately. The modified thoracoscopic expanded thymic resection under the costal arch of the xiphoid process is not only suitable for TSCC but also for thymic cyst, thymoma, locally invasive thymoma, and thymic carcinoma.

Use of uniportal video-assisted thoracic surgery combined with a posterior approach to resect a dumbbell-shaped mediastinal granular cell tumor: A case report

Introduction

A dumbbell-shaped mediastinal granular cell tumor has never been reported, and there have been no reports of dumbbell-shaped tumors resected with a combination of uniportal video-assisted thoracic surgery and the posterior approach.

Presentation of case

An 18-year-old woman was diagnosed with a mediastinal dumbbell-shaped granular cell tumor by computed tomography. Complete resection was achieved via a posterior approach combined with the uniportal video-assisted thoracic surgery. First, a T3 left hemilaminectomy was performed in the prone position and the tumor located inside the intervertebral foramen was removed as far as possible. Next, the patient was repositioned to the right lateral decubitus position, a 2.5-cm skin incision was made on the 4th intercostal posterior axillary line, and resection of the residual tumor was performed. Pathological diagnosis of the resected tumor revealed a benign granular cell tumor. The patient recovered post-surgery and no tumor was reported in the 4-month follow-up magnetic resonance imaging.

Discussion

This is the first reported case of a mediastinal dumbbell-shaped granular cell tumor and its successful resection using a combined posterior and uniportal video-assisted thoracic surgery approach.

Conclusion

This is a potentially safe and effective procedure for mediastinal granular cell tumors, with outstanding cosmetic advantages.

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Our case presented with a rare mediastinal dumbbell-shaped granular cell tumor.

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The tumor was resected using a combined posterior and uniportal VATS approach.

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This is a safe and effective procedure for mediastinal dumbbell-shaped tumors.

[Comparative analysis of thoracoscopic and open thymectomy for thymoma stage I-II]

OBJECTIVE

To improve the short-term postoperative outcomes in patients with thymoma stage I-II by using of thoracoscopic thymectomy (VATS TE) and to compare this technique with open (OTE) thymectomy.

MATERIAL AND METHODS

A retrospective analysis included 98 patients who had undergone surgery for thymoma stage I and II for the period from January 2001 to December 2019. VATS TE (main group) was performed in 53 (54.1%) cases, OTE (control group) - in 45 (45.9%) patients.

RESULTS

Duration of VATS TE and OTE was similar. VATS procedure was characterized by less intraoperative blood loss (50 vs 225 ml, p=0.000), lower pain scores and morphine consumption (p=0.000), shorter postoperative pleural drainage (1.5 vs 3.8 days, p=0.000), and postoperative hospital-stay (7.6 vs 12.7 days, p=0.000). Incidence of major complications was significantly less in the main group (9.4% vs. 1.9%, p=0.001).

CONCLUSION

VATS TE is effective and safe procedure for thymoma stage I-II. Postoperative period after VATS TE is characterized by less intraoperative blood loss, incidence of complications, duration of pleural drainage and hospital-stay.

Subxiphoid versus Unilateral VATS Thymectomy for Thymomas: A Propensity Score-matching Analysis

BACKGROUND

The appropriate surgical approach of VATS for early-stage thymoma remains unclear. The present study aimed to explore the safety and feasibility of subxiphoid and subcostal arch thoracoscopic thymectomy in comparison with unilateral thoracoscopic thymectomy for treatment of early-stage thymoma.

METHODS

The outcomes of 237 patients without myasthenia gravis who had undergone thoracoscopic thymectomy for Masaoka stage I and II thymoma from January 2015 to May 2019 at our center were retrospectively evaluated (subxiphoid and subcostal arch approach: 39; unilateral VATS approach: 198). A propensity score-matching analysis was generated to control for selection bias due to nonrandom group assignment in a 1:1 manner.

RESULTS

There was no surgery-related mortality in included patients. Matching of patients according to propensity score resulted in a cohort that consisted of 39 patients in both groups. Patients had similar clinical characteristics in both groups. Compared with those in the unilateral group, patients in the subxiphoid group yielded lower pain scores at 24- and 72-hours post-operation, respectively (P<0.01). In addition, the operation time was longer in the subxiphoid group (147.5±43.6min vs. 93.2±33.8min, p<0.01). There were no significant differences in blood loss, total volume and time of drainage, complications or postoperative hospital stays between the two groups.

CONCLUSIONS

Subxiphoid and subcostal arch thoracoscopic thymectomy for early-stage thymoma appears to be a safe and feasible procedure. It is considered to be less invasive as it may cause minimal postoperative pain compared to the unilateral VATS approach.

Uniportal video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery are feasible approaches with potential advantages in minimally invasive mediastinal lesions resection

Background

This study aims to identify the feasibility of uniportal video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) compared with multiportal VATS in the resection of mediastinal lesions.

Methods

Patients who underwent mediastinal lesion resection were enrolled and allocated to the uni-VATS, tri-VATS, and RATS groups according to the surgical approach. Propensity score-matched (PSM) analysis was performed between the VATS and RATS groups as well as the uni-VATS and tri-VATS groups. The operative and recovery parameters were compared.

Results

Totally, 274 patients were enrolled. There was no difference in the operative parameters among the groups. Compared with multiportal VATS, uniportal VATS and RATS had a significantly shorter chest tube placement time (2.43±0.88 vs. 1.78±1.22 vs. 2.21±1.11 days, P<0.001) and hospital length of stay (LOS) (4.07±1.75 vs. 3.27±1.05 vs. 3.62±1.21 days, P=0.001) without increasing the incidence rate of complications (5.6% vs. 7.2% vs. 5.7%, P=0.864). After PSM, the RATS group showed a significantly lower unplanned conversion rate than the VATS group (0.0% vs. 8.2%, P=0.041), while the uni-VATS group had a shorter chest tube placement time (1.83±1.20 vs. 2.35±0.86 days, P=0.013) and hospital LOS (3.23±1.03 vs. 3.95±2.00 days) than the tri-VATS group.

Conclusions

Compared with multiportal VATS, uniportal VATS and RATS are technically safe and feasible with potential advantages for mediastinal lesion resection.

Application of 3D modeling and printing technology in accurate resection of complicated thoracic tumors

Background

To explore the application value of three-dimensional (3D) reconstruction and 3D printing in preoperative evaluation of precise resection of complicated thoracic tumors.

Methods

A retrospective analysis of 34 patients with complicated thoracic tumors who were treated by radical surgery from March 2016 to June 2019 was made. According to whether 3D reconstruction and 3D printing was used, the patients were divided into research group and control group. In the control group, preoperative evaluation was performed according to CT image data, and the operation plan was drawn up; in the research group, preoperative simulation and preoperative operation plan design were carried out according to 3D reconstruction and 3D printing technology. The operation time, change of operation approach, intraoperative blood loss, hospitalization time and postoperative complications were compared between the two groups. We also retrospectively reviewed additional 12 cases of unresectable complicated thoracic tumors. The above 34 patients who were treated by radical surgery were set as the resectable group. Three-dimensional reconstruction was performed for all cases. The tumor size, location, smoothness of tumor-vascular contact surface, close contact with adjacent organs were compared between these two groups.

Results

The 3D reconstruction and 3D printing model were successfully established. The indexes of operation time, change of incision approach and blood loss in the research group were lower than those in the control group (P<0.05). All the patients were followed up for 6 months, and there was no death, no tumor recurrence and metastasis in the two groups. In the unresectable group, the score of position and smoothness of tumor-vascular contact surface were significantly higher than that in the resectable group.

Conclusions

3D reconstruction and 3D printing can effectively help surgeons carry out accurate surgical treatment, reduce the operation time and bleeding, reduce the risk of surgery, and facilitate the postoperative rehabilitation of patients, which has the value of promotion and application.

Uniportal video-assisted thoracoscopic thymectomy: the glove-port with carbon dioxide insufflation

Background

Since 2004, uniportal video-assisted thoracic surgery (VATS) approach was progressively widespread and also applied in the treatment of thymoma, with promising results. We report the first series of patients who undergone uniportal VATS thymectomy using a homemade glove-port with carbon dioxide (CO₂) insufflation. The aim of this article is to analyze the safety and feasibility to perform an extended thymectomy (ET).

Methods

A prospective, single-centre, short-term observational study including patients with mediastinal tumours undergoing scheduled uniportal VATS resection using a glove-port with CO₂. Operations were performed through a single incision of 3.5 cm at the fifth intercostal space, right or left anterior axillary line. A 5 mm-30° camera and working instruments were employed through a glove-port with CO₂.

Results

Thirty-eight patients (20 men; mean age 61.6 years) underwent ET between September 2016 and October 2019. Thirteen patients had a history of Myasthenia Gravis (MG) with thymoma and 8 had incidental findings of thymoma. Additionally, 8 mediastinal cysts and 9 thymic hyperplasia were included. Mean diameter of the tumor was 5.1 cm (range, 1.6-14 cm) and mean operation time was 143 minutes. Mean postoperative drainage duration and hospital stay were 2.3 and 4.3 days, respectively. Mean blood loss was 41 mL. There was no occurrence of surgical morbidity or mortality. During the follow-up period (1-36 months), no recurrence was noted.

Conclusions

Our results suggest that uniportal VATS thymectomy through glove-port and CO₂ is safe and feasible procedure, even with large thymomas. Furthermore, the glove-port system represents a valid, cheap and widely available alternative to the commercial devices usually adopted in thoracic surgery.

Novice training: The time course for developing competence in single port video-assisted thoracoscopic lobectomy

The competency in video-assisted thoracoscopic (VATS) lobectomy is expected to be achieved after surgeons practiced 30 to 50 cases according to previous reports. Does single port video-assisted thoracoscopic (SPVATS) lobectomy have a steeper learning curve and being harder to perform correctly, leading to long development times and high defect rates?From January, 2014 to February, 2017, 8 individual surgeons (3 were novices, 5 were pioneers in SPVATS surgery) submitted their cases chronologically to evaluate the learning curve of SPVATS lobectomy. Operating time (OT) was set as a surrogate marker for surgical competency. Postoperative outcomes and OT between the 2 groups were compared using propensity score matching (1:1 nearest neighbor). The learning curve for OT was evaluated using the cumulative sum (CUSUM) method.In the entire study cohort, a total of 356 cases were included (93 in junior consultant group [group A], 263 in senior consultant group [group B]). There were no significant differences between the 2 groups in operative time, conversion rate, postoperative complication rate, 30 and 90 days mortality rate. After propensity-score matching (86 pairs), operative time was longer in group A (214.33 ± 62.18 vs 183.62 ± 61.25 minutes, P = .001). Two-year overall survival rate was similar among 2 groups (P = .409). Competency was reached after junior surgeon completed 30th case of SPVATS lobectomy.SPVATS lobectomy is safe for the novice surgeon who wants to adopt this new surgical approach under well-developed training program. The learning curves for competence in SPVATS lobectomy are similar to VATS lobectomy in our series.

Devising the guidelines: the concept of uniportal video-assisted thoracoscopic surgery-incisions and anesthetic management

Uniportal video-assisted thoracoscopic surgery (VATS) is an already established minimally invasive technique in the field of thoracic surgery. The feasibility, safety and efficacy of the technique are already well documented. Comparative studies and meta-analyses have shown a clear advantage over open surgery and other minimally invasive techniques in terms of pain, length of stay (LOS), chest drain duration and morbidity. It covers a broad spectrum of indications for both malignant and benign diseases, including pulmonary and mediastinal tumor resections, diaphragm procedures (plication), esophageal surgery and airway surgery (bronchial resections, carinal resections). Its swift and wide adoption has resulted into many variations, all of whom are common in the fact they utilize a single incision to enter the chest and conduct the planned procedure. With this article, we attempt to standardize the technique as to the incision and the anesthetic management.

Simultaneously thoracoscopic resection of lung cancer and anterior mediastinal lesions by video-assisted thoracoscopic surgery

Background

Video-assisted thoracoscopic surgery (VATS) has been widely applied to various types of pulmonary and mediastinal resections in recent years. However, there are still limited experiences of simultaneous thoracoscopic resection for lung cancer and mediastinal tumor. The aim of the study is to investigate the technical safety and feasibility of uniportal VATS for simultaneous resection for concurrent diseases of lung and anterior mediastinum and to compare with multiportal VATS.

Methods

From June 2014 to December 2017, all patients who underwent simultaneously thoracoscopic resection for lung cancer and anterior mediastinal mass under uniportal or multiportal VATS via the same incision were retrospectively reviewed. Study cohort was divided according to surgical approach. Perioperative outcomes, including operative time, intraoperative blood loss, and postoperative hospitalization, were compared between uniportal and multiportal VATS groups.

Results

A total of 51 patients were included in the study, of whom 33 patients had uniportal VATS and 18 patients had multiportal VATS. When compared to multiportal VATS group, uniportal VATS group had similar time of operation (149.1±49.0 vs. 159.1±58.5, P=0.518), intraoperative blood loss (103.0±184.3 vs. 105.6±80.2, P=0.956), and postoperative length of hospital stay (4.7±2.0 vs. 5.5±3.0, P=0.246). No operative deaths occurred in this study.

Conclusions

Uniportal VATS for simultaneously thoracoscopic resection for lung cancer and anterior mediastinal disease is technically safe and feasible and has comparable operative parameters with multiportal VATS.

[Thoracoscopy in combined treatment of thymoma (in Russian only)]

The experience of video-assisted thoracoscopic interventions for thymus tumors in the Research Institute of Oncology of Tomsk National Research Medical Center is presented. We also evaluate the features of postoperative management of these patients.

Is a Chest Tube Necessary after Video-Assisted Thoracoscopic Mediastinal Tumor Resection?

BACKGROUND

The omission of chest tubes after thoracoscopic procedures such as sympathectomy, lung biopsy, and lung resection has proven efficacious in decreasing pain and length of hospital stay in some cases. However, its safety for mediastinal diseases remains unclear. This study evaluated the feasibility and outcome of eliminating chest drains after video-assisted thoracoscopic surgery (VATS) for mediastinal tumor resection.

METHODS

We retrospectively investigated 70 patients receiving VATS mediastinal tumor resection in a single institution between January 2016 and November 2018. A total of 39 patients (drain group) received postoperative chest drains and 31 patients (no-drain group) did not. Group clinical outcomes and operation data were compared. A propensity score matching analysis was further performed to yield a fairer comparison.

RESULTS

Before propensity score matching, the no-drain group had a higher prevalence of cystic lesions, a shorter operative time, and less blood loss compared with the drain group (p = 0.015, p = 0.018, and p < 0.001, respectively). After matching, the group differences in these perioperative variables lost significance (p = 0.095, 0.4, and 0.2, respectively). The no-drain group had lower postoperative day 2 pain scores and shorter postoperative hospital stays than the drain group, regardless of whether they were matched (pain: p = 0.028; hospital stay < 0.001) or not (pain: p = 0.003; hospital stay < 0.001). No major adverse events occurred in either group during hospitalization or follow-up period.

CONCLUSION

Eliminating chest drain placement after VATS mediastinal tumor resection may benefit some patients and decrease postoperative pain and hospital stay without increasing complications or compromising patient safety.

Uniportal Thoracoscopic Approach For Pulmonary Hydatid Cyst: Preliminary Results

PURPOSE

Pulmonary hydatid cyst is a preventable parasitary disease with high prevalence in low-medium income countries. Thoracoscopic approach is seen in the literature as small-case groups and multiple-port incisions are observed in these studies. Unlike other thoracoscopic approaches for the surgical treatment, we describe the single-port technique for the first time in our study. We attempt to compare the clinical outcomes and preliminary results of patients with pulmonary hydatid cyst treated with either minimally invasive or thoracotomy.

METHODS

The medical records of 66 patients undergoing surgery for pulmonary hydatid cyst disease between January 2013 and July 2017 were reviewed. The number of patients who underwent thoracotomy was 48, whereas 18 were managed by single-port video-assisted thoracoscopic surgery. Variables statistically compared between the 2 groups were age, diameter of the cystic, operation time, volume and duration of the drainage, postoperative complications, length of stay, duration of narcotic analgesic usage, and pain score.

RESULTS

Thoracoscopic approach was superior to conventional thoracotomy in terms of operation time, drainage volume, time to drain removal, hospital stay, narcotic analgesic treatment duration, and postoperative pain scores. All thoracoscopic procedures were concluded successfully, and conversion to open surgery was not required. No postoperative mortality was seen in either group. During the follow-up period, no recurrence was encountered in either group.

CONCLUSIONS

Uniportal thoracoscopic approach is a safe option for the treatment of hydatid cyst disease. It can be used as an alternative to thoracotomy, depending on the size and location of the lesion.

Management of intra-operative major bleeding during single-port video-assisted thoracoscopic anatomic resection: two-center experience

BACKGROUND

Our objective is to report on two centers' experience of intra-operative management of major vascular injury during single-port video-assisted thoracoscopic (SPVATS) anatomic resections, including bleeding control techniques, incidence, results, and risk factor analysis.

METHODS

Consecutive patients (n = 442) who received SPVATS anatomic lung resections in two centers were enrolled. The different clinical parameters studied included age, previous thoracic surgery, obesity (BMI > 30), tumor location, neoadjuvant therapy, and pleural symphysis. In addition, peri-operative outcomes were compared between the groups, with or without vessel injury.

RESULTS

There were no intra-operative deaths in our study. Overall major bleeding incidence was 4.5%, whereby 70% of major bleeding episodes could be managed with SPVATS techniques. In order to determine risk factors possibly related to intra-operative bleeding, we used case control matching to homogenize our study population. After case control matching, pleural symphysis was significantly related in the univariate (p = 0.005, Odds ratio 4.415, 95% CI 1.424-13.685) and multivariate analysis (p = 0.006, Odds ratio 4.926, 95% CI 1.577-15.384). Operative time (p < 0.001), blood loss (p < 0.001), and post-operative hospital stay (p = 0.012) were longer in patients with major vascular injury. There were no differences in 30-day mortality and 90-day morbidity.

CONCLUSIONS

In summary, major intra-operative bleeding episodes during SPVATS anatomic lung resections are acceptable and most such bleeding episodes can be safely managed with SPVATS techniques.

Short-term outcomes of single- versus multi-port video-assisted thoracic surgery in mediastinal diseases

OBJECTIVES

Although there is growing interest in single-port video-assisted thoracic surgery for a number of thoracic operations, there is still not enough known about its use for mediastinal pathologies. The present study was aimed at assessing the safety and efficacy of single-port video-assisted thoracic surgery in comparison with the multi-port variants in terms of short-term perioperative outcomes.

METHODS

From July 2013 to December 2015, 285 consecutive non-myasthenic adult patients undergoing single- or multi-port video-assisted thoracic surgery for mediastinal diseases including thymoma were retrospectively reviewed. Patients were stratified depending on whether the pathology was thymoma. A propensity score matching pertaining to the approach used was performed within each stratified category. Perioperative outcomes were compared between matched cohorts.

RESULTS

During the study period, 141 (49.5%) patients were treated with single-port thoracoscopic surgery. Preoperative variables were comparable between both pairs of cohorts after matching. No morbidity or mortality occurred, except 1 case of empyema in a 2-port case. Single-port technique exhibited shorter operation time (thymoma: 78.8 vs 120.0 min, P = 0.011; non-thymoma: 78.4 vs 107.9 min, P < 0.001), less intraoperative blood loss (thymoma: 42.0 vs 78.4 ml, P = 0.002; non-thymoma: 46.0 vs 62.2 ml, P = 0.001) and a lower postoperative 10-point visual analogue scale pain score (thymoma: 2.6 vs 3.3, P = 0.026; non-thymoma: 2.4 vs 3.2, P < 0.001) than multi-port techniques in both patient categories.

CONCLUSIONS

Single-port video-assisted thoracic surgery is a safe approach for patients with loco-regional mediastinal disease, with potential advantages of shorter operative time, less intraoperative bleeding and less postoperative pain when compared with multi-port techniques.

Minimally invasive techniques in thymic surgery: a worldwide perspective

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.

Troubleshooting of single port video-assisted thoracoscopic lung resection

By now single port video-assisted thoracoscopic surgery is in full swing all over the world. Series of papers have been proved its safety and feasibility. There are still some tricks which could help beginner to overcome the obstacle of operation. In this article, we tried to focus on how to retrieve the specimen from chest wall cavity simply and how to deal with the bleeding episode during operation.

Uniportal bilateral video-assisted sequential thoracoscopic extended thymectomy

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.

Application of single-port video-assisted thoracoscope in treating thoracic oesophageal squamous cell carcinoma using McKeown approach

Objective:

This study aims to investigate the feasibility of single-port video-assisted thoracoscope (SPVATS) in treating thoracic oesophageal squamous cell carcinoma (TESCC) using McKeown approach.

Materials and Methods:

Totally 10 McKeown approach-based SPVATS surgeries (8 males and 2 females, aged 42–68 years) were carried out from January 2015 to December 2015 to treat TESCC, including one case in upper thoracic segment, 5 cases in median thoracic segment and 4 cases in inferior thoracic segment. All the cases were pathologically diagnosed as SCC pre-operatively. SPVATS was performed to free thoracic oesophagus and dissect the lymph nodes, and laparoscopy was performed to free stomach and to perform oesophagus-left gastric collum anastomosis.

Results:

All the patients were successfully completed SPVATS, with average thoracic surgery time as 150 min, intra-operative blood loss as 30–260 ml (average 90 ml), and post-operative hospital stay as 9–16 days (average 12 days).

Conclusions:

SPVATS was technically feasible and safe in treating TESCC using McKeown approach, with less trauma and rapid post-operative recovery, and hence, it could be used as a new surgical option for McKeown approach-based TESCC treatment.

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

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.

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

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.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0547-3) contains supplementary material, which is available to authorized users.

Management of post-operative pain by placement of an intraoperative intercostal catheter after single port video-assisted thoracoscopic surgery: a propensity-score matched study

BACKGROUND

The establishment of a golden standard for post-operative analgesia after thoracic surgery remains an unresolved issue. Benefiting from the rapid development of single port video-assisted thoracoscopic surgery (VATS), a good candidate for the alleviation of patients' pain is the placement of an intercostal catheter (ICC) safely after uniport VATS. We hypothesized that continual infusion through ICC could provide effective analgesia for patients with only one wound and we evaluate its postoperative analgesic function in uniport VATS patients with or without intercostal nerve blockade.

METHODS

Since March 2014, 235 patients received various kinds of single port VATS. We identified 50 patients who received single port VATS with intercostal nerve blockade and retrospectively compared them with a group of patients who had received single port VATS without intercostal nerve blockade. The operative time, post operation day 0, 1, 2, 3 and discharge day pain score, narcotic requirements, drainage duration and post-operative hospital stay were collected. In order to establish a well-balanced cohort study, we also used propensity scores matching (1:1) to compare the short term clinical outcome in two groups.

RESULTS

No operative deaths occurred in this study. The uniport VATS with intercostal nerve blockade group was associated with less post operation day 0 and day 1 pain score, and narcotic requirements in our cohort study (P<0.001, <0.001, and 0.003). After propensity scores matching, there were 50 patients in each group. Mean day 0 and day 1, day 2, day 3 pain score, drainage duration, post-operative hospital stay, and narcotic requirements were smaller in uniport VATS with intercostal nerve blockade (P<0.001, <0.001, 0.038, 0.007, 0.02, 0.042, and 0.003).

CONCLUSIONS

In conclusion, in patients post single port VATS, continual intercostal nerve block with levobupivacaine infusion appears to be a safe, effective and promising technique in our study, associated with a shorter hospital stay and less post-operative pain. Further prospective trials are needed to determine the long term outcomes.

Single port VATS mediastinal tumor resection: Taiwan experience

BACKGROUND

To present the technique of single-port video-assisted thoracoscopic mediastinal tumor resection, which includes limited thymectomy, extended thymectomy, cyst excision and posterior mediastinal tumor excision, and the early results of resection with the use of this technique.

METHODS

Forty patients with mediastinal tumors were treated with single-port thoracoscopic mediastinal resection at Chang Gung Memorial Hospital between April 2014 and September 2015. The surgical intervention was performed through the fourth or fifth intercostal space at the anterior axillary line. A 5 or 10 mm 30 degree video camera and working instruments were employed simultaneously at this incision site throughout the surgery.

RESULTS

Among the 40 cases included in the final analysis, 10 extended thymectomies, 7 limited thymectomies, nine cyst excisions and 14 tumor excisions were performed successfully without the need for conversion. For the 40 patients who underwent single-port video-assisted thoracoscopic surgery (VATS), the mean operation time was 97.3±31.2 min and the average blood loss was 29.75±39.77 mL. The average length of the incision wound was 3.22±0.79 cm and the average length of postoperative hospital stay was 3.72±1.63 days. There were no mortalities and mobility was achieved within 30 days postoperatively.

CONCLUSIONS

Our preliminary report suggests that uniportal VATS for mediastinal tumor resection is a promising and safe technique within a short-term period.

Thoracoscopic resection of bulky thymoma assisted with artificial pneumothorax: A report of 19 consecutive cases

The aim of the present study was to examine the feasibility and efficacy of thoracoscopic radical resection of large retrosternal thymoma using artificial pneumothorax. A retrospective analysis was performed on 19 patients with bulky thymoma who underwent thoracoscopic resection using artificial pneumothorax by CO₂ insufflation. The operations were performed with unilateral or bilateral thoracic incisions via single lumen endotracheal intubation and two-lung ventilation. This approach provided excellent exposure of the thoracic cavity and reliable control of the neuro-vascular structures in the anterior mediastinum, which was of vital importance for the extended resection of malignant thymoma. The operation time was 140.0±51.4 min without conversion to thoracotomy or sternotomy. The pathological diagnosis was confirmed by immunohistochemistry, including 5 cases of thymus lipomyoma, 1 case of thymus hyperplasia, 1 case of thymus cyst, 2 cases of type AB thymoma, 4 cases of type B1 thymoma, 4 cases of type B3 thymoma, and 2 cases of thymic carcinoma. Furthermore, there were no complications such as recurrent laryngeal nerve injury, phrenic nerve injury, pulmonary infection or atelectasis, with a hospital stay of 5.0±3.0 days. In conclusion, the thoracoscopic resection of thymoma using artificial pneumothorax is a preferable approach, that may be considered for patients with bulky retrosternal tumors.

Subxiphoid and subcostal arch thoracoscopic extended thymectomy: a safe and feasible minimally invasive procedure for selective stage III thymomas

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has been applied to resection of small and well-encapsulated thymomas. However, few data are available regarding to the application of VATS in stage III thymomas.

METHODS

A novel subxiphoid and subcostal arch approach for thoracoscopic extended thymectomy was developed by us. From January 2014 to August 2015, 14 patients with stage III thymoma were treated by using this new technique in the Department of Thoracic Surgery, Tangdu hospital, Xi'an, China. These patients were retrospectively reviewed and analyzed.

RESULTS

Among the 14 patients, 1 patient was converted to transsternal approach owning to invasion of the superior vena cava. The other 13 patients with thymomas invading the pericardium, lung tissues and left innominate vein (LIV), were successfully operated on by using this new technique. The average operation time was 120.0±32.7 min (80-170 min), the average volume of estimated blood loss was 51.5±44.8 min (10-150 mL) and the average postoperative hospital stay was 4.8±1.5 days (3-9 days). There was no perioperative death. Two patients suffered postoperative complications including one patient with atrial fibrillation (AF) and the other one with myasthenic crisis (MC). The postoperative pain score decreased dramatically from 3.8±1.0 [3-6] at 24 hours to 1.5±0.9 [0-6] at 48 hours, and finally to 0 at 3 months after surgery (P=0.000). The patients reported a higher cosmetic score of 92.6±2.7 [90-96]. There was no tumor recurrence and the five patients with myasthenia gravis had improvement and did not need any medication until follow-up.

CONCLUSIONS

Based on our limited experience, the subxiphoid and subcostal arch thoracoscopic extended thymectomy is safe and feasible for selective stage III thymoma, and might reduce the postoperative pain and provide satisfied cosmetic effect.

Global development and current evidence of uniportal thoracoscopic surgery

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

Video-assisted thoracoscopic thymectomy using 5-mm ports and carbon dioxide insufflation

The continuous development and refinement of minimally invasive approaches to thymectomy over the last two decades has potential benefits for patients in terms of better cosmesis, less postoperative pain, shorter length of stay, earlier return to daily activities, less bleeding and fewer complications overall with similar outcomes regarding survival, recurrence of thymoma and complete remission (CR) for myasthenia gravis patients. A variety of different approaches have been described previously. This is a detailed description of video-assisted thoracoscopic thymectomy using three 5 mm ports, carbon dioxide (CO2) insufflation and bipolar electrocoagulation (LigaSure).