CO2 during single incisional thoracoscopic bleb resection with two-lung ventilation

Video-assisted thoracoscopy with two-lung ventilation and CO2 insufflation in primary spontaneous pneumothorax: propensity score matching comparison

Background

Primary spontaneous pneumothorax (PSP) is commonly treated with video-assisted thoracoscopic surgery (VATS), which traditionally requires one-lung ventilation (OLV) with double-lumen endotracheal intubation to optimize the surgical field. However, OLV may be associated with complications such as airway trauma and postoperative sore throat. In contrast, two-lung ventilation (TLV) with CO2 insufflation has been proposed as an alternative that may reduce airway-related complications while maintaining adequate visualization. This study assessed the feasibility of VATS with TLV and CO2 insufflation for PSP compared to the conventional OLV approach.

Methods

We retrospectively analyzed 181 patients with PSP treated at our center between July 2020 and December 2023; of these, 134 underwent thoracoscopic bullectomy. Fifty-six patients received VATS with TLV and CO2 insufflation. Seventy-eight patients underwent OLV via double-lumen endotracheal intubation. Patient data were categorized into groups based on the minimization of bias between those receiving TLV and those receiving OLV, following analysis matched by propensity scores. A comparative analysis across these groups was also conducted, focusing on demographic data and intraoperative and postoperative outcomes.

Results

The TLV group demonstrated several advantages, including shorter anesthesia induction time (13.45±5.25 min, P=0.01), shorter total anesthesia time (63.18±14.45 min, P=0.003), fewer days of chest tube drainage (1.41±1.22 days, P=0.04), shorter postoperative hospital stay (2.36±0.88 days, P=0.01), lower wedge resection specimen weight (3.21±2.5 g, P=0.03), fewer instances of postoperative ipsilateral and contralateral recurrence, and lower likelihood of short-term recurrence. No significant differences were found in surgical time (P=0.17), anesthesia recovery time (P=0.48), use of endostaplers (P=0.35), number of wedge resections (P=0.21), and pleurodesis (P=0.73).

Conclusions

In appropriately selected patients, TLV appears to be a viable option that does not increase recurrence risk compared to OLV while offering the benefit of a shorter anesthesia duration. Therefore, this method may be suitable for patients with PSP.

New Trends in Uniportal Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax: A Narrative Review

Background: Minimally invasive thoracic surgery has advanced since the introduction of multiportal video-assisted thoracoscopic surgery (mVATS) in 1991. Primary spontaneous pneumothorax (PSP) is an ideal condition for refining minimally invasive techniques owing to its straightforward procedures and predictable bullae distributions. Methods: Uniportal VATS (uVATS), which involves a single incision, is an alternative to mVATS, offering reduced postoperative pain, lower paresthesia rates, and comparable recurrence outcomes. This review explores two main uVATS approaches: intercostal and subxiphoid. Results: The intercostal approach is common to surgeons trained in mVATS, easier to adopt, and provides excellent cosmetic outcomes. Innovations such as the chest wall pulley method and anchoring sutures further enhance its operability and prevent recurrence. Subxiphoid uVATS minimizes intercostal nerve damage and postoperative pain, making it advantageous for bilateral PSP surgeries. However, it poses challenges such as longer operative times and limited dorsal visualization. Emerging strategies, including drainless postoperative management and two-lung ventilation with CO2 insufflation, have reduced surgical invasiveness. Additionally, cosmetic techniques such as subaxillary incisions enhance patient satisfaction. Conclusions: uVATS continues to redefine PSP surgery, prioritize patient-centered outcomes, and integrate novel strategies to achieve superior results.

Single-port robotic subcostal major pulmonary resection using the single-port robotic system

BACKGROUND

The da Vinci single-port system (SPS) (Intuitive Surgical, Sunnyvale, CA, USA) was designed for single-port (SP) surgery. Although we have reported our clinical outcomes using the SPS for a simple procedure in general thoracic surgery, major pulmonary resection had been performed only in cadaveric experiments to date. This study evaluated the feasibility of SP subcostal robotic major pulmonary resection using the SPS. Here, we present our initial clinical experience of SP subcostal robotic major pulmonary resection at our institution.

METHODS

Twenty-five patients with lung cancer underwent SP major subcostal pulmonary resection using the SPS between March and November 2022. Patient characteristics, intraoperative and perioperative outcomes were assessed. Questionnaires were used to evaluate patient satisfaction with the cosmetic results and quality of life through face-to-face or telephone interviews on postoperative day 30.

RESULTS

All patients underwent major pulmonary resection with complete radical resection (R0). Nineteen patients underwent lobectomy, whereas six patients underwent segmentectomy. The mean docking time and total operative time were 4.16 ± 1.19 min (range, 2.3-7.8 min) and 197.6 ± 55.33 min (range, 130-313 min), respectively. No patients underwent conversion to open thoracotomy. One patient required an additional assistant port due to severe pleural adhesions.

CONCLUSIONS

SP subcostal robotic major pulmonary resection using the SPS is feasible and safe. With the continuous development of robotic technology and surgical techniques, we believe that more complex general thoracic surgeries will be performed in the future using SPS.

Video-assisted thoracic surgery for spontaneous pneumothorax under two-lung ventilation and single-lumen endotracheal tube intubation

BACKGROUND

This study investigated the feasibility of video-assisted thoracic surgery (VATS) performed under two-lung ventilation (TLV) and single-lumen endotracheal tube (SLET) intubation in patients with spontaneous pneumothorax.

METHODS

From January 2016 to December 2019, 344 patients who underwent VATS with spontaneous pneumothorax, whether primary or secondary, were enrolled. The surgery was performed through TLV using SLET intubation or one-lung ventilation (OLV) using double-lumen endotracheal tube (DLET) intubation. Patient data were collected retrospectively from medical records and compared with an emphasis on the time required for anesthesia and surgery.

RESULTS

The average anesthesia time was 72.6±17.8 min for TLV and 89.9±24.3 min for OLV (P<0.001). The average operating time was 42.1±16.2 min for TLV and 54.7±23.8 min for OLV (P<0.001). The average time from the onset of anesthesia to incision was 23.6±7.0 min for TLV and 27.6±9.5 min for OLV (P<0.001). There was no case of conversion to OLV using DLET intubation during surgery with TLV using SLET intubation. Removal of the chest tube took 1.6±1.1 days for the TLV group and 2.3±3.6 days for the OLV group (P=0.017). Patients were discharged at 2.7±1.2 days after surgery for the TLV group and 3.2±2.3 days after surgery for the OLV group (P=0.009).

CONCLUSIONS

TLV using SLET intubation could shorten the time required for anesthesia-related procedures and surgery. In addition, it can be a beneficial surgical and anesthetic option for pneumothorax.