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

Effects of Preserving the Pulmonary Vagus Nerve Branches on Cough After Pneumonectomy During Video-Assisted Thoracic Surgery

Background

Cough is one of the most common complications of early-stage non-small cell lung cancer (NSCLC) after video-assisted thoracoscopic surgery (VATS). The vagus nerve plays an important role in pulmonary inflammation and the cough reflex. In this study, we attempted to reduce the incidence of postoperative chronic cough and other complications by preserving the pulmonary vagus nerve branches.

Patients and Methods

This study was a randomized controlled double-blinded trial of subjects and observers. A total of 158 NSCLC patients were enrolled. We randomly assigned 79 patients to Group A (pulmonary branch of vagus nerve preservation group) and 79 cases to Group B (conventional surgical treatment group). In the final analysis, 72 patients from Group A and 69 patients from Group B were included. The main outcome measure of the study was the occurrence of CAP or other postoperative complications within five weeks. This trial was registered with ClinicalTrials.gov (number NCT03921828).

Results

There was no significant difference in preoperative general clinical data between the two groups. No death during the perioperative period occurred in either of the two groups. There was no significant difference between the two groups in operation time, intraoperative bleeding, number of lymph nodes sent for examination, number of cases transferred to ICU after operation, postoperative catheterization time, or postoperative hospital stay (P>0.05). There was no significant difference in other pulmonary and cardiovascular complications between the two groups, including pulmonary infection (2.78% vs. 8.70%, P = 0.129), atelectasis (1.39% vs. 0%, P = 0.326), pleural effusion (2.78% vs. 1.45%, P = 0.585), persistent pulmonary leakage (2.78% vs. 2.90%, P = 0.965), arrhythmia (2.78% vs. 1.45%, P = 0.585), and heart failure (0% vs. 1.45%, P = 0.305). The incidence of CAP in Group A was significantly lower than that in Group B (13.89% vs. 30.43%, P = 0.018). The LCQ-MC scores in Group A were significantly higher than those in Group B at two and five weeks after operation (P<0.05). Univariate and multivariate analysis showed that the risk factors for postoperative CAP were surgical side (right lung), surgical lung lobe (upper lobe), preservation of pulmonary branch of the vagus nerve during operation, and duration of anesthesia.

Conclusions

Preserving the pulmonary vagus nerve branches during VATS in patients with stage IA1-2 NSCLC can reduce the incidence of postoperative CAP.

Uniportal Video-assisted Thoracoscopic Surgery (u-VATS) for Management of pulmonary hydatid cyst: A systematic review

BACKGROUND AND OBJECTIVES

Hydatid disease of the lung, caused by Echinococcus granulosus, is an unusual parasitic disease. The aim of the current review for managing pulmonary hydatid cysts by uniportal video-assisted thoracoscopic surgery (u-VATS), and their complications, the size of hydatid cyst, length of hospital stay, surgery time, the rate of conversion from u-VATS to thoracotomy or mini-thoracotomy, follow-up, and outcomes.

METHODS

We conduct the platform searches on the PubMed and Google Scholar electronic databases from inception to January 20, 2022, among patients diagnosed with pulmonary hydatid cyst (PHC) who underwent the u-VATS approach.

RESULTS

This systematic review comprised five studies reporting 85 cases of PHC underwent (u-VATS) approach. Most patients were adults. The most common location of pulmonary hydatid cyst was the right lower lobe followed by the left lower lobe. The average size of PHC was 8.41 cm in all studies. The length of hospital stay was 3.85 days. The duration of operation time based on the means of the included studies was 86.19 min for each patient. Furthermore, the overall complication occurred in 9.35% of patients (n = 11) from 85 cases. The most complication was emphysema and prolonged air leak. The recurrence of pulmonary hydatid cyst did not occur in all studies.

CONCLUSION

The feasibility of the video-assisted thoracoscopic surgery (VATS) approach has been proven globally in terms of reducing the overall complication, shorter chest tube duration, shorter surgery time, reduce postoperative pain, shorter chest tube duration, lower chest tube drainage, and less required to pain killers postoperatively.

Treatment of lumbar and intrathoracic meningocele: bioethical implications

Myelomeningocele is  a  congenital malformation caused by a developmental defect of the spinal cord structures. The exactcause is unknown, but different factors have been involved includingradiation, malnutrition, drugs. Myelomeningocele can develop at any point in the spine, but the lumbosacral region is affected in over 75% of cases. Chest X-raysand computed tomography study are mandatory to reveal tracheal malformations or associatedanomaliesof the ribs.  Treatment of myelomeningocele must be multidisciplinary  and involve at the same time neurologists, radiologists, neurosurgeons, thoracic surgeons, bioethical experts and take care of the childand also of the family. Some experiences concern the possibility of a in-utero correction of myelomeningocele, in order to avoiding serious and progressive damages to the nervoussystem.  Given the improvement of myelomeningocele management, the quality of life is nowadays more acceptable than in the past; however, some severe forms of myelomeningocele cannot still be corrected: in this cases, a "non-interventional" approach may require a form of passive euthanasia that should be discussed and approved with and by parents and  Any dissent of the parents must be respected and considered reasonable. The choice of a "non-intervention", which should be guaranteed to all the people capable of self-determination, is not however so immediate and direct in the case of the minor: the dissent expressed on his behalf by the parents or legal representative may be ethically difficult to be accepted.In this case, the best interest of the child must prevail as the goal of any therapeutic choice.

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.

Ground glass opacities management in the lung cancer screening era

Pulmonary ground glass opacity (GGO) is becoming an important clinical dilemma in oncology as its diagnosis in clinical practice is increasing due to the introduction of low dose computed tomography (CT) scan and screening. The incidence of cancer in GGO has been reported as high as 63%. The purpose of this manuscript is to review best available evidence papers on management of GGO in lung cancer to address the following questions: (I) how to correlate CT findings with malignancy; (II) when and who operate? (III) how to perform intraoperative detection of intrapulmonary GGO? (IV) wedge, segmentectomy or lobectomy? Taking a cue from a clinical scenario, a review on PubMed was conducted. The words search included: "Lung ground glass opacity". The research was limited to human and adults. We considered all published articles from 1990 to April 2017, which reported on at least sufficient data, to be eligible. The literature search was limited to articles in English. A total of 1,211 articles have been found. Interestingly, while in 1991, only one paper was published on low-dose high-resolution CT, in 2016, 126 papers have been published. Most cited and recent papers have been chosen for discussion. Many recent papers have been published from Asian groups. It is clearly not possible to conclude from these data what is the best strategy for GGO in the lung cancer screening era. Certainly, when there is uncertainty, personal opinion and experience should not influence decision making, on the contrary decision should be taken by a multidisciplinary team.

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.

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.

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.

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.

[Development, Application Details, and Prospects of Uni-VATS on Lung Cancer Radical Operation under the Concept of "Precise Medical Treatment"]

单孔电视胸腔镜手术（uni-portal uideo-assisted thoracic surgery, Uni-VATS）的推广，是近年微创胸外科最重大的进展之一。随着腔镜下成像设备、切割缝合器械及电分离器械的改进，单孔VATS的应用范围已从最初的肺组织活检术逐渐扩大到解剖性肺叶/段切除、全肺切除、支气管/血管袖式吻合。多中心大量报道已证实：单孔VATS行肺叶切除安全、可行，清扫纵隔淋巴结的组数及总数均不低于传统多孔VATS，在疼痛、创伤及术后恢复方面也有积极的结果。虽然暂未得到多中心、大样本的临床数据如5年生存率，但有序地逐步开展单孔VATS仍是微创胸外科未来发展的重要方向。本文将围绕单孔VATS的原理及具体操作细节，结合肺癌根治术的基本操作理念进行讨论及综述，以期为单孔VATS的有序、规范化开展提出思考和探索。

Technical steps in single port video-assisted thoracoscopic surgery lobectomy

Video-assisted thoracoscopic surgery (VATS) has transformed the way of treating patients with lung diseases over the past two decades and this is particularly true referred to patients with lung carcinoma. The indication for surgical treatment could be extended to those patients that were functionally unable to receive a thoracotomy and overall this approach shortened the length of stay in hospital and improved the quality of life of these patients postoperatively. The best VATS technique for lobectomy has not been well defined yet. The VATS approach to lobectomy can be performed via 1-4 incisions without rib spreading with similar outcomes. Over the last few years the single port VATS approach has generated a growing interest in the scientific thoracic surgery community as less invasive for the patients and comfortable for the performing surgeon. The aim of this video-article is to show the different steps of this technique and to provide some tips and tricks to improve and facilitate the execution of the uniportal VATS lobectomy.