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Uniportal VATS for non-small cell lung cancer
Abstract
The video-assisted thoracic surgery (VATS) technique has evolved from its multiport origins to even less invasive approaches grounded in its proven benefits over open surgery for the treatment of early stage lung cancer. In this evolution process, the Uniportal VATS (UniVATS) strategy emerged. This technique is giving some evidence of benefits when compared to the multiport VATS and has been embraced by the surgical community spreading its geographical and surgical boundaries. Moreover, UniVATS has proven its feasibility for numerous and more complex procedures for lung cancer diagnosis and treatment, which are reviewed in this document as well as its current and future development.
... In this paper, they concurred about its definition, indications, contraindications, and perioperative management [7], making clear that the practice has spread widely. At present, there are enough data to state that UniVATS is feasible and safe to implement for many clinical situations as well as anatomic lung resections in the context of early-stage NSCLC treatment in selected patients [34,35]. In addition, every year much more complex procedures are being performed, providing data about their feasibility, such as the case of locally advanced disease, tracheal or carinal reconstructions, and less invasive UniVATS approaches such as subcostal, subxiphoid, and non-intubated surgeries [35]. ...
... At present, there are enough data to state that UniVATS is feasible and safe to implement for many clinical situations as well as anatomic lung resections in the context of early-stage NSCLC treatment in selected patients [34,35]. In addition, every year much more complex procedures are being performed, providing data about their feasibility, such as the case of locally advanced disease, tracheal or carinal reconstructions, and less invasive UniVATS approaches such as subcostal, subxiphoid, and non-intubated surgeries [35]. Moreover, there is also a trend offering better quality studies showing improved post-operative QOL and recovery with shorter hospital stay compared to multiport [31,32]. ...
... Another important remark is the better access to posterior structures. The operative technique has been described in previous publications [35]. It is worth mentioning that it is being addressed in combination with the SP robot, as having the potential to allow the execution of every pulmonary resection [78]. ...
The use of video-assisted thoracic surgery (VATS) as an approach for early-stage lung cancer treatment has revealed benefits compared to open surgery by minimizing trauma to the patients. This trend has brought the evolution of VATS to less and less invasive methods, eventually leading to the development of Uniportal VATS (UniVATS) technique. This new approach has shown to be resourceful, proving its feasibility even for complex oncological procedures. Furthermore, data is starting to express some benefits over multiport VATS, thus spurring on its development towards newer and more complex procedures. It is also been adopted by the surgical community achieving fast evolution and worldwide diffusion. Here, we review the evolution of UniVATS, its current state of evidence, some basic technical aspects, the present role it has in lung cancer treatment and the ongoing development of the technique.
Relevance for patients:
This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.
... Gonzalez-Rivas first reported uniportal VATS segmentectomy in 2012 (11) and briefly discussed the development of uniportal VATS in lung cancer treatment (12). After several years of development, increasingly thoracic surgeons can perform uniportal VATS segmentectomy and even subsegmentectomy. ...
... Resection margins and the metastasis state of No. 12 and No. 13 LNs should also be considered when discussing radical resection. Evidence shows a higher incidence of locoregional recurrence and worse patient survival when the surgical margin is inadequate (17). ...
Background:
Anatomical segmentectomy has become more and more universal in thoracic surgery because of the increasing detection of pulmonary nodules with ground-glass opacity (GGO), most of which proved early staged non-small cell lung cancer (NSCLC) postoperative. With the advantage of preservation of normal lung tissues, segmentectomy may be performed by surgeons when computed tomography (CT) scan shows pure GGO or multiple GGOs appearing. Especially when the patients with poor cardiopulmonary function or severe comorbidities or in the circumstance of bilateral pulmonary GGOs, segmentectomy can provide opportunities to radically resect all lesions. With the development of minimally invasive surgery technology, uniportal video-assisted thoracoscopic surgery (VATS) has become the regular operative route in many medical centers because it can provide less access trauma, less stress response, less pain, shorter hospital stays, and a lower postoperative complication rate and corresponds well with the idea of "minimally invasive". However, all of the procedures must be performed in one tiny portal, so uniportal VATS anatomical segmentectomy not only needs the skill and patience of surgeons but the effective cooperation of assistants, nurses and anesthetists, and plenty of details must be paid special attention.
Case description:
Here we present a video of a patient undergoing S1 segmentectomy of right upper lobectomy (RUL) under uniportal VATS. The chief complaints of the patients was that two pure GGOs in the bilateral upper lobe were found by physical examination for 26 months and he had no symptoms. We performed S1 segmentectomy of RUL under uniportal first time and performed trisegmentectomy of left upper lobectomy (LUL) 3 months later. With routinely follow-up, no evidence of relapse and metastasis disease was found.
Conclusions:
We think anatomical segmentectomy under uniportal VATS can be a feasible and safe procedure that reduces trauma and has equivalent oncology outcomes to lobectomy in early-stage lung cancer but need a more experienced medical center to perform.
Keywords:
Uniportal video-assisted thoracoscopic surgery (uniportal VATS); segmentectomy; non-small cell lung cancer (NSCLC); case report.
... Among surgical approaches, U-VATS is expected to reduce postoperative neuropathic pain compared to conventional multiportal VATS (M-VATS); therefore, we have introduced U-VATS lobectomy and segmentectomy since July 2018 (18). Many reports on U-VATS have been related to safety and feasibility (2)(3)(4)(5)(6)(7)(8)(9)(10), and few studies have strictly evaluated postoperative neuropathic pain, time effects, and the necessity of epidural anesthesia. ...
... These were almost the same this study as well. However, postoperative neuropathic pains of U-VATS have been not fully investigated (2)(3)(4)(5)(6)(7)(8)(9)(10). Based on our postoperative neuropathic pain studies (15)(16)(17), it is important to introduce a less invasive surgical approach and to shorten the surgical time. ...
Background: We aimed to analyze perioperative complications, postoperative neuropathic pain, and the necessity of epidural anesthesia in uniportal video-assisted thoracoscopic surgery (U-VATS) compared to conventional multiportal VATS (M-VATS) for anatomical lung resection.
Methods: This retrospective study included all patients who underwent elective VATS lobectomy and segmentectomy between April 2016 and December 2019. The exclusion criteria were as follows: age ≤19 years, planned thoracotomy, re-operation in thoracic surgery, median sternotomy, robot-assisted thoracic surgery, simultaneous resection of extrathoracic organs, locally invasive lung tumor with bronchoplasty or angioplasty, past or current neuropathic pain, and a large tumor with a minimum diameter ≥5 cm. M-VATS had 4 ports approach. U-VATS port positions were placed by extending the thoracoscope port of M-VATS. Results: U-VATS patients showed significant differences compared to M-VATS patients: smaller intraoperative bleeding (1 vs. 30 mL; P=0.0010), shorter operative time (141 vs. 183 min; P<0.0001), post- hospitalization (5 vs. 8 days; P=0.0002), fewer complications (23.9% vs. 40.9%; P=0.048), less acute pain, less postoperative neuropathic pain (32.4% vs. 52.1%; P=0.027) and shorter duration of neuropathic pain (30 vs. 60 days; P=0.041). For the postoperative neuropathic pain and pain score until postoperative day 5, there were no differences between the groups with and without epidural anesthesia.
Conclusions: As a single-center initial experience, U-VATS lobectomy and segmentectomy seemed safe and minimally invasive based on not only postoperative neuropathic pain and complications but also time management. U-VATS would provide better pain control, without epidural anesthesia.
... Thoracoscopic surgery has gained popularity because of reduced hospital stay and morbidity, as well as minimal invasion and early recovery [27]. Although thoracoscopic surgery is one common minimal invasive surgery with reduced pain intensity, these patients still suffer from moderate to severe pain scores [28]. ...
Background: The efficacy of erector spinae plane block for thoracoscopic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the impact of erector spinae plane block on thoracoscopic surgery. Methods: We searched the PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through February 2022 for randomized controlled trials (RCTs), assessing the effect of erector spinae plane block on thoracoscopic surgery. This meta-analysis was performed using the random-effect model. Results: Seven RCTs, involving 439 patients, are included in the meta-analysis. Overall, compared with the control group for thoracoscopic surgery, erector spinae plane block (ESPB) results in significantly reduced pain scores at 1 h (standard mean difference (SMD) = –4.26; 95% confidence interval (CI) = –7.63 to –0.88; p = 0.01), 4 h (SMD = –4.08; 95% CI = –4.56 to –3.60; p < 0.00001), 8 h (SMD = –4.13; 95% CI = –4.62 to –3.65; p < 0.00001), and postoperative anesthesia consumption (SMD = –3.04; 95% CI = –4.58 to –1.50; p = 0.0001) and can decrease the incidence of nausea and vomiting (odd ratio (OR) = 0.18; 95% CI = 0.08 to 0.39; p < 0.001). Conclusions: ESPB can substantially enhance pain relief for thoracoscopic surgery.
... In the past 10 years, uniportal video-assisted thoracoscopic surgery (VATS) has become one of the minimally invasive approaches [10,11]. Uniportal VATS is associated with less trauma, less pain, shorter hospitalization, and lower complication rates [12][13][14][15]. ...
Background
Pulmonary extended segmentectomy is an optional surgical treatment for early-stage non-small cell lung cancer that helps to achieve optimal surgical margins. Here, we describe a challenging instance of extended segmentectomy via uniportal video-assisted thoracic surgery with virtual-assisted lung mapping, a preoperative bronchoscopic dye marking procedure.
Case presentation
A 72-year-old woman presented with two tumors that were clinically diagnosed as early-stage lung cancer; extended right apical segmentectomy was indicated. Because the tumors had appeared unidentifiable intraoperatively, we performed virtual-assisted lung mapping for tumor localization and delineation of the optimal resection area. Surgery was conducted through a single port. All virtual-assisted lung mapping markings were visible. After dissection of the apical vessels and bronchi, a putative intersegmental line was determined using collateral ventilation. Based on the putative intersegmental plane identified by collateral ventilation and the virtual-assisted lung mapping markings, the resection line was delineated. Extended apical segmentectomy along the resection line was successfully performed via uniportal video-assisted thoracic surgery. The postoperative course was uneventful. The pathological diagnosis was minimally invasive adenocarcinoma and adenocarcinoma in situ.
Conclusions
Virtual-assisted lung mapping can help to achieve optimal extended segmentectomy via uniportal video-assisted thoracic surgery.
... 5 VATS is most often performed via three access sites but can also be done via one single thoracentesis, called uniportal-VATS (uVATS). 6 Besides minimizing the pure surgical trauma, anesthesiological adoptions may also contribute to reduced overall procedural invasiveness and faster recovery. Nonintubated (NI) VATS are performed on nearly awake, spontaneously breathing patients. ...
Background The so-called nonintubated or awake video-assisted thoracoscopic surgery (NIVATS) is performed on spontaneously breathing patients, which was shown to reduce postoperative complications and shorten hospital stay.
Case Description Awake uniportal VATS was indicated for the evacuation of an extensive, superinfected hemothorax with symptomatic mediastinal shift in a patient with advanced mediastinal SMARCA4-deficient tumor and declined condition, who did not allow a general anesthetic procedure and was not a candidate for extensive surgery.
Conclusion This short microinvasive intervention was a prerequisite to stabilize the threat to the patient's life and thus potentially enable any further tumor-specific therapy.
... Compared with M-VATS, the advantages of U-VATS include fewer incisions, less pain, shorter hospital stay, and faster recovery of lung function [11][12][13] .There are also some disadvantages of U-VATS, such as prolonged time when performing lymph node dissection, especially for subcarinal lymph nodes. Also, because of the small space, the surgical instruments and the thoracoscope will interfere with each other. ...
Background:Uniportal Video-Assisted Thoracoscopic Surgery (U-VATS) has emerged as a feasible approach for treating non-small cell lung cancer (NSCLC). However, there is a lack of studies reporting the long-term survival outcomes of U-VATS lobectomy for NSCLC.
Objective:This study aims to compare the perioperative outcomes and long-term survival of U-VATS lobectomy for NSCLC with multiportal VATS (M-VATS, involving two ports or more) lobectomy.
Method: A total of 339 patients who underwent intentional VATS lobectomy for NSCLC between 2012 and 2017 were included in the analysis. Perioperative outcomes and long-term survival were evaluated. Propensity score matching was utilized to minimize baseline characteristic differences between the two groups.
Results:Out of the total cases, 17 (5.01%) were converted to open thoracotomy. The conversion rates were 4.96% (7/141) in the U-VATS group and 5.05% (10/198) in the M-VATS group. A total of 322 consecutive patients underwent VATS lobectomy and mediastinal lymphadenectomy. After propensity matching, 106 pairs were obtained, consisting of 83 males and 129 females. Intraoperative bleeding volume, number of retrieved lymph nodes, explored nodal stations, drainage time and volume, and postoperative hospital stay were similar between the two groups. Both groups exhibited comparable morbidity and mortality rates. From the multivariable analysis, there was no significant difference observed in terms of overall survival (OS) and disease-free survival (DFS) between the two patient cohorts.
Conclusions: U-VATS demonstrated comparable perioperative outcomes and long-term efficacy to M-VATS. However, further confirmation of these findings is required
... In this approach, the thoracic surgeon performs his procedure using one incision and specific instruments designed for UniVATS. Although this approach has been described in some reports already dating back more than 20 years ago, it is only quite recently that studies have shown its safety and feasibility in lung cancer surgery [52]. Furthermore, evidence suggests that, in terms of postoperative pain, UniVATS is likely to be better, or at least no worse, than the standard three-port VATS approach [53,54]. ...
In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.
... Compared with M-VATS, the advantages of U-VATS include fewer incisions, less pain, shorter hospital stay, and faster recovery of lung function [11][12][13] .There are also some disadvantages of U-VATS, such as prolonged time when performing lymph node dissection, especially for subcarinal lymph nodes. Also, because of the small space, the surgical instruments and the thoracoscope will interfere with each other. ...
Background:Uniportal Video-Assisted Thoracoscopic Surgery (U-VATS) has emerged as a feasible approach for treating non-small cell lung cancer (NSCLC). However, there is a lack of studies reporting the long-term survival outcomes of U-VATS lobectomy for NSCLC.
Objective:This study aims to compare the perioperative outcomes and long-term survival of U-VATS lobectomy for NSCLC with multiportal VATS (M-VATS, involving two ports or more) lobectomy.
Method: A total of 339 patients who underwent intentional VATS lobectomy for NSCLC between 2012 and 2017 were included in the analysis. Perioperative outcomes and long-term survival were evaluated. Propensity score matching was utilized to minimize baseline characteristic differences between the two groups.
Results:Out of the total cases, 17 (5.01%) were converted to open thoracotomy. The conversion rates were 4.96% (7/141) in the U-VATS group and 5.05% (10/198) in the M-VATS group. A total of 322 consecutive patients underwent VATS lobectomy and mediastinal lymphadenectomy. After propensity matching, 106 pairs were obtained, consisting of 83 males and 129 females. Intraoperative bleeding volume, number of retrieved lymph nodes, explored nodal stations, drainage time and volume, and postoperative hospital stay were similar between the two groups. Both groups exhibited comparable morbidity and mortality rates. From the multivariable analysis, there was no significant difference observed in terms of overall survival (OS) and disease-free survival (DFS) between the two patient cohorts.
Conclusions: U-VATS demonstrated comparable perioperative outcomes and long-term efficacy to M-VATS. However, further confirmation of these findings is required
... Because standard lobectomy removes more lung parenchyma than segmentectomy, loss of lung function is greater and postoperative recovery poorer. [11,12] Uniportal VATS (U-VATS) [13,14] is widely used for lung segmental resection in major centers, but the benefits of U-VATS lung segment resection versus U-VATS lobectomy with regard to immediate and long-term lung function recovery and postoperative quality of life (QoL) have not been fully investigated. The aim of this study was to compare the safety and short-term effectiveness of U-VATS anatomical segmental lung excision versus U-VATS lobectomy in patients with early-stage non-small cell lung cancer (NSCLC). ...
In patients with stage IA non-small cell lung cancer (NSCLC), uniportal video-assisted thoracic surgery (U-VATS) anatomical segmentectomy removes the lung tumor while preserving lung function as much as possible, and it is therefore an alternative to lobectomy. Patients with stage IA NSCLC receiving U-VATS segmental resection at our institution from September 2017 to June 2019 were compared with patients receiving U-VATS lobectomy. A total of 47 patients received segmentectomy and 209 patients received U-VATS lobectomy in the same period. Propensity score matching was conducted to diminish bias. The final study cohort included 42 patients who received segmentectomy and 42 propensity score matching-matched patients who received lobectomy. Perioperative parameters and postoperative complications, length of hospital stay, postoperative forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) were compared between the 2 groups. Surgery was successfully completed in all patients. The mean follow-up was for 8.2 months. The postoperative complication rate was comparable between the 2 groups: 31.0% in segmentectomy patients versus 35.7% in lobectomy patients (P = .643). At 1 month after surgery, FEV1% and FVC% were not significantly different between the 2 groups (P > .05). At 3 months after surgery, FEV1 and FVC were higher in segmentectomy patients than in lobectomy patients (FEV1, 82.79% ± 6.36% vs 78.55% ± 5.42%; FVC, 81.66% ± 6.09% vs 78.90% ± 5.58%, P < .05). Patients receiving segmentectomy suffer less pain and have better postoperative lung function and higher quality of life.
... La lobectomía VATS implica realizar de dos a cuatro incisiones pequeñas en la pared torácica, dependiendo del lóbulo a extraer, sin necesitar una incisión mayor con separación de las costillas para exponer el contenido intratorácico 3 . También se ha desarrollado la técnica de puerto único (VATS uniportal), la cual ha demostrado efectivi-dad y seguridad para el tratamiento de diversas patologías torácicas, como el cáncer de pulmón 4,5 . ...
Introducción. La lobectomía pulmonar es uno de los procedimientos más frecuentes en la cirugía torácica en Colombia y a nivel mundial. El objetivo de este estudio fue proporcionar información sobre el comportamiento clínico de los individuos sometidos a este tipo de cirugías.
Métodos. Estudio observacional retrospectivo en un Hospital Universitario de Cali, Colombia, que incluyó todos los pacientes sometidos a lobectomía pulmonar, por causas benignas o malignas, entre los años 2010 y 2020. La información se extrajo del registro institucional de cirugía de tórax, obteniendo datos demográficos, clínicos y patológicos.
Resultados. Se evaluaron los registros clínicos de 207 individuos. El 55,5 % eran mujeres, la edad promedio fue 58 años y el 41 % tuvieron antecedente de tabaquismo. En el 51,6 % de los casos se diagnosticaron neoplasias, de las cuales el 47,8 % eran primarias de pulmón, siendo el adenocarcinoma el subtipo más común. Las enfermedades benignas no tumorales representaron el 48,3 % de los casos y la causa más frecuente fueron las infecciones, dentro de las que se incluyeron 17 casos de tuberculosis pulmonar. La técnica más frecuente fue la cirugía toracoscópica video asistida (82,6 %). Presentaron un porcentaje de reintervención del 5,8 %, 10,6 % de complicaciones severas y una mortalidad hospitalaria del 4,3 %.
Conclusión. La población evaluada muestra una carga alta de comorbilidades y riesgo operatorio elevado; de forma consecuente, al compararla con otras series internacionales, se encontró un porcentaje mayor de complicaciones perioperatorias y mortalidad.
... 1,2 The development of VATS and uniportal VATS (uVATS), first described by Rocco et al., 3 has gained a great deal of attention, and the indication for uniportal VATS surgery has rapidly expanded from minor procedures such as biopsy and wedge resection to complex operations such as lobectomy, segmentectomy, and even bronchoangioplasty. 4 However, while the "territory" of uVATS continues to expand, 5 one should adequately distinguish the exploratory nature so far of most of the accomplishments of uVAT. Furthermore, because the evidence for the use of uVATS is currently at a preliminary stage, 6 the indications for uVATS remain far from clear. ...
Background:
The performance of uniportal VATS lobectomy (uVATS) for non-small cell lung cancer (NSCLC) larger than 5 cm is uncertain due to a lack of evidence. Here, we present a retrospective, propensity-score matched cohort study to evaluate the safety and effectiveness of uVATS for patients with locally advanced NSCLC.
Methods:
The data of patients with NSCLC larger than 5 cm diameter who underwent curative resection via uVATS or thoracotomy lobectomy between January 2015 and December 2020 was collected. Propensity-score matching was utilized to control the observable biases.
Results:
Seventy-two patients underwent uVATS lobectomy, while 38 received thoracotomy lobectomy. No conversion to open surgery or perioperative death occurred. uVATS lobectomy achieved similar total lymph node dissection counts compared to thoracotomy and even yielded a higher amount of lymph node dissection in pTNM stage II patients. The long-term overall and recurrence-free survival rates were also similar between the two groups. Results from the propensity-score matching generated cohort agreed with those from the full cohort.
Conclusions:
uVATS lobectomy is feasible and effective for curative lobectomy for NSCLC larger than 5 cm in diameter in selected patients. Further validations from well-designed prospective studies are required for uVATS lobectomy for patients with locally advanced NSCLC.
... In oncological thoracic surgery, failure to obtain R0 resection by VATS (regarding tumor extension or lymph node dissection) is a strong indication to convert to open thoracic surgery -oncological resection and safety are supreme goals (14)(15)(16). ...
Video-Assisted Thoracic Surgery (VATS) is already practised worldwide, in almost every condition addressed by open thoracic surgery. As part of minimally invasive thoracic surgery (MITS), VATS offers to patients and to healthcare providers excellent results and great satisfactions. Learning and performing VATS use different pathways in trainees and in experienced surgeons. This article presents VATS in its essence: classification, indications, contraindications, instruments and tools, incisions and access, troubleshooting, learning curve and training. We wish that the information helps our colleagues, both trainees and experienced thoracic surgeons, to start and continue performing VATS as standard care in thoracic surgery.
... It was initially adopted for pulmonary wedge resection, and uniportal VATS lobectomy was first reported by Diego Gonzalez-Rivas (2,3) in 2011. Since that initial report, uniportal VATS has been actively studied and used in anatomical pulmonary resection in the treatment of lung cancer (1,(4)(5)(6). Uniportal VATS has been considered more difficult than multiportal VATS because it is performed by inserting 2 or 3 surgical instruments and the thoracoscope through a single incision. ...
Background:
Uniportal video-assisted thoracoscopic surgery (VATS) is considered a challenging procedure in cases of lung cancer where the entire pleura and lung are attached (whole pleural adhesion). The purpose of this study was to evaluate the surgical results of uniportal VATS for the treatment of lung cancer with whole pleural adhesion.
Methods:
For all patients who underwent VATS lung cancer surgery at a single hospital in Korea, multiportal VATS was performed before 2017 and uniportal VATS was performed after January 2017 by the same surgeons. The surgical results of multiportal VATS and uniportal VATS for the treatment of lung cancer with whole pleural adhesion were compared retrospectively.
Results:
There were 16 eligible uniportal VATS cases and 57 multiportal VATS cases. There were no significant differences of clinicopathologic characteristics between the two groups. There were 5 conversions to open thoracotomy in the multiportal VATS group and no conversion to open thoracotomy in the uniportal group (P=0.579). The perioperative and postoperative outcomes were not different between the two groups. There was no mortality in all patients. For patients undergoing VATS lobectomy, the perioperative and postoperative outcomes were similar after uniportal and multiportal VATS lobectomy. For all patients, the 3-year recurrence-free survival (RFS) was 80.0% after uniportal VATS and 79.5% after multiportal VATS (P=0.951) and for patients with stage I non-small cell lung cancer (NSCLC), the 3-year RFS after uniportal VATS was 91.7% and the 3-year RFS after multiportal VATS was 89.3% (P=0.999). Uniportal VATS was not a significant risk factor for recurrence in the multivariate analysis.
Conclusions:
Uniportal VATS was not inferior to multiportal VATS in surgical outcome or short-term prognosis in resection of lung cancer with whole pleural adhesion. Whole pleural adhesion is not a contraindication to uniportal VATS, which has been safe and feasible in cases of lung cancer with whole pleural adhesion.
... Currently, uniportal video-assisted thoracoscopic surgery (VATS) is being increasingly used in thoracic surgery. Compared with traditional multi-portal surgery, uniportal VATS has achieved the quintessential level in minimally invasive incisions and is gradually accepted by more and more thoracic surgeons, especially young physicians [4,5]. However, the literature regarding the application of uniportal video-assisted thoracoscopic segmental ...
Introduction:
The literature regarding the application of uniportal video-assisted thoracoscopic segmental resection of the lung in patients aged over 65 years with non-small cell lung cancer (NSCLC) is sparse. This paper reports 175 cases of uniportal video-assisted thoracoscopic segmental resection of the lung performed at one center, of which 63 patients were over 65 years old.
Aim:
To investigate the safety and feasibility of uniportal video-assisted thoracoscopic segmental resection of the lung in elderly patients aged over 65 years with NSCLC.
Material and methods:
A retrospective analysis of 175 NSCLC patients who underwent uniport video-assisted thoracoscopic segmental resection of the lung in the center from August 2018 to August 2020 was conducted, and based on the age of 65 years, patients were divided into elderly and non-elderly groups. The general data and perioperative indicators of the two groups were compared.
Results:
The procedures were completed in all patients without death or conversion to open surgery. In the general data of the two groups of patients, the prevalence of emphysema in the elderly group was significantly higher than that in the non-elderly group (p = 0.001). However, there was no statistically significant difference between the two groups in surgery time, intraoperative blood loss, thoracic drainage tube retention time, postoperative hospital stay, incision satisfaction, or postoperative complications (p > 0.05).
Conclusions:
Uniportal video-assisted thoracoscopic segmental resection of the lung is feasible and safe in elderly patients with NSCLC aged over 65 years.
... Mediastinal mature teratoma can be definitively diagnosed by histopathological examination as the tumors are generally composed of ectodermal, mesodermal, and endodermal derivatives [4]. Video-assisted thoracoscopic surgery (VATS) technology has evolved from its multiport origins to even less invasive approaches due to its identified advantages compared with open surgery for a series of thoracic cavity tumors [5]. During the course of its evolution, Uniportal VATS (UniVATS) has emerged, which has proved to be superior to multiport VATS and has extended the surgical boundaries [6]. ...
Background:
Mediastinal mature teratoma is the most common histological type of primary extragonadal germ cell tumor. In this report, we describe a rare case of giant mature teratoma located primarily in the anterior mediastinum and causing partial atelectasis of the upper and middle lobes of the right lung, as well as extrinsic compression of the right atrium.
Case summary:
A 31-year-old male with a giant mediastinal mature teratoma presented with progressive exertional dyspnea and chest pain for 1 mo. Computed tomography of the chest indicated the diagnosis of anterior mediastinal teratoma. The patient underwent right uniportal anterior approach video-assisted thoracoscopic surgery (VATS). En bloc resection of the giant teratoma, wedge resection of the upper and middle lobes of the right lung, resection of the thymus and partial excision of the pericardium were successfully performed. The pathological diagnosis revealed a mature cystic teratoma with foreign-body reaction that was closely related to the right lung, atrium dextrum, superior vena cava and ascending aorta. An atrophic thymic tissue was also discovered at the external teratoma surface. The patient was discharged on postoperative day 7.
Conclusion:
This is the first report of the use of uniportal VATS for complete resection of a teratoma in combination with wedge resection of the right upper and middle lung lobes and partial resection of the pericardium.
... Video-assisted thoracoscopic surgery (VATS) has gained popularity because of reduced hospital stay and morbidity [2]. The main advantage of this procedure is that it allows early recovery. ...
Background
The aim of this prospective, randomized, controlled study was to evaluate the analgesic effect of ultrasonography (USG) guided continuous erector spinae plane block (ESPB) for postoperative analgesia in video-assisted thoracoscopic surgery (VATS).Methods
Eighty American Society of Anesthesiologists (ASA) physical status I-III patients aged 18–75 and who were to undergo VATS were included in this study. Randomization was performed in 2 groups, continuous ESPB (ESPB Group) and no intervention (Control Group). 20 mL of 0.25% bupivacaine was administered for the block. Immediately after surgery, the patient received continuous infusion of 0.125% bupivacaine at 4 mL h−1 via the catheter inserted for the block. Patients in both groups received tramadol via an intravenous patient-controlled analgesia device. Tramadol and meperidine consumption, visual analog scale pain scores and opioid-related side effects were recorded at 0, 1, 4, 8, 12, 24, 36, and 48 h postoperatively.ResultsThe use of continuous ESPB in VATS significantly decreased the amount of tramadol used in the first 48 h postoperatively (P < 0.001). There was a statistically significant difference in the number of meperidine rescue analgesia administered between the ESPB and Control Groups (P < 0.001). While the incidences of nausea and itching were higher in Control Group, there were no differences in terms of the other side effects between the groups.Conclusions
This study shows that USG-guided continuous ESPB provides adequate analgesia following VATS as part of multimodal analgesia. Continuous ESPB significantly reduced opioid consumption and opioid-related side effects compared to those in the Control Group.
... Although TEA was used in initial studies, ICNB provides a simpler, safer, and more effective alternative for intraoperative pain control (17)(18)(19)(20). Given the recent development of uniportal VATS that decreases postoperative pain (21,22), the role of TEA may be decreasing. Propofol is most commonly used for sedation, likely due to its fast induction, the ease with which the level of sedation can be altered, and its quick recovery (23). ...
... Uniportal VATS (uVATS) represents the latest development of minimally invasive thoracic surgery and is gaining more popularity and acceptance over the last few years (29)(30)(31). Through a single-incision of 3-4 cm, the whole thoracic cavity is reached and complex procedures, including vascular and bronchial sleeve resections may be performed. ...
Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.
... The current surgical standard for early-stage non-small-cell lung cancer (NSCLC) is lobectomy. After the introduction of video-assisted thoracoscopic surgery (VATS), lung resection can now be conducted mini-invasively via three-portal incision or even uniportal incision [4]. Compared with open thoracotomy, VATS lobectomy is associated with lower morbidity, lower incidence of complications, less intraoperative blood loss, shorter time of postoperative chest drainage and hospital stay as well as less postoperative pain [5,6]. ...
Introduction
Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy.
Methods
Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery.
Results
Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) ( p = 0.868), at 6 months (9.4 vs. 12.4%) ( p = 0.785), and at 12 months (3.3 vs. 5.9%) ( p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant ( p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain ( p = 0.03), while cardiac disease ( p = 0.6), perioperative morbidity ( p = 0.228), prolonged air leak ( p = 0.057), and repeat drainage ( p = 0.626) were not.
Conclusion
Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain.
Lung cancer has become one of the key life-threatening factors and is the most common type of tumor. With the improvement of equipment and the improvement of lung cancer awareness, the surgical treatment of lung cancer is becoming more and more mature. Surgery can provide an important part of individualized treatment strategies for patients with different stages of lung cancer and different wishes. In addition, the concept of minimally invasive, precise, and intelligent has triggered a revolutionary change in the surgical treatment strategy for lung cancer. Therefore, this review focuses on the development of lung cancer surgery history, summarizing the era from traditional surgery to the era of minimally invasive thoracic surgery based on TV-assisted thoracic surgery. The operating methods and treatment effects of different surgical methods are comprehensively introduced, and the optimization and improvement of different surgical methods in the future are also discussed. Along with the concept of minimally invasive surgical techniques, there are more and more explorations of nanotechnology in the surgical treatment of lung cancer. The application of nanotechnology in lung cancer imaging, and the combination of surgery with nanomedicine is an effective solution for cancer treatment today. So, this review also summarizes the application prospects of nanotechnology before, during and after lung cancer surgery.
Background:
Thoracoscopic radical lobectomy is a routine procedure for radical surgery of lung cancer. Meanwhile, thoracoscopic surgery has been gradually transformed from assisted small incision and multiport thoracoscopic radical surgery to uniportal thoracoscopic surgery for treatment of early-stage lung cancers. However, there are still controversies regarding the efficacy and feasibility of 2 surgical methods. The purpose of this study is to investigate the effect and feasibility of uniportal thoracoscopic surgery for treatment of early-stage lung cancer in a primary hospital.
Methods:
Clinical data of 142 patients with early-stage lung cancer were retrospectively chosen in the period from September 2019 to March 2021 in our hospital and divided into 2 groups: a control group (66 patients) with 3-port thoracoscopic radical surgery and an experimental group (76 patients) with uniportal thoracoscopic radical surgery. The baseline clinical data, perioperative clinical data, and lymph node dissection of 2 groups were compared.
Results:
There was no significant difference in baseline general clinical data between 2 groups (P>0.05), and no significant difference in the incidence of postoperative complications, conversion rate, or operation time between 2 groups (P>0.05). The intraoperative blood loss volume, postoperative chest drainage volume, postoperative hospitalization time, and postoperative catheter time of experimental group were significantly lower than those of control group (P<0.05). There was no significant difference in the total number of lymph node dissection stations and lymph node dissections, the number of N2 lymph node dissection stations, or N2 lymph node dissections between 2 groups (P>0.05). There was also no significant difference in the number of left and right lymph node dissection stations between 2 groups (P>0.05).
Conclusions:
Compared with 3-port thoracoscopic radical surgery, uniportal thoracoscopic radical surgery in the treatment of patients with early-stage lung cancer provides the same effect of lymph node dissection and has advantages in reducing surgical trauma and accelerating postoperative rehabilitation, popularizing for use in primary hospitals.
Video-assisted thoracoscopic surgery (VATS) is beneficial for patients; but for the anesthetist, it can be even more difficult than an open thoracotomy. General challenges of airway management, one-lung ventilation, fluid management remain, with some additional conditions, like “no continuous positive airway pressure in VATS,” or “delayed treatment of bleeding.” Anesthesia for thymectomy in myasthenic patients, or an anesthetic approach in “nonintubated” VATS are some of the specific conditions. Analgesia is also still a challenge; new peripheral blocks offer new horizons.
Objectives:
Subxiphoid uniportal video-assisted thoracoscopic surgery (SUVATS) is a technically difficult and challenging operation that can help decrease pain around the incision after traditional intercostal uniportal video-assisted thoracoscopic surgery (IUVATS), and can also treat bilateral lesions through the same incision. We aimed to compare perioperative outcomes and pain scores after SUVATS and IUVATS in patients receiving synchronous treatment of bilateral lung lesions.
Methods:
Patients who received SUVATS and IUVATS bilateral lung resections from September 2014 to February 2018 were analysed. Ultimately a total of 381 cases were analysed after using one-to-one propensity score matching to match baseline characteristics between the 2 groups.
Results:
The 381 patients included 56 with SUVATS and 325 with IUVATS. After matching, 54 SUVATS and 54 IUVATS cases were analysed. The 2 groups had similar preoperative factors and did not differ with respect to duration of chest tube placement, length of stay in hospital and incidence of postoperative complications. SUVATS was associated with a significantly longer operative time (212.3 vs 154.6 min, P < 0.001) and more blood loss (190.9 vs 72.7 ml, P < 0.001), lower pain score on the first day after operation (2.6 vs 3.0, P = 0.03) and before discharge (0.8 vs 1.4, P < 0.001). Furthermore, less patients in group SUVATS requested for additional analgesic therapy (P = 0.03).
Conclusions:
Compared with IUVATS, despite the longer operative time and greater blood loss, SUVATS for bilateral lung lesions is a safe surgical procedure associated with significantly less postoperative pain and a similar incidence of postoperative complications in selected patients.
This introduces the history, development and current status of uniportal VATS by pioneers and authorities of this technique. The highly illustrated content in the chapters enhances readers to rapidly understand the techniques of uniportal VAT. The use of video clips adds value to the learning experience and applicability of the techniques. The contents will be of great interest to thoracic surgeons who are already practicing video-assisted thoracic surgery, as well as those who are starting training. It will also serve as authoritative reference text for doctors, students and allied health professionals who would like to learn more about the new technique of uniportal VATS.
Subcostal access is a novel approach for anatomical lung resection. To perform surgery via this access, specially designed long instruments are required. Subcostal access provides excellent visualization of the mediastinum and anterior lung hilum. We exhibit here a subcostal middle lobectomy with systematic en-block mediastinal lymphadenectomy in an obese 52-year-old male patient with body mass index (BMI=37.7) performed via this single incision. The operation was completed efficiently within 30 minutes with negligible postoperative pain.
Background:
Performing sub-lobar resection for early stage non-small cell lung carcinoma is becoming increasingly popular with studies suggesting equivalent outcomes to lobectomy when sufficient lymph node sampling is performed. Furthermore, there has been a move to minimally invasive thoracic surgery facilitating enhanced recovery and reduced postoperative morbidity. The subxiphoid VATS approach (SVATS) is a novel technique that is becoming increasingly popular, with evidence of reduced postoperative pain. Here we report experience and the technique of performing segmentectomy by the uniportal SVATS approach METHODS: The uniportal SVATS approach was used to perform all possible segmentectomies. Specific instruments were designed to facilitate performing surgery through this approach, and the operative technique is described and demonstrated with videos.
Results:
Between September 2014 to April 2017 242 segmentectomies were performed by uniportal SVATS. Twenty-nine of the patients underwent bilateral procedures. The mean duration of surgery was 2.14±0.78 hours. Lymph node stations were accessible and a mean of 4.00±1.00 lymph node stations and 10.64±3.38 lymph node were sampled. The mean postoperative hospital length of stay was 4.67±9.54 days. Only 4 cases required conversion to thoracotomy and 3 to full lobectomy. There were no perioperative deaths, with 30 day survival of 100%.
Conclusions:
This report demonstrates that the uniportal SVATS approach can be safely and effectively utilised to perform pulmonary segmentectomies. Our series demonstrates that it is possible to access and resect all segments by this novel approach to VATS surgery.
Background:
The aim of this nationwide observational cohort study was to investigate the early postoperative complications and long-term survival following video-assisted thoracoscopic surgery (VATS) lobectomy compared to open thoracotomy lobectomy for early stage non-small cell lung cancer (NSCLC).
Methods:
We used the Swedish national quality register for general thoracic surgery and included all patients who underwent lobectomy for NSCLC during 2012-2015. We compared postoperative complications and long-term survival in patients who underwent VATS lobectomy at our institution to patients who underwent open lobectomy at the other seven hospitals in Sweden. We used inverse probability of treatment weighting to limit differences in baseline characteristics between the groups and used standardized mean differences to assess balance after weighting.
Results:
We included 1,601 patients who underwent open (n=1,316) or VATS (n=285) lobectomy for NSCLC. The mean age was 67.7 years in both groups and comorbidities were well balanced, but the open thoracotomy group had a higher proportion of patients with more advanced cancer stage. After weighting, all baseline characteristics were well balanced. Most patients (84%) did not have postoperative complications; 83% vs. 86% in the open and VATS group, respectively (P=0.41). The 30- and 90-day mortality was 0.7% vs. 0.3% (P=0.38) and 1.7% vs. 0.3% (P=0.09) in the open thoracotomy and VATS group, respectively. There were significantly more transfusions (5.0% vs. 1.4%, P=0.008) and pneumonia (5.5% vs. 0.6%, P=0.002) in the in the open thoracotomy and VATS group, respectively. The overall survival at 1 and 5 years was 92% vs. 97% and 63% vs. 78% in the open thoracotomy and VATS group, respectively; HR (95% CI): 0.47 (0.33-0.68).
Conclusions:
We found less postoperative complications and better long-term survival following VATS lobectomy compared to open thoracotomy lobectomy for NSCLC. The implementation of a VATS lobectomy program did not compromise patient safety or the oncological efficacy.
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.
Background:
Uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative to the conventional multiportal approach in the treatment of lung cancer. The benefits of this uniportal technique have not yet been characterized in patients undergoing VATS lobectomy. This meta-analysis aimed to compare the clinical outcomes of uniportal and multiportal VATS lobectomy for patients with lung cancer.
Methods:
A systematic review was conducted using seven electronic databases. Endpoints for analysis included perioperative mortality and morbidity, operative time, length of hospital stay, perioperative blood loss, duration of postoperative drainage and rates of conversion to open thoracotomy.
Results:
Eight relevant observational studies were identified and included for meta-analysis. Results demonstrated a statistically significant reduction in the overall rate of complications, length of hospital stay and duration of postoperative drainage for patients who underwent uniportal VATS lobectomy. There were no significant differences between the two treatment groups in regard to mortality, operative time, perioperative blood loss and rate of conversion to open thoracotomy.
Conclusions:
The present meta-analysis demonstrated favourable outcomes for uniportal VATS lobectomy in the treatment of lung cancer compared to the conventional multiportal approach. However, long-term follow-up data is still needed to further characterize the benefits of the uniportal approach.
Background:
Both uniportal and triportal thoracoscopic lobectomy and sublobectomy are feasible for early-stage non-small cell lung cancer (NSCLC). The aim of this study was to compare the perioperative outcomes of uniportal and triportal thoracoscopic lobectomy and sublobectomy for early-stage NSCLC.
Methods:
A total of 405 patients with lung lesions underwent thoracoscopic lobectomy or sublobectomy through a uniportal or triportal procedure in approximately 7-month period (From November 2014 to May 2015). A propensity-matched analysis, incorporating preoperative variables, was used to compare the short-term outcomes of patients who received uniportal or triportal thoracoscopic lobectomy and sublobectomy.
Results:
Fifty-eight patients underwent uniportal and 347 patients underwent triportal pulmonary resection. The conversion rate for uniportal and triportal procedure was 3.4% (2/58) and 2.3% (8/347), respectively. The complication rate for uniportal and triportal procedure was 10.3% and 9.5%, respectively. There was no perioperative death in either group. Most patients had early-stage NSCLC in both groups (uniportal: 45/47, 96%; triportal: 313/343, 91%). Propensity score-matching analysis demonstrated no significant differences in operation time, intraoperative blood loss, numbers of dissected lymph nodes, number of stations of lymph node dissected, duration of chest tube, and complication rate between uniportal and triportal group for early-stage NSCLC. However, the duration of postoperative hospitalization was longer in the uniportal group (6.83 ± 4.17 vs. 5.42 ± 1.86 d, P = 0.036) compared with the triportal group.
Conclusions:
Uniportal thoracoscopic lobectomy and sublobectomy is safe and feasible, with comparable short-term outcomes with triportal thoracoscopic pulmonary resection. Uniportal lobectomy and sublobectomy lead to similar cure rate as triportal lobectomy and sublobectomy for early NSCLC.
Objectives:
To assess the feasibility, safety and postoperative wound pain of single-incision thoracoscopic surgery (SITS) for Stage I lung cancer in patients who had previously undergone surgery compared with conventional video-assisted thoracoscopic surgery (c-VATS).
Methods:
Lobectomy by SITS (60) and c-VATS (20) was performed for Stage I lung cancer between 2011 and 2014. In SITS, an ∼5-cm small incision was placed at the fourth or fifth intercostal space from the anterior to posterior axillary line. C-VATS was performed via three or four ports using trocars only. The evaluation items were general operative outcomes, pain stress using the Numeric Rating scale (NRS) on postoperative days 3, 7 and 30, and some pathological symptoms related to the neuropathic wound pain through the operative course. The number of days of use of analgesic agents was also evaluated for 1 month after surgery.
Results:
SITS showed similar perioperative outcomes (postoperative hospital stay, blood loss, surgical time, drainage duration, creatine phosphokinase (CPKmax), creactive protein (CRPmax) and frequency of postoperative complications) to those of c-VATS. Additionally, the average NRS in SITS decreased on postoperative days 7 and 30 (Day 7: 2.4 ± 0.4 vs 4.2 ± 0.3, P = 0.041, Day 30: 1.7 ± 0.4 vs 3.3 ± 0.3, P = 0.038) and the number of days analgesic agents were administered was also reduced (SITS: 8.1 ± 0.9 vs c-VATS 13.1 ± 1.2 days, P = 0.045). The frequency of allodynia, hyperalgesia, hypaesthesia and numbness was significantly reduced in the SITS group.
Conclusions:
Although conclusive evidence has not yet been obtained, SITS is more minimally invasive in regard to postoperative wound pain compared with c-VATS. This procedure should be considered as a treatment option for early-stage lung cancer.
Objectives:
The feasibility and radicalism of lymph node dissection for lung cancer surgery by a single-port technique has frequently been challenged. We performed a retrospective cohort study to investigate this issue.
Methods:
Two chest surgeons initiated multiple-port thoracoscopic surgery in a 180-bed cancer centre in 2005 and shifted to a single-port technique gradually after 2010. Data, including demographic and clinical information, from 389 patients receiving multiport thoracoscopic lobectomy or segmentectomy and 149 consecutive patients undergoing either single-port lobectomy or segmentectomy for primary non-small-cell lung cancer were retrieved and entered for statistical analysis by multivariable linear regression models and Box-Cox transformed multivariable analysis.
Results:
The mean number of total dissected lymph nodes in the lobectomy group was 28.5 ± 11.7 for the single-port group versus 25.2 ± 11.3 for the multiport group; the mean number of total dissected lymph nodes in the segmentectomy group was 19.5 ± 10.8 for the single-port group versus 17.9 ± 10.3 for the multiport group. In linear multivariable and after Box-Cox transformed multivariable analyses, the single-port approach was still associated with a higher total number of dissected lymph nodes.
Conclusions:
The total number of dissected lymph nodes for primary lung cancer surgery by single-port video-assisted thoracoscopic surgery (VATS) was higher than by multiport VATS in univariable, multivariable linear regression and Box-Cox transformed multivariable analyses. This study confirmed that highly effective lymph node dissection could be achieved through single-port VATS in our setting.
Objectives:
Uniportal video-assisted thoracic surgery (VATS) is well accepted by surgeons for anatomical major lung resections. However, large series evaluating the results, safety and efficacy of the technique for sleeve resections are still lacking. The aim of this study was to examine our experience with the use of uniportal VATS for sleeve resections.
Methods:
From September 2014 to January 2018, a total of 79 consecutive patients were offered uniportal VATS sleeve resection for centrally located tumours invading the orifice of the lobar bronchus or extending into the main stem bronchus by a single surgical team of the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. Perioperative data were collected and analysed. Survival data were collected via telephone calls.
Results:
Sixty-six of the 79 patients had a diagnosis of non-small-cell lung cancer, 47 of whom had squamous cell carcinoma. Twenty-one of the group with non-small-cell carcinoma were already at an advanced stage (III, IV) when operated on. The mean number of lymph node stations dissected was 5.5 ± 0.97 (4-8) and that of lymph nodes harvested was 13.7 ± 3.7 (5-23). A right upper lobectomy was the most common and time-consuming procedure. There was 1 conversion to a thoracotomy due to bleeding. No anastomotic-related complications were noted. The mean length of stay was 5.14 ± 1.56 (2-11) days. The 1- and 2-year survival rates were 98% and 80%, respectively.
Conclusions:
Uniportal VATS sleeve resection is a safe and efficient procedure for the treatment of centrally located tumours otherwise requiring a pneumonectomy.
The optimal number of incisions for video-assisted thoracoscopic surgery (VATS) lobectomy, the standard treatment for early-stage nonsmall cell lung cancer (NSCLC), is still a matter of great debate. To compare single-incision (uniportal) VATS (U-VATS) with traditional multiportal VATS (M-VATS), we retrospectively reviewed the surgical outcomes of a large cohort of patients. Our prospectively maintained institutional database was queried retrospectively. All patients from 2014 to 2017 who underwent VATS lobectomy as the primary procedure for clinical stage I or II NSCLC were identified. A univariate comparison and a propensity-matched analysis incorporating preoperative variables were performed. The incidence of postoperative complications was compared. During the study period, 722 patients underwent VATS lobectomy for early-stage NSCLC, 62% by M-VATS, and 38% by U-VATS. In the univariate analysis, U-VATS performed by an experienced surgeon was associated with decreased intraoperative bleeding and shortened duration of surgery, duration of chest tube drainage, and length of hospital stay as compared with M-VATS (P < 0.001). Mediastinal lymph node dissection and complete resection were accomplished similarly using U-VATS and M-VATS. When the 2 approaches were compared through propensity matching, U-VATS was associated with fewer pneumonias (P = 0.012), as well as decreased intraoperative bleeding (P < 0.001), faster surgery (P < 0.001), shorter duration of chest tube drainage (P = 0.001), and shorter hospital stay (P < 0.001). At our institution, in the hands of an experienced surgeon, U-VATS lobectomy is safe, feasible, and can result in similar short-term outcomes for early-stage NSCLC as compared with M-VATS.
Objectives:
Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training.
Methods:
The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds.
Results:
Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions.
Conclusions:
The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.
Objective:
Video-assisted thoracic surgery (VATS) lobectomy was introduced over 25 years ago. More recently, the technique has been modified from a multiport video-assisted thoracic surgery (mVATS) to uniportal (uVATS) and robotic (rVATS), with proponents for each approach. Additionally most lobectomies are still performed using an open approach. We sought to provide evidence-based recommendations to help define the optimal surgical approach to lobectomy for early stage non-small cell lung cancer.
Methods:
Systematic review and meta-analysis of articles searched without limits from January 2000 to January 2018 comparing open, mVATS, uVATS, and rVATS using sources Medline, Embase, and Cochrane Library were considered for inclusion. Articles were individually scrutinized by ISMICS consensus conference members, and evidence-based statements were created and consensus processes were used to determine the ensuing recommendations. The ACC/AHA Clinical Practice Guideline Recommendation Classification system was used to assess the overall quality of evidence and the strength of recommendations.
Results and recommendations:
One hundred and forty-five studies met the predefined inclusion criteria and were included in the meta-analysis. Comparisons were analyzed between VATS and open, and between different VATS approaches looking at oncological outcomes (survival, recurrence, lymph node evaluation), safety (adverse events), function (pain, quality of life, pulmonary function), and cost-effectiveness. Fifteen statements addressing these areas achieved consensus. The highest level of evidence suggested that mVATS is preferable to open lobectomy with lower adverse events (36% versus 42%; 88,460 patients) and less pain (IIa recommendation). Our meta-analysis suggested that overall survival was better (IIb) with mVATS compared with open (71.5% versus 66.7% 5-years; 16,200 patients). Different VATS approaches were similar for most outcomes, although uVATS may be associated with less pain and analgesic requirements (IIb).
Conclusions:
This meta-analysis supports the role of VATS lobectomy for non-small cell lung cancer. Apart from potentially less pain and analgesic requirement with uVATS, different minimally invasive surgical approaches appear to have similar outcomes.
Objective:
To compare outcomes after open versus thoracoscopic (VATS) lobectomy for clinical stage II (cN1) non-small-cell lung cancer (NSCLC).
Background:
There have been no published studies evaluating the impact of a VATS approach to lobectomy for N1 NSCLC on short-term outcomes and survival.
Methods:
Outcomes of patients with clinical T1-2, N1, M0 NSCLC who underwent lobectomy without induction therapy in the National Cancer Data Base (2010-2012) were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis.
Results:
Median follow-up of 1559 lobectomies (1204 open and 355 VATS) was 43.2 months. The VATS approach was associated with a shorter median hospitalization (5 vs 6 d, P < 0.001) than the open approach. There were no significant differences between the VATS and open approach with regard to nodal upstaging (12.0% vs 10.5%, P = 0.41), 30-day mortality (2.3% vs 3.1%, P = 0.31), and overall survival (5-yr survival: 48.6% vs 48.7%, P = 0.76; multivariable-adjusted HR for VATS approach: 1.08, 95% CI: 0.90-1.30, P = 0.39). A propensity score-matched analysis of 334 open and 334 VATS patients who were well matched by 14 common prognostic covariates, including tumor size, and comorbidities, continued to show no significant differences in nodal upstaging, 30-day mortality, and 5-year survival between the VATS and open groups.
Conclusion:
In this national analysis, VATS lobectomy was used in the minority of N1 NSCLC cases but was associated with shorter hospitalization and similar nodal upstaging rates, 30-day mortality, and long-term survival when compared to open lobectomy. These findings suggest thoracoscopic techniques are feasible for the treatment of stage II (cN1) NSCLC.
In 1947 the first bronchoplasty took place to remove a benign tumor [1]. Thereafter, in 1959 the first bronchial carcinoma was removed [2]. A right pneumonectomy with en-bloc resection of the carina was reported in 1950 [3]. Gibbon described in 1959 the first case of a right sleeve pneumonectomy [4] and in the eighties decade, Grillo and coworkers described carinal resections [5]. Pulmonary artery reconstruction for lung cancer was reported in 1950. During the 1970s and 1980s a few groups also described these procedures in a series of cases [6].
Video-assisted thoracic surgery is increasingly being performed by many groups as surgical management for non-small cell lung cancer, only if it is technically possible. The role of this approach is unclear when you perform the lymphadenectomy [1]. On the other hand the number of lymph nodes, stations sampled and lymph node ratio have a direct relationship with a correct pathologic staging, and thus with the prognosis.
Updated and expanded, this comprehensive new edition captures the considerable evolution in the anesthetic management of patients requiring anesthesia for non-cardiac intrathoracic diagnostic and therapeutic procedures. Major advances addressed include the expanded role of ultrasound beyond trans-esophageal echocardiography, the role of extra-corporeal membrane oxygenation in thoracic anesthesia, and postoperative pain management for thoracic surgery. Chapters are authored by prominent anesthesiologists and feature cases commonly encountered in clinical practice. Authoritative and the leading text in the field, this book will serve as an indispensible guide to practitioners of thoracic anesthesia at all levels.
Objectives:
The emergence of ultra-high-volume centres promises new opportunities for thoracic surgical training. The goal of this study was to investigate the effectiveness of a novel observership course in teaching video-assisted thoracoscopic surgery (VATS) at an ultra-high-volume centre.
Methods:
Two-week courses in VATS at a specialist unit now performing >10 000 major lung resections annually (>50 daily on average) were attended by 230 surgeons from around the world from 2013 to 2016. An online survey preserving responder anonymity was completed by 156 attendees (67.8%).
Results:
Attendees included 37% from Western Europe, 18% from Eastern Europe and 17% from Latin America. Experience with open thoracic surgery for more than 5 years was reported by 67%, but 79% had less than 5 years of VATS lobectomy experience. During the course, 70% observed over 30 uniportal VATS operations (including 38% observing over 50), and 69% attended an animal wet lab. Although 72% of the responders attended the course less than 12 months ago, the number of ports used (P < 0.001), operation times (P < 0.001) and conversion rates (P < 0.001) reported by the responders were reduced significantly after the course. Improvements in the problem areas of tissue retraction, instrumentation, stapler application and coordination with the assistant during VATS were reported by 56%, 57%, 58% and 53%, respectively. Of those who had attended other VATS courses previously, 87% preferred the training from this high-volume course.
Conclusions:
High-volume intensive observership training at an ultra-high-volume centre may improve VATS proficiency in a short period of time, and may provide a time-efficient modality for future thoracic surgical training.
Comprehensive, authoritative, and up-to-date, Principles and Practice of Anesthesia for Thoracic Surgery covers all aspects of anesthesia for diagnostic and therapeutic thoracic procedures, including advances not addressed by other volumes, such as extracorporeal ventilatory support, new chest imaging modalities, lung isolation with a difficult airway, pulmonary thromboendarterectomy, chronic postthoracotomy pain, management of one-lung anesthesia, lung isolation, lung transplantation,and pharmacologic therapy of pulmonary hypertension. The book is aimed at residents, fellows, and staff anesthesiologists, as well as nurse anesthetists, nurse practitioners, and anesthesia assistants.
Major topics and special features:
Underlying basic science
Preoperative evaluation of the patient
Airway procedures
Mediastinal procedures
The complicating factors of significant co-morbidities and/or advanced age
Uncommon and complex thoracic surgical procedures
Post-operative care
End-stage lung disease
Pediatric Thoracic Anesthesia
“Key Points” summarizing each chapter’s Highlights
Clinical case discussion, with the Author’s recommendations, in every clinical chapter
The video-assisted thoracoscopic surgery (VATS) for major pulmonary resections has evolved in a period of only 7 years from 3-4 incisions to a single incision approach. However, Uniportal VATS approach is different from other forms of minimally invasive thoracic surgery, and the technique of lung exposure and stapler insertion through a single hole should be learned step by step. The main advances of uniportal VATS during the last years are related to improvements in surgical technique, evolving to a concept of "advanced VATS instrumentation", and implementation of new technology. One recent advance in uniportal VATS is the possibility of using a robotic or pneumatic articulated arm that holds the camera stable and no needs a surgical assistant. This is called "unisurgeon uniportal VATS" in where the surgeon has more freedom of movements and eliminates the fatigue of assistant holding the camera. We are still in the beginning of the "unisurgeon era" that probably will be more popular in the next coming years thanks to the Implementation of wireless cameras and graspers by means of magnetic control.
Since it was first performed in 2010, lobectomy via a single port—uniportal video-assisted thoracoscopic surgery (VATS)—has become increasingly popular among surgeons. However, this most minimally invasive surgical approach requires a different skill set compared with even conventional multiportal VATS. For those beginning to learn uniportal VATS, the technical challenges can seem considerable. This article shares some tips and tricks from experienced uniportal VATS practitioners that will help those wishing to learn the approach, and covers the principles of operative setup and instrumentation as well as specific pointers on surgery for each lung lobe.
Objective:
The objective of this study was to compare the long-term survival of open versus thoracoscopic (VATS) lobectomy for early stage non-small-cell lung cancer (NSCLC).
Background:
Data from national studies on long-term survival for VATS versus open lobectomy are limited.
Methods:
Outcomes of patients who underwent open versus VATS lobectomy for clinical T1-2, N0, M0 NSCLC in the National Cancer Data Base were evaluated using propensity score matching.
Results:
The median follow-up of 7114 lobectomies (5566 open and 1548 VATS) was 52.0 months. Propensity score matching resulted in 1464 open and 1464 VATS patients who were well-matched by 14 common prognostic covariates including tumor size and comorbidities. The VATS approach was associated with a shorter median length of stay (5 vs. 6 days, P < 0.001) and better 5-year survival (66.0% vs. 62.5%, P = 0.026), and was not significantly different compared with the open approach with regard to nodal upstaging (11.2% vs. 12.5%, P = 0.46), and 30-day mortality (1.7% vs. 2.5%, P = 0.14). In the propensity-matched analysis of 2928 patients, there were no significant differences in 5-year survival between the VATS and open groups (66.3% vs. 65.8%, P = 0.92).
Conclusions:
In this national analysis, VATS lobectomy was used in the minority of patients with stage I NSCLC. VATS lobectomy was associated with shorter length of stay and noninferior long-term survival when compared with open lobectomy. These results support previous findings from smaller single- and multi-institutional studies that suggest that VATS does not compromise oncologic outcomes when used for early-stage lung cancer and suggest the need for broader implementation of VATS techniques.
Background:
A core principle in surgery is that high surgical volumes are conducive toward better outcomes. Ultra-high volume centers (UHVCs) have now emerged in thoracic surgery in China that now perform a volume of thoracic operations far greater than even traditional international centers of excellence.
Methods:
In 2016, two hospitals in Shanghai performed over 10,000 major pulmonary, esophageal and mediastinal resections each. A qualitative analysis of the lessons learned in achieving such large operation volumes was undertaken.
Results:
The advent of these UHVCs gives important insights for not only thoracic surgeons, but for surgical oncologists and surgeons globally. First, these ultra-high volumes were achieved to a large degree by cancer screening-but the success of the screening programs relies on reaching wider patient groups and allowing for affordable 'self-screening.' Second, the ultra-high clinical volumes at UHVCs offer unique opportunities for surgical training and research, potentially changing paradigms for academic surgery. Third, these ultra-high volumes may place new stresses on existing healthcare resources and prompt novel management strategies in response.
Conclusions:
The UHVCs represent a revolutionary development in modern surgery, and it behooves surgeons to both accept the challenges and harness the advantages they may bring.
Objectives
Pneumonectomy through a thoracotomy carries both high morbidity and mortality. Video-assisted thoracoscopic surgery (VATS) has reduced perioperative risks and allowed less fit patients to undergo cancer resection. In this way, VATS is ideally placed to reduce the insult and burden of pneumonectomy itself. However, little has been reported on the outcomes of VATS pneumonectomy. In this study we review our experience of VATS pneumonectomy.
Methods
We carried out a retrospective observational study comparing VATS with open pneumonectomy. Between January 2003 and December 2012, 39 patients (33 males, 6 females) underwent pneumonectomy (20 left, 19 right) for primary lung cancer, of which 12 (30.8%) were by VATS (VATS) and 27 (69.2%) were through a thoracotomy (open).
Results
The mean age was 59.8 years (Open 58 vs VATS 65, P = 0.02). Laterality was similar between the two groups [14 (52%) right-sided vs 5 (42%), P = 0.73]. Five patients received neoadjuvant chemotherapy [4 (16%) vs 1 (9%), P = 0.51]. The mean tumour sizes were similar (5.4 cm vs 5.6 cm, P = 0.80) as was the distribution of pathological stage (P = 0.45). The operating time was shorter for the VATS group (mean 234 min vs 178 min, P = 0.03) and blood loss was also less (median 350 ml vs 100 ml, P = 0.008). All resections were complete (R0) in the VATS group, and there were four R1 and one R2 resection in the open group. Bronchopleural fistula occurred in one open and none of the VATS cases. Length of stay was shorter in the VATS group (median 9 days vs 7 days, P = 0.06). The 30-day mortality was 10.3% [3 (11.1%) vs 1 (8.3%), P = 0.64]. The overall median survival was 34 months (22 months vs 34 months, P = 0.97).
Conclusions
VATS pneumonectomy in selected patients is safe with outcomes comparable to open pneumonectomy.
Disclosure
All authors have declared no conflicts of interest.
Due to its intrinsic characteristics, video assisted thoracic surgery (VATS) lobectomy is currently the recommended surgical approach for early stage lung cancer treatment. The importance of increasing the number of surgeons capable of performing VATS lobectomies is implicit and of utmost importance. In fact, the need of performing independently and routinely VATS lobectomies for early stage lung cancer will soon be a prerequisite to the new generation of thoracic surgeons. The feeling that VATS lobectomy teaching should be part of their training is strongly felt among trainees but, at the moment, a formal, uniform and certified process of learning VATS lobectomy is not available in all training centres. Perhaps, through the supervision, support and aid from national and European Thoracic Surgery Societies, programs of integration of recognized, standardized and certified teaching of VATS lobectomy could be planned and undertaken by the training centres, both at national as well as European level.
Background:
Video-assisted thoracoscopic surgery (VATS) using a single incision (uniportal) may result in better pain control, earlier mobilization and shorter hospital stays. Here, we review the safety and efficiency of our initial experience with uniportal VATS and evaluate our learning curve.
Methods:
We conducted a retrospective review of uniportal VATS using a prospectively maintained departmental database and analyzed patients who had undergone a lung anatomic resection separately from patients who underwent other resections. To assess the learning curve, we compared the first 10 months of the study period with the second 10 months.
Results:
From January 2014 to August 2015, 250 patients underwent intended uniportal VATS, including 180 lung anatomic resections (72%) and 70 other resections (28%). Lung anatomic resection was successfully completed using uniportal VATS in 153 patients (85%), which comprised all the anatomic segmentectomies (29 patients), 80% (4 of 5) of the pneumonectomies and 82% (120 of 146) of the lobectomies attempted. The majority of lung anatomic resections that required conversion to thoracotomy occurred in the first half of our study period. Seventy patients underwent other uniportal VATS resections. Wedge resections were the most common of these procedures (25 patients, 35.7%). Although 24 of the 70 patients (34%) required the placement of additional ports, none required conversion to thoracotomy.
Conclusions:
Uniportal VATS was safe and feasible for both standard and complex pulmonary resections. However, when used for pulmonary anatomic resections, uniportal VATS entails a steep learning curve.
Background:
Video-assisted thoracic surgery (VATS) double-sleeve lobectomy and carinal resections are two of the most complex procedures in thoracic surgery. The uniportal approach provides an advantage for performing these procedures successfully; however, knowledge of the important technical details is required. This study describes the experience of implementing these procedures by Russian specialists.
Methods:
Six patients (one woman; mean age, 57.3±3.6 years) who underwent a uniportal VATS double sleeve and carinal resections were consecutively included in this study. A 5- to 6-cm incision was made at the fifth intercostal space on the middle axillary line.
Results:
Double sleeve left upper lobectomy was completed in four cases. One case of the right sleeve carinal pneumonectomy and one case of the right sleeve carinal upper lobectomy were completed. The mean operation time was 280±13 minutes. There was no conversion to thoracotomy. The mean postoperative hospital stay was 10.8±0.8 days. There was no postoperative mortality. In one case of double-sleeve lobectomy, postoperative pneumonia developed. The postoperative diagnoses of the four uniportal double-sleeve cases were as follows: T2aN2M0 in one case, T3N1M0 in two cases, and T2aN0M0 in one case. The postoperative diagnoses of the two uniportal totally carinal resections were as follows: T4N0M0 and T3N0M0.
Conclusions:
This study results suggest that a uniportal VATS approach might be a feasible option for complex sleeve resections with acceptable postoperative outcomes in the advanced stages of lung cancer. To further evaluate the feasibility, safety, and efficacy of this technique, more experience would be required.
Background:
Single-port video-assisted thoracoscopic surgery (VATS) has attracted much attention recently; however, it is still very challenging to perform especially on more technically demanding sublobar anatomic resection procedures such as segmentectomy. Therefore we conducted a retrospective study on the perioperative results of single-port segmentectomy using a propensity-matched method for comparison with multi-port segmentectomy in patients with primary lung cancer.
Methods:
For procedures of anatomic segmentectomy performed between May 2006 and March 2014, we retrieved data on patients' demographic information, medical history, cancer information, and postoperative outcomes from our surgical database of thoracoscopic lung cancer surgery. Outcome variables included the number of lymph nodes retrieved during the surgery, the amount of blood loss, the duration of hospitalization, the length of the wound, the operation duration in minutes, and incidence and types of complication. The t-test and Chi-squared test were used to compare demographic and clinical variables between single- and multi-port approaches.
Results:
A total of 98 consecutive patients who underwent VATS segmentectomy for lung cancer treatment were identified in our database: 52 (53.1%) underwent a single-port segmentectomy and 46 (46.9%) had a multi-port segmentectomy. After propensity score matching, the differences in patients' age, pulmonary function tests, tumor size, and operating surgeons were no longer significant between the two sample groups. The length of the wound was the only surgical outcome for which single-port segmentectomy had a significantly better outcome than multi-port segmentectomy (P value <0.001).
Conclusions:
This study showed that single-port VATS segmentectomy yielded comparable surgical outcomes to multi-port segmentectomy despite technique difficulties and smaller wound in our setting.
The uniportal video assisted thoracic surgery (VATS) approach to lung lobectomy has generated phenomenal interest in recent years. It promises to offer patients less morbidity and faster recovery, even when compared to conventional multiportal VATS. However, critics of the uniportal VATS approach may raise concerns about whether this most minimally invasive surgical approach for lung surgery may compromise safety and treatment efficacy. This debate has great potential importance not only in determining how patients are operated on, but in understanding how 'success' is gauged in major pulmonary surgery. This article explores both sides of this debate, drawing on the experience of how clinical research in multiportal VATS evolved over the years. Systematic generation of clinical evidence with progressively increasing sophistication is required to fairly evaluate the uniportal VATS approach. A review of the current literature suggests that there remain many large gaps in the evidence surrounding uniportal VATS. Hence, at the present time, the reasons voiced by critics as to why uniportal VATS should not be performed should not be lightly dismissed. Instead, it behoves surgeons on both sides of the debate to continue to generate good clinical evidence to resolve it.
Background:
To address the feasibility and advantages of subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for lobectomy.
Methods:
Since August 2014, 105 cases of subxiphoid uniportal VATS lobectomy were successfully performed. The clinical information was retrospectively analyzed.
Results:
96 cases underwent unilateral operation and 9 underwent bilateral operations. Surgeries were successfully performed with a complication rate of 10.5%. The average pain scores 8 hours, day 1, 2 and 3 after surgery, as well as the day before discharge were 2.39±0.99, 2.06±0.85, 1.68±0.87, 1.29±0.78, and 0.48±0.51, respectively, which were significantly lower than those in the control group (standard intercostal uniportal VATS) (P<0.001).
Conclusions:
The subxiphoid uniportal VATS lobectomy is safe and reliable, which is appropriate for bilateral lung diseases, and significantly relieves postoperative incision pain.
Background:
Extended thymectomy is indicated for patients with myasthenia gravis (MG) when drug-resistance or dependence is seen. We have employed a technique for subcostal thoracoscopic extended thymectomy (STET) on patients with MG.
Methods:
Clinical data of 15 eligible patients who underwent STET in our department from February 2015 to November 2015 by the same surgical team were retrospectively analyzed. The operation time, blood loss, duration of postoperative hospital stay, thoracic drainage periods were concerned.
Results:
All the surgeries were finished successfully without conversion to sternotomy. Mean operation time was 157.53±40.31 min (range, 73-275 min). Mean blood loss was 56.33±7.07 mL (range, 10-200 mL). Mean pleural drainage volume in the first 24 hours was 72.67±17.68 mL (range, 0-250 mL). Mean postoperative thoracic drainage periods were 1.20±0.71 days (range, 0-3 days). Mean duration of postoperative hospital stay was 6.13±0.71 days (range, 3-22 days).
Conclusions:
This procedure showed satisfactory results for patients with MG. Moreover, the STET approach is more easily for surgeons to fully reveal the bilateral phrenic nerve and the upper thymic poles. We believe that STET is a satisfactory procedure for performing extended thymectomy in well selected patients.
OBJECTIVES
Single-port video-assisted thoracic surgery (VATS) technique has been used for thoracic diseases. There was no report about single-port VATS in large series. Outcomes following single-port VATS were analysed to determine its efficacy and safety.
METHODS
From June 2012 to June 2014, 1063 single-port VATSs were performed by four surgeons. Patient demographics, perioperative parameters, histopathology and outcomes were analysed.
RESULTS
There were 1063 patients (524 men and 539 women). The median age was 56.1 ± 8.7 years (range, 15–86 years). Lobectomy was performed in 569 patients, segmentectomy in 162, wedge resection in 264, pleural biopsy in 7, drainage of effusion in 20, pleural tumour resection in 5, mediastinal tumour resection in 54, mediastinal tumour biopsy in 2, bilobectomy in 7, sleeve lobectomy in 3 and pneumonectomy in 2. Synchronous bilateral single-port VATS was performed in 27 cases, whereas metachronous bilateral single-port VATS was performed in 5 cases. Pathological diagnoses included primary lung cancer in 635 cases, metastatic lung cancer in 19, mediastinal tumour in 56, pleural disease in 32 and benign pulmonary conditions in 353. Fifteen intraoperative vascular injuries were identified in 15 patients. The total conversion rate was 4.6%. The average operation time was 135 ± 31 min (range, 30–230 min), and the average blood loss was 117 ± 47 ml (range, 50–2000 ml). The median intensive care unit stay was 1 day (0–4 days). The postoperative hospital stay was 6.2 ± 2.6 days on average. There was no operative death, and operative complications occurred in 59 patients (5.6%). The 1-year overall survival and 1-year disease-free survival for the primary lung cancer group were 98 and 96%, respectively.
CONCLUSIONS
Our findings indicate that single-port VATS for thoracic diseases is safe and feasible.
Locally advanced lung tumours often require complex surgical techniques to achieve an oncological and safe procedure. Sleeve resections when operating on endobronchial lesions or hilar tumours should be attempted whenever possible rather than performing a pneumonectomy. These procedures result in improved survival, better quality of life, a reduced loss of lung function and an improved operative mortality compared with pneumonectomy. Although the most common approach is an open thoracotomy, these complex surgical techniques can be performed in a thoracoscopic way with the skills and the experience gained from major video-assisted thoracoscopic procedures (VATS). However, despite the multiple advantages of VATS compared with thoracotomy, such as decreased postoperative pain and better recovery, this minimally invasive approach is still not widely adopted for advanced stages of lung cancer and complex resections. Concerns about performing an adequate oncological resection and safe reconstruction VATS are the main reasons for the low adoption of these minimally invasive approaches. Like other thoracoscopic techniques, VATS sleeve procedures also have a steep learning curve, and should therefore be performed either by or with skilled and experienced VATS surgeons to ensure safety and avoid complications. In this article, we describe the technique of thoracoscopic sleeve procedures through a single-incision (uniportal) approach for bronchial, bronchovascular, tracheal and carinal reconstruction, and review the literature reporting sleeve resections by VATS.
The aims of this study were to develop virtual reality simulation software for video-assisted thoracic surgery (VATS) lobectomy, to explore the opinions of thoracic surgeons concerning the VATS lobectomy simulator and to test the validity of the simulator metrics.
Experienced VATS surgeons worked with computer specialists to develop a VATS lobectomy software for a virtual reality simulator. Thoracic surgeons with different degrees of experience in VATS were enrolled at the 22nd meeting of the European Society of Thoracic Surgeons (ESTS) held in Copenhagen in June 2014. The surgeons were divided according to the number of performed VATS lobectomies: novices (0 VATS lobectomies), intermediates (1-49 VATS lobectomies) and experienced (>50 VATS lobectomies). The participants all performed a lobectomy of a right upper lobe on the simulator and answered a questionnaire regarding content validity. Metrics were compared between the three groups.
We succeeded in developing the first version of a virtual reality VATS lobectomy simulator. A total of 103 thoracic surgeons completed the simulated lobectomy and were distributed as follows: novices n = 32, intermediates n = 45 and experienced n = 26. All groups rated the overall user realism of the VATS lobectomy scenario to a median of 5 on a scale 1-7, with 7 being the best score. The experienced surgeons found the graphics and movements realistic and rated the scenario high in terms of usefulness as a training tool for novice and intermediate experienced thoracic surgeons, but not very useful as a training tool for experienced surgeons. The metric scores were not statistically significant between groups.
This is the first study to describe a commercially available virtual reality simulator for a VATS lobectomy. More than 100 thoracic surgeons found the simulator realistic, and hence it showed good content validity. However, none of the built-in simulator metrics could significantly distinguish between novice, intermediate experienced and experienced surgeons, and further development of the simulator software is necessary to develop valid metrics.
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
To compare the feasibility and safety of single-port vs. triple-port complete thoracoscopic lobectomy for non-small cell lung cancer (NSCLC).
A retrospective study was conducted on 82 patients with NSCLC who underwent complete thoracoscopic lobectomy from August 2014 to October 2014 in Department of Thoracic Surgery, Fujian Medical University Union Hospital. There were 33 cases in single-port complete thoracoscopic lobectomy group (single-port group) and the other 49 ones in triple-port complete thoracoscopic lobectomy group (triple-port group). Total lymph node harvest, mediastinal lymph node harvest, dissection of mediastinal lymph node groups, operation time, intraoperative blood loss, chest drainage duration, postoperative hospital stay, postoperative one-day pain visual analogue scale (POP-VAS), and the complications were thoroughly compared between the two groups.
There were no significant differences in total lymph node harvest, mediastinal lymph node harvest, dissection of mediastinal lymph node groups, intraoperative blood loss, chest drainage duration, postoperative hospital stay, and complications between the two groups (P>0.05). However, the operation time of single-port group was significantly longer than that of triple-port group (181.3±27.5 vs. 149.5±30.9 min, P<0.05). POP-VAS in single-port group was significantly lower than that in triple-port group (3.6±0.7 vs. 5.5±1.0, P<0.05).
For NSCLC, the feasibility and safety of single-port complete thoracoscopic lobectomy is similar to triple-port complete thoracoscopic lobectomy. Compared with triple-port complete thoracoscopic lobectomy, the operation time of single-port complete thoracoscopic lobectomy is longer, but its postoperative pain is gentler. As the experience accumulating, single-port complete thoracoscopic lobectomy should be popularized with its merits of minimal invasiveness.
Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Background Video-assisted thoracic surgery (VATS) for major lung resection has undergone major changes from three or four-port approach to the recently possible single-port VATS approach. Outcomes following single-port VATS major lung resection are analyzed to determine safety and efficacy. Methods A prospective database of 150 consecutive patients who underwent single-port VATS major lung resection between March 2012 and January 2014 was reviewed. Patient demographics, perioperative parameters, histopathology, and outcomes up to follow-up of 2 years were analyzed by descriptive and Kaplan-Meier survival statistics. Results Single-port VATS major lung resection was successfully performed in 142 patients (conversion rate 5.3%) for both malignant and benign diseases of the lung. Overall, 130 patients (87%) had nonsmall-cell lung carcinoma (NSCLC), 9 (6%) had other types of primary lung cancer, and the remaining for secondary malignancies and benign diseases. Among the 130 patients with NSCLC, 93 (71.5%) were stage I, 28 were stage II (21.5%), and 9 (7%) were stage III or greater. There was no intraoperative or 30-day mortality. However, one perioperative death occurred on day 49, and another on day 60 postoperatively due to infective causes. The overall 2-year mortality rate for all patients was 3%. The disease-free survival rate for subgroups, stage I NSCLC, and stage II or greater NSCLC were 96 and 83%, respectively. Conclusions Single-port VATS major lung resection for malignant and benign lung diseases is associated with low perioperative morbidity and mortality. Disease-free survival rates for NSCLC are acceptable and comparable with conventional VATS.
Georg Thieme Verlag KG Stuttgart · New York.
Surgical patients with chronic obstructive pulmonary disease (COPD) are at increased risk of perioperative complications. In this study, we sought to quantify the benefit of avoiding general anesthesia in this patient population.
Data from the National Surgical Quality Improvement Program database (2005-2010) were used for this review. Patients who met the National Surgical Quality Improvement Program definition for COPD and underwent surgery under general, spinal, epidural, or peripheral nerve block anesthesia were included in this study. For each primary current procedural terminology code with ≥1 general and ≥1 regional (spinal, epidural, or peripheral nerve block) anesthetic, regional patients were propensity score--matched to general anesthetic patients. Propensity scoring was calculated using all available demographic and comorbidity data. This match yielded 2644 patients who received regional anesthesia and 2644 matched general anesthetic patients. These groups were compared for morbidity and mortality.
Groups were well matched on demographics, comorbidities, and type of surgery. Compared with matched patients who received regional anesthesia, patients who received general anesthesia had a higher incidence of postoperative pneumonia (3.3% vs 2.3%, P = 0.0384, absolute difference with 95% confidence interval = 1.0% [0.09, 1.88]), prolonged ventilator dependence (2.1% vs 0.9%, P = 0.0008, difference = 1.2% [0.51, 1.84]), and unplanned postoperative intubation (2.6% vs 1.8%, P = 0.0487, difference = 0.8% [0.04, 1.62]). Composite morbidity was 15.4% in the general group versus 12.6% (P = 0.0038, difference = 2.8% [0.93, 4.67]). Composite morbidity not including pulmonary complications was 13.0% in the general group versus 11.1% (P = 0.0312, difference = 1.9% [0.21, 3.72]). Thirty-day mortality was similar (2.7% vs 3.0%, P = 0.6788, difference = 0.3% [-1.12, 0.67]). As a test for validity, we found a positive association between pulmonary end points because patients with 1 pulmonary complication were significantly more likely to have additional pulmonary complications.
The use of regional anesthesia in patients with COPD is associated with lower incidences of composite morbidity, pneumonia, prolonged ventilator dependence, and unplanned postoperative intubation.
Interest has been renewed in segmentectomy for non-small cell lung cancer (NSCLC). However, whether the oncologic outcomes are comparable with lobectomy is conflicting. To assess the evidence base, a systematic search identified 31 comparative studies for meta-analysis. No higher local or distant recurrence in segmentectomy compared with lobectomy. Nevertheless, worse outcomes in overall and recurrence-free survival for patients treated with segmentectomy were found. Lobectomy conferred a significant survival advantage compared with segmentectomy for stage I. However, segmentectomy was more suitable for stage IA NSCLC, with survivals equivalent to lobectomy. Further randomized controlled trials are needed to confirm the results.
Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
The surgical approach to lung resections is evolving constantly. Since the video-assisted thoracoscopic surgery (VATS) anatomic lobectomy for lung cancer was described two decades ago, many units have successfully adopted this technique. The VATS lobectomy can be defined as the individual dissection of veins, arteries and bronchus, with a mediastinal lymphadenectomy, using a videothoracoscopic approach visualized on screen and involving 2 to 4 incisions or ports, with no rib spreading. However, the surgery can be performed by only one incision with similar outcomes. Since 2010, when the uniportal approach was introduced for major pulmonary resections, the technique has been spreading worldwide. This technique provides a direct view of the target tissue. The parallel instrumentation achieved during the single-port approach mimics the maneuvers performed during open surgery. It represents a less invasive approach than the multiport technique, and minimizes the compression of the intercostal nerve. As the surgeon's experience with the uniportal VATS lobectomy grows, more complex cases can be performed by using this approach, thus expanding the indications for single-incision thoracoscopic lobectomy.
Background:
It is unclear whether thoracoscopic (video-assisted thoracoscopic surgery [VATS]) pneumonectomy improves outcomes compared with open approaches.
Methods:
One hundred seven consecutive pneumonectomies performed at an experienced center from January 2002 to December 2012 were studied retrospectively. Forty cases were open, and 50 successful VATS and 17 conversions were combined (intent-to-treat [ITT] analysis).
Results:
The VATS cohort had more preoperative comorbidities (three vs two, P = .003), women (57% vs 30%, P = .009), and older ages (65 years vs 63 years, P = .07). Although advanced clinical stage was less for VATS (26% vs 50% stage III, P = .035), final pathologic staging was similar (25% vs 38%, P = .77). Pursuing a VATS approach yielded similar complications (two vs two, median, P = .73) with no catastrophic intraoperative events like bleeding. Successful VATS pneumonectomy rates rose from 50%-82% by the second half of the series (P < .001). Completion pneumonectomy cases (13.4% VATS, 7.5% open) had similar outcomes. Having similar initial discomforts as patients undergoing open surgery, more patients undergoing VATS were pain-free at 1 year (53% vs 19%, P = .03). Conversions resulted in longer ICU stays (4 days vs 2 days, P = .01). Advanced clinical stage (III-IV) ITT VATS had longer median overall survival (OS) (42 months vs 13 months, log-rank P = .042). Successful VATS cases with early pathologic stage (0-II) had a median OS of 80 vs 16 months for converted and 28 months for open (log rank = 0.083).
Conclusions:
Attempting thoracoscopic pneumonectomy at an experienced center appears safe but does not yield the early pain/complication reductions observed for VATS lobectomy. There may be long-term pain/survival advantages for certain stages that warrant further study and refinement of this approach.
Ground glass opacities, also known as GGOs, are detected on computed tomography (CT) scans as hazy areas if increased attenuation in the lung, and my represent a variety of pulmonary processes. Natural history of GGOs and their clinical implications are not yet fully understood. Controversies associated with the management of GGOs surround their histological classification, malignant potential, indications, timing, and type of intervention. Herein we discuss the principles and role of surgical therapy for ground glass opacities.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with resectable non-small-cell lung cancer, is video-assisted thoracoscopic segmentectomy a suitable alternative to thoracotomy and segmentectomy in terms of morbidity and equivalence of resection?' Altogether 232 papers were found as a result of the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Only one study compared the survival rates of video-assisted thoracoscopic surgery (VATS) and open surgery and found no significant difference in overall (P = 0.605) and disease-free (P = 0.996) survival between these groups. The mean length of hospital stay was reported as shorter following VATS when compared with open surgery in all of the studies looking at this outcome. The greatest difference in length of hospital stay reported was 4.8 days (VATS 3.5 days and open 8.3 days). The duration of chest tube placement was also universally reported as shorter in patients having VATS procedures when compared with open procedures. Two studies compared the number of lymph nodes that could be sampled when completing this operation by VATS using an open approach and neither found there to be a significant difference between these numbers. Using the evidence collected, we conclude that anatomical segmentectomy performed by VATS is a safe and effective alternative to conventional techniques in the surgical management of non-small-cell lung cancer. We are aware that the current evidence is limited and existing studies all examine small numbers of patients. Unfortunately, at present there is no blinded randomized control trial comparing these two surgical methods. There is also no study comparing the utility of each method for differing anatomical locations of segments. This should be kept in mind when interpreting the results of the studies presented.