Outcomes of single- versus multi-port video-assisted thoracoscopic surgery: Data from a multicenter randomized controlled trial of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer.

Objectives: Surgery through a single port may be less painful because access is supplied by 1 intercostal nerve or more painful because multiple instruments are used in 1 port. We analyzed data collected from the video-assisted thoracoscopic surgery group of a randomized controlled trial to compare differences in pain up to 1 year. Methods: Groups were compared in a prespecified exploratory analysis using direct (regression) and indirect comparison (difference with respect to thoracotomy). In-hospital visual analogue scale pain scores were used, and analgesic ratios were calculated. After discharge, pain was evaluated using European Organization for Research and Treatment of Cancer Quality of Life Questionnaires-Core 30 scores up to 1 year. Results: From July 2015 to February 2019, we randomized 503 participants. After excluding 50 participants who did not receive lobectomy, surgery was performed using a single port in 42 participants (predominately by a single surgeon), multiple ports in 166 participants, and thoracotomy in 245 participants. No differences were observed in-hospital between single- and multiple-port video-assisted thoracoscopic surgery when modeled using a direct comparison, mean difference of -0.24 (95% CI, -1.06 to 0.58) or indirect comparison, mean difference of -0.33 (-1.16 to 0.51). Mean analgesic ratio (single/multiple port) was 0.75 (0.64 to 0.87) for direct comparison and 0.90 (0.64 to 1.25) for indirect comparison. After discharge, pain for single-port video-assisted thoracoscopic surgery was lower than for multiple-port video-assisted thoracoscopic surgery (first 3 months), and corresponding physical function was higher up to 12 months. Conclusions: There were no consistent differences for in-hospital pain when lobectomy was undertaken using 1 or multiple ports. However, better pain scores and physical function were observed for single-port surgery after discharge.

Uniportal video-assisted thoracoscopic surgery (UVATS) right lower lobectomy for a giant T4 squamous cell lung tumour.

Video-assisted thoracoscopic surgery (VATS) is one of the unique methods that have revolutionized the discipline of minimally-invasive thoracic surgery in the last two decades. Previously, double-port VATS lobectomy has been used for the resection of T4 tumours. This current case report presents a 68-year-old male that presented with a productive cough of 3 months' duration, associated with fever, chest pain and loss of body weight. He was haemodynamically stable. The patient underwent surgery under general anaesthesia using a uniportal VATS (UVATS) approach. A 2-cm incision was made in the mid-axillary line through the right 5th intercostal space with no rib spreading. The tumour was put into a specimen bag, cut into pieces and then removed via the mouth of the bag using a grasper. After good haemostasis, a single chest drain was placed and the small incision was sutured in layers. The postoperative course was uneventful and no complications were observed. On the 6th day postoperative, the patient was discharged home. This current case demonstrated that UVATS resection for T4 tumours might be a viable approach in the hands of skilled surgeons. It should also provide decreased postoperative pain, faster recovery and shorter hospitalization.

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

Background and objectives: Hydatid disease of the lung, caused by Echinococcus granulosus, is an unusual parasitic disease. The aim of the current review for managing pulmonary hydatid cysts by uniportal video-assisted thoracoscopic surgery (u-VATS), and their complications, the size of hydatid cyst, length of hospital stay, surgery time, the rate of conversion from u-VATS to thoracotomy or mini-thoracotomy, follow-up, and outcomes. Methods: We conduct the platform searches on the PubMed and Google Scholar electronic databases from inception to January 20, 2022, among patients diagnosed with pulmonary hydatid cyst (PHC) who underwent the u-VATS approach. Results: This systematic review comprised five studies reporting 85 cases of PHC underwent (u-VATS) approach. Most patients were adults. The most common location of pulmonary hydatid cyst was the right lower lobe followed by the left lower lobe. The average size of PHC was 8.41 cm in all studies. The length of hospital stay was 3.85 days. The duration of operation time based on the means of the included studies was 86.19 min for each patient. Furthermore, the overall complication occurred in 9.35% of patients (n = 11) from 85 cases. The most complication was emphysema and prolonged air leak. The recurrence of pulmonary hydatid cyst did not occur in all studies. Conclusion: The feasibility of the video-assisted thoracoscopic surgery (VATS) approach has been proven globally in terms of reducing the overall complication, shorter chest tube duration, shorter surgery time, reduce postoperative pain, shorter chest tube duration, lower chest tube drainage, and less required to pain killers postoperatively.

Uniportal video-assisted thoracoscopic surgery for retained shrapnel in the thoracic cavity: An update surgical approach for removal of foreign body.

Uniportal video-assisted thoracoscopic surgery commonly used for removal of bullet, tumours and foreign bodies in the chest cavity. However, shrapnel fragments related war can injure many organs and life-threatening condition. Furthermore, standard treatment for removal foreign bodies retained in the chest is conventional thoracotomy. Alternatively, single port video-assisted thoracoscopic surgery approach can be used in patients hemodynamically stable. In addition, retained foreign bodies after a penetrating thoracic injury remain challenge for u-VATS surgeons. Here we present A 35-year-old man presented to the emergency department with multiple shells injury associate with right site chest injury. The patient underwent surgery using uniportal video-assisted thoracoscopic surgery u-VATS without spreading of the ribs for removal of a shrapnel retained in the thoracic cavity. The postoperative course was uneventful. On the 2nd day postoperative, the patient was discharged home. The u-VATS approach could be performed by experienced u-VATS surgeons and specialized nurses for this approach. In conclusion, our study revealed that u-VATS is safe, simple and feasible for retained foreign bodies in the thoracic cavity. The u-VATS have many benefits such as decrease postoperative complication, pain and earlier return to work.

Early surgical and oncological outcomes during adoption of a single port VATS lung resection in a tertiary cancer center: a retrospective analysis.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is a safe and effective surgical approach for pulmonary resection. VATS can be accomplished with only a single incision, resulting in less postoperative pain and paresthesia, better cosmetic results, and greater patient satisfaction. Single-port VATS (spVATS) has become increasingly common for lung resection. We assess the early surgical and oncological outcomes after adopting this new technique at our tertiary cancer center as the first institution to do so in the country. METHOD: Medical records for 257 patients in a tertiary cancer center, with a diagnosis of non-small cell lung cancer, pulmonary metastasis, or other chest-confined pathology, were accessed to obtain perioperative outcomes, pathologic results, post-operative follow-up data, and early surgical and oncological outcomes. All patients underwent spVATS for limited or major lung resection. Simple descriptive analysis was utilized. RESULTS: spVATS was either performed with curative intent (79.8%, N = 205), or as a diagnostic procedure (20.2%, N = 52). Resection types were subcategorized for curative intent group as limited (73.6%, N = 151), lobectomy (16.6%, N = 34), and complex (9.7%, N = 20). Resection with a negative margin (R0) rate was 100% for the primary lung cancer (PLC) patients and 97% for the pulmonary metastasectomy (PM) group. The complication rate was 5%. Three-year disease-free survival was 87% and 68.5% for PLC and PM group, respectively. The 3-year overall-survival was 91.3% for the PLC and 82.8% for PM. Operation duration showed a downtrend over the study period in each curative subcategory with a borderline difference in the limited resection (P value = 0.05). CONCLUSION: All the spVATS procedures were successfully performed without perioperative severe complications or mortality, regardless of complexity. R0 resection was excellent. Middle- and long-term efficacies of spVATS for lung cancer require further follow-up. With proper training, appropriate indication and meticulous application, adopting spVATS is safe and feasible technique that does not compromise surgical and oncological outcomes.

Comparative early results of a robotics-assisted endoscope holder in single port thoracoscopic surgery in the era of COVID-19.

BACKGROUND: Innovations in surgical instruments have made single-port surgery more widely accepted and lead to a reduced demand for surgical assistants. As COVID-19 has ravaged the world, maintaining minimum medical staffing requirements and proper social distancing have become major topics of interest. We sought to evaluate the feasibility of applying the unisurgeon approach in single-port video-assisted thoracoscopic surgery aided by a robotic camera holder. METHODS: Operative time, blood loss, setup time, postoperative hospital stays, and the number of participating surgeons in single-port video-assisted thoracoscopic lung resections were gathered for investigation after the introduction of the ENDOFIXexo robotic endoscope holder system. In this cohort, we collected 213 patients who underwent single port video thoracoscope surgery, including 57 patients underwent robotic endoscope arm assisted surgery and case-matched 52 patients in the robotic arm-assisted group with patients in the human-assisted group through propensity score-matched analysis. RESULTS: In wedge resection, a single surgeon was able to completely operate on all lobes of target lesions. However, for anatomical resections, namely segmentectomy, the success rate was 95%, and for lobectomy, the success rate was only 64%. No significant differences between setup times, blood loss, or operative times between the two groups were observed. CONCLUSIONS: When an experienced uniport surgeon is assisted by a robotic endoscope holder, wedge resection is the most suitable procedure to be performed through unisurgeon single-port video-assisted thoracoscopic surgery without increasing setup time, operative time, or short-term complications. Verification of the technique's applicability for use in anatomic resections requires further investigation.

Transdiaphragmatic single-port video-assisted thoracoscopic surgery; a novel approach for pulmonary metastasectomy through laparotomy incision - case series.

BACKGROUND: Pulmonary metastasectomy was performed in the early twentieth century and ever since, it has evolved to be one of the main treatment options for certain metastatic malignancies. The advancement of minimally invasive procedures enabled new techniques to minimize morbidity and improve patient quality of care and overall outcome. CASES PRESENTATION: Herein we present three patients, aged 53, 48, and 27 years, known to have sigmoid, rectal, and non-seminomatous germ cell tumors respectively. All patients were diagnosed to have metastatic lung nodules and underwent laparotomy to excise abdominal tumors followed by trans-diaphragmatic single-port video-assisted thoracoscopic pulmonary metastasectomy. All patients achieved complete surgical tumor excision, and none had pulmonary related complications on follow-up. CONCLUSION: Our prescribed novel trans-diaphragmatic single-port video-assisted thoracoscopic surgery (VATS) technique for synchronous pulmonary metastasectomy and intra-abdominal tumor resection is safe and can achieve complete resection with negative margins.

Metastatic non-functional paraganglioma to the lung.

INTRODUCTION: Paragangliomas are rare endocrine tumors that arise from the extra-adrenal autonomic paraganglia and sympathetic paragangliomas usually secret catecholamines and are located in the sympathetic paravertebral ganglia of thorax, abdomen, and pelvis. In contrast, most parasympathetic paragangliomas are nonfunctional and located along the glossopharyngeal and vagal nerves in the neck and at the base of the skull. Such neoplasms, although rare, are clinically important because they may recur after surgical resection and 10% of them give rise to metastases causing death with the lymphatic nodes, bones, liver, and lungs being the most common locations. CASE PRESENTATION: We present a case of a 26-year-old male patient that was diagnosed with paraganglioma of the right-frontal lobe infiltrating the falx and frontal bone which was diagnosed after suffering from a headache and abnormal vision. On initial work-up he was found to have right pulmonary nodules that increased in size after follow up and other nodules appeared in the contralateral lung. He underwent subtotal resection of the brain tumor and complete resection of the bilateral pulmonary nodules. CONCLUSION: To our knowledge, paraganglioma is considered to be a rare entity in the central nervous system with very few cases being reported in the supratentorial region and no cases were reported of metastatic such paraganglioma to the lung.

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

BACKGROUND: Our objective is to report on two centers' experience of intra-operative management of major vascular injury during single-port video-assisted thoracoscopic (SPVATS) anatomic resections, including bleeding control techniques, incidence, results, and risk factor analysis. METHODS: Consecutive patients (n = 442) who received SPVATS anatomic lung resections in two centers were enrolled. The different clinical parameters studied included age, previous thoracic surgery, obesity (BMI > 30), tumor location, neoadjuvant therapy, and pleural symphysis. In addition, peri-operative outcomes were compared between the groups, with or without vessel injury. RESULTS: There were no intra-operative deaths in our study. Overall major bleeding incidence was 4.5%, whereby 70% of major bleeding episodes could be managed with SPVATS techniques. In order to determine risk factors possibly related to intra-operative bleeding, we used case control matching to homogenize our study population. After case control matching, pleural symphysis was significantly related in the univariate (p = 0.005, Odds ratio 4.415, 95% CI 1.424-13.685) and multivariate analysis (p = 0.006, Odds ratio 4.926, 95% CI 1.577-15.384). Operative time (p < 0.001), blood loss (p < 0.001), and post-operative hospital stay (p = 0.012) were longer in patients with major vascular injury. There were no differences in 30-day mortality and 90-day morbidity. CONCLUSIONS: In summary, major intra-operative bleeding episodes during SPVATS anatomic lung resections are acceptable and most such bleeding episodes can be safely managed with SPVATS techniques.

Extended uniportal video-assisted thoracic surgery for lung cancer: is it feasible?

Since the first description of uniportal video-assisted thoracic surgery (U-VATS) (or single-port) lobectomy, several centers in Asia and Europe rapidly adopted this technique as a standard approach for treatment of early stage non-small cell lung cancer (NSCLC). Despite the controversies regarding feasibility and completeness of resection, thoracic surgeons in high volume centers keep pushing the limits to perform very complex procedures also known as "extended resections" through minimally invasive surgery. Published series and case reports confirm the viability of U-VATS in highly complex surgical cases such as pneumonectomy, chest wall resection and bronchoplasty, which require experience and technical ability to be performed through a 3-6 cm single incision. In this article, the authors would like to present several clinical indications of locally advanced NSCLC and the technical aspects to accomplish an extended resection through U-VATS.

Important Technical Details During Uniportal Video-Assisted Thoracoscopic Major Resections.

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.

Uniportal Video-Assisted Thoracoscopic Surgery Segmentectomy.

This article addresses technical details of uniportal VATS segmentectomy by lung segments, suggesting available techniques for lesion localization and identification of the intersegmental plane. Long-term results and superiority have not yet been characterized in standard VATS for lung malignancy. Indications include almost all thoracic procedures currently performed by conventional multiport VATS. We review our experience and published literature on the feasibility of uniportal VATS segmentectomy.

Uniportal Video-Assisted Thoracic Surgery Esophagectomy.

Several minimally invasive approaches for esophagectomy have been described, including robot-assisted esophagectomy and hybrid techniques, total transhiatal laparoscopic approach, esophagectomy using right thoracoscopy, combined laparoscopic and right thoracoscopic esophagectomy, and esophageal resection through mediastinoscopy. However, very few publications have focused on the uniportal video-assisted thoracic surgery (VATS) approach. The authors describe their technique of the minimally invasive esophagectomy using uniportal VATS as the thoracic step.

Uniportal video-assisted thoracic surgery for pneumothorax and blebs/bullae.

The last British Society of Thoracic Surgeons guidelines of 2010 for the management of primary spontaneous pneumothorax (PSP) stated that, after the first recurrence, the treatment of PSP should be a surgical operation, like a bullectomy accompanying with a procedure for inducing pleural adhesions. Therefore, the surgical approach is considered the best treatment to minimise the risk of recurrence in patients who experienced a PSP. There is substantial evidence in the literature demonstrating that the minimally invasive approach should be preferred to the thoracotomic procedure since it can reduce the postoperative pain and it is associated with a faster recovery of the physical and working activity. The video-assisted thoracic surgery (VATS) approach has been shown to offer greater advantages about patient pain and respiratory function when compared to thoracotomic incisions. A single port or single incision or uniportal approach was developed as an alternative to the standard multi-port VATS. Uniportal technique has shown to be safe and efficient not only for pulmonary resections and biopsies but also for lobectomy. When used for PSP, the bullectomy/blebectomy and pleural abrasion/pleurectomy is performed through the single incision through which the chest drain is then inserted. In this perspective, evidence showed that the minimally invasive approach should be preferred, confirming the advantages in comparison with traditional techniques.

Initial experience of single-port video-assisted thoracoscopic surgery sleeve lobectomy and systematic mediastinal lymphadenectomy for non-small-cell lung cancer.

BACKGROUND: In this study, we evaluate the feasibility and safety of single-port video-assisted thoracoscopic surgery (VATS) sleeve lobectomy (SL) and systematic mediastinal lymphadenectomy and summarize our surgical experience. METHODS: From October 2014 to December 2015, eight cases of single-port VATS SL [seven male patients and one female patient, median age 56.0 (range, 38-63) years] were performed by a single group of surgeons in Fujian Medical University Fujian Union Hospital. The median tumor size was 2.7 cm. Types of resection included four right upper, one right lower, and three left upper sleeve lobectomies. Systematic mediastinal lymphadenectomy was performed in all patients. A modified anastomosis technique developed by the author (Chen's technique) was applied for bronchial anastomosis. Postoperative outcome and short-term follow-up data were recorded and analyzed. RESULTS: All eight operations were completed uneventfully with no conversion to thoracotomy or reoperation required. No perioperative death was observed. Major results (medians or percentages) were as follows: operative duration, 234.5 [185-345] min; bronchial anastomosis duration, 38.0 [30-43] min; blood loss, 65.0 [50-200] mL; number of lymph node dissected, 22.5 [18-37]. The postoperative complication rate was 37.5% (three of eight cases, including two pulmonary infections and one atrial fibrillation). All patients recovered and were discharged uneventfully with symptomatic therapy. Pathology showed squamous cell carcinoma in seven patients and adenocarcinoma in one patient; two patients were in TNM stage IB, three in stage IIA, one in stage IIB, and two in stage IIIA. The mean follow-up was 7.5 [2-15] months. There were no tumor recurrences or bronchial anastomotic complications. CONCLUSIONS: Single-port VATS SL and mediastinal lymphadenectomy are safe and feasible. Improvements in operating procedures can help facilitate single-port VATS. The application of Chen's technique in bronchial anastomosis is easy and reliable and shows a satisfactory short-term clinical outcome.

Clinical innovations in minimally invasive surgery in Korea.

Over the past decade, the surgical approach to treating thoracic disease has shifted to minimally invasive surgery. Without compromising the outcomes, this approach may lead to fewer resections and fewer incisions for those resections. Video-assisted thoracoscopic surgery (VATS) is a recent but major advancement that has become an established approach for major thoracic surgery. More recently, robotic surgery has been gaining recognition because it can overcome the limitations of VATS and encourage a minimally invasive approach. Indications and applications of many other innovative surgical techniques and strategies to improve overall survival have expanded rapidly. In this article, we do not represent all thoracic surgeries occurring in Korea and do not reflect the large active centers in the country. However, as one of the most innovative and active Korean centers for thoracic surgery and research, we reviewed our procedures and programs for thoracic surgery.

Double-sleeve and carinal resections using the uniportal VATS technique: a single centre experience.

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.

Management of acute postoperative pain with continuous intercostal nerve block after single port video-assisted thoracoscopic anatomic resection.

BACKGROUND: Effective postoperative pain control for thoracic surgery is very important, not only because it reduces pulmonary complications but also because it accelerates the pace of recovery. Moreover, it increases patients' satisfaction with the surgery. In this study, we present a simple approach involving the safe placement of intercostal catheter (ICC) after single port video-assisted thoracoscopic surgery (VATS) anatomic resection and we evaluate postoperative analgesic function with and without it. METHODS: We identified patients who underwent single port anatomic resection with ICC placed intraoperatively as a route for continuous postoperative levobupivacaine (0.5%) administration and retrospectively compared them with a group of single port anatomic resection patients without ICC. The operation time, postoperative day 0, 1, 2, 3 and discharge day pain score, triflow numbers, narcotic requirements, drainage duration and post-operative hospital stay were compared. RESULTS: In total, 78 patients were enrolled in the final analysis (39 patients with ICC and 39 without). We found patients with ICC had less pain sensation numerical rating scale (NRS) on postoperative day 0, 1 (P=0.023, <0.001) and better triflow performance on postoperative day 1 and 2 (P=0.015, 0.032). In addition, lower IV form morphine usage frequency and dosage (P=0.009, 0.017), shorter chest tube drainage duration (P=0.001) and postoperative stay (P=0.005) were observed in the ICC group. CONCLUSIONS: Continuous intercostal nerve blockade by placing an ICC intraoperatively provides effective analgesia for patients undergoing single port VATS anatomic resection. This may be considered a viable alternative for postoperative pain management.