Approaches to single port mediastinal surgery

One-port (uniportal) video-assisted thoracic surgical resections—A clear advance

Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.

Thoracic sympathectomy remains an effective method for treatment of palmar hyperhidrosis refractory to other conservative forms of management. The procedure has become more acceptable following the introduction of the minimally invasive technique using video-assisted thoracic surgery (VATS). More recently, single-port VATS has gained popularity as an alternative approach to performing sympathectomy. We report on our experience and early results of single-port bilateral VATS sympathectomy using the Vasoview(®) (Maquet Inc., Rastatt, Germany) device at our institute. All patients who underwent VATS sympathectomy for primary palmar hyperhidrosis between June 2011 and March 2012 were recruited into this prospective study. Patients' demographics and intraoperative and postoperative outcomes were collected. Effectiveness of the procedure, postoperative pain, duration of hospital stay, and complications were also measured. Sixteen patients underwent Vasoview bilateral VATS sympathectomy for severe palmar hyperhidrosis. Mean age was 23.8 years (range, 17-36 years), and mean operative time to complete the bilateral procedure was 56 minutes (range, 42-81 minutes). The procedure was successfully completed in all patients without the need to enlarge the incision or convert. Postoperatively, there was no mortality and no residual palmar hyperhidrosis. Mean postoperative stay was 0.9 days (range, 0.7-1.9 days). The mean visual analog pain score at discharge was 1.8 (range, 1.2-3.4). Single-port Vasoview sympathectomy for treatment of severe palmar hyperhidrosis is technically feasible and safe with satisfactory immediate and early results. Intermediate and long-term follow-up is required to monitor recurrence or late complications. Future studies are warranted to compare Vasoview single-port and other minimal invasive VATS approaches.

Objective To explore the effects of single-port video-assisted thoracic surgery versus three-port videoassisted thoracic surgery for primary spontaneous pneumothorax. Methods Video-assisted thoracic surgery was performed for primary spontaneous pneumothorax in 58 patients from April 2012 to April 2013. We reviewed the medical records of these 58 patients, retrospectively. Thirty patients underwent the three-port video-assisted thoracic surgery (three-port group) and 28 patients underwent the single-port video-assisted thoracic surgery (single-port group). Following the operation, clinical outcomes, complications and overall survival were evaluated. Results There was no difference in patient characteristics between two groups. Compared with three-port video-assisted thoracic surgery, single-port video-assisted thoracic surgery had shorter hospital stay, shorter chest tube drainage, lower visual analog scale score score of 6 h postoperative pain and visual analog scale score score of 24 h postoperative pain. Meanwhile, there were no statistical differences between both groups in intraoperative bleeding, overall survival and progression-free survival. Conclusions Single-port video-assisted thoracic surgery can reduce the postoperative pain and get better clinical outcomes in treatment of primary spontaneous pneumothorax. Key words: Thoracoscopes; Monotremata; Pneumothorax; Case-control studies

Video-assisted thoracic surgery (VATS)-assisted lobectomy is widely used to treat non-small cell lung carcinoma (NSCLC). There are no reports concerning the comparison between single-port VATS and two-port VATS in treating NSCLC. This study aimed to compare the perioperative and short-term follow-up results between these two methods for treating NSCLC. A retrospective surgical evaluation of patients undergoing either single-port VATS or two-port VATS for NSCLC between January 2013 and June 2015 was conducted. The propensity score (PS) matching method was used to reduce selection bias by creating two groups. After generating the PSs, 1:1 ratio and nearest-neighbor score matching was completed. The primary outcome measures were surgical time, blood loss, drainage time, length of hospital stay, postoperative pain score and patient satisfaction score. The data were analyzed statistically with P<0.05 defined as statistically significant. Of the 143 patients who met the inclusion criteria, 66 (46.2%) were operated on using two-port VATS and 77 (53.8%) using single-port VATS. After 1-to-1 PS matching, 63 pairs were selected. Both groups were well balanced for age, gender, body mass index, pulmonary function, preoperative comorbidity, tumor size and tumor type. The single-port VATS group had less blood loss, less postoperative pain, and a higher satisfaction score than those in the two-port VATS group, with statistical significance. Postoperative complications occurred in 2 (2/63, 3.2%) patients in the single-port VATS group and 6 (6/63, 9.5%) patients in the two-port VATS group, not a significant difference. No deaths occurred during the follow-up period. A single-port VATS-assisted lobectomy is suggested to be safe and feasible for treating NSCLC. Compared with two-port VATS, single-port VATS has many advantages, including reduced blood loss, less postoperative pain and a higher satisfaction score.

The utilization of single-port video-assisted thoracic surgery for pulmonary aspergilloma (PA) has not been well studied. The study was performed to evaluate the safety and feasibility of it for PA compared with multi-port video thoracic-assisted surgery. From August 2007 to December 2019, consecutive PA patients receiving surgeries at Shanghai Pulmonary Hospital were enrolled retrospectively. Propensity score matching based on preoperative clinical variables was utilized to compare perioperative and long-term outcomes. In all 358 patients, a total of 63 patients underwent single-port video-assisted thoracic surgery, and 63 out of 145 patients for multi-port surgeries were paired with the single-port video-assisted thoracic surgery recipients. The median follow-up period was 40 months (range, 2-140 months). Patients receiving single-port video-assisted thoracic surgery showed a similar operation time, intraoperative blood loss, drainage duration and drainage volume to those of multi-port video-assisted thoracic surgery recipients (P > 0.05). Patients undergoing lobectomy by single-port approach experienced a shorter postoperative hospital stay {4.9 [standard deviation (SD): 2.0] vs 5.9 (SD: 2.3), P = 0.014}. The average postoperative pain scores [day 0: 2.6 (SD: 0.7) vs 3.1 (SD: 0.8), day 3: 4.0 (SD: 0.9) vs 4.8 (SD: 3.9), day 7: 2.2 (SD: 0.5) vs 3.1 (SD: 0.8), P < 0.001] and the number of days that patients required analgesic agents [3.0 (SD: 2.2) vs 4.8 (SD: 2.1), P < 0.001] were also decreased in the single-port video-assisted thoracic surgery group. Single-port video-assisted thoracic surgery is a safe and feasible alternative to multi-port video-assisted thoracic surgery for simple PA and selected complex ones, with a potential advantage of reduced postoperative pain.

BackgroundThe aim of this study was to evaluate the feasibility of single-port video-assisted thoracic surgery (VATS) in the treatment of secondary spontaneous pneumothorax (SSP).MethodsTwenty-four patients who were scheduled to undergo single-port VATS for SSP were studied. The medical records of the patients were retrospectively reviewed. The mean follow-up duration was 26.1±19.8 months. In order to evaluate the feasibility of single-port VATS for SSP, the postoperative results of single-port VATS (n=15) in patients with emphysema were compared with those of emphysematous patients who underwent three-port VATS (n=15) during the study period.ResultsSingle-port VATS was feasible in 19 of 24 patients (79.2%), while an additional port was needed in five patients. In the single-port VATS patients, the median operation time, duration of chest tube drainage, and hospital stay were 84.0 minutes, one day, and two days, respectively. Postoperative complications included prolonged chest tube drainage for more than five days (n=1), wound infection (n=1), and vocal fold palsy (n=1). No recurrence of pneumothorax was observed during the follow-up period. The median operation time, duration of chest tube drainage, and hospital stay of the emphysematous patients who underwent single-port VATS were shorter than those who underwent three-port VATS group (p<0.05 for all parameters).ConclusionSingle-port VATS proved to be a feasible procedure in the treatment of patients with secondary spontaneous pneumothorax.

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Video-assisted thoracic surgery (VATS) procedures for thymic tumors and myasthenia gravis were introduced in Asia in the middle 1990s in at least two regions, Hong Kong and Japan. To overcome difficulties in obtaining a wide view of the anterior mediastinum, several methods for lifting the sternum or anterior chest wall have been presented, mainly by Japanese surgeons. More recently, single port VATS through a subxiphoid incision was also introduced in Japan. The long-term outcome of a VATS extended thymectomy for myasthenia gravis has been shown to be comparable to that of a trans-sternal extended thymectomy, while the long-term outcome of a VATS thymectomy for thymic epithelial tumors remains to be elucidated. Nevertheless, its indication for tumors in an early stage is now widely accepted, and the number of VATS procedures is steadily increasing in Japan and China. Single-port VATS through a subxiphoid incision was developed in Japan and might become accepted as a useful approach in the near future when combined with robot-assisted thoracoscopic surgery. In addition, robot-assisted thoracoscopic surgery for the thymus has also been introduced in some areas in Asia. Although few of those surgical procedures for the thymus have been performed, results obtained thus far indicate that it might be preferable to lung resection. Several novel minimally invasive thymectomy techniques have been invented and developed in Asia, and further advancements in this field by Asian surgeons are anticipated.

Single-port video-assisted thoracic surgery (SPVATS) is a relatively new minimally invasive thoracic approach and is rapidly being adopted around the world. SPVATS is not merely a variation of the established multi-portal VATS, because it requires specific skills. We here describe our transition from 2-port VATS to SPVATS. From January 2017 to May 2018, we performed SPVATS in 54 patients. The procedures performed included 21 anatomic lung resections and 23 decortications for empyema. Perioperative outcomes were good with few complications and low postoperative pain scores. Despite some challenges due to our location and public health system, we successfully integrated SPVATS into our operative repertoire in a relatively short time.

BackgroundRecently, single-port video-assisted thoracic surgery (VATS) has been proposed as an alternative to the conventional three-port VATS for primary spontaneous pneumothorax (PSP). The aim of this study is to evaluate the early outcomes of the single-port VATS for PSP.MethodsVATS was performed for PSP in 52 patients from March 2012 to March 2013. We reviewed the medical records of these 52 patients, retrospectively. Nineteen patients underwent the conventional three-port VATS (three-port group) and 33 patients underwent the single-port VATS (single-port group). Both groups were compared according to the operation time, number of wedge resections, amount of chest tube drainage during the first 24 hours after surgery, length of chest tube drainage, length of hospital stay, postoperative pain score, and postoperative paresthesia.ResultsThere was no difference in patient characteristics between the two groups. There was no difference in the number of wedge resections, operation time, or amount of drainage between the two groups. The mean lengths of chest tube drainage and hospital stay were shorter in the single-port group than in the three-port group. Further, there was less postoperative pain and paresthesia in the single-port group than in the three-port group. These differences were statistically significant. The mean size of the surgical wound was 2.10 cm (range, 1.6 to 3.0 cm) in the single-port group.ConclusionSingle-port VATS for PSP had many advantages in terms of the lengths of chest tube drainage and hospital stay, postoperative pain, and paresthesia. Single-port VATS is a feasible technique for PSP as an alternative to the conventional three-port VATS in well-selected patients.

SC20.04 Uniportal VATS

We evaluated whether single-port video-assisted thoracic surgery is feasible without compromising outcomes, and whether the technique could be reproduced by a trainee. In a 6-month period, 37 operations were performed by single-port video-assisted thoracic surgery. Of the 37 patients, 27 (73%) were male and the mean age was 45.1 ± 21 years. Twenty-three (62%) were operated on by consultants and 14 (38%) by trainees. The procedures included 19 (51.3%) operations for treatment of pneumothoraces, 8 (21.6%) metastasectomies, 7 (18.9%) lung biopsies, 2 (5.4%) empyema débridements, and 1 (2.7%) pleuropericardial window. Mean operative time was 51.8 ± 14.7 min. Patient-controlled analgesia infusion was used for 1.3 ± 1 days. Three (8.1%) patients needed an operative reintervention, but there was no intensive treatment unit admission or hospital mortality. Mean postoperative hospital stay was 3.3 ± 2.7 days. On follow-up, all patients had a tissue diagnosis and all lung nodules were R0 resections. Patients operated on by consultants and trainees had similar preoperative profiles and postoperative outcomes, except that those operated on by trainees used patient-controlled analgesia significantly longer (1.8 ± 1.48 vs. 1 ± 0.48 days; p = 0.03). Single-port video-assisted thoracic surgery can be performed and reproduced well without compromising outcomes. It is considered aesthetically better and may reduce analgesic requirements, but it might not reduce hospital stay.

Uniportal video-assisted thoracic surgery (VATS), also known as single port VATS or single incision VATS has taken the world of minimally invasive thoracic surgery by storm. The technique originated more than a decade ago for minor procedures and stood still, until recent developments in surgical technique and instrumentation allowed the most complex of thoracic procedures to be performed by the uniportal approach. However, it is also the determination, courage, skill and unshakable belief of an individual, Dr Diego Gonzalez-Rivas that has shaped the uniportal world as we all know it today.

The concept of personalized medicine, which aims to provide patients with targeted therapies while greatly reducing surgical trauma, is gaining popularity among Asian clinicians. Single port video-assisted thoracic surgery (VATS) has rapidly gained popularity in Hong Kong for major lung resections, despite bringing new challenges such as interference between surgical instruments and insertion of the optical source through a single incision. Novel types of endocutters and thoracoscopes can help reduce the difficulties commonly encountered during single-port VATS. Our region has been the testing ground and has led the development of many of these innovations. Performing VATS, in particular single-port VATS in hybrid operating theatre helps to localise small pulmonary lesions with real-time images, thus increasing surgical accuracy and pushes the boundaries in treating subcentimeter diseases. Such approach may be assisted by use of electromagnetic navigational bronchoscopy in the same setting. In addition, sublobar resection can also be more individualised according to pathologic tumour subtype that require rapid intraoperative diagnostic test to guide appropriate surgical therapy. A focus on technology and innovation for large tumours that require chest wall resection and reconstructions have also been on going, with new materials and prostheses that may be tailored to each individual needs. The current paper reviews the literature pertaining to the above topics and discusses recent related innovations in Hong Kong, highlighting the study results and future perspectives.