Invited Commentary

Abstract

One of the concerns with uniportal video-assisted thoracic surgery (VATS) has always been the reproducibility of the technique outside a few institutions aiming at the extremes of surgical invasiveness in the management of intrathoracic conditions [1Rocco G. Martucci N. La Manna C. et al.Ten-year experience on 644 patients undergoing single-port (uniportal) video-assisted thoracoscopic surgery.Ann Thorac Surg. 2013 Jun 19; http://dx.doi.org/10.1016/j.athoracsur.2013.04.044Google Scholar, 2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar]. In line with the current literature [2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar], this report from Tam and Lim [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] supports a more widespread adoption of uniportal VATS lobectomy. Finally moving away from the feasibility and safety issues of the uniportal technique, the next foreseeable step in the codification of uniportal VATS lobectomy should be a standardized approach. In particular, from a comparison of the current report [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]with the established experience of the Coruña group [2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar], issues that need clarifying include whether or not to use a wound protector that may still function as a retractor, the use of articulating versus modified/conventional open instruments, the strategy for addressing fissures, the number of inserted chest drains against the risk of intercostal nerve impingement, and the technical alternatives when local anatomy is unfavorable from the anterior incision [2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar, 3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. In this setting, the backup operation in the event of conversion was thoracotomy, according to Tam and Lim [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Indeed, even in their description of uniportal VATS lobectomy [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar], the emphasis is placed on the performance of the procedure by monitor visualization, inasmuch as the anterior incision up to 4 cm should function as an enlarged port only. Also, when comparing uniportal VATS with conventional VATS and minimally invasive open lobectomy, a clear definition of the outcomes is needed: what are the expected operative time and length of stay, what postoperative morbidity and pain can be expected, and, ultimately, what is the oncologic value of uniportal VATS lobectomy? Until then, skeptics will maintain that the advantages provided by uniportal VATS lobectomy are intuitive but that similar results in terms of chest tube duration, postoperative stay, and respiratory complications can be achieved through more standardized approaches without the need for what it might be perceived as an added difficulty. Moreover, the learning curve for uniportal VATS lobectomy needs clarifying: should a stepwise evolution from three to two ports to one port only be advisable, or also should surgeons used to lobectomy through an anterior open approach be assisted in directly shifting to uniportal VATS lobectomy? In conclusion, enough preliminary data are available for uniportal VATS lobectomy to avoid the stigma of an acrobatic surgical exercise. However, the need for an international registry, a homogeneous educational offer, and, last but not least, a prospective, multicenter trial of conventional versus uniportal VATS lobectomy involving the institutions with the largest uniportal VATS lobectomy experience, are all obvious desiderata if uniportal VATS lobectomy needs to be rightfully contemplated as a routine procedure for lobar resection in the current and future thoracic surgical repertoire. One of the concerns with uniportal video-assisted thoracic surgery (VATS) has always been the reproducibility of the technique outside a few institutions aiming at the extremes of surgical invasiveness in the management of intrathoracic conditions [1Rocco G. Martucci N. La Manna C. et al.Ten-year experience on 644 patients undergoing single-port (uniportal) video-assisted thoracoscopic surgery.Ann Thorac Surg. 2013 Jun 19; http://dx.doi.org/10.1016/j.athoracsur.2013.04.044Google Scholar, 2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar]. In line with the current literature [2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar], this report from Tam and Lim [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] supports a more widespread adoption of uniportal VATS lobectomy. Finally moving away from the feasibility and safety issues of the uniportal technique, the next foreseeable step in the codification of uniportal VATS lobectomy should be a standardized approach. In particular, from a comparison of the current report [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]with the established experience of the Coruña group [2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar], issues that need clarifying include whether or not to use a wound protector that may still function as a retractor, the use of articulating versus modified/conventional open instruments, the strategy for addressing fissures, the number of inserted chest drains against the risk of intercostal nerve impingement, and the technical alternatives when local anatomy is unfavorable from the anterior incision [2Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Crossref PubMed Scopus (258) Google Scholar, 3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. In this setting, the backup operation in the event of conversion was thoracotomy, according to Tam and Lim [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Indeed, even in their description of uniportal VATS lobectomy [3Tam K.C. Lim K.S. Total muscle-sparing uniportal video-assisted thoracoscopic surgery lobectomy.Ann Thorac Surg. 2013; 96: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar], the emphasis is placed on the performance of the procedure by monitor visualization, inasmuch as the anterior incision up to 4 cm should function as an enlarged port only. Also, when comparing uniportal VATS with conventional VATS and minimally invasive open lobectomy, a clear definition of the outcomes is needed: what are the expected operative time and length of stay, what postoperative morbidity and pain can be expected, and, ultimately, what is the oncologic value of uniportal VATS lobectomy? Until then, skeptics will maintain that the advantages provided by uniportal VATS lobectomy are intuitive but that similar results in terms of chest tube duration, postoperative stay, and respiratory complications can be achieved through more standardized approaches without the need for what it might be perceived as an added difficulty. Moreover, the learning curve for uniportal VATS lobectomy needs clarifying: should a stepwise evolution from three to two ports to one port only be advisable, or also should surgeons used to lobectomy through an anterior open approach be assisted in directly shifting to uniportal VATS lobectomy? In conclusion, enough preliminary data are available for uniportal VATS lobectomy to avoid the stigma of an acrobatic surgical exercise. However, the need for an international registry, a homogeneous educational offer, and, last but not least, a prospective, multicenter trial of conventional versus uniportal VATS lobectomy involving the institutions with the largest uniportal VATS lobectomy experience, are all obvious desiderata if uniportal VATS lobectomy needs to be rightfully contemplated as a routine procedure for lobar resection in the current and future thoracic surgical repertoire. Total Muscle-Sparing Uniportal Video-Assisted Thoracoscopic Surgery LobectomyThe Annals of Thoracic SurgeryVol. 96Issue 6PreviewConventional video-assisted thoracoscopic lobectomy uses multiple incisions, including an access incision and several port incisions. This series aims to evaluate the technical feasibility and early results of uniportal video-assisted thoracoscopic surgery (UVATS) lobectomy using a small, total muscle-sparing incision. Full-Text PDF