Operative VATS: the need for a different intrathoracic approach

Abstract

I read with interest the report by Sasaki and colleagues [1] about the triangle target principle to address intrathoracic lesions by three-port VATS. I would like to congratulate the authors on having emphasized the need for a VATS approach to target lesions inside the chest not from the time-honored laterolateral view, but from a sagittal, craniocaudal perspective. This echoes the fundamental concept of the already published uniportal VATS approach [2]. Indeed, the authors themselves conclude that ‘partial resection is easy because the forceps and endoscopic stapler meet at a right angle’. In fact, the pictures they have enclosed in the manuscript are also remarkably similar to the ones contained in the reports of uniportal VATS wedge resections [2,3]. The major difference between the triangle technique and the uniportal approach is the use of three ports instead of one for similar diagnostic and therapeutic indications. In this setting, the choice of the VATS strategy can have consequences in terms of residual pain and paresthesia [4]. On the other hand, the authors claim that ‘the tumor can be palpated through the wound of the target trocar when the tumor is not visible by thoracoscopy’. This is not exactly an advantage exclusive to their principle, since the standard three-port approach can also allow for digital palpation of the lung. In addition, it is common experience to fail occasionally to detect small and more deeply located nodules by palpation at standard thoracoscopy. In this context, the real breakthrough will be efficient for preor intraoperative marking, according to a principle already followed by the authors as shown in one of the illustrations. In conclusion, it is important to assess the concurrence of opinions as to the need for a different geometric VATS approach inside the chest, which, in my opinion, can be easily accomplished through just one strategically located port.