Single-port thoracoscopic surgery using the SILS port

Abstract

We read with interest the article by Yang et al. [1]. We appreciate the novelty of the technique and how important it is to incorporate the development of new technologies into daily practice, and we also know how hard it is to convince colleagues to begin using new technologies. Surgeons who have already learned and mastered a technique are reluctant to start using a new one because of the inconvenience that this represents, the difficulty in obtaining new materials and learning a new surgical technique, and the trouble of convincing patients and families of the efficacy of the new method. After reviewing the article and taking into consideration the details of the variables to be analyzed, the homogeneity of the sample, and the extensive literature on the matter, we would like to make some comments. To our knowledge, there are very few published studies of the use of the single-incision laparoscopic surgery (SILS) port in thoracic surgery. There are case reports [2] and the retrospective series published by Yang et al. However, one of us (JMM) has recently had accepted for publication in this journal a prospective, nonrandomized, comparative pilot study [3]. This forthcoming series and the study of Yang et al. have several results in common that we would like to highlight. Both the duration of hospital stay and the cost were similar in our forthcoming series and in the study by Yang et al. Although they did not mention it, presumably the permanence of the chest tube drainage was also similar to that found in our study. Our results differ from their series in regard to pain. We used the visual analog scale for pain assessment, as did Yang et al., but we obtained significantly better results for patients with a SILS port than the three-port technique. In support of the finding that in the SILS technique pain and scarring satisfaction is better than with the classic three-port technique, Yang et al. mentioned that six of their patients had been previously operated on the contralateral side, and five of them were more satisfied with the SILS method than with the classic three-port method. The SILS port had lower postoperative neurological sequelae such as paresthesia and better cosmetic results. However, our study found higher rates of surgical wound complications, which we attribute to the fact that, with the SILS port being a single port, the tissues are compressed, and in addition it is the same wound used for chest tube placement. We find two points that diverge from the study of Yang et al.. First is the routine use of fibrin glue spray in all patients. Even after making the air leak test under the solution and finding none, we regard this as an excessive measure. It also raises intraoperative costs significantly, and there is no current evidence to suggest that this practice is universally accepted. Second is the fact that some of the cases of pneumothorax in patients who underwent surgery were their first event of pneumothorax. According to some of the most often used protocols in the world, such as the SEPAR guidelines for pneumothorax [4], surgery is only considered in the first event if the first episode is hypertensive pneumothorax, if there is prolonged air leak ([7 days), and if the patient is at risk as a result of practices involving changes in atmospheric pressure, among others. A disadvantage of the SILS technique is the requirement of prior training in the simulator provided by Covidien SILS (Tyco Health-Care, Norwalk, CT, USA) for the use of an instrumental angular tip. J. M. Mier (&) G. F. S. Otaola E. G. de Alba P. S. Doherty Thoracic Surgery Department, Instituto Nacional de Enfermedades Respiratorias ‘‘Ismael Cosio Villegas’’ (INER), Calzada de Tlalpan 4502. Col. Seccion XVI., Tlalpan, Mexico D.F., Mexico e-mail: jmmo50@hotmail.com