Multiportal Video-assisted Thoracic Surgery Research Articles

Electronic symptom monitoring after lung cancer surgery: establishing a core set of patient-reported outcomes for surgical oncology care in a longitudinal cohort study.

Electronic symptom monitoring via patient-reported outcome in surgical oncology is limited owing to lengthy instruments and non-specific items in common patient-reported outcome instruments. To establish electronic symptom monitoring through a clinically relevant and fit-for-purpose core set of patient-reported outcome in patients undergoing lung cancer surgery. One qualitative (Cohort 1) and two prospective studies (Cohorts 2 and 3) were conducted between 2018 and 2023. Patients undergoing lung cancer surgery were recruited. Items of symptoms and daily functioning were generated through extensive interviews in Cohort 1 and incorporated into a smartphone-based platform to establish the electronic Perioperative Symptom Assessment for Lung surgery (ePSA-Lung). This tool was finalized and validated in Cohort 2. Patients in Cohort 3 were longitudinally monitored for the first year post-surgery using the validated ePSA-Lung. In total, 1,037 patients scheduled for lung cancer surgery were recruited. The 11-item draft PSA-Lung was generated based on qualitative interview with 39 patients and input from a Delphi study involving 42 experts. A 9-item ePSA-Lung was finalized by assessing 223 patients in the validation cohort; the results supported the instrument's understandability, reliability, sensitivity, and surgical specificity. In Cohort 3 (n=775), compliance ranged from 63.21% to 84.76% during the one-year follow-up after discharge. Coughing, shortness of breath, and disturbed sleep were the most severe symptoms after discharge. Longitudinally, patients who underwent single-port video-assisted thoracic surgery had a lower symptom burden than those who underwent multi-port video-assisted thoracic surgery or thoracotomy (all symptoms, P<0.001). The ePSA-Lung is valid, concise, and clinically applicable as it supports electronic symptom monitoring in surgical oncology care. The need for long-term extensive care was identified for patients after discharge, even in early-stage cancer with potential curative treatment.

VATS Lung Resection in Bosnia and Herzegovina

Background: Video-assisted thoracic surgery (VATS) for both minor and major thoracic procedures has become routine practice worldwide. In this study, we present our experience with multiportal and uniportal VATS (MVATS and UVATS) in Bosnia and Herzegovina (B&amp;H). MVATS and UVATS procedures were performed in two B&amp;H Clinical Centers: Tuzla and Sarajevo. The first MVATS procedure at Tuzla Clinical Center was conducted in 2004, and the first UVATS lobectomy was performed in 2019. At Sarajevo Clinical Center, the initial MVATS took place in 2005, and the first UVATS lobectomy was carried out in 2020. Methods: We retrospectively analyzed 401 VATS procedures with prospective data, collected between 06/2017 and 04/2023. The VATS technique was employed for wedge resections, partial resections, lobectomies, and other types of resections, including metastasectomy. Results: Out of the 401 patients, 242 (60.34%) were male, and 159 (39.66%) were female, with a mean age of 57.2±23 years. The procedures consisted of 231 UVATS and 170 MVATS. Lobectomy was performed in 61 (15.21%) cases, wedge resections in 216 (51.37%), partial resections in 85 (21.19%), and other types of resections in 39 (9.72%) patients. The median duration of the procedure was 210 minutes for lobectomy, and 77.5 minutes for wedge and other types of resections. Major complications, such as bronchopleural fistula in 22 (5.49%) cases, wound infections in 20 (4.99%), atelectasis in 19 (4.74%), lung infiltrations in 15 (3.74%), and bleeding in 15 (3.74%) patients, were observed. The overall mean hospital stay for all procedures was 6.45 days. Conclusion: Uniportal and multiportal VATS techniques are feasible and safe for various indications in thoracic surgery. VATS can be performed in middle-income countries such as Bosnia and Herzegovina with acceptable results, by thoracic surgeons experienced in general thoracic surgery

Transition from multiportal video-assisted thoracic surgery to uniportal video-assisted thoracic surgery… and evolution to uniportal robotic-assisted thoracic surgery?

The greatest disruptive innovation in lung cancer surgery in modern times has been the switch from open thoracotomy to video-assisted thoracic surgery (VATS). More recently, the transition from multiportal VATS (MVATS) to uniportal VATS (UVATS) has represented another mini-advance in reducing surgical access trauma. In the search for the next breakthrough in lung cancer surgery, a number of promising candidates have emerged, including screening, sublobar resections, 3D technology, enhanced peri-operative care pathways, ablative therapy and multi-modality management. However, could the way forwards be simply a further minimization of surgical access trauma, and could this be achieved by uniportal robotic surgery? Emergence of a 'winning' candidate will depend on a systematic evaluation of the evidence for the benefits and costs of each.

Single- versus multi-port video-assisted thoracic surgery for pulmonary aspergilloma: a propensity-matched study.

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.

Uniportal robotic versus thoracoscopic assisted surgery: a propensity score-matched analysis of the initial 100 cases.

Minimally invasive surgery (MIS) is becoming the standard of care for anatomic lung resections. The advantages of the uniportal approach compared to the conventional multiple incision approach, multiportal video-assisted thoracic surgery (mVATS) and multiportal robotic-assisted thoracic surgery (mRATS), have been previously described. However, no research studies comparing early outcomes between uniportal video-assisted thoracic surgery (uVATS) and uniportal robotic-assisted thoracic surgery (uRATS) have been reported. Anatomic lung resections performed by uVATS and uRATS from August 2010 to October 2022 were enrolled. Early outcomes were compared after propensity score-matched (PSM) analysis by applying a multivariable logistic regression model including gender, age, smoking habit, forced expiratory volume in the first second (FEV1), cardiovascular risk factors (CVRF), pleural adhesions and tumor size. A total of 200 patients who underwent anatomic lung resections by the same surgeon were recruited in this study, including the initial 100 uVATS patients and the initial 100 uRATS patients. After PSM analysis, each group included 68 patients. The comparison of the two groups showed no significant differences according to the TNM stage in patients with lung cancer, surgical time, intraoperative complications, conversion, number of nodal stations explored, opioid usage, prolonged air leak, length of intensive care unit (ICU) and hospitalization, reintervention and mortality. However, there were significant differences concerning the histology and type of resection (anatomic segmentectomies, the proportion of complex segmentectomies and the sleeve technique were significantly higher in the uRATS group), number of resected lymph nodes (significantly higher in the uRATS group), postoperative complications and duration of chest drain (significantly lower in the uRATS group). Judging from the short-term outcomes, our results confirm the safety, feasibility and efficacy of uRATS as a new minimally invasive technique that combines the benefits of the uniportal method and robotic systems.

Single-versus Two-port Video-assisted Thoracic Surgery in Thymoma: A Propensity-matched Study

背景与目的近年来随着临床微创技术的不断进步，胸腔镜胸腺瘤切除术经历了从三孔操作到单操作孔、单孔的发展历程。然而，单孔胸腔镜技术的可行性及安全性尚未得到普遍认可。本研究拟探讨单孔胸腔镜手术在胸腺瘤切除中的安全性与可行性，以期为临床手术方式的选择提供参考。方法回顾性分析2018年1月-2021年9月在北京同仁医院接受胸腔镜胸腺瘤切除手术治疗的197例患者的临床资料。按照手术方式将患者分为单孔胸腔镜胸腺瘤切除组(单孔组，n=42)和单操作孔胸腔镜胸腺瘤切除组(单操作孔组，n=155)。经倾向性评分匹配，单操作孔组获得与单孔组术前基线资料具有可比性的42例患者，其中单孔组男性17例、女性25例，年龄28-72(48.00±9.43)岁; 单操作孔组男性20例、女性22例，年龄30-75(50.38±9.83)岁。对比两组的临床疗效。结果两组均顺利完成手术，均无中转开胸或增加手术切口。单孔组和单操作孔组比较，胸腔引流时间和住院时间更短[(2.95±0.76) d vs (3.33±0.85) d; (4.57±0.83) d vs (5.07±1.13) d]，术后24 h及72 h视觉疼痛评分更低[(3.64±0.85)分vs (4.05±0.66)分; (2.33±0.75)分vs (3.07±0.68)分]，差异有统计学意义(P < 0.05)。单孔组、单操作孔组在手术时间[(130.00±26.23) min vs (135.24±27.03) min]、术中出血量[(69.52±22.73) mL vs (82.38±49.23) mL]等方面差异无统计学意义(P > 0.05)。结论单孔胸腔镜胸腺瘤切除术是一种安全、可行、更微创的术式，术后疼痛较多孔胸腔镜手术减轻，恢复更快。

Outcomes of Single-Incision Thoracoscopic Surgery Using the Spinal Needle Anchoring Technique for Primary Spontaneous Pneumothorax.

BackgroundAlthough classical multi-port video-assisted thoracic surgery has been widely performed, single-incision thoracoscopic surgery (SITS) is a popular surgical technique for the treatment of primary spontaneous pneumothorax (PSP). However, the inconvenient alignment of instruments and the limited field of view occasionally make surgeons convert from SITS to multi-port surgery or extend the incision. This study aimed to present an easy and safe SITS technique for PSP using a spinal needle.MethodsIn total, 139 patients underwent SITS between May 2011 and December 2017. We used a spinal needle to hook the bulla or bleb, and wedge resection was performed through a small incision. Patients’ medical records were reviewed retrospectively, and a telephone survey was conducted to investigate the recurrence rate.ResultsThe mean age of the 139 patients was 23.62±9.60 years. The mean operative time was 36.69±14.64 minutes, and multi-port conversion was not performed. The mean postoperative hospital stay was 3.00±0.78 days, and the mean indwelling chest tube duration was 1.97±0.77 days. No complications were observed. In the mean follow-up period of 86.75±23.20 months, recurrence of pneumothorax was found in 3 patients.ConclusionWe suggest that SITS for PSP with the aid of a spinal needle to replace a grasper is a safe and easy technique that only requires a small incision.

Systemic Inflammation after Uniport, Multiport, or Hybrid VATS Lobectomy for Lung Cancer.

Different video-assisted thoracic surgery (VATS) approaches can be adopted to perform lobectomy for non-small cell lung cancer. Given the hypothetical link existing between postoperative inflammation and long-term outcomes, we compared the dynamics of systemic inflammation markers after VATS lobectomy performed with uniportal access (UNIVATS), multiportal access (MVATS), or hybrid approach (minimally invasive hybrid open surgery, MIHOS). Peripheral blood-derived inflammation markers (neutrophil-to-lymphocyte [NTL] ratio, platelet-to-lymphocyte [PTL] ratio, and systemic immune-inflammation index [SII]) were measured preoperatively and until postoperative day 5 in 109 patients undergoing UNIVATS, MVATS, or MIHOS lobectomy. Differences were compared through repeated-measure analysis of variance, before and after 1:1:1 propensity score matching. Time-to-event analysis was also done by measuring time to NTL normalization, based on the reliability change index for each patient. After UNIVATS, there was a faster decrease in NTL ratio (p = 0.015) and SII (p = 0.019) compared with other approaches. MVATS exhibited more pronounced PTL rebound (p = 0.011). However, all these differences disappeared in matched analysis. After MIHOS, NTL ratio normalization took longer (mean difference: 0.7 ± 0.2 days, p = 0.047), yet MIHOS was not independently associated with slower normalization at Cox's regression analysis (p = 0.255, odds ratio: 1.6, confidence interval: 0.7-4.0). Furthermore, surgical access was not associated with cumulative postoperative morbidity, nor was it with incidence of postoperative pneumonia. In this study, different VATS approaches resulted into unsubstantial differences in postoperative systemic inflammatory response, after adjusting for confounders. The majority of patients returned back to preoperative values by postoperative day 5 independently on the adopted surgical access. Further studies are needed to elaborate whether these small differences may still be relevant to patient management.

Uniportal video-assisted thoracic surgery for major lung resection is associated with less immunochemokine disturbances than multiportal approach

Multiportal video-assisted thoracic surgery (VATS) for major lung resection causes less immunochemokine production compared to thoracotomy. Whether uniportal VATS is similarly associated with lower early postoperative circulating levels of immunochemokines compared to multiportal VATS have not been studied. Selected patients who received uniportal or multiportal VATS major lung resection were recruited. Blood samples were collected preoperatively and on postoperative days 1 and 3 for enzyme linked immunosorbent assay of serum levels of Tissue Inhibitor of Metalloproteinase (TIMP)-1, Insulin Growth Factor Binding Protein (IGFBP)-3, and Matrix Metalloproteinase (MMP)-9. A linear mixed-effects models were used to analyze the effects of uniportal VATS on the postoperative circulating chemokine levels. From March 2014 to April 2017, 68 consecutive patients consented for the prospective study and received major lung resection by either uniportal VATS (N = 29) or multiportal VATS (N = 39) were identified. Uniportal VATS major lung resection was associated with lower post-operative levels of TIMP-1 and MMP-9 compared to multiportal VATS after controlling for the effects of the corresponding baseline level and the time of follow-up measurement. No difference was observed for the level of IGFBP-3. Less immunochemokine disturbances was observed after uniportal VATS major lung resection compared to multiportal VATS.

Decortication as an Option for Empyema Thoracis.

To analyse the outcome and morbidity associated with decortication in empyema thoracis. A case series. Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018. This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases. There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths. Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.

Is uni-portal video-assisted thoracic surgery a feasible approach for the surgical treatment of bronchopulmonary sequestration?

BackgroundBronchopulmonary sequestration (BPS) is a rare congenital pulmonary disease. This study aimed to explore the role of uni-portal video-assisted thoracic surgery (VATS) in the surgical treatment of BPS.MethodsPatients who received surgical treatment for BPS in Shanghai Pulmonary Hospital between January 2012 and October 2018 were retrospectively analyzed. Perioperative characteristics, mortality and morbidity were compared between VATS group and control (open surgery) group. Subgroup analysis was further performed in the VATS group.ResultsA total of 89 patients with BPS were reviewed, including 39 males and 50 females with a mean age of 43.9 years (range, 15–71 years). The mean operation time was 142.5 min (range, 30–345 min), the mean blood loss was 168.9 mL (range, 20–1,600 mL), the mean duration of chest drainage was 4.6±1.9 days in the whole group. There were 21 patients in the uni-portal VATS group, 46 in the multi-portal VATS group and 22 in the control group. Patients in the VATS groups had significantly better outcome, shorter operation time, shorter postoperative hospital stay (POS), less blood loss and less postoperative complications (P<0.05). The rate of conversion to open surgery in the uni-portal VATS group and multi-portal VATS group was 9.1% and 8.7% respectively. Compared with multi-portal VATS group, the operation time, duration of chest drainage and POS were shorter in the uni-portal VATS group, but the incidence of postoperative complications was similar.ConclusionsUni-portal VATS is a safe, feasible and effective method for selected BPS patients.

Current role of Uniportal Video Assisted Thoracic Surgery for lung cancer treatment

This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.

Uniportal versus multiportal video-assisted thoracic surgery for lung cancer.

Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients. We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting. The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008). We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.

Uniportal VATS for non-small cell lung cancer.

The video-assisted thoracic surgery (VATS) technique has evolved from its multiport origins to even less invasive approaches grounded in its proven benefits over open surgery forthe treatment of early stage lung cancer. In this evolution process, the Uniportal VATS (UniVATS) strategy emerged. This technique is giving some evidence of benefits when compared to the multiport VATS and has been embraced by the surgical community spreading its geographical and surgical boundaries. Moreover, UniVATS has proven its feasibility for numerous and more complex procedures forlung cancer diagnosis and treatment, which are reviewed in this document as well as its current and future development.

P2.17-40 Analysis of 7 Years Experiences of Uniportal Video-Assisted Thoracic Surgery for Stage I and II Lung Cancer

Recently, video-assisted thoracic surgery (VATS) has been accepted as a feasible, safe and effective approach for the treatment of early lung cancer. With the evolution of the VATS technique, uniportal VATS for early lung cancer has been performed and its advantages has been reported including less postoperative pain, less paresthesia and favorable cosmetic results because only one intercostal space is involved. We analyzed our experiences to evaluate results of uniportal VATS in patients with early lung cancer. We analyzed retrospectively medical records of patients who underwent surgical treatments for stage I and II lung cancer at our institute between March 2011 and December 2018. There were 126 patients in multiportal group (MG) and 102 patients in uniportal group (UG). All patients underwent the lobectomy and mediastinal lymph nodes dissection. Multiport VATS was performed through 3 small incisions (2cm, 2cm and 4-5cm). Uniportal VATS was performed through only one 4-5cm sized incision (Figure 1). There was no difference between both groups in gender, age, underlying diseases, location of tumor, TNM stage, cell type and the number of dissected lymph nodes. The mean tumor size of UG was slightly smller than that of MG (2.5 vs 3.0 cm, p=0.02). The mean operation time of UG was shorter than that of MG (189 vs 214 minutes, p=0.01). The mean duration of tube drainage and hospital stay of UG was shorter than those of MG (tube drainage: 5.3 vs 6.7 days, p=0.01, hospital stay: 8.1 vs 11.1 days, p<0.01). There were 7 hospital mortalities in MG and 1 hospital mortality in UG (p=0.06). The cause of hospital mortality was ARDS in all patients. There were 4 complications (empyema, pneumothorax, chylothorax and persistent air leak) in MG and 4 complications (chylothorax, pneumothorax in 2 and pleural effusion) in UG. The 5-year disease free survival rate was 77% in MG and 90 % in UG (p=0.59). The 5-year survival rate was 81% in MG and 99% in UG. However, there was no statistically significant difference. In our study, uniportal VATS showed similar results with a smaller incision when compared to multiport VATS in the surgical treatment for stage I and II lung cancer. Uniportal VATS might be one of options in the surgery for stage I and II lung cancer.

Techniques of uniportal video-assisted thoracic surgery—esophageal and mediastinal indications

Uniportal approach for esophagus and mediastinum is gaining popularity. While a transthoracic approach is applied for esophagus frequently from the 5th or 6th intercostal space on the posterior axillary line, approach to anterior mediastinum is variable with access through right/left chest, cervical and subxiphoid regions. The results of uniportal approach for esophagus and mediastinum are comparable with multiport video-assisted thoracic surgery (VATS) and open approach in terms of bleeding, oncologic adequacy and operation times. Indications are similar with open and multiportal VATS cases, however large mediastinal tumors (>5 cm) and T3-4 esophageal cancers can be challenging in the beginning in terms of oncologic adequacy of the operations. Uniportal approach for esophagus and mediastinum is utilized more frequently and initial reports show that it is feasible and its applicability and advantages will become apparent in the coming years.

Modified marionette technique for uniportal video-assisted thoracic surgery: a case report

BackgroundThe current state of thoracoscopic technology allows less invasive surgical procedures and requires fewer ports and incisions. Totally video-assisted thoracic surgery with a single port has emerged as the least invasive thoracoscopic approach.However, uniportal video-assisted thoracic surgery brings about considerable difficulties, necessitating the development of skillful techniques as well as specific surgical devices. In such situations as dense pleural adhesion and anatomical abnormality, it may be more burdensome, necessitating the conversion to conventional multiportal video-assisted thoracic surgery or even to thoracotomy. To troubleshoot these situations, we herein propose the use of additional technique which could support to sustain the confident operative field for uniportal video-assisted thoracic surgery. This procedure also provides the same cosmetic outcomes as uniportal video-assisted thoracic surgery.Case presentationA previously healthy, 77-year-old female was referred to our hospital, with a lung adenocarcinoma measuring 28 mm in the right upper lobe. Uniportal video-assisted thoracoscopic surgery was planned to resect the tumor. During operation, we found the incomplete interlobar fissure between the upper and the middle lobe and the abnormal lobulation of the upper lobe. Therefore, the modified marionette technique was introduced to make the procedure safer and easier. This technique proposed herein consists of employing the untethered gripping forceps to retract the lung, not requiring additional traumatic trocars. The postoperative course was uneventful and the patient `was discharged in 1 week after a modified uniportal video-assisted thoracic surgery for the right upper lobectomy.ConclusionsThe modified marionette technique produced sufficient operative views to attain uniportal video-assisted thoracic surgery safely in this case, rendering operative conversion unnecessary.

Awake non-intubated pulmonary metastasectomy

Background: Pulmonary metastasectomy has been progressively considered a procedure feasible through a thoracoscopic approach under awake non-intubated anesthesia. Methods: Since 2000 we established the program named “Awake Thoracic Surgery Research” under the guidance of Prof. Tommaso Claudio Mineo. To our knowledge, this program is the first in the world to be created for this specific purpose. From the beginning until 2005 procedures were carried out in an awake patient under thoracic epidural anesthesia and triportal approach. From 2005 onwards we shifted to an intercostal blockade and sedation controlled by bispectral index analysis through an uniportal approach. Results: From 2000 to 2018 a total of 106 patients underwent lung metastasectomy: 14 with triportal and 92 with uniportal approach. Only 7 (6.6%) patients required the conversion to general anesthesia for intolerance of the procedure or technical difficulties. Median operative time was 31 [interquartile range, 23–53] minutes and a global in-operatory room stay was 51 [39–62] minutes per procedure. Multiportal video-assisted thoracic surgery (VATS) had a shorter operating time but compensated by the longer time for establishing effective thoracic epidural anesthesia. No mortality was documented. Major morbidity affected 6 patients (6.1%). Hospital stay was 3 [2–4] days. Not even in this case differences between group were evidenced. Overall survival at 3 years was 49%. No difference was correlated to the type of approach. Conclusions: Selection for awake non-intubated lung metastasectomy should include patients with peripheral oligometastases easy to palpate and small enough to be safely resected with a limited number of staple firing.

Video-assisted thoracic surgery assisted by articulated arm (AVATS): a new way towards ergonomics and optimization of surgical resources

In recent years, the video-assisted thoracic surgery (VATS), and uniportal VATS approach has become the routine approach in numerous centers. Nevertheless, uniportal VATS learning curve is a challenge even for those surgeons with experience in multiportal VATS surgery. Among the surgeons who prefer the use of the multiportal VATS approach it is noteworthy that many of them are more comfortable through several ports because they feel this approach is more ergonomic. We present our routine programme of VATS surgery assisted by articulated arm (AVATS) for major resections, as a technique that allows ergonomic surgery for both, surgeon and first assistant and cooperative surgical field when is needed.

Initial experience with uniportal video-assisted thoracic surgery esophagectomy.

Multiportal thoracoscopic approach is already a well standardized procedure for minimally invasive esophagectomy (MIE); conversely very few reports have been published about uniportal video-assisted thoracic surgery (VATS) technique till now. We present our preliminary experience with uniportal VATS esophagectomy, evaluating short-term outcomes as perioperative mortality, complications, oncological radicality, postoperative pain and cosmetic results. From December 2016 to November 2017, the prospectively collected clinical data of 12 patients, who underwent uniportal VATS esophagectomy and reconstruction with a stomach conduit, according to McKeown technique, were reviewed and outcomes evaluated. The mean age of population was 60.67±8.61 years. Ten (83.3%) patients were males. The main histological type was a squamous cell carcinoma in six patients (50%). No patient had a local recurrence. After 4.33±3.31 months 10 patients (83.3%) were alive with no evidence of disease; 2 (16.7%) patients died of other causes. Two (16.7%) patients developed an anastomotic leak (treated conservatively) and one (8.3%) patient a chylothorax (which required a surgical treatment). The mean operative time of uniportal VATS esophagectomy was 104.67±20.66 min. Mean number of thoracic nodes removed was 10.44±3.94. Post-operative hospitalization was 15.73±14.29 days (median of 9 days). The mean level of pain was 1.92±0.90 in first postoperative day with a duration of 2.25±1.54 days. Cosmetic result was 2.42±0.79 on a 3-point scale. Uniportal VATS esophagectomy seems to be a safe, feasible and effective alternative to multiportal VATS in terms of operative time, postoperative mortality, hospital stay and oncological outcomes. Less postoperative pain and better cosmetic results seem to be some advantages in favor of Uniportal VATS, however further studies with longer follow-up are claimed.