Port Video-assisted Thoracic Surgery Research Articles

Short-term Outcome of Uniportal and Three Portal Video-assisted Thoracic Surgery for Patients with Non-small Cell Lung Cancer

背景与目的目前多孔胸腔镜肺部手术治疗肺部疾病的优势研究报道较多，但单孔和多孔胸腔镜（video-assisted thoracic surgery, VATS）之间的比较报道较少。本研究旨在评估单孔与三孔VATS两种手术方式对非小细胞肺癌（non-small cell lung cancer, NSCLC）患者术后近期疗效的比较。方法回顾性分析266例行单孔或三孔VATS肺癌根治术的患者，比较两组患者临床病理特征、围手术期资料和短期生活质量。结果两组患者临床病理特征无统计学差异（P > 0.05）；相较三孔组，单孔组术中出血量和术后引流量更少，术后胸管留置时间和术后住院时间更短（P < 0.05），两组患者淋巴结清扫数目和站数无统计学差异（P > 0.05）。单孔组术后疼痛得分明显低于三孔组（P < 0.05）。单孔组总并发症、肺部并发症发生率低于三孔组，无统计学意义（P > 0.05）。结论单孔VATS作为一种更加微创的手术，治疗可切除NSCLC安全有效，能够达到甚至优于三孔VATS手术效果。

A prospective comparative study examing the impact of uniportal and three portal video-assisted thoracic surgery on short-term quality of life in lung cancer

Objective: To evaluate the effect of the postoperative short-term quality of life between uniportal and three portal video-assisted thoracic surgery for radical lung cancer resection. Methods: The perioperative data and short-term quality of life of 120 patients received uniportal and three portal video-assisted thoracic surgery for radical lung cancer resection were analyzed from September to November 2017 at Department of Thoracic Surgery, the First Affiliated Hospital of University of Science and Technology of China. There were 64 male and 56 female patients aging of (62±10) years (ranging from 28 to 82 years). There were 60 cases received uniportal (uniportal group) and 60 cases received three portal video-assisted thoracic surgery (three-portal group). Quality of life by measurement of functional and symptom scales was assessed before surgery at baseline, and 1, 2, 4, and 8 weeks after the operation. The t test, χ(2) test, Fisher exact test and Wilcoxon rank-sum test were used to compare the date between the 2 groups. Repeated measurement variance was used for comparison of the quality of life at different time points. Results: There were no statistically significant differences in the clinicopathological features of the two groups (P>0.05). Intraoperative bleeding volume ((92±85) ml vs. (131±91) ml, t=2.387, P=0.019), postoperative catheter time ((4.4±3.1) days vs. (6.0±3.9) days, t=2.401, P=0.018), and postoperative hospitalization time ((6.2±4.0) days vs. (8.3±4.6) days, t=2.626, P=0.010) in the patients with uniportal group were less than that in three-portal group. Preoperative functional areas, symptom areas and overall health scores were similar in the two group. The functional areas such as physical function, role function, emotional function and social function and overall health status of uniportal group were significantly higher than those of three-portal group in postoperative time, while the fatigue and pain of uniportal group were significantly lower than that of three-portal group. Conclusions: Uniportal video-assisted thoracic surgery can achieve the same safety and radical of three-portal video-assisted thoracic surgery. It has advantages in intraoperative bleeding volume, postoperative time after operation, hospitalization time and postoperative life quality.

A glance at the history of uniportal video-assisted thoracic surgery.

In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.

Uniportal video assisted thoracic surgery with 2 cm skin incision for right middle lobectomy with systematic lymphadenectomy

Today, video-assisted thoracic surgery (VATS) was very popular and more and more common, which could be carried out at all levels of medical centers, most of which used multiple-ports VATS techniques. However, uniportal VATS was more difficult technique compared with multiple-ports VATS, and was not yet completely universal. Uniportal port VATS with 2 cm incision was more difficult surgery, and asked the surgeon to master more surgical techniques and good collaborations with each other, however, which not only could reduce the postoperative pain and skin numbness but supply cosmetology and psychological comfort for patients. To reduce unnecessary damage to patients, we minimized the incision to 2 cm. Therefore, we called it precise uniportal port VATS technique in our surgical center and introduced it here.

Minimally invasive surgical procedures for thymic disease in Asia.

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.

VATS surgery for anatomical lung resection: a different approach for every surgeon

Video assisted thoracic surgery (VATS) is becoming the standard of practice in the surgical treatment of lung cancer (1). French et al . made an important contribution having reported an interesting experience of transition from multiple ports to single port VATS for anatomic pulmonary resection (2), and they conclude that patient safety and oncologic quality are preserved during the transition period.

Transition from multiple-port to single-port video-assisted thoracic surgery pulmonary lobectomy: a technical evolution?

Minor and major anatomic pulmonary resections performed by a video-assisted thoracoscopic approach have been proved to be safe and feasible as demonstrated from the first multi portal video-assisted thoracic surgery (VATS) experiences published in early 1990s.

VATS lobectomy, a standardised approach?

The article by French and colleagues (1) published in Annals of Cardiothoracic Surgery has the merit of being the first published article on the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) in minimally invasive anatomic pulmonary resections. The authors have carefully designed and conducted a comparative study to evaluate the safety and feasibility of this transition and to assess its impact on intraoperative and early postoperative outcomes. They add to the existing literature a series of 50 consecutive S-VATS anatomical lung resections which were compared to an equal, historical and prospective cohort of multiple port VATS cases; all of them were performed at the same institution and by the same surgeon. Its main clinical message is that the transition from multiple port VATS to S-VATS lung resection is safe, efficient and with good surgical quality. However they failed in their attempt to find differences in perioperative outcomes between approaches, specifically in patient reported pain in favor of S-VATS.

Preface to the book This is life: the journey of uniportal VATS

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.

Single port video-assisted thoracoscopic thymectomy.

Over the past decade, video-assisted thoracic surgery (VATS) has started to replace median sternotomy for the resection of non-invasive anterior mediastinal masses, including thymoma. In fact, many studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for non-invasive thymomas as long as en bloc resection of the tumour is achieved. Classically three ports are used, but the current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paraesthesia, and length of hospitalization. Uniportal VATS thymectomy for non-invasive mediastinal tumour resection is proven to be a safe and reliable method. In this paper we describe and illustrate our technique for single port VATS thymectomy.

Transition from multiple port to single port video-assisted thoracoscopic anatomic pulmonary resection: early experience and comparison of perioperative outcomes.

Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches. Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery. Over 12 months, 50 S-VATS procedures were completed by one surgeon and compared to an equal number of VATS patients. The groups were similar in age, gender, BMI, comorbidity, tumor size and pulmonary function. There was no statistically significant difference in operative time. All tumors were completely resected (R0) and the median number of lymph nodes evaluated pathologically was equivalent {S-VATS=7 [4-10]; VATS=7 [4-10]; P=0.92}. There was no significant difference in conversion rate {S-VATS=2 (4%); VATS=1 (2%); P=0.56}. The median length of stay was similar in both groups {S-VATS=4 [3-7]; VATS=4 [3-7]; P=0.99}. There was no mortality and no significant difference in the rate of major complications {S-VATS=10/50 [20%]; VATS=5/50 [10%]; P=0.26}. There was no difference in patient reported pain as measured by a visual analog scale at 24 hours {S-VATS=4 [2-5]; VATS=4 [3-5]; P=0.63}. Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required. Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Single port VATS: recent developments in Asia.

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.

The management of doornail lymph node in lobectomy.

The management of heavily adhesion caused by enlarged or calcified lymph nodes is long been one of the most common difficulties in lobectomy. Some of the lymph nodes, known as "the doornail lymph node", develop such massive adhesions that it significantly elevated the risk of uncontrollable bleeding and consequent conversion. We performed a triple portal video-assisted thoracic surgery procedure. Lymph nodes were managed with coagulator, aspirator, scissors and suture. Arteries, veins and bronchus were ligated with stapler. One case of a 74-year-old female patient with multiple doornail lymph nodes was presented. An optimal technique to manage these lymph nodes was utilized: first, dissect the sheath of the blood vessel to find a bypass, second, remove the calcified core of the lymph node, and last, suture through the lymph node to ligate the adjacent artery. The surgery was successfully performed without complication. The sequential technique of sheath dissection, core removal and suture ligation might be an optimal procedure in the management of doornail lymph node.

Uniportal VATS-a new era in lung cancer surgery.

It is perhaps surprising that this quotation comes from a gentleman of tradition and conservatism. However, even one of the greatest prime ministers of Great Britain recognized that we live in a constantly evolving world and adaptation is the key to survival. In surgery for lung cancer, we are witnessing a significant revolutionary change in approach that has not been witnessed since the 1990’s when major lung resection became possible through minimally invasive “key-hole” surgery in the form of video-assisted thoracic surgery (VATS) instead of through a large open thoracotomy. In 2011, as we recognized the 20 th anniversary of VATS lobectomy (1), another promising major advance in lung surgery, uniportal (single port) VATS lobectomy, was developed that has subsequently been more rapidly adopted than its parent procedure (2,3).

Uniportal VATS in Asia.

The history of uniportal Video-assisted thoracic surgery (VATS) stretches back almost a decade with the treatment of simple thoracic conditions. As the technique matures with increasing ability to tackle the full spectrum of thoracic surgical diseases, most notably major lung resections for lung tumours, the spread of uniportal VATS across the globe has been phenomenal. VATS centres in Asia are now performing uniportal VATS, and developing their individual styles and techniques with great successes. The enthusiasm from surgeons, demand from patients, as well as the dynamism and diversity of uniportal VATS in the region have helped fuel this excitement and change. The 1st Asian Single Port VATS Symposium in 2013 heralded the beginning of academic exchange between uniportal VATS centres in Asia and experts from around the world. Wetlabs in the region will provide further training for thoracic surgeons interested in super-specializing in uniportal VATS. The future of this approach will hinge on good regional collaboration, research and training.

Ten-Year Experience on 644 Patients Undergoing Single-Port (Uniportal) Video-Assisted Thoracoscopic Surgery

Uniportal video-assisted thoracic surgery (VATS) technique has been described both for diagnostic and therapeutic indications. Outcomes after uniportal VATS have never been reported in large series. Between January 2000 and December 2010, 644 uniportal VATS procedures (334 male and 310 female patients; median age, 55.5 years; range, 16 to 85) were performed by a single surgeon. This figure represents 27.7% of all the thoracic surgical procedures in the study period (2,369). Of the 644 uniportal VATS, 329 (51.1%) were diagnostic procedures for pleural conditions. Of the remaining 315 uniportal VATS procedures, 14 (2.2%) were performed for pre-thoracotomy exploration for lung cancer, and 115 (17.8%) for miscellaneous conditions including diagnosis of mediastinal masses. In addition, 186 nonanatomic wedge resections (28.9% of the total uniportal VATS procedures) were performed for pulmonary conditions; of these, 146 were done for pulmonary nodules. Median operative time was 18 and 22 minutes for uniportal VATS for diagnostic non-pulmonary indications and for wedge resections, respectively. Out of 644 patients, conversion to either 2 or 3 port VATS or minithoracotomy was necessary in 3.7% of the patients, often due to incomplete lung collapse (92%). Inclusive of the day of insertion, the chest drain was removed after a median of 4.3 (range, 2 to 20) and 2.4 days (range, 0 to 6) after uniportal VATS for pleural effusions and uniportal VATS lung wedge resections, respectively. Mortality and major morbidity after uniportal VATS was 0.6% and 2.8%, respectively. All deaths reported after uniportal VATS were for pleural effusions. Inclusive of the operative day, median hospitalization after surgery for uniportal VATS for pleural effusions and for wedge resections were 5.3 and 3.4 days, respectively. In our experience, uniportal VATS was performed in one third of our surgical candidates with limited operative time, a very low conversion rate to conventional VATS or minithoracotomy, a very low morbidity and mortality, and, short hospitalization. Uniportal VATS is an underappreciated procedure that can be reliably used in the diagnostic pathways of several intrathoracic conditions and to resect small pulmonary nodules with either diagnostic or therapeutic purposes. As such, uniportal VATS represents a consolidated addition to the surgical armamentarium.

Bilateral staged uniportal VATS for synchronous lung cancers

We report a case of bilateral staged uniportal video-assisted thoracic surgery (VATS) pulmonary resections for synchronous early stage squamous cell carcinoma in a patient with limited respiratory reserve. Wide wedge resections and lymph nodes sampling were performed. Postoperative respiratory function and pain scores were unaffected by the bilateral operations. Uniportal VATS proved to be a feasible alternative to more traditional procedures (three portal VATS or minithoracotomy) in case lesser resections are required for compromised respiratory function and may contribute to increase operability in high-risk patients.