Single-incision Thoracoscopic Surgery Research Articles

Sub-axillary cosmetic incision versus single-incision thoracoscopic surgery for primary spontaneous pneumothorax

BackgroundIn recent years, single-incision thoracoscopic surgery (SITS) has been increasingly applied as an optimal treatment option for primary spontaneous pneumothorax (PSP). However, most SITS techniques are used in the fourth to sixth intercostal space between the anterior axillary and mid axillary lines. To find out more concealed incisions, this study performed PSP surgery via the sub-axillary cosmetic incision (SACI) technique.MethodsA total of 128 PSP patients were subjected to video-assisted thoracoscopic surgery (VATS) between January 2017 and January 2019 at our institution. These patients were evaluated and assigned into SACI (n = 21) and SITS (n = 57) groups. Propensity score matching (PSM) was performed based on patients’ backgrounds, and the enrolled cohort was divided into 21 pairs. The incision satisfaction was assessed at 2 weeks and 6 months post-surgery.ResultsThe 21 pairs with matching baseline characteristics in the two groups did not exhibit significant differences in their backgrounds and surgical results. However, compared with the SITS group, the operation time was longer in the SACI group (p = 0.013). There were no post-operative complications in both groups. At 2 weeks and 6 months, incision satisfaction scores in the SACI group were significantly lower than those in the SITS group (p = 0.022 and p = 0.039, respectively). There were no recurrences of ipsilateral pneumothorax in both groups.ConclusionsSACI is a safe and feasible surgical method for PSP treatment. In addition, incision concealment can be used for patients with incision needs.

Application of bilateral simultaneous sequential single-incision video-assisted thoracic surgery in multiple nodules both lungs: a single-center experience of 10 cases

ObjectiveTo discuss the application of bilateral simultaneous sequential single-incision video-assisted thoracic surgery in multiple nodules in both lungs.MethodsA retrospective analysis of 10 patients in Zhengzhou People’s Hospital who underwent single-incision thoracoscopic surgery to treat multiple nodules in both lungs at the same time from September 2019 to January 2021, and analyze the perioperative indicators (general condition, smoking history, family history, follow-up time of pulmonary nodules, size, location, height and weight, pulmonary function, intraoperative blood loss, operation time, color and volume of drainage fluid, catheterization time, perioperative complications, length of stay, pathology, patient satisfaction, etc.).ResultsAll 10 patients used single-incision thoracoscopy to complete bilateral simultaneous sequential operations, aged 32 to 70 years, 8 female patients, 2 male patients, preoperative follow-up time ranging from 1 day to 2 years, a total of 23 lung nodules were removed except for the benign lesions in one nodule in the 2 patients, the other nodules were tumorous lesions (91.3%). The average total hospital stay was 10.5 days (8–14 days), and the average operation time was 194.5 min (145–292 min). The blood loss ranged from 10 to 280 ml, all patients had no serious complications during the perioperative period, and they recovered well and were discharged smoothly, and the satisfaction reached 100%.ConclusionSingle-incision bilateral simultaneous sequential thoracoscopy have certain advantages in the treatment of patients with multiple nodules in both lungs, conforms to the concept of rapid recovery, and is a feasible choice in the shared decision making of doctors and patients.

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.

Pain versus Gain: Multiport versus single-port thoracoscopic surgery for pediatric pneumothorax a case series

BackgroundThe indications for single-incision thoracoscopic surgery in children are expanding. We present outcome comparisons in single versus multi-port surgical technique for management of Primary Spontaneous Pneumothorax (PSP) in seven children. MethodsThis retrospective chart review of the outcomes from a single-surgeon's experience in thoracoscopic technique over a two-year period includes seven cases, divided into two groups: traditional multiport video assisted thoracoscopic surgery (MP-VATS) (n = 3) versus single-port VATS (SP-VATS) (n = 4). Data for patient demographics, chest tube placement, operation details, opioids usage, and postoperative course were recorded and analyzed. ResultsSeven patients had a median age of 14.88 years [range 12–17 years] with a male predominance 67% MP-VATS and 75% SP-VATS (p = 0.41). Average time to surgery: 3.6 days (p = 0.21) operating time: 1.2 hours (p = 0.09). Estimated blood loss was higher for MP-VATS 5.33 ml vs SP-VATS 2.25 ml but not statistically significant (p = 0.11). Opioids given in the post-operative period until chest tube removal were similar: MP 0.19 vs SP 0.12 mg/kg (p = 0.17). Time to chest tube removal was significantly longer at 5.54 vs 3.59 days for MP-VATS vs SP-VATS (p < 0.05). Length of stay was 10.46 vs 8.33 days for MP-VATS vs SP-VATS (p = 0.30). One SP patient had recurrent pneumothorax after chest tube removal, requiring replacement of chest tube, one MP patient required an additional surgery for contralateral PSP. ConclusionIn this small case series, outcomes were similar for MP-VATS and SP-VATS for PSP, but chest tube removal was earlier in SP. This provides a convincing basis to expand the usage for this technique.

Application of small-bore pigtail catheter to improve pleural drainage after single-incision thoracoscopic lobectomy for lung cancer.

In order to overcome the problems associated with the drainage of single-incision thoracoscopic surgery, we investigated the efficiency of applying an 8-Fr pigtail catheter in addition to the conventional 26-Fr chest tube. This prospective study includes 88 consecutive patients who underwent single-incision thoracoscopic lobectomy between July 2017 and March 2018. Patients were treated either with (smaller pigtail group) or without (larger drain group) 8-Fr pigtail catheter in addition to conventional 26-Fr chest tube. Post-operative recovery was assessed by analysing the post-operative drainage volume on the first 2 days, the duration (days) of drainage, re-intubation after 2 weeks, air leak time, length of stay, subcutaneous emphysema, pleural effusion after 2 weeks and pain score. The patients in the pigtail tube group had a significantly shorter drainage time and higher drainage volume on the first 2 days than those in the larger drain group. The percentage of patients that developed pleural effusion after 2 weeks was 4.54% in the smaller pigtail group and 25% in the larger drain group (P = 0.007). The pain score in the smaller pigtail tube group decreased significantly on the third day after surgery compared with larger drain group (P < 0.001). There were no significant differences between the two groups in the air leak time, subcutaneous emphysema, wound healing and pain score on the first day. Application of 8-Fr pigtail catheter after single-incision thoracoscopic lobectomy for primary lung cancer can accelerate the post-operative recovery of patients.

Comparative study between local anesthesia and general anesthesia in the treatment of primary spontaneous pneumothorax.

There is increasing interest in non-intubated video-assisted thoracoscopic surgery (VATS). At present, this method is used in various types of thoracic surgery. Especially, simple wedge resection via VATS is thought to be an optimal indication of non-intubated VATS. This study was performed to evaluate the usefulness of VATS bullectomy under local anesthesia by comparison with bullectomy under general anesthesia. A total of 183 cases of wedge resection under general anesthesia and 52 cases of wedge resection under local anesthesia were examined. Medical records were retrospectively reviewed to assess the feasibility, usability, and cost effectiveness of wedge resection under local anesthesia. The preoperative clinical parameters, including age, sex, and the number of pneumothorax episodes and previous operations, were used to match cases and controls. There were no significant differences between the local and general anesthesia groups in operative time (57.5±23.1 and 56.6±25.6 min, respectively; P=0.857), type of operation [single-incision thoracoscopic surgery (SITS), n=48 and n=47, respectively; multi-port-VATS (M-VATS), n=4 and n=5, respectively; P=0.730], or chest tube indwelling time (3.6±1.5 and 4.4±2.5 days, respectively; P=0.064). The mean times from arrival at the operating room (OR) to skin incision (16.4±12.3 and 46.4±17.2 min, respectively; P<0.001), and from the end of surgery to arrival at the general ward (36.0±25.6 and 58.1±20.9 min, respectively; P<0.001) were significantly shorter in the local anesthesia group than the general anesthesia group. The total cost was significantly lower in the local anesthesia group than in the general anesthesia group (4,890.6±717.1 and 5,739.1±1,154.6, respectively; P<0.001). Local anesthesia shortened the overall hospital stay by reducing the interval between admission and surgery, allowing immediate ambulation after surgery. In addition, this method reduced costs by avoiding the need for anesthesia.

Primary spontaneous pneumothorax in children and adolescents: a systematic review

Primary spontaneous pneumothorax (PSP) is common in young population. But despite its incidence, specific guidelines for pediatric patients are not available and an agreement on the optimal management of this pathology has not been reached yet. Current protocols for treatment of PSP are not up to date at genetic and pathologic advances, remaining those of 20th century. If the presence of blebs and bullae in the apex of the lung is still considered the principal determinant for PSP, the process underlying their formation is not completely clarified. Research on connective tissue pathology and on elastogenesis pathway allowed physicians to identify further predisposing factors for the onset of PSP, for that reason the belief that this disease occurs in “otherwise normal lungs” might be reviewed. For pediatric patients, a more accurate risk stratification of PSP and a specific tailored strategy are required. When inherited or acquired predisposing factors are present, children and adolescents have a higher likelihood to develop PSP than adults, and an early surgical treatment can be proposed. When surgery is needed, mini-invasive approaches are the option of choice. After the advent of videothoracoscopy, surgical techniques have been developed up to a single incision thoracoscopic surgery which allows better outcomes and can be more accepted by younger patients. The aim of this review is to summarize the last thirty years of literature on PSP in young patients, to focus the evidences which can improve the management of this disease.

Malign plevral efüzyonlarda tek port torakoskopik talk plöredez

Aim The aim of this study was to evaluate the efficacy of single-incision thoracoscopic surgery (SITS) talc pleurodesis for malignant pleural effusion.Material and Methods We examined the medical records of all consecutive patients with malignant pleural effusion who underwent single port thoracoscopic pleurodesis from 2014 to 2018 at the Health Sciences University Antalya Practice and Research Center. There were 30 males (54.5%) and 25 females (45.4%), ranging in age from 35 to 88 years (mean age: 64.0 years). Pleurodesis was achieved by insufflation of 4g of sterile asbestos-free talc; the chest tube was left in place a minimum of 3 days and was removed when fluid drainage was less than 100 ml/24 h. Patients were discharged the day after chest tube removal and a return visit was scheduled on the 30th post-operative day, for clinical evaluation and for a new chest radiograph. Pleurodesis was regarded as successful if the amount of the fluid on chest radiograph on the 30th post-operative day showed a pleural effusion occupying less than one-fourth of the pleural space.Results The main causes of malignant pleural effusion were non-small cell lung carcinoma and breast cancer. Major symptoms were dyspnea, chest pain and radiographic findings of pleural fluid. The effusion was on the right side in 40 patients (72.7%) and on the left side in 15 (27.2%). There was no intraoperative mortality. The postoperative complication rate was 10.9% (6 patients), and included fever in 1.8% (one patient) and chest pain in 9.0% (5 patients) of the patients. Duration of postoperative pleural drainage ranged between 3 and 13 days (mean: 3.36 days). The postoperative hospital stay ranged from 3 to 15 days (mean: 5.6 days). A successful pleurodesis was achieved in 34 of 55 patients (61.8%). Conclusion SITS talc pleurodesis is an effective and safe treatment for the management of malignant pleural effusion.

The “loop” technique for primary spontaneous pneumothorax: a retrospective study of 18 patients

Background: Primary spontaneous pneumothorax (PSP) is a well-known disease but with multiple different surgical approaches. The objective of our study is to present the results of an innovative minimal uniportal approach for patients with such a disease. This will be able to reduce postoperative pain simultaneously considering the cosmetic problems of otherwise ‘healthy’ patients. Methods: We retrospectively evaluated the surgical results of 18 patients who underwent single incision thoracoscopic surgery (SITS) using a loop at our institution between January 2015 and August 2016. Single access of 20 mm was done at the level of the 8th intercostal space. We used a ‘loop’ of a non-absorbable braided suture inserted through the IV intercostal space to isolate and suspend any dystrophic area to resect. In every patient, the pulmonary ligament was dissected and pleurodesis done with pleural abrasion. Results: We had no complications after SITS. The mean operative time for SITS was 55±7.36 (standard deviation) minutes. Usually, the chest tube is removed in the 2nd postoperative day, and the patient discharged the day after. There were no conversions from SITS to three-port VATS or thoracotomy. Nobody reported chronic pain and paraesthesia. No patients had an ipsilateral recurrence of pneumothorax in the 2 years after surgery. Conclusions: The operation we propose is safe and easily reproducible. Considering the small number of patients, this technique offers excellent results regarding the duration of recovery, postoperative pain and paraesthesia, without increasing the risks of complications for the patient and the costs of surgery.

CO2 during single incisional thoracoscopic bleb resection with two-lung ventilation.

CO2 insufflation could provide a better surgical field during single-incision thoracoscopic surgery (SITS) with small tidal two-lung ventilation (ST-TLV). Here we compared the surgical field and physiological effects of ST-TLV with and without CO2 during SITS. Patients underwent scheduled SITS bullectomy. Surgery under ST-TLV general anesthesia performed without CO2 (group NC) or with CO2 insufflation (group C). The surgical field was graded at thoracoscope introduction and at bulla resection as follows: good (more than half of the 1st rib visible; bleb easily grasped with the stapler), fair (less than half of the 1st rib visible; some manipulation needed to grasp the bleb with the stapler), or poor (1st rib non-visible; bleb ungraspable). Vital signs, arterial blood gas analysis (ABGA), and mechanical ventilation parameters, postoperative chest tube indwelling duration, length of hospital stays, and complications were recorded. A total of 80 patients were ultimately included. The surgical field at thoracoscope introduction was better in group C (P=0.022). However, at bleb resection, the surgical fields did not differ (P=0.172). The operation time was significantly longer in group C (P=0.019) and anesthesia recovery time was not different (P=0.369). During the CO2 insufflation, the airway pressure was higher in group C (P=0.009). Mean PaCO2 was significantly higher (P=0.012) and mean PaO2 was significantly lower (P=0.024) in group C, but both values were within the physiologically normal range. Postoperative chest tube indwelling duration and length of hospital stays were not statistically different (P=0.234 and 0.085 respectively). Postoperative complication frequencies were similar (12.5% for group NC, 10.0% for group C, P=0.723). SITS with CO2 insufflation during ST-TLV did not produce a superior surgical field except at the beginning of surgery. CO2 insufflation required more time and resulted in higher mean PaCO2 and peak airway pressure.

Comparison of survival between lung cancer patients receiving single or multiple-incision thoracoscopic surgery.

The effect of single-incision thoracoscopic surgery for lung cancer on long-term survival is unknown and no studies have investigated whether there are differences in survival between single and multiple incision approaches. We aimed to compare long-term overall survival and disease-free survival of patients who underwent single-incision thoracoscopic surgery with those who received multiple-incision thoracoscopic surgery for lung cancer. We retrospectively analyzed 532 patients with lung cancer who underwent either single-incision (n=150) or multiple-incision thoracoscopic resection (n=382) during the period January 2000 to December 2014. Patients were matched on propensity score at a 1:2 ratio to estimate the effect of treatment on long-term and disease-free survival. Overall survival and disease-free survival were assessed using the Kaplan-Meier method, the log-rank test and Cox proportional-hazards regression. Propensity matching resulted in 138 patients in the single-incision group and 276 patients in the multiple-incision group. The matched patients in the single-incision group had a significantly better 5-year overall survival than those in the multiple-incision group (P=0.027). Disease-free survival was similar between the two groups before and after matching. The number of chest wall incisions did not influence overall survival or disease-free survival. The long-term outcomes of single-incision thoracoscopic surgery are comparable to those of multiple-incision thoracoscopic surgery for lung cancer.

Pros-cons debate about the role and evolution of uniportal video-assisted thoracic surgery (VATS)

Uniportal video-assisted thoracic surgery (VATS) is the latest advancement in minimally invasive surgery, combining the advantages of triportal thoracoscopic surgery, such as less pain or paresthesia and faster recovery, with optimal cosmetic outcomes. The uniportal access was first described by Marcello Migliore and Gaetano Rocco for minor thoracic procedures like wedge resection (1,2) and nowadays, thanks to the gained experience in the past years, more complex cases are performed hence expanding the indications for single-incision thoracoscopic surgery.

Magnetic Traction System-Assisted Thoracoscopic Surgery

We described here a method of port-reduced thoracoscopic surgery by application of a magnetic traction system. We applied this technique for a 28-year-old male with spontaneous pneumothorax and a 68-year-old male with peripheral lung nodule. To reduce postoperative chest wall paresthesia related to the portal sites, new methods such as single-incision thoracoscopic surgery (SITS) have been exploited. However, this technique has a few limitations, such as reduced working space, triangulation difficulty, and instrument collision. To overcome these limitations, development of new instruments is needed. This is the first report on use of a magnetic traction system for thoracoscopic surgery.

Single-incision versus multiport video-assisted thoracoscopic surgery in the treatment of lung cancer: a systematic review and meta-analysis

Objectives: Recent studies compared single-incision thoracoscopic surgery (SITS) with more widely used conventional multiport video-assisted thoracoscopic surgery in the treatment of lung cancer. To establish the safety and feasible of SITS in the treatment of lung cancer, we conducted this systematic review and meta-analysis.Methods: Eleven studies were identified from the databases of PubMed, Cochrane Library, SpringerLink, and ScienceDirect. The randomized controlled trials (RCTs) and non-randomized studies evaluated the outcomes of SITS compared with multiport video-assisted thoracoscopic surgery in the treatment of lung cancer were included for analysis. Odds ratio (OR, used to compare dichotomous variables) and weight mean difference (WMD, used to compare continuous variables) were calculated with 95% confidence intervals (CIs) based on intention-to-treat analysis.Results: Eleven studies including 1314 patients were included for analysis. Our analysis showed that the operative time, blood loss amount, mean duration of chest tube, lymph nodes retrieved were similar between two approaches, the SITS pulmonary resection might be associated with shorter hospital stay (p = .008) and lower complication rate (p = .009) when compared with conventional multiport video-assisted thoracoscopic surgery approaches.Conclusions: In selected patients SITS is safe, feasible and may be considered an alternative to multiport VATS.

Feasibility of single-incision thoracoscopic surgery using a modified chest wall pulley for primary spontaneous pneumothorax: a propensity score matching analysis.

Recently, single-incision thoracoscopic surgery (SITS) has been recognized as a favorable treatment choice for primary spontaneous pneumothorax (PSP) compared with conventional three-port video-assisted thoracoscopic surgery (VATS). However, conventional SITS bullectomy often results in collisions with surgical devices. Therefore, we devised a method of SITS using a chest wall pulley for lung excision (PulLE) and modified PulLE (mPulLE) system, which substitutes threads to eliminate such collisions. We compared the mPulLE system with conventional procedures using propensity score matching (PSM) to adjust for patient backgrounds. Using PSM, we evaluated the surgical results of 210 PSP patients who underwent VATS, including mPulLE (n = 23) and three-port VATS (n = 102), at our institution between January 2010 and August 2016. We selected 17 mPulLE cases and 17 three-port VATS. There were no marked differences between the groups in the patient backgrounds or surgical results. However, there was a significant difference between the mPulLE cases and the three-port VATS cases in the operative time (71.7 ± 15.7 vs. 85.9 ± 25.5min, respectively, P = 0.0388) and the number of autosutures used (3.6 ± 1.2 vs. 4.5 ± 1.2, respectively, P = 0.0178). The surgical results of mPulLE in patients with PSP with multiple lesions were equivalent to those achieved with three-port VATS under the same conditions.

Learning curve of single-incision thoracoscopic surgery for primary spontaneous pneumothorax.

Single-incision thoracoscopic surgery (SITS) requires extensive time and practice to achieve satisfactory technical skills. The aim of this study was to evaluate the learning curves of SITS for primary spontaneous pneumothorax (PSP). This study included a total of 274 consecutive patients who underwent PSP surgery by a single operator between May 2011 and February 2014. During this period, SITS was applied as a routine approach. Learning curves were made by the cumulative sum (CUSUM) method using the number of cases and four surgical technique-related factors, including operation time, postoperative complication, non-SITS rate, and ipsilateral PSP recurrence. Among the 274 patients, 16 patients who were presented with a previous 3-port wound scar or inadequate chest tube site before surgery were not eligible for SITS. Hence, SITS was attempted on 258 patients and performed successfully in 251 patients. For these successful SITS patients, the mean age was 22.9±8.1years, the mean operation time was 65.6±22.2min, the mean chest tube indwelling time was 1.5±1.1days, and the mean postoperative hospital stay was 1.7±1.1days. The mean operation time decreased from 84.0 to 47.6min when a comparison was made between patients operated in the initial 6months and the last 6months of the study period. As revealed by the CUSUM technique, more than 50% of the cases experienced an operation time of <70min after the first 92 cases. After 57 cases, the postoperative complication rate was maintained at <5%. The non-SITS rate was achieved to be lower than 5% after 112 cases. The ipsilateral PSP recurrence rate was maintained at below 8% after 102 cases. Although PSP is the most applicable scenario for the beginner of SITS, at least 100 cases of experience are needed to achieve optimal technical level.

Single-incision versus conventional three-port video-assisted surgery in the treatment of pneumothorax: a systematic review and meta-analysis.

Single-incision thoracoscopic surgery (SITS) has been applied in the treatment of pneumothorax. To establish the feasibility of SITS in comparison with conventional three-port video-assisted thoracoscopic surgery (3P-VATS), we conducted this meta-analysis. Relevant studies were searched in PubMed, Cochrane Library, SpringerLink and ScienceDirect. Studies that compared the outcomes between SITS and 3P-VATS were included for analysis. Nine eligible studies with 768 participants were included. Our analysis indicates that when compared with 3P-VATS, SITS was associated with less postoperative pain (weight mean difference, WMD = -0.67, 95% confidence interval, CI = -1.11 to -0.22, P = 0.004 for postoperative pain at 24 h; WMD = -0.62, 95% CI = -1.11 to -0.12, P = 0.01 for postoperative pain at 72 h), lower paraesthesia rate (odds ratio, OR = 0.09, 95% CI = 0.04-0.21, P = 0.01) and shorter hospital stay (WMD = -0.34 days, 95% CI = -0.60 to -0.08, P = 0.01). No significant association was found in operative time, mean duration of chest tube, complications and recurrence rates. SITS was a safe and efficient procedure for the treatment of pneumothorax with less postoperative pain and faster recovery. The complication and recurrence rates were equivalent when compared with 3P-VATS.

Single-incision thoracoscopic surgery for spontaneous pneumothorax in a 14-year-old girl

Single-incision thoracoscopic surgery has become popular because of its potential to further extend the benefits of thoracoscopic surgery, such as less pain, a faster recovery time, and improved cosmesis, but the limited visualization due to crowding of instruments requires a certain amount of skill, especially in children. We herein describe a singleaccess video-assisted thoracoscopic surgery for a pediatric spontaneous pneumothorax. This procedure was useful, led to less postoperative pain and a better cosmetic appearance, and resulted in satisfactory results. Keywords : single-incision thoracoscopic surgery, spontaneous pneumothorax, video-assisted thoracoscopic surgery

Single-incision thoracoscopic right pneumonectomy with primary division of the pulmonary artery.

In recent years video-assisted thoracoscopic surgery (VATS) techniques have gained popularity also for major lung resections. Furthermore, especially in experienced VATS centers, single-incision thoracoscopic surgery is more and more adapted due to its even lesser invasiveness. Most thoracic surgeons still prefer an open approach to perform pneumonectomy, although reports of VATS and even single-incision VATS pneumonectomy are increasing. Unlike other authors we prefer to divide the pulmonary artery (PA) as one of the first steps of the procedure in order to obtain a clear field of vision on one hand and to obtain optimal control of bleeding and total blood loss on the other hand. Herein we describe our technique for single incision thoracoscopic right pneumonectomy and mediastinal lymphadenectomy without rib-spreading and with division of the PA as a first step. Furthermore we prefer to routinely cover the bronchial stump (BS) with an in situ azygos vein (AV) flap during right pneumonectomy.

Right-Side Paratracheal Lymph Node Dissection during Single-Incision Thoracoscopic Surgery Featuring Placement of a Bidirectional Retraction Suture.

In single-incision thoracoscopic surgery (SITS), multiple instruments are inserted through a single working window and at least three hands must move within the limited operative field. When lobectomy is required, SITS has not been preferred for right-side paratracheal lymph node dissection because of instrument collisions. We used our bidirectional traction suture technique to eliminate the need for an azygos vein retractor during dissection, and thereby overcame the instrument collision problem.