Uniportal Approach Research Articles

European questionnaire on the clinical use of video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery (VATS) has emerged as a safe and efficacious alternative approach to conventional thoracotomy for selected patients with non-small-cell lung cancer. The aim of the present study was to assess the current clinical practice of VATS among the European Society of Thoracic Surgeons (ESTS) members. A standardized questionnaire was sent to thoracic surgeons on the ESTS mailing list, with collection of data on demographics, use of multiportal or uniportal VATS, institutional experience with VATS procedures and proportion of operations performed by different approaches. Analysis was performed using SPSS statistical software. Complete questionnaire results were collected from 100 unique institutions in 31 countries, representing data on the clinical practice of 461 board-certified thoracic surgeons. Three hundred and twenty-four of the 461 (70%) surgeons claimed to perform anatomical VATS resections, with a total estimated caseload of 9519 resections per year. Two hundred and thirty-one (50%) surgeons reported to have performed lobectomies primarily through the VATS approach. The case volume was significantly correlated to the number (P = 0.019) and proportion (P = 0.001) of surgeons who performed VATS anatomical resections. Overall, 47% of the centres performing anatomical VATS resections reported some use of uniportal approach. There was no association between the number of thoracic surgeons within an institution and the likelihood of performing uniportal VATS lobectomy. Compared to previous surveys, results of the present European study suggested that there is a strong trend favouring VATS for a range of thoracic procedures in the current clinical setting. However, the use of uniportal VATS is still not yet widespread. The evolving adoption of VATS in Europe should be further assessed with regard to clinical outcomes in the form of large standardized registries.

Extended uniportal bilateral sympathectomy.

Hyperhidrosis affect 3% of the population and, despite benign nature of the disease, the individuals seek medical advice in order to improve their quality of life which can be severely compromised. The interruption of the sympathetic chain (sympathectomy) and of the nerve of Kuntz established its role as the definitive treatment of primary hyperhidrosis. In this manuscript, we present our extended uniportal technique with the aid of the video. Uniportal approach expresses all its benefit when applied for this procedure because there is no specimen to be retrieved and all the surgery is accomplished through a 1-2 cm port access.

Minimally invasive techniques in thymic surgery: a worldwide perspective.

Minimally invasive surgical techniques are important in surgical management of thymic pathologies. Traditional access techniques are being replaced with minimally invasive techniques using multiportal or uniportal approach. Adoption of minimally invasive techniques for thymic malignancies has been slow due to long term recurrence concerns. Recent studies show that minimally invasive video-assisted thoracoscopic surgery (VATS) or robotic approach to early stage thymic malignancies are associated with less intraoperative bleeding, lower rate of respiratory complications, shorter chest tube duration and shorter hospital stay. Oncologic outcomes are at least equivalent to open approach. Minimally invasive approach for benign pathologies is widely applied. There are significant variations in VATS approaches for thymus, showing a multinational interest in the issue of minimizing trauma during thymectomy. Use of robotic technology is also popular, as the retrosternal area is a narrow anatomic space to manipulate conventional instruments. The evolution of minimally invasive surgery for thymus has been possible with contribution from centers all around the world. In the current practice, various approaches are being adopted and every surgeon should prefer a technique depending on surgical preference and experience.

VATS pneumonectomy and sleeve carinal resections—full thoracoscopic and uniportal approach

Advantages of thoracoscopic pulmonary resections can’t be doubted and are confirmed by numerous studies. These procedures allow significantly reducing surgical trauma and blood loss, decreasing the length of hospital staying and less the need for anesthetics. Other benefits include early recovery, rapid rehabilitation and improvement of quality of life. Moreover, if needed, adjuvant chemotherapy might be provided earlier. Despite the high incidence rates of lung cancer in the world and the fact, which most patients present with stage II or, predominantly, stage III of the disease, there has been a decrease in the number of pneumonectomies over the past years. It is attributed to novel neoadjuvant schemes of treatment, which has recently come into play, as well as to the emphasis on organ sparing surgeries with angioplasty and bronchoplasty. However, for some patients with centrally located lung tumors or with tumor infiltrating of hilar structures or interlobar fissure, the only possible surgical procedure is radical pneumonectomy. One of the major problems in selecting patients for thoracoscopic pneumonectomy is unavailability of palpation and lack of full intraoperative revision in order to evaluate tumor spreading. Nevertheless, there is a small group of patients for whom broncho-angioplasty is not possible and who require radical lung removal often with the resection of the surrounding structures and sleeve carinal resections.

Uniportal Video-Assisted Thoracoscopic Surgery and Outcomes for Recurrent Primary Spontaneous Pneumothorax: Single-Institution Experience

Introduction: Primary spontaneous pneumothorax is relatively common condition in young adults. Uniportal video-assisted thoracoscopic surgery (uniportal VATS) has been accepted as a less invasive technique for the treatment of primary spontaneous pneumothorax. Strong evidence suggests that Uniportal VATS procedures are technically feasible and safe with excellent outcomes comparable to conventional VATS approach. Objectives: This article aims to discuss our experience with uniportal thoracoscopic approach as a valuable option in patients with recurrent spontaneous pneumothorax. Study Design: A retrospective study analysis between January 2014 and December 2016. Materials and Methods: From January 2014 to December 2016, 22 consecutive patients with unilateral recurrent spontaneous pneumothorax were to undergo uniportal video-assisted thoracic surgery (uniportal VATS). Their chronic residual postoperative pain, hospital stay and recurrence rate were analyzed. Results: Twenty-two patients with unilateral recurrent spontaneous pneumothorax were included; all received uniportal video-assisted thoracic surgery (uniportal VATS) and mechanical pleurodesis. Conclusions: We conclude that uniportal video-assisted thoracic surgery (uniportal VATS) demonstrated benefits to patients with primary spontaneous pneumothorax a safe, effective and also faster recovery, and decreased postoperative pain and short hospital stay.

Massive Posterior Mediastinal Goiter Managed by ranscervical and Right Uniportal (Single Incision) Approach

The present case is of a 55-year-old female who underwent right hemi-thyroidectomy for a benign multinodular goiter 19 years before. Computed tomography showed the presence of a large posterior mediastinal mass which extended from the neck to the level of the right main bronchus adherent to the boyden branch of the right pulmonary artery. The patient underwent thyroidectomy through cervicotomy and right uniportal anterolateral thoracotomy. The mass was dissected free and then successfully removed. The patient was discharged 12 days post-operatively. There were no signs of recurrence at 6-year follow-up.

Thoracoscopic anatomic lung resections for cancer in patients with previous cardiac surgery.

We reported the feasibility of thoracoscopic anatomical resections for lung cancer in four consecutive patients undergoing previous cardiac surgeries as coronary artery by-pass graft (CABG) using left internal mammary artery (LIMA) graft (n=1), cardiac transplantation (n=2), and mitral valve replacement (n=1). A three-port approach was used in all patients but one where an uniportal approach was adopted. Lobectomy was carried out in two patients; left upper three-segmentectomy and upper bilobectomy in the other two. All procedures were successfully performed without needing conversion. No intra-operative, post-operative morbidity and mortality were recorded. At last follow-up, all patients were alive without recurrence but one who had cerebral metastasis. Thoracoscopic lung resection after cardiac surgery is a feasible but complex procedure that should be performed in centres having a cardiac surgery team ready to operate in case of cardiac complications.

Uniportal lobectomy and segmentectomy-is it for all?

Technological advances have markedly transformed the philosophy of thoracic surgery in the current era, with notable improvements in patient outcomes with video-assisted thoracoscopic surgery (VATS). More recently, innovations in uniportal VATS approaches have been promising, although robust data on their efficacy is limited. Nonetheless, the lessons learned from experience with the 2-port and 3-port VATS lobectomy and segmentectomy can be applied to further improve the efficacy of uniportal approaches, in terms of achieving oncologic efficacy and improving patient outcomes. This perspective reviews contemporary outcomes of uniportal lobectomy and segmentectomy, highlights our institutional experience, and examines future directions and challenges pertaining to widespread adoption of this innovative technique.

Value of nonintubated thoracoscopic biopsy for mediastinal masses

Background: The development and success of the nonintubated anesthesia video-assisted thoracoscopic surgery (VATS) biopsy has progressively replaced cervical mediastinoscopy, anterior mediastinotomy, and computed tomography (CT)-guided needle biopsy in the diagnosis of mediastinal masses. In this paper we have evaluated the value of this approach comparing traditional multiportal VATS in thoracic epidural anesthesia with the more recent uniportal approach under intercostal bloc. Methods: Since October 2001 to August 2017, 213 consecutive patients underwent nonintubated biopsies of mediastinal masses. Until July 2006, the approach was multiportal in thoracic epidural anesthesia (n=68) and afterwards uniportal under intercostals bloc (n=145). Positron emission tomography (PET) was routinely performed since 2006 and allowed targeted biopsies. Results: We had no perioperative mortality. Complication rate was lower, yet not significantly, in uniportal group (17.6% vs. 15.3%). Uniportal VATS required significantly shorter in-operatory room stay, operative time and recovery room stay with lesser economical costs. Furthermore, the approach was significantly less painful at 7 days with a better patient acceptance score at one month. One-hundred and seven patients were managed under outpatient regimen. Seventeen patients had a redo VATS biopsy. Diagnostic accuracy was improved by the use of PET. Conclusions: Nonintubated VATS biopsy proved safe and reliable. Uniportal approach under intercostal bloc allowed shortening the operatory room utilization, reducing chronic postoperative pain and morbidity, permitting the majority of the operation to be accomplished in outpatient regimen thus ultimately reducing the economical costs.

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 for esophageal cancer.

Classical video-assisted thoracic surgery (VATS) approach to esophageal cancer uses four incisions. The rationale is to facilitate movement of the instruments and the esophagus and also suturing during placement of a purse-string suture for an intrathoracic anastomosis. Uniportal VATS (U-VATS) is challenge for surgeons, as you have to do an esophageal mobilization and anastomosis from a single 3-5 cm incision. The incision is placed either at the 5th or 6th intercostal space close to the posterior axillary line. Esophagus is mobilized en bloc with the subcarinal and periesophageal lymph nodes. The crucial parts are inclusion of subcarinal lymph node in the specimen, mobilization of the specimen from the left main bronchus and esophagogastric anastomosis. Esophagus is encircled with a thick penrose drain and retracted anterior and posteriorly during this dissection. Once the esophagus is completely mobilized, if an intrathoracic anastomosis is to be performed, gastric conduit is pulled inside the chest in correct orientation. A linear completely stapled side to side anastomosis is performed. A thick tissue endoscopic stapler is used for posterior and anterior wall. A single chest drain is placed and incision is closed. There are several intrathoracic anastomotic techniques. All of these techniques can be applied through a uniportal approach. Side to side completely stapled anastomosis is safe, fast and easy to perform. There is a single report on esophagectomy comparing uniportal and multiportal VATS approaches in esophageal cancer which showed comparable results in terms of duration of surgery, amount of bleeding, lymph node yield and leak rates. U-VATS for esophageal cancer is emerging as a new approach and the technique is feasible and certainly future studies will show if it is reproducible and provides a clinical advantage for the patient.

Uniportal video-assisted thoracoscopic surgery in hemothorax

The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.

Uniportal video assisted thoracic surgery: hilar dissection

In recent years, the uniportal approach has become one of the most exciting and innovative developments in minimally invasive thoracic surgery. While the debate over its supposed advantages, learning curve and complexity continues, this manuscript explores the technical aspects of performing the hilar dissection for a lobectomy via the uniportal approach. Using a step-by-step narration, surgical details and key tips and tricks are laid out for the beginner hoping to clarify basic steps of the technique.

Left upper lobectomy and pulmonary angioplasty by uniportal video-assisted thoracic surgery.

Diego Gonzalez-Rivas and his colleagues performed the first case for pulmonary major resection by the uniportal approach in 2010. In the following years, more and more expert surgeons developed the uniportal approach and even applied it to very complex cases. Many centers have showed that uniportal video-assisted thoracic surgery (VATS) lobectomy is a safe and feasible technique. The patient presented here is a complex case: The lingular segmental artery was invaded seriously by the tumor and it was difficult to divide it freely, and the pulmonary artery plasty was needed. Although this condition made the procedure some technically challenging, the case was performed successfully without any operative complications.

Uniportal video-assisted thoracic surgery for pneumothorax and blebs/bullae

The last British Society of Thoracic Surgeons guidelines of 2010 for the management of primary spontaneous pneumothorax (PSP) stated that, after the first recurrence, the treatment of PSP should be a surgical operation, like a bullectomy accompanying with a procedure for inducing pleural adhesions. Therefore, the surgical approach is considered the best treatment to minimise the risk of recurrence in patients who experienced a PSP. There is substantial evidence in the literature demonstrating that the minimally invasive approach should be preferred to the thoracotomic procedure since it can reduce the postoperative pain and it is associated with a faster recovery of the physical and working activity. The video-assisted thoracic surgery (VATS) approach has been shown to offer greater advantages about patient pain and respiratory function when compared to thoracotomic incisions. A single port or single incision or uniportal approach was developed as an alternative to the standard multi-port VATS. Uniportal technique has shown to be safe and efficient not only for pulmonary resections and biopsies but also for lobectomy. When used for PSP, the bullectomy/blebectomy and pleural abrasion/pleurectomy is performed through the single incision through which the chest drain is then inserted. In this perspective, evidence showed that the minimally invasive approach should be preferred, confirming the advantages in comparison with traditional techniques.

Subxiphoid complex uniportal video-assisted major pulmonary resections.

In recent years, the search for a less invasive and thus, less painful approach has driven technical innovation in modern thoracic surgery. In this context, subxiphoid uniportal approach has emerged as an alternative to avoid intercostal space manipulation and decrease postoperative pain and intercostal nerve chronic impairment. Subxiphoid uniportal major lung resections have been safe and effective procedures when performed by experienced surgeons even in complex cases or unexpected intraoperative situations. We present six of these surgical scenarios such as big tumors, incomplete or absent fissures, hilar calcified lymph nodes, active bleeding and massive adhesions to show the feasibility of subxiphoid approach to manage even these conditions.

Subxiphoid Uniportal Approach is it Just a Trend or the Future of VATS

Subxiphoid Uniportal Approach is it Just a Trend or the Future of VATS

Single-staged uniportal VATS in the supine position for simultaneous bilateral primary spontaneous pneumothorax

BackgroundSimultaneous bilateral primary spontaneous pneumothorax (SBPSP) is rare, but requires surgery on both sides, in patients with definite bilateral bullae to prevent life-threatening conditions. Recently, uniportal video-assisted thoracoscopic surgery (VATS) has been widely accepted as a less invasive technique for the treatment of pneumothorax. Thus, we introduced single-staged uniportal VATS technique in the supine position, for the management of two cases of SBPSP.Case presentationA 17-year-old boy presented with bilateral spontaneous pneumothorax and he underwent single-staged uniportal VATS in the supine position. Single wide draping in consecutive bilateral approaches removes the needs of changing patients’ position. Whole thoracoscopic procedure for wedge resection of bullae lesions was conducted without difficulty. The total operation time took 65 min and the patient discharged 3 days after the operation. The patient was followed for 24 months without recurrence of both sides. Another 18-year-old boy was admitted with bilateral spontaneous pneumothorax and single-staged uniportal VATS was also performed in the supine position. The total operation time took 79 min and the patient discharged on postoperative day 4. He was followed for 19 months without recurrence of both sides.ConclusionsSingle-staged uniportal VATS approach yielded satisfactory results from simplicity that not requires position change compared to conventional multi-ports VATS in the lateral position, and with better cosmetics. This technique is thought to be a feasible procedure in selective patients with SBPSP or with contralateral bullae for preventive role.

Uniportal video-assisted thoracic surgery in the diagnosis of mediastinal lymphadenopathy of unknown aetiology

Background: Recently endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been widely reported to be useful for patients with lung cancer for lymph node staging, and this tool may be the first line procedure for patients with mediastinal and hilar lymphadenopathy of unknown aetiology. However, more invasive techniques as mediastinoscopy and video-assisted thoracic surgery (VATS) are useful in well-selected patients, and surgery has a significant role in the evaluation of some areas in the mediastinum. The purpose of the current study was to investigate the clinical utility of VATS with the uni-portal approach in the diagnosis of mediastinal lymphadenopathies of unknown aetiology. Methods: Retrospective chart review of our VATS database between 2003 and 2013 (10-year experience) was performed. All mediastinal lymphadenopathies of unknown origin were included in the study and were classified and designated according to the International Staging System. Pathological diagnosis was determined in all patients and was classified into two categories: malignant lymphadenopathy and benign lymphadenopathy. Results: A total of 136 patients with mediastinal lymphadenopathy of unknown origin were identified, and the final diagnosis was available in all patients’ means of VATS surgery with uniportal technique. We no consider mediastinoscopy cases. The final diagnosis was available in all patients and was 114 malignant lymphadenopathies and 22 benign lymphadenopathies. VATS was safe (without complications) and had a sensitivity and a specificity of 100%, and it permits to study all areas of the mediastinum. Additionally, VATS surgery is accurate in the diagnosis of EBUS-TBNA negative lymphadenopathy (26 patients, 19%). Conclusions: VATS is a safe and reliable minimally invasive approach for a sampling of mediastinal and hilar lymphadenopathies, and it should be considered a second line procedure for a sampling of mediastinal tissue. However, in some areas of the mediastinum (anterior, posterior, left 5–6 lymph node stations) and in the cases where EBUS-TBNA fails, this is a winning tool for obtaining a pathological diagnosis of mediastinal disease. We also believe that for these patients are paramount a multidisciplinary approach.

Uniportal Nuss procedure for pectus excavatum, where to place the camera?-but we've always done it this way.

This study was stimulated by the increasing use of uniportal thoracoscopic surgery. If a lobectomy can be performed through one small incision why not the much simpler Nuss procedure? The Nuss procedure was performed with the use of the surgical incision for the camera. Initially the patient was positioned so that the standard site for the camera could be utilized. Once it become obvious that the uniportal approach worked the patient was positioned in the middle of the table. In all cases the uniportal approach in my hands was easy and made the operation less cumbersome. I offer this approach to simplify the operation.