Uniportal VATS Approach Research Articles

Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach.

The present study reports the first clinical experience with subcostal uniportal VATS (suVATS) compared with the conventional lateral uniportal VATS (luVATS) approach. All patients who underwent suVATS between January 2019 and April 2020 were included. Patients who had undergone luVATS for similar indications were included as the control group. The data were prospectively and retrospectively analysed. The suVATS group included 38 patients with a mean age of 61 (30-83) years. The luVATS group included 33 patients (mean age, 69 years; range: 46-89 years). An intercostal block was performed intraoperatively in the luVATS group. Local infiltration under anaesthesia was performed around the incision in the suVATS group. The duration of the surgery was significantly longer in the suVATS group. However, the chest tube treatment and hospital stay duration were significantly shorter in the suVATS group. The routinely recorded Visual Analogue Scale scores on the first post-operative day and the day of discharge were significantly lower in the suVATS group. Subcostal uniportal VATS enables a shorter drainage treatment duration and hospital stay and significantly reduces post-operative pain. Thus, a faster patient recovery can be achieved.

The Efficacy of Continuous Serratus Anterior and Erector Spinae Plane Blocks vs Intercostal Nerve Block in Uniportal-Vats Surgery: A Propensity-Matched Prospective Trial.

To evaluate the analgesic efficacy of continuous erector spinae plane block(c-ESPB) and serratus anterior plane block(c-SAPB) versus the intercostal nerve block (ICNB) in Uniportal-VATS in terms of pain control, drug consumption, and complications. Ninety-three consecutive patients, undergone one of the three peripheral nerve blocks after Uniportal-VATS, were prospectively enrolled. A 1:1 propensity score matching was used to minimize bias. C-ESPB and c-SAPB groups had no difference in morphine request upon awakening compared to ICNB. A higher VAS-score was recorded in c-ESPB compared to ICNB in the first 12 h after surgery. A significantly lower consumption of paracetamol in II postoperative day (p.o.d.) and tramadol in I and II p.o.d. was recorded in the c-ESPB group compared to the ICNB group. A higher dynamic VAS score was recorded at 24 h and 48 h in the ICNB group compared to the c-SAPB. No difference was found in safety, VAS-score and drug consumption between c-ESPB and c-SAPB at any given time, except for a higher tramadol request in c-SAPB in II p.o.d. C-ESPB and c-SAPB appear to have the same safety and analgesic efficacy when compared between them and to ICNB in Uniportal-VATS approach. C-ESPB showed a delayed onset of analgesic effect and a lower postoperative drug consumption compared to ICNB.

Uniportal-VATS vs. open McKeown esophagectomy: Surgical and long-term oncological outcomes.

Till now there are very few reports about surgical results of Uniportal-VATS esophagectomy and no one about long-term outcomes. This study is the first comparing surgical and oncological outcomes of Uniportal-VATS with open McKeown esophagectomy, with the largest reported series and longest oncological follow-up. The prospectively collected clinical, surgical and oncological data of 75 patients, undergone McKeown esophagectomy at our Thoracic Surgery Department, from January 2012 to August 2022, were retrospectively analyzed. Nineteen patients underwent esophagectomy by thoracotomy and reconstruction according to McKeown technique while 56 by Uniportal-VATS approach. Gastric tubulization was performed totally laparoscopic or through a mini-laparatomic access and cervical anastomosis was made according to Orringer's technique. The mean operative thoracic time was similar in both accesses (102.34 ± 15.21 min in Uniportal-VATS vs. 115.56 ± 23.12 min in open, p: 0.646), with a comparable number of mediastinal nodes retrieved (Uniportal-VATS:13.40 ± 8.12 vs. open:15.00 ± 6.86, p: 0.275). No case needed conversion from VATS to open. The learning curve in Uniportal-VATS was completed after 34 cases, while the Mastery was reached after 40. Both approaches were comparable in terms of minor post-operative complications (like pneumonia, lung atelectasis, anemization, atrial fibrillation, anastomotic-leak, left vocal cord palsy, chylothorax), while the number of re-operation for major complications (bleeding or mediastinitis) was higher in open group (21.0% vs. 3.6%, p: 0.04). Both techniques were also effective in terms of surgical radicality and local recurrence but VATS approach allowed a significantly lower chest tube length (11.89 ± 9.55 vs. 25.82 ± 24.37 days, p: 0.003) and post-operative stay (15.63 ± 11.69 vs. 25.53 ± 23.33, p: 0.018). The 30-day mortality for complications related to surgery was higher in open group (p: 0.002). The 2-, 5- and 8-year survival of the whole series was 72%, 50% and 33%, respectively. Combined 2- and 5-year OS in Uniportal-VATS group was 76% and 47% vs. 62% and 62% in open group, respectively (Log-rank, p: 0.286; Breslow-Wilcoxon: p: 0.036). No difference in DFS was recorded between the two approaches (5 year-DFS in Uniportal-VATS: 86% vs. 72%, p: 0.298). At multivariate analysis, only pathological stage independently affected OS (p: 0.02), not the surgical approach (p: 0.276). Uniportal-VATS seems to be a safe, feasible and effective technique for performing McKeown esophagectomy, with equivalent surgical and long-term oncological results to standard thoracotomy, but with a faster and unharmed recovery, and a quite short learning curve.

Uniportal fully robotic-assisted sleeve resections: surgical technique and initial experience of 30 cases.

Since the first uniportal video-assisted thoracoscopic surgery (uVATS) performed in 2010, the uniportal approach has evolved up to a point where even the most complex cases can be done. This is thanks to the experience acquired over the years, the specifically designed instruments and improvements in imaging. However, in these last few years, robotic-assisted thoracoscopic surgery (RATS) has also shown progress and distinct advantages compared to the uniportal VATS approach, thanks to advanced maneuverability of the robotic arms as well as the three-dimensional (3D) view. Excellent surgical outcomes have been reported and so too, the ergonomic benefits to the surgeon. The main limitation we find of the robotic systems is that they are designed for a multiport approach, requiring between three to five incisions to be able to perform surgeries. With the aim to offer the least invasive approach, using the robotic technology we decided to adapt the Da Vinci Xi® in September 2021 to develop the uniportal pure RATS approach (uRATS) performed by a single intercostal incision, without rib spreading and using the robotic staplers. We have now reached a point where we perform all type of procedures, including the more complex sleeve resections. Sleeve lobectomy is now widely accepted as a reliable and safe procedure to allow complete resection of centrally located tumors. Although it is a technically challenging surgical technique, it offers better outcomes when compared to pneumonectomy. The intrinsic characteristics of the robot such as the 3D view and improved maneuverability of instruments make the sleeve resections easier compared to thoracoscopic techniques. As in uVATS vs. multiport VATS, the uRATS approach, due to its geometrical characteristics, requires specific instrumentation, different movements and learning curve compared to multiport RATS. In this article we describe the surgical technique and our initial uniportal pure RATS experience with bronchial, vascular sleeves and carinal resections in 30 patients.

Role of subxiphoid uniportal video-assisted thoracoscopic surgery in pulmonary metastasectomy.

Optimal management for patients with pulmonary metastasis is still debated. True survival benefit from widely practiced pulmonary metastasectomy (PM) is yet to be proved from high-quality randomized controlled trials. The ideal surgical approach for PM is also not generally agreed. VATS offers enhanced recovery and superior functional outcomes but at the expense of less detection of lung nodules and higher possibility of narrow/positive resection margins. The subxiphoid uniportal VATS (uVATS) approach is an evolving new approach with potential advantages including simultaneous access to both lung fields, less pain and faster rehabilitation. These advantages make it a favorable approach for PM, particularly in the setting of bilateral metastases. However, its use is still limited to case reports of a small number of patients. There is room for improvements in subxiphoid uVATS due to reported technical challenges and limitations. Herein, we aim to publicize a comprehensive review of literature on applications of subxiphoid uVATS in PM.

Pretreatment clamping of pulmonary artery during uniportal thoracoscopic lobectomy

BackgroundIntraoperative pulmonary artery (PA) hemorrhage is one of the leading reasons for conversion from uniportal VATS to open thoracotomy, especially for the small incision (≤3 cm) uniportal VATS performed by our department. So, We designed a technology called pretreatment clamping of the pulmonary artery, which may be helpful to solve the problem.MethodsA retrospective analysis of 19 patients who had pulmonary artery bleeding during uniportal thoracoscopic lobectomy in which one group had undergone preventive pulmonary artery clamping, the clamping group (n = 11), and one group which did not receive preventive clamping, the non-clamping group (n = 8). We compared the rates of conversion from the uniportal VATS approach to open thoracotomy or multi-incision operation, duration of pulmonary artery repair, blood loss, length of postoperative hospital stay and postoperative complications of the two groups.ResultsCompared to the non-clamping group, the clamping group had lower rates of conversion to open thoracotomy (0% vs 62.5%, p < 0.05) and lower rates of conversion to multi-incision operations (18.2% of non-clamping converted to 2-port approach vs 12.5% of clamping converted to 2-port approach and 12.5% converted to 3-port approach, p < 0.05). Duration of pulmonary artery repair was reduced in the clamping group (10.1 ± 3.2 min vs 18.3 ± 5.5 min, p < 0.05). The clamping group also had decreased blood loss (23.6 ± 11.2 ml vs 47.5 ± 14.9 ml, p<0.05). There were no significant differences in postoperative hospital stay and postoperative complications between the two groups.ConclusionPretreatment clamping of the pulmonary artery in VATS lobectomy can decrease conversion rates, decrease blood loss, shorten repairing time of the pulmonary artery, and feasibly can be applied in uniportal thoracoscopic lobectomy.

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience.

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Endometriosis Involving the Diaphragm: A Patient‐Tailored Minimally Invasive Surgical Treatment

Diaphragmatic endometriosis is a rare presentation of endometriosis and no standardized technique for surgical treatment is available so far. We aim to verify and describe feasibility, safety and post-operative outcomes of patients affected by diaphragmatic endometriosis treated with a minimally invasive video-assisted thoracic approach. We prospectively collected data of all patients we operated on at our Institution for diaphragmatic endometriosis between 2015 and 2019. We included all patients with a previous histological diagnosis of pelvic or abdominal endometriosis who have complained chronic thoracic pain or who had two or more episodes of pneumothorax with or without radiological evidence of pleural and diaphragmatic endometriosis. During the study period, we operated on 22 patients, 20 on the right side, one on the left side and one bilaterally. Indication for surgery was based on symptoms and/or radiological evidence of diaphragmatic disease. Diaphragm was resected and reconstructed according to intraoperative findings; in 11 cases, an additional mesh was used to reinforce the suture. According to our experience with VATS, we shift from an open approach to a uniportal VATS technique. Surgery for diaphragmatic endometriosis can be safely performed using a minimally invasive VATS approach, which is feasible and safe even when more extensive diaphragmatic resections are required, and it allows a lower post-operative pain compared to the open approach. Moreover, uniportal VATS approach guarantees similar outcomes with better cosmetic results.

UNIPORTAL VIDEO-ASSISTED THORACOSCOPIC APPROACH FOR PULMONARY HYDATID CYST

PURPOSE: Hydatid cyst disease affects humans through food and drink contaminated with the feces of cattle that contains echinococcus parasites. The disease is endemic in the Middle East and Eastern Europe. The parasite is usually transmitted from the gastrointestinal tract into the bloodstream, where up then to the different organs of the body (most commonly to the liver and lungs) where it grows up forming cystic sacks. Surgical excision or “opening and evacuating” the cyst (Capitonage) is usually the most effective treatment. To date, the conventional open thoracotomy approach for pulmonary hydatid cyst is still being used in the majority of the centers of thoracic surgery in the world for the belief that it is the safest way to avoid the rupture of the cyst during the operation, which may lead to serious complications such as anaphylaxis. Based on our experience in the Minimally invasive thoracic surgery, we decided in our clinic to adopt the technique of uniportal VATS and improve the technique to treat these cases. METHODS: We present our initial experience in utilizing the uniportal VATS approach for treating 24 cases of pulmonary hydatid cyst. RESULTS: Very satisfactory results, short hospital stay, no major complications or operative mortality. CONCLUSIONS: Conclusion, Surgical treatment of the pulmonary hydatid cyst is not mandatory to be the traditional way. In the hands of expert minimally invasive thoracic surgeons, Uniportal VATS can be safely utilized in these cases with excellent results. CLINICAL IMPLICATIONS: Our technique may reduce complications associated with the open thoracotomy approach.

Uniportal VATS approach for treatment of empyema: Challenges and recommendations

The uniportal VATS approach is now taking the lead in the practice of thoracic surgery and is transforming the way we operate. We describe here how to perform a uniportal VATS debridement and decortication, with a special focus on tips and tricks for getting inside an empyema pouch and identifying the optimal plane of cleavage for decortication.

Uniportal video-assisted thoracic surgery in the treatment of pleural empyema.

The efficacy of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has recently been proven. Till today, very few works evaluated the role of uniportal-VATS (U-VATS) approach in the treatment of pleural empyema even if it currently represents the most innovative and less invasive thoracoscopic approach. We report our experience with U-VATS in the treatment of pleural empyema. A retrospective bicentric analysis of 35 consecutive patients who underwent surgical treatment of stage II and stage III pleural empyema was performed, from January 2015 to May 2017. The mean age of patients was 57.26±18.29 years and 54.3% of them were males. In 85.7% of the cases, empyema was related to a complicated parapneumonic effusion; in only 5 cases it was a post-surgical consequence. All patients were treated with broad-spectrum antibiotics and subsequent target therapy for 14.62±21.76 days prior to operation and 23 patients needed the placement of a chest tube. Twenty patients (57.1%) presented with stage III, 11 patients (31.4%) stage II and 4 patients (11.4%) stage I empyema. Complete debridement and decortication were obtained in all patients through U-VATS approach and no conversion or further access was needed for any reason. No major complication was recorded. Only 2 cases of trapped lung were not responsive to surgical treatment. At a mean follow-up of 247.42±306.29 days, 33 patients (94.3%) were alive with no recurrence, 2 patients died for causes unrelated to the operation. According to our experience, we consider U-VATS as an adequate procedure in the treatment of "stages II and III" empyemas when the necessary surgical expertise has been achieved. Indeed, U-VATS permits an easier performance and complete debridement and decortication, with a very low risk for conversion and excellent postoperative outcomes in terms of less pain, fast recovery and cosmetic results.

Uniportal VATS lobectomies-masterclass in Bratislava.

On February 5-6, an event on uniportal VATS approach to pulmonary resections took place in Bratislava. It focused on developing uniportal VATS technique. The two-day event gave opportunity to discuss the topic with masters of thoracic surgery such as Prof. Hasan Batirel and Diego Gonzalez, to train basic skills on simulators developed by Dr. Tomaz Stupnik and to watch live surgery performed by Diego Gonzalez. Two patients underwent uniportal VATS lobectomy. This event was another step to advance miniinvasive major pulmonary procedures.

Uniportal VATS lymphadenectomy

Lymphadenectomy is an important part of the surgical treatment for lung malignancies. The criticism of limitations in minimally invasive techniques regarding lymphadenectomy has been shown not to be evidenced. We describe the techniques of mediastinal lymphadenectomies during the uniportal VATS (uniVATS) approach with video attachments.

Safe vascular and bronchial division techniques for VATS uniportal lung resections

VATS anatomic lung resections are becoming the standard of care for lung cancer with a long record of safety, feasibility, oncological adequacy. Following the multi-port VATS, uniportal VATS resections are becoming popular. However, uniportal VATS approach has unique challenges concerning vascular anatomy, angle of traction, stapler insertion and safe division of vessels and bronchi. In this article we are presenting a systematic description of technique for safe vascular and bronchial division for VATS uniportal anatomic resections. All operations were performed through a 3–5 cm utility incision at 5th intercostal space, using thoracoscopic and open surgical tools and endoscopic harmonic scalpel. After preparation of a vessel for division, a vascular tape was placed around the vessel and appropriate retraction for safe stapler orientation and passage was provided through intrathoracic manipulation of the vascular tape using a systemic approach. Bronchus was divided with the principle of cartilage to membranous approximation. Safe vascular and bronchial division are the most critical points for VATS lobectomy/segmentectomy operations. Uniportal VATS approach imposes additional geometric challenges for stapler orientation and placement due to further restriction of access, equipment crowding and hilar anatomy. Our technique provides practical solutions for uniportal lung resection.

Complex uniportal video-assisted thoracoscopic sleeve lobectomy during live surgery broadcasting.

The uniportal approach for major pulmonary resections began in 2010 with the first case being performed by González-Rivas and colleagues in La Coruña. Since then a number of teams around the world had being performing hundreds of cases, applying it to more advance and complex cases recently. The technique has been reported to be feasible and reliable with similar results to that obtained in early stage lung cancer lobectomies. The case presented in this article is an example of an extreme condition: very obese patient, strong adhesions, fused lower lobe to the diaphragm and enlarged inflammatory adenopathies that made the procedure very technically challenging. In addition, the surgery was performed during a live surgery event and it was broadcasted to an auditorium. However, the case was successfully completed through a uniportal VATS approach with no complications.

Operative VATS: the need for a different intrathoracic approach

I read with interest the report by Sasaki and colleagues [1] about the triangle target principle to address intrathoracic lesions by three-port VATS. I would like to congratulate the authors on having emphasized the need for a VATS approach to target lesions inside the chest not from the time-honored laterolateral view, but from a sagittal, craniocaudal perspective. This echoes the fundamental concept of the already published uniportal VATS approach [2]. Indeed, the authors themselves conclude that ‘partial resection is easy because the forceps and endoscopic stapler meet at a right angle’. In fact, the pictures they have enclosed in the manuscript are also remarkably similar to the ones contained in the reports of uniportal VATS wedge resections [2,3]. The major difference between the triangle technique and the uniportal approach is the use of three ports instead of one for similar diagnostic and therapeutic indications. In this setting, the choice of the VATS strategy can have consequences in terms of residual pain and paresthesia [4]. On the other hand, the authors claim that ‘the tumor can be palpated through the wound of the target trocar when the tumor is not visible by thoracoscopy’. This is not exactly an advantage exclusive to their principle, since the standard three-port approach can also allow for digital palpation of the lung. In addition, it is common experience to fail occasionally to detect small and more deeply located nodules by palpation at standard thoracoscopy. In this context, the real breakthrough will be efficient for preor intraoperative marking, according to a principle already followed by the authors as shown in one of the illustrations. In conclusion, it is important to assess the concurrence of opinions as to the need for a different geometric VATS approach inside the chest, which, in my opinion, can be easily accomplished through just one strategically located port.