Uniportal Video-assisted Thoracic Surgery Approach Research Articles

Goal-Directed Fluid Therapy Using Pulse Pressure Variation in Thoracic Surgery Requiring One-Lung Ventilation: A Randomized Controlled Trial.

Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters.

Uniportal Laser-Assisted Video-Assisted Thoracoscopy (U-LA-VATS) for Lung Metastasectomy: Technical Description, Peri-Operative Results and Pertinent Literature Review.

Pulmonary metastasectomy (PM) is a well-established treatment that is able to contribute to the cure of oligometastatic cancer. Surgery should adopt the most lung-sparing approach possible to preserve pulmonary function (and, consequently, the quality of life) and to spare the lung for potential additional lung resections. In this framework, laser technology has been introduced in recent decades, but only few experiences combining laser technology with VATS approaches have been reported till now. The main focus of this manuscript is to report our institutional experience in performing lung-sparing laser-assisted PM by uniportal VATS (uniportal laser-assisted VATS: U-LA-VATS). The surgical technique and peri-operative results from our series of patients were herein presented and compared with the pertinent literature. Methods: Between March 2021 and November 2023, among 98 patients who underwent PM, a total of 24 patients (18 men (75%); 6 women (25%); mean age 61.4 years; age range 13-83 years) were treated with laser-assisted PM at our institution. Patients who underwent anatomical resection were excluded for the purpose of the analysis. The U-LA-VATS procedure adopted a modified laser-assisted lung resection technique for performing PM via VATS. Dedicated instruments are used, characterized by a long shape and a curved shape, with distal and proximal articulations. A surgical laser system (Thulium + Diodo OUTPUT 30-10 W, Quanta System S.p.a., Solbiate Olona, Italy) was used, and a 550-μm sterile optical fibre conducted through a specific thoracoscopic handpiece was introduced in the lowest part of the incision. Peri-operative results were analysed in all cohort and compared according to the surgical technique. Moreover, these results were compared with those reported in the literature. Comprehensive research of the literature was conducted on PubMed from 2000 to 2024. A review was performed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: In 12 cases (50%), thulium laser-assisted resection was performed using uniportal video-assisted thoracic surgery (VATS), and in the other cases (12, 50%), a (mini)thoracotomy access was adopted. In the thoracotomy group, the mean duration of surgery was 95 ± 57.7 min; meanwhile, it was 73.5 ± 35.5 in the uniportal VATS group. At the univariate analysis, this difference resulted to be statistically significant (p value 0.025). We did not observe intra-operative complications or remarkable malfunction of the laser system. We also did not report major complications after surgery; also the air-leak rate was 8.3% and 0% after thoracotomic and VATS procedures, respectively. Surgical margins were free from disease in all cases. Major and minor post-op complication rates were similar in both groups. The mean hospitalization after surgery was 2.9 ± 0.3 days for the uniportal VATS group and 3.7 ± 0.9 days for the thoracotomy group, this difference being statistically significant at the univariate analysis (p value = 0.015). Conclusions: U-LA-VATS is a safe and effective procedure, able to combine a parenchymal sparing exeresis with a mini-invasive approach. This procedure is associated with a shorter hospital stay compared with PM performed by a thoracotomic approach. Compared with the selected works for the review, our series is the only one describing the use of laser resection combined with a uniportal VATS approach.

Intermediate oncologic outcomes after uniportal video-assisted thoracoscopic thymectomy for early-stage thymoma.

BackgroundRecent years have seen a trend towards utilizing a video-assisted thoracic surgery (VATS) approach for treatment of thymoma. Although increasing in practice, intermediate- and long-term oncologic outcome data is lacking for the VATS approach. There is no oncologic data for the uniportal VATS approach. We sought to evaluate the feasibility and impact on patient survival of uniportal VATS thymectomy for early-stage thymoma.MethodThe clinical outcomes for 17 patients with Masaoka stage I to II thymomas treated between January of 2009 and July of 2014 at a single institution were collected retrospectively. Primary endpoint was overall survival (OS) and secondary endpoint was recurrence-free survival (RFS).ResultsTen women and seven men underwent uniportal VATS thymectomy; eleven had stage I thymoma and six had stage II thymoma. There were no conversions to open surgery. Operative mortality was zero. Mean tumor size was 3.8±1.0 centimeters, with a range of 1.9 to 6.0 centimeters. All patients underwent a R0 resection. Five-year survival was 100%, and the estimated RFS was 100%.ConclusionsOur findings suggest that uniportal VATS thymectomy for early-stage thymoma is feasible, and the intermediate-term oncologic outcomes are comparable to historic standards for open and multi-incision VATS thymectomy. However, additional follow-up is required to evaluate for long-term oncologic outcomes.

Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections.

Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

An uncommon presentation of cystic pachypleuritis successfully treated by uniportal VATS—case report

We herein report the uncommon presentation of a cystic pleuritis affecting a young woman. The patient presented chronic and continuous right posterior interscapular pain, so a chest X-ray detected an apical superior mass confirmed at the computed tomography. In particular, it was 8×6.5 centimeters, occupying the right apex with compression on the right upper lobe, also if it was difficult to determinate if it originated form the lung or from the pleura. Considering the dimension and the presence of symptoms, surgery was indicated performing an uniportal video assisted thoracic surgery (VATS) approach to investigate the nature and to provide to the resection. Intraoperatively, the mass presented a smooth hyaline surface and had a large implant on the parietal pleura, completely covering the apex, while a small tenacious region of contact with the lung parenchyma was present. So, after a small wedge resection and aspiration of the fluid content, obtaining more operative space and easier mobilization of the mass, a complete resection was possible through an uniportal access, despite the initial dimension and rigidity. The histologic exam described the presence of a chronic cystic pleuritis, un uncommon pleural disease that in this case was characterized by a single giant symptomatic pleural cyst, successfully treated using an uniportal VATS approach. We present the following case in accordance with the CARE guideline.

Climbing the slope of the learning curve in the subxiphoid uniportal video-assisted thoracic surgery approach

“I like the scientific spirit—the holding off, the being sure but not too sure, the willingness to surrender ideas when the evidence is against them: this is ultimately fine—it always keeps the way beyond open always gives life, thought, affection, the whole man, a chance to try over again after a mistake—after a wrong guess.”

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

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

Surgical simulation for safe uniportal VATS

An established trend in obtaining a radical anatomical resection through a safe minimally invasive approach has been observed in the recent years. However, since the establishment of the three or more ports video-assisted thoracic surgery (VATS), the interest in the uniportal VATS to lung lobectomy has been gaining a phenomenal and global interest from the thoracic surgeons. A specific training in the uniportal VATS approach is crucial to ensure safety and radical treatment. It should aim at giving the surgeon independence and self-confidence throughout the procedure. The learning curve for a surgical intervention, especially in VATS, whereby surgeons acquire expertise, poses important ethical and medico-legal issues since practice, training and instituting a new surgical procedure is predominantly done on patients who, often, are not totally aware or properly informed. In this field, the role of training becomes mandatory, and simulation is decisive, providing a technological “close to reality experience” and a “hands off the patient” but “hands on the procedure”. A proper training aiming at safeguarding patients but at the same time promoting a standardised, close to reality experience to all thoracic residents during their training, and to those surgeons who wish to learn important advances in technical procedures (uniportal VATS), is presently important but will be a prerequisite in the near future. Industries in the thoracic field are encouraged to develop new technological advances [3D, virtual reality (VR)] which will allow a systematic, progressive, realistic and safe training in this global leap into uniportal VATS.

Thinking on the Training of Uniportal Video-assisted Thoracic Surgery

近年来，单孔胸腔镜技术迅速发展，已成为全球外科发展方向。单孔胸腔镜外科医师的针对性，规范化、系统化培训已成为重要的课题，技术培训是保证手术安全性的必不可少的重要环节。单孔电视胸腔镜技术培训应包括：由临床大中心经验丰富的专家直接面对面的教授手术技巧，或聘请专家导师前往学员所在单位进行针对性现场指导，这是一个代表性的、不可缺少的重要环节。网络视频通常也可以作为培训的方式。目前的技术提供了很多模拟训练，诸如：体外模拟器，人工合成胸腔、肺模型，动物实验，3D和VR技术能够为学习者提供各种层面的培训需求。对于大样本量的培训中心，短期的集中培训和中长期的系统性培训目前越来越受关注。根据学员的分级评估，采用多元化的培训模式，因材施教的针对性训练，有助于提高培训效果。我科在单孔胸腔镜外科医师培训方面做了一些工作，积累了一些培训经验，我们认为这样的培训是可行且完全有必要的。

Teaching uniportal video-assisted thoracic surgery in Rome.

Uniportal video-assisted thoracic surgery (VATS) has recently gained popularity as procedure for major lung resections, and actually seems to be the future of thoracic surgery. Uniportal VATS has shown to be feasible and safe as thoracotomy when a correct and appropriate learning curve is done. However, switching from open or triportal VATS to uniportal VATS approach requires a proper training and a consequent learning curve even among experienced thoracoscopic surgeons.

Uniportal thoracoscopic decortication for pleural empyema and the role of ultrasonographic preoperative staging.

The surgical approach to chronic pleural empyema is still controversial. Video-assisted thoracic surgery (VATS) debridement and decortication has shown favourable outcomes, while the uniportal VATS (U-VATS) approach is still anecdotal. We report our experience with ultrasonographic (US) preoperative staging followed by U-VATS decortication for pleural empyema. We performed a retrospective analysis of patients who underwent surgical treatment of stage II and stage III pleural empyema from 2012 to 2015. Pre-, intra- and postoperative data were investigated to evaluate outcomes including postoperative complications and disease recurrence. Results were analysed according to preoperative US appearance of pleural space (stages A-E) and surgical approach (thoracotomy vs U-VATS). We performed 30 (47%) uniportal thoracoscopic pleural decortication and 34 (53%) open decortication for empyema in stage II (40%) or III (60%) obtaining a complete debridement and decortication in all patients. In-hospital mortality was zero and overall morbidity was 29%. U-VATS was associated with lower blood loss (118 ± 80 ml vs 247 ± 140 ml P < 0.001), lower chest tubes duration (5.6 ± 1.4 vs 10.6 ± 4.4 days P < 0.001), shorter hospital stay (6.7 ± 1.9 vs 12.2 ± 4.7 days, P < 0.001) and lower complications (10% vs 16%, P < 0.001). Elevated US patterns (D-E) are associated with thoracotomy, higher blood loss, operative time and a significant incidence of complications. Uniportal thoracoscopic decortication for pleural empyema is a safe and effective approach for selected patients based on a combination of clinical and imaging staging. US patterns well corresponded with intraoperative pleural findings and showed a prognostic value.

Why perform uniportal video-assisted thoracic surgery?-multiple considerations.

Video-assisted thoracic surgery (VATS) via a single incision for major procedures is taking the specialty by a storm over the past 5 years since its description by Gonzalez et al . (1). The development of this approach originated as a progression of the anterior multiport VATS approach, as expansion of the uniportal VATS experience for intermediate procedures (2), but also as a direct evolution from anterior limited thoracotomies. While posterior VATS approaches never really became widely performed even after more than 20 years of being described, the anterior approach alternative has finally been adopted in recent years as a valid widely offered alternative to thoracotomy (3). However, its expansion has taken the best part of 15 years. One has to wonder what are the reasons to explain the rapid adoption of the uniportal VATS approach in contrast to the slow spread of multiport VATS lobectomies.

Right pneumonectomy for carcinoid tumor extending through the intermediate bronchus and the interlobar artery.

Uniportal video-assisted thoracic surgery (VATS) is the emerging technique in the modern thoracic surgery practice in Assiut University Hospitals in Egypt we try to keep up with the cutting edge of knowledge to deliver the best available service to our patient. So we invite Dr. Diego Gonzalez-Rivas the world pioneer surgeon in uniportal VATS approach to initiate a uniportal VATS program starting with a workshop with live surgery. The workshop was attended by 84 thoracic surgeons from all across Egypt with a high motivation for adopting the technique in the everyday practice. We believe that uniportal will be the first choice approach for thoracic surgeon in Egypt in the upcoming year.

Reasons not to perform uniportal VATS lobectomy.

The uniportal video assisted thoracic surgery (VATS) approach to lung lobectomy has generated phenomenal interest in recent years. It promises to offer patients less morbidity and faster recovery, even when compared to conventional multiportal VATS. However, critics of the uniportal VATS approach may raise concerns about whether this most minimally invasive surgical approach for lung surgery may compromise safety and treatment efficacy. This debate has great potential importance not only in determining how patients are operated on, but in understanding how 'success' is gauged in major pulmonary surgery. This article explores both sides of this debate, drawing on the experience of how clinical research in multiportal VATS evolved over the years. Systematic generation of clinical evidence with progressively increasing sophistication is required to fairly evaluate the uniportal VATS approach. A review of the current literature suggests that there remain many large gaps in the evidence surrounding uniportal VATS. Hence, at the present time, the reasons voiced by critics as to why uniportal VATS should not be performed should not be lightly dismissed. Instead, it behoves surgeons on both sides of the debate to continue to generate good clinical evidence to resolve it.

Double-sleeve and carinal resections using the uniportal VATS technique: a single centre experience.

Video-assisted thoracic surgery (VATS) double-sleeve lobectomy and carinal resections are two of the most complex procedures in thoracic surgery. The uniportal approach provides an advantage for performing these procedures successfully; however, knowledge of the important technical details is required. This study describes the experience of implementing these procedures by Russian specialists. Six patients (one woman; mean age, 57.3±3.6 years) who underwent a uniportal VATS double sleeve and carinal resections were consecutively included in this study. A 5- to 6-cm incision was made at the fifth intercostal space on the middle axillary line. Double sleeve left upper lobectomy was completed in four cases. One case of the right sleeve carinal pneumonectomy and one case of the right sleeve carinal upper lobectomy were completed. The mean operation time was 280±13 minutes. There was no conversion to thoracotomy. The mean postoperative hospital stay was 10.8±0.8 days. There was no postoperative mortality. In one case of double-sleeve lobectomy, postoperative pneumonia developed. The postoperative diagnoses of the four uniportal double-sleeve cases were as follows: T2aN2M0 in one case, T3N1M0 in two cases, and T2aN0M0 in one case. The postoperative diagnoses of the two uniportal totally carinal resections were as follows: T4N0M0 and T3N0M0. This study results suggest that a uniportal VATS approach might be a feasible option for complex sleeve resections with acceptable postoperative outcomes in the advanced stages of lung cancer. To further evaluate the feasibility, safety, and efficacy of this technique, more experience would be required.

The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery.

The history of Minimally Invasive Surgery in the thorax is one of evolution, not revolution. The concept of video-assisted thoracic surgery (VATS) to greatly reduce the trauma of chest operations was born over two decades ago. Since then, it has undergone a series of step-wise modifications and improvement. The original practice of three access ports in a 'baseball diamond' pattern was modified to suit operational needs, and gradually developed into 'next generation' approaches, including Needlescopic and 2-port VATS. The logical, incremental progression has culminated in the Uniportal VATS approach which has stirred considerable interest within the field of Thoracic Surgery in recent years. This measured, evolutionary process has significant implications on how the surgeon should approach, master and realize the full potential of the Uniportal technique. This article gives a précis of the evolutionary history of minimally invasive thoracic surgery, and highlights the lessons it provides about its future.

Minimally invasive combined approach for an hourglass-shaped mass at the thoracic inlet

A variety of surgical approaches have been proposed for malignant tumors located at the thoracic inlet. Usually, local invasiveness either precludes surgery or imposes wide exposure for extended resections. The attendant morbidity may not be justified when dealing with benign lesions, which should be removed in accordance with a conservative surgical strategy. A 48-year-old man was referred for diagnosis of a bulging mass in the left supraclavicular fossa detected suddenly after moderate weight lifting. On examination, the lesion seemed cystic and was neither painful nor mobile. A chest computed tomographic scan and subsequent magnetic resonance imaging showed a 3 × 7 cm hourglass mass protruding from the left supraclavicular area into the apex of the hemithorax (Figure 1). Despite a negative preoperative workup for malignancy (including a positron emission tomographic scan study), the patient insisted on having this lesion removed. We decided to approach the lesion in a minimally invasive fashion from the neck and from the chest. Two surgical teams simultaneously performed a short left supraclavicular cervicotomy and uniportal video-assisted thoracic surgery (VATS) through which the lesion was isolated from the neurovascular structures of the thoracic inlet and removed (Figure 2). The postoperative course was uneventful, and the patient was discharged on postoperative day 2 (Figure E1). Final pathologic examination demonstrated a lipoma with benign histologic features.Figure 2Intraoperative views: a, Uniportal VATS identification and dissection of the pleural mass; b, neck dissection of the cervicothoracic lipoma (L).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure E1The patient at the 2-week follow-up visit.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In the literature, lipomas originating from the fat tissue of the pleural apex have been previously described.1Dissmann E. Intrathoracic lipoma of the pleural cupula.Fortschr Geb Rontgenstr Nuklearmed. 1950; 73: 102-104Crossref Google Scholar In addition, many different types of lesions have been identified in the supraclavicular fossa with the potential of insinuating into the chest, thereby requiring combined surgical attention for diagnosis and treatment.2Yamaguchi M. Yoshino I. Kameyama T. Osoegawa A. Tagawa T. Maehara Y. Thoracoscopic surgery combined with a supraclavicular approach for removing a cervico-mediastinal neurogenic tumor: a case report.Ann Thorac Cardiovasc Surg. 2006; 12: 194-196PubMed Google Scholar Intrathoracic lipomas can be successfully resected by traditional VATS,3Naruse H. Katayama Y. Inada K. Ikeda T. An adult case of intrathoracic chest wall type lipoma by VATS resection.Kyobu Geka. 1998; 51: 517-520PubMed Google Scholar but in most cases these lesions are well defined in their anatomic position, thus making the resection achievable through one thoracic approach. Recently, single-port (uniportal) VATS has been successfully used in the diagnosis and treatment of several intrathoracic conditions, resulting in decreased postoperative pain and paresthesia.4Jutley R.S. Khalil M.W. Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia.Eur J Cardiothorac Surg. 2005; 28: 43-46Crossref PubMed Scopus (175) Google Scholar In our case, the combined cervical and uniportal VATS approach was justified by the uncertainty of the diagnosis, given the numerous differentials suggested by the radiologist. Among them, given the recent history, the possibility of a lesion originating from the thoracic duct was considered, thus necessitating intrathoracic visualization of the lesion.5Ray J. Braithwaite D. Patel P.J. Spontaneous thoracic duct cyst.Eur Arch Otorhinolaryngol. 2003; 260: 280-282PubMed Google Scholar We anticipate that uniportal VATS could be used in other situations when optimal control of a mass in the thoracic inlet is necessary. In addition, transillumination from the chest may facilitate the dissection in the supraclavicular area. In this setting, during combined cervicothoracic procedures, the uniportal VATS approach can be used with a morbidity comparable with that of a simple chest drain incision and with the same advantage, described with traditional VATS, of rendering the identification of the anatomic structures at the thoracic inlet more reliable and the dissection more secure.