Uniportal Video-assisted Thoracic Surgery Lobectomy Research Articles

Pulmonary Lobectomy for Early-Stage Lung Cancer with Uniportal versus Three-Portal Video-Assisted Thoracic Surgery: Results from a Single-Centre Randomized Clinical Trial.

Video-assisted thoracic surgery (VATS) is a consolidated approach; however, there is no consensus on the number of ports leading to less postoperative pain. We compared early postoperative pain after uniportal and three-portal VATS lobectomy for early-stage NSCLC. In this randomized clinical trial, patients undergoing VATS lobectomy were randomly assigned to receive uniportal (U-VATS Group) or three-portal (T-VATS Group) VATS. The inclusion criteria were age ≤ 80 years and ASA < 4. The exclusion criteria were clinical T3, previous thoracic surgery, induction therapy, chest radiotherapy, connective tissue or vascular diseases, major organ failure, and analgesics or corticosteroids use. The postoperative analgesia protocol was based on NRS. Pain was measured as analgesic consumption; the secondary endpoints were intra- and postoperative complications, conversion rate, surgical time, dissected lymph nodes, hospital stay, and respiratory function. Out of 302 eligible patients, 120 were included; demographics were distributed homogeneously. The mean cumulative morphine consumption (CMC) in the U-VATS Group after 7 days was lower than in the T-VATS Group (77.4 mg vs. 90.1 mg, p = 0.003). Intraoperative variables and postoperative complications were comparable. The 30-day intercostal neuralgia rate was lower in the U-VATS Group, without reaching statistical significance. Patients undergoing U-VATS showed a lower analgesic consumption compared with the T-VATS Group; analgesic consumption was moderate in both groups.

Surgical Effectiveness of Uniportal-VATS Lobectomy Compared to Open Surgery in Early-Stage Lung Cancer.

BackgroundAlthough the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes.MethodsThe clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS).ResultsThe intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications (p: 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p: 0.440). The chest tube duration was longer in the open group (p: 0.025), with a higher post-operative pain (p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy (p: 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% (p: 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively (p: 0.917).ConclusionsUniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay.

Predictive factors for pleural drainage volume after uniportal video-assisted thoracic surgery lobectomy for non-small cell lung cancer: a single-institution retrospective study

ObjectiveTo identify the predictive factors associated with pleural drainage volume (PDV) after uniportal video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC).MethodsA total of 440 consecutive NSCLC patients who underwent uniportal VATS lobectomy were enrolled in this study between November 2016 and July 2019. Thirty-four parameters, including patients’ clinicopathological characteristics and other potential predictors were collected. Daily drainage volume was summed up as PDV. Univariate analysis and multivariate regression models were fitted to identify independent predictive factors for PDV.ResultsThe median PDV was 840 ml during the median drainage duration of 4 days. A strong correlation was observed between PDV and drainage duration (correlation coefficient = 0.936). On univariate analysis, age, forced expiratory volume in 1 s % predicted (FEV1%), left ventricular ejection fraction (LVEF), operation time, serum total protein (TP), and body mass index (BMI) showed a significant correlation with PDV (P value, < 0.001, < 0.001, 0.003, 0.008, 0.028, and 0.045, respectively). Patients with smoking history (P = 0.030) or who underwent lower lobectomy (P = 0.015) showed significantly increased PDV than never smokers or those who underwent upper or middle lobectomy, respectively. On multivariate regression analysis, older age (P< 0.001), lower FEV1% (P< 0.001), lower LVEF (P = 0.011), lower TP (P = 0.013), and lower lobectomy (P = 0.016) were independent predictors of increased PDV.ConclusionsPredictive factors of PDV can be identified. Based on these predictors, patients can be treated with tailored individualized safe chest tube management.

Uniportal versus multiportal video-assisted thoracic surgery for lung cancer.

Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients. We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting. The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008). We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.

AN UNUSUAL COMPLICATION OF PULMONARY BIOPSY: ATRAUMATIC LUNG HERNIATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Lung herniation, in which lung tissue protrudes through its bounding structures, is a rare condition which may occur as a result of trauma, thoracic operations, increased thoracic pressure, or congenital abnormalities(1). CASE PRESENTATION: A 57-year-old African American man presented to the emergency department after one day of right-sided chest pain accompanied by worsening dyspnea after a coughing episode. He described a painful pressure-like sensation adjacent to the sternum that worsened with deep inspiration and was not relieved with positioning. The patient had a history of a sarcoidosis, daily marijuana use, and a prior thoracoscopic right anterior lung wedge resection for a pulmonary biopsy 2 years prior. On physical exam the patient had a heart rate of 108 beats per minute, blood pressure of 137/98 mmHg, respiratory rate of 18, and oxygen saturation of 95% on room air. He had tenderness to palpation of the right upper quadrant of his abdomen with no palpable mass in the chest or abdomen. There was no tenderness to anterior rib palpation. Chest x-ray was unremarkable except for post-surgical changes of the right hemithorax. A chest computed tomography scan revealed a partial herniation of the right middle lobe of the lung between the right fourth and fifth ribs anteriorly. After initial assessment by thoracic surgery, the patient elected for conservative management and was discharged from the hospital. Due to increasing chest pain, he underwent successful surgical repair of the hernia six months later with subsequent resolution of his chest pain. DISCUSSION: Postoperative intercostal hernias are more common after minimally-invasive surgeries, such as video-assisted thoracoscopy (VATS), compared to major thoracic interventions(2). This increased risk has been attributed to the limited access to tissue in minimally-invasive procedures and resultant inadequate closure of the chest wall. Challenges with wound closure leading to lung hernia have been reported in the literature related to VATS with an anterior approach(3). Our case presents a patient with lung herniation likely secondary to inadequate closure of his prior mediastinoscopy incision. Additionally, his underlying sarcoidosis may have predisposed him to inadequate wound healing, and his chronic coughing from marijuana use may have incited the herniation through increased intrathoracic pressure. CONCLUSIONS: In a patient with a history of minimally invasive thoracic surgery who is complaining of parasternal pleuritic chest pain, lung herniation must be on the differential diagnosis. Increasing size, worsening pain, or incarceration of the hernia are indications for urgent surgical intervention that physicians must keep in mind when treating patients with this rare cause of chest pain. Reference #1: Weissberg D. Lung hernia - a review. Adv Clin Exp Med. 2013. Reference #2: Temes RT, Talbot WA, Green DP, Wernly JA: Herniation of the lung after video-assisted thoracic surgery. Ann Thorac Surg. 2001. Reference #3: Vasileios K. Kouritas, Robert S. George, Alessandro Brunelli, Emmanouel Kefaloyannis; Lung herniation after uniportal video-assisted thoracic surgery lobectomy presenting with subcutaneous surgical emphysema, European Journal of Cardio-Thoracic Surgery. 2016. DISCLOSURES: No relevant relationships by Dave Gupta, source=Web Response No relevant relationships by Erica Sheline, source=Web Response No relevant relationships by Manasi Tannu, source=Web Response

Corrigendum to 'Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS)' [Eur J Cardiothorac Surg 2019;56:224-9

Corrigendum to 'Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS)' [Eur J Cardiothorac Surg 2019;56:224-9

Uniportal and three-portal video-assisted thoracic surgery lobectomy: analysis of the Italian video-assisted thoracic surgery group database

This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay. This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I-II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy. Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P < 0.001). There was a statistical difference on the second and third postoperative days; odds ratio (OR) 2.28 [95% confidence interval (CI) 1.62-3.21; P < 0.001] and OR 2.58 (95% CI 1.74-3.83; P < 0.001), respectively. The uniportal-VATS group had higher operative time (P < 0.001), shorter chest drain permanence (P < 0.001) and shorter length of stay (P < 0.001). Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.

Application of uniportal video-assisted thoracic surgery (VATS) in pulmonary tumors.

At present, lung cancer resection can be done by different approaches and methods, such as traditional thoracotomy, small incision thoracotomy, thoracoscopic surgery and robot surgery. Video-assisted thoracic surgery (VATS) lung cancer resection greatly reduces the trauma of traditional thoracotomy, and has obvious advantages in terms of hospital stay, complication rate, survival time and so on (1,2). However, with the development of the minimally invasive technique, the operation method has gradually developed from 4 ports, to 3 ports, to double-port and finally, to the uniportal approach, which can further reduce the trauma of patients. Since Rocco et al. reported the experience of uniportal VATS wedge resection for the first time in 2004 (3), the indications of uniportal VATS in the diagnosis and treatment of pulmonary diseases have been continuously expanded. For the first time in 2011, Gonzalez et al. reported a uniportal VATS lobectomy. A single thoracoscopic minimally invasive operation was performed with only a small incision of about 3 cm in length. All surgical equipment, including for thoracoscopy, passed through this small hole during the operation of lung cancer (4). Subsequently, Gonzalez has reported on more difficult types of uniportal VATS lung cancer resection, such as segmental resection (5), total pneumonectomy (6), lobectomy (7), bronchial sleeve lobectomy (8), and bronchial and pulmonary double sleeve lobectomy (9). So far, the uniportal VATS has basically covered all kinds of major resection of lung cancer. The technique has the advantages of less surgical trauma, less postoperative pain, faster recovery and less surgical scarring (10). The aim of this video is to show the operative points and postoperative rehabilitation of uniportal lung cancer minimally invasive surgery (Figure 1). Open in a separate window Figure 1 The operative points and postoperative rehabilitation of right upper lobectomy with uniportal VATS is depicted in this video (11). VATS, video-assisted thoracic surgery. Available online: http://www.asvide.com/article/view/29632

Notes on the first uniportal video-assisted thoracic surgery lobectomy on June 25, 2009

20 years ago open thoracotomy was considered the standard approach for thoracic surgery. My journey in thoracic surgery started in 1999 at the University of Manitoba in Canada, where I learned to perform the full range of thoracic surgery using the open thoracotomy technique. At that time we performed multiportal VATS for pleural conditions only.

Uniportal video-assisted thoracic surgery lobectomy in a patient with carcinoid tumor located at the orifice of the right lower lobe.

We present here a 47-year old male patient who had a typical carcinoid tumor located at the orifice of right lower lobe bronchus underwent uniportal thoracoscopic lower lobectomy following bronchoscopic removal of the endobronchial tumor. Tumor was seen by bronchoscopy to protrude out from the lower lobe into the intermediary bronchus obstructing the lower lobe completely and the middle lob partially. However, the origin of the endobronchial tumor was in the distal part of the lower lobe bronchus. In this case, open surgery could be an alternative to save the middle lobe by incising the lower lobe bronchus to pull out the endobronchial tumor first during thoracotomy. The other alternative could be a thoracoscopic lower bilobectomy for achieving a curative resection. In this patient, we performed sequential approaches at the same session as; bronchoscopic removal of the endobronchial tumor first, and then uniportal VATS lower lobectomy. Frozen section pathological analyses of bronchial stump of resected right lower lobe as well as the postoperative bronchoscopic biopsy confirmed a tumor-free margin. Patient was discharged on postoperative day four after an uneventful postoperative course.

Uniportal video-assisted thoracic surgery lobectomy using a novel perfused ex vivo simulation model.

Simulation may provide a solution to acquire advanced skills in thoracic surgery, however to date there are no reports in the English literature about a perfused ex vivo model. We developed a low cost and hi fidelity model using an ex vivo in bloc heart and lung specimen from a swine. The swine was previously used in a non-thoracic experiment, so we extracted the lung and heart for this ex vivo based model to reduce animal use. The cost of the whole model is 70 USD and it can be reused many times changing the ex vivo tissue, so this model may help reduce the costs and animal use associated to this high complexity surgery.

Left upper lobectomy and systematic lymph nodes dissection in enlarged pulmonary hilar lymph nodes in primary lung cancer patient by uniportal video-assisted thoracic surgery.

Uniportal video-assisted thoracic surgery (VATS) anatomical pulmonary resection, with only one small incision for surgery instruments and camera insertion, requires higher operative skills, especially in the cases of the enlarged pulmonary hilar lymph nodes. With improved technology and increased experiences in VATS lobectomy, uniportal VATS lobectomy has been applied in major medical centers recently. A 67-year-old male patient with left upper peripheral lung cancer and enlarged hilar lymph nodes underwent unipotal VATS lobectomy and systemic mediastinal lymph node dissection. The patient recovered uneventfully.

Left upper lobectomy and systematic lymph nodes dissection in enlarged pulmonary hilar lymph nodes in primary lung cancer patient by uniportal video-assisted thoracic surgery

Uniportal video-assisted thoracic surgery (VATS) anatomical pulmonary resection, with only one small incision for surgery instruments and camera insertion, requires higher operative skills, especially in the cases of the enlarged pulmonary hilar lymph nodes. With improved technology and increased experiences in VATS lobectomy, uniportal VATS lobectomy has been applied in major medical centers recently. A 67-year-old male patient with left upper peripheral lung cancer and enlarged hilar lymph nodes underwent unipotal VATS lobectomy and systemic mediastinal lymph node dissection. The patient recovered uneventfully.

Development, Application Details, and Prospects of Uni-VATS on Lung Cancer Radical Operation under the Concept of "Precise Medical Treatment"

单孔电视胸腔镜手术（uni-portal uideo-assisted thoracic surgery, Uni-VATS）的推广，是近年微创胸外科最重大的进展之一。随着腔镜下成像设备、切割缝合器械及电分离器械的改进，单孔VATS的应用范围已从最初的肺组织活检术逐渐扩大到解剖性肺叶/段切除、全肺切除、支气管/血管袖式吻合。多中心大量报道已证实：单孔VATS行肺叶切除安全、可行，清扫纵隔淋巴结的组数及总数均不低于传统多孔VATS，在疼痛、创伤及术后恢复方面也有积极的结果。虽然暂未得到多中心、大样本的临床数据如5年生存率，但有序地逐步开展单孔VATS仍是微创胸外科未来发展的重要方向。本文将围绕单孔VATS的原理及具体操作细节，结合肺癌根治术的基本操作理念进行讨论及综述，以期为单孔VATS的有序、规范化开展提出思考和探索。

The evolution of uniportal video assisted thoracic surgery in Costa Rica.

Video-assisted thoracic surgery (VATS) has become one of the most important advances in thoracic surgery in this generation. It has evolved continuously into a less invasive approach, being uniportal VATS the last step in this evolution. Since the first uniportal VATS lobectomy was performed in La Coruña in 2010, the procedure has suffered and exponential growth that has allowed it to widespread around the world, expanding the indications from initially early stage lung cancer cases to complex advance cases nowadays. In Costa Rica, uniportal VATS started to be used for major pulmonary resection in June 2014, thanks to the tutoring from Dr. Gonzalez-Rivas. In our center, uniportal VATS is the standard approach for minimally invasive procedures, and major pulmonary resections had only been done through the single port approach. In order to evolve and progress in the experience of the procedure, and to expand the indications in which it was being performed, a "uniportal VATS master class" was held in Rafael Angel Calderón Guardia Hospital in San José, Costa Rica, from September 16 to September 18 2015. The master class was led by Dr. Diego Gonzalez-Rivas and it counted with the contribution of Dr. Li Wentao and Dr. Yang Yang, from Shanghai Pulmonary Hospital. The course attracted almost every thoracic surgeon in our country and participants also included anesthesiologists, pulmonologists, nurses and medical students. Three uniportal VATS were performed during the course, a left lower and a right upper lobectomy and a wedge resection that was the first non-intubated VATS procedure ever performed in our country.

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.

Nonintubated uniportal video-assisted thoracic surgery course-live surgery.

"Uniportal video-assisted thoracic surgery (VATS) course-live surgery" was held on 23rd of November 2015 in Lithuania, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics. This international event has attracted many thoracic surgeons, doctors anesthesiologists-reanimatologists, operative theatre nurses and other medical specialists from Lithuania, Latvia, Estonia and Poland. The special guests of the conference were thoracic surgeon Dr. Diego Gonzalez-Rivas and doctor anesthesiologist Dr. Humberto Aymerich Cano. Since the first uniportal VATS lobectomy was performed on 29th of July, 2010, this innovative minimally invasive surgical technique has been adopted in many countries of the world. The first nonintubated VATS for lobectomy was initially described in 2007, although general anesthesia with intubation and one lung ventilation was traditionally considered to be necessary for major thoracoscopic pulmonary resections. During this course, right upper and left upper uniportal VATS lobectomies were performed for nonintubated patients, diagnosed with non-small cell lung cancer. These successful examples demonstrate a minimally invasive surgical technique-uniportal VATS lobectomy for a nonintubated patient.

Uniportal video-assisted thoracic surgery lobectomy in semiprone position: primary experience of 105 cases.

Uniportal video-assisted thoracic surgery (VATS) is becoming popular, and uniportal lobectomy in semiprone position was reported in 2014. This study aimed to investigate the feasibility and safety of uniportal VATS in semiprone position. From May 28, 2014 to October 19, 2015, we attempted uniportal VATS lobectomy in semiprone position in 105 cases. Forty-five patients were male, and 60 patients were female. Average age was 57.1±10.6 years (24-76 years). Perioperative parameters were documented. There were two conversions to three-port lobectomy, one conversion to double-port lobectomy, and three conversions to thoracotomy. Among the patients who received uniportal VATS in semiprone position, mean operation duration was 137.4±47.8 minutes. Mean estimated blood loss was 60.7±102.7 mL. Mean time of drainage was 3.0±2.1 days, and postoperative length of stay averaged 4.9±2.3 days. In the cases of primary lung cancer, the mean number of nodal stations explored was 7.2±1.3, with a mean of 20.8±6.3 lymph nodes resected. As to the mediastinal lymph node specifically, a mean of 4.4±1.0 nodal stations were explored, and the number of resected mediastinal lymph nodes averaged 12.8±5.1. No perioperative death or major complication occurred. Uniportal VATS lobectomy in semiprone position is feasible and safe.

Uniportal VATS-a new era in lung cancer surgery.

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

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