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Hybrid operating room with capabilities for performing image-guided video-assisted thoracic surgery. Ground-glass opacity in the right lower lobe located by real-time on-table DynaCT, with a frozen section showing adenocarcinoma, followed by image-guided single-port video-assisted thoracic lobectomy.
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Single-port video-assisted thoracic surgery (VATS) has slowly established itself as an alternate surgical approach for the treatment of an increasingly wide range of thoracic conditions. The potential benefits of fewer surgical incisions, better cosmesis, and less postoperative pain and paraesthesia have led to the technique's popularity worldwide....
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Over the last few years, there has been a significant rise in designing small, agile and flexible medical systems that can navigate through natural orifices. In the case of endoscopic surgery, existing systems vary significantly from each other which raises the question of the existence of a general design that can do it all. In this context, this...
Citations
... Despite improving surgical techniques to overcome these hurdles, there has been slow progress in bringing about more specialized equipment catered for the uniportal approach; rather, the majority of us have 'settled' with the instruments of the multiport era. Advancement of articulating, flexible VATS instruments like FlexDex (FlexDexSurgical, Brighton, Michigan, USA) and ArtiSential (LIVSMED Inc., Seongnam, Republic of Korea) have already been introduced to the market (1,2), and the widespread adoption of this equipment may facilitate the uniportal approach, particularly in more complex procedures, by increasing the maneuverability within a single, small incision. Development of more advanced multi-instrument equipment is also useful to increase the economy of motion throughout the procedure i.e., having different energy devices or graspers that can be switched around, along with suction capabilities. ...
... In addition, recent advancements in video-assisted thoracoscopic surgery (VATS), robot-assisted thoracic surgery (RATS) (5,6), and uniport VATS (7,8) have popularized these methods as alternatives to conventional multiport VATS. Compared to thoracotomy, VATS results in a smaller wound and is less invasive, making it safer than open thoracotomy for older adults and high-risk patients (9). ...
Background:
Palpation of tumors during thoracoscopic surgery remains difficult, and identification of deep-seated tumors may be impossible. This preclinical study investigated the usefulness of a novel indocyanine green (ICG) fluorescence spectroscopy system for tumor localization.
Methods:
ICG was diluted to 5.0×10-2 mg/mL in fetal bovine serum (FBS) and mixed with silicone resin to prepare pseudo-tumors. Sponges of different densities and a porcine lung were placed on top of the pseudo-tumors, which were examined using a novel fluorescence spectroscopy system and a near-infrared (NIR) camera. Spectra were measured for different sponge and lung thicknesses, and the lung spectra were measured during both inflation and deflation.
Results:
The fluorescence spectroscopy system was able to identify tumors at depths ≥15 mm, while the NIR system was not. The spectroscopy system also detected tumors at greater depths when the density of the intervening material was lower. Depending on the density and thickness of the intervening material, the system could detect spectra as deep as 40 mm for sponges and 30 mm for lungs.
Conclusions:
This new fluorescence spectroscopy system can be used to identify lung tumors up to a depth of 30 mm in experiments using pseudo-tumors and a porcine lung, which may aid in tumor identification during thoracoscopic surgery.
... Compared to conventional VATS, the use of single-port VATS is increasing. 2,3 Additionally, with the increase in technology advancements and innovations, robotic-assisted thoracic surgery (RATS) has been performed as an alternative to VATS in lung cancer surgery. [4][5][6] Multiple methods have been developed with VATS to overcome the limitations caused by digital palpation of the lung parenchyma to achieve accurate and efficient pulmonary nodule resection. ...
Background
When early‐stage lung cancer is diagnosed, the recommended treatment is anatomical resection using video‐assisted thoracoscopic surgery (VATS) or robotic lobectomy. However, nonanatomical resection, known as wedge resection (WR), which is performed to diagnose pulmonary nodules, can be problematic for clinicians performing VATS or robotic‐assisted thoracic surgery (RATS). The purpose of this study was to evaluate the safety and effectiveness of VATS WR using multiplanar computed tomography reconstruction (CT MPR)‐fluoroscopy after CT guided microcoil localization to achieve complete pulmonary nodule resection.
Methods
Between January 2016 to December 2020, the medical records of patients who underwent CT‐guided microcoil localization for suspicious malignant pulmonary nodules and VATS WR with CT MPR and intraoperative fluoroscopy were retrospectively reviewed.
Results
All 130 patients successfully underwent CT‐guided localization. The success rate of VATS WR with CT MPR‐intraoperative fluoroscopy was 98.5%. Mean operation time was 58 min (range 50–84 min). The postoperative complication rate was 3.1%, and no major postoperative complications were reported. The mean postoperative length of hospital stay was 4.7 days (range 4–8 days).
Conclusions
VATS WR using CT MPR‐fluoroscopy after CT guided microcoil localization is a safe and highly effective approach for complete pulmonary nodule resection. However, even in uniport VATS or recently performed robotic surgery, localization and resection of nonvisible, nonpalpable pulmonary nodules is a challenging problem. Consequently, satisfactory outcomes can be expected if this technique is used for suspicious malignant pulmonary nodule resection.
... Since first introduced, the benefits of video-assisted thoracoscopic surgery (VATS) have been clearly demonstrated; as a result, VATS has become the gold-standard treatment for primary spontaneous pneumothorax (PSP), as it is a quick, safe, and effective procedure, with comparable recurrence to open thoracotomy [1]. Due to improvements in surgical technique and equipment, single-port VATS (s-VATS) is emerging as an alternative approach to conventional three-port VATS (t-VATS) [2][3][4]. PSP is not a critical disease, but may become problematic due to recurrence. With the s-VATS approach, since all the instruments are manipulated through just one small hole, limitations in the visual field and surgical procedure are inevitable [5]. ...
Background
The benefits of video-assisted thoracoscopic surgery (VATS) have been demonstrated over the past decades; as a result, VATS has become the gold-standard treatment for primary spontaneous pneumothorax (PSP). Due to improvements in surgical technique and equipment, single-port VATS (s-VATS) is emerging as an alternative approach to conventional three-port VATS (t-VATS). The aim of this study was to evaluate s-VATS as a treatment for PSP by comparing operative outcomes and recurrence rates for s-VATS versus t-VATS.
Methods
Between March 2013 and December 2015, VATS for PSP was performed in 146 patients in Kyungpook National University Hospital. We retrospectively reviewed the medical records of these patients.
Results
The mean follow-up duration was 13.4±6.5 months in the s-VATS group and 28.7±3.9 months in the t-VATS group. Operative time (p<0.001), the number of staples used for the operation (p=0.001), duration of drainage (p=0.001), and duration of the postoperative stay (p<0.001) were significantly lower in the s-VATS group than in the t-VATS group. There was no difference in the overall recurrence-free survival rate between the s-VATS and t-VATS groups.
Conclusion
No significant differences in operative outcomes and recurrence rates were found between s-VATS and t-VATS for PSP. Therefore, we cautiously suggest that s-VATS may be an appropriate alternative to t-VATS in the treatment of PSP.
... Conventional multi-port VATS have been widely performed as a reasonable surgical modality with many advantages comparing to thoracotomy. Since 1998, single incisional thoracoscopic approach was introduced and has been increasingly performed for treatment of various thoracic diseases (3,4,11). Due to its less-invasiveness such as less pain and cosmetic reasons over the multi-port VATS, uniportal VATS have been broadened its application in lobectomy, limited resection pneumonectomy, even in complex sleeve procedures with favorable results by skillful techniques and accumulated experiences (4-6). ...
Background: Uniportal video-assisted thoracoscopic surgery (VATS) is an alternative modality for treatment of primary spontaneous pneumothorax (PSP) with its less invasiveness and acceptable surgical outcomes. However, a few reports have been introduced for wound management to achieve better cosmetic wound healing and for placement of the chest tube in uniportal VATS. Thus, we aimed to evaluate the feasibility of our novel method for wound closure and concomitant tube placement using continuous barbed suture material in uniportal VATS for PSP.
Methods: Between July 2012 and December 2015, consecutive 31 patients (22 males) underwent uniportal VATS to treat PSP. Bilateral approaches were performed in four patients, thus total 35 cases were enrolled. We divided them into two groups with one group of 17 (48.5%) cases (group A), using barbed absorbable wound closure device for knotless continuous wound closure and subsequent chest tube anchoring, and the other group of 18 (51.4%) cases (group B), using conventional suture anchoring after skin closure using absorbable suture device. Postoperative surgical outcomes were compared to assess the feasibility of this technique.
Results: Demographic data demonstrate no significant difference in both groups. There was no significant difference in length of hospital stay (3.7±1.2 vs. 4.1±1.2 days, P=0.267) and in median chest tube indwelling time (2.4±0.9 vs. 3.1±1.2 days, P=0.066), respectively. Operation time in group A was shorter than in group B but there was no significant difference (41.7±11.8 vs. 45.6±16.0 minutes, P=0.415). There was neither conversion to two or three port VATS in all cases. In group A, all chest tubes were removed with concomitant sealing the tube removal site by pulling the thread. Residual knots do not exist that stitch out procedure is not required. There was no wound complication in both groups during the median follow-up period of 18 months.
Conclusions: Knotless, barbed suture material technique for continuous wound closure with concomitant chest tube placement achieved equivocal outcomes in comparison to the conventional suture anchoring method. We suggest this simple technique for wound closure and easy tube removal with cosmetic wound healing in uniportal VATS for PSP.
... The single incision is made closer to the hilar structures. With this uniportal technique, there is a change in the angle of dissection and stapling from the acute angles used in cVATS lobectomy to more-obtuse angles in UVATS lobectomy (6,7). Although this may seem to be a limitation at the beginning, it actually represents an improvement. ...
Background:
To describe modified procedure for uniportal video-assisted thoracoscopic surgery (UVATS) lobectomy with a small, total muscle-sparing incision.
Methods:
Forty-eight UVATS leucotomy were attempted and successfully completed. A single incision of approximately 3 cm was made in an intercostal space along the anterior axillary line. Muscle-sparing technique was applied with this single-incision approach using muscle sparing technique.
Results:
Incision size was kept to a minimum, with a median of 3 cm. Mediastinal lymph node dissection was performed in all patients with malignancy. Overall median operative time was 1.3 hours. Median hospitalization was 13.5 days (range, 6-21 days). Morbidity rate was low at 3%. There were no other postoperative complications, mortality, or re-admissions.
Conclusions:
Modified procedure of lobectomy with UVATS might be easy to operate with less surgical time and morbidity rate, muscle sparing technique might reduce post-operation pain.
... In Figure 1 the rate of conversion is illustrated showing improvement with increasing experience in group number two. SVATS for major lung resections is an alternative approach with a new learning curve to pass same as occur when a surgeon decide to evolve from conventional VATS to Uniportal VATS (16)(17)(18). The different view caudacranial and anterior to posterior, the dissection of the hilar structures and lymph node dissection makes more challenging this approach. ...
Background: Subxiphoid uniportal video-assisted thoracic surgery (SVATS) for major lung resections is a new approach. Clinical evidence is lacking. The aim of this article is to describe the learning curve of the 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision, and with the lessons learned from this early experience in SVATS and from the experience with transthoracic uniportal VATS we sought to compile “tips and tricks” for managing the multiple intraoperative technical difficulties that can arise during the SVATS and help to set the recommendations for a SVATS program.
Methods: We describe the learning curve of the first 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision From September 2014 with early-stage non-small cell lung carcinoma (NSCLC) and benign disease. We examine the rate of conversion and the operating time comparing group one (first 100 cases) with group two (subsequent 100 cases).
Results: Of the 200 consecutive selected cases (72 males, 128 females) with a mean age of 57.4±9 years, underwent either uniportal subxiphoid lobectomy or segmentectomy 136 were lobectomies and 64 were segmental resections The mean operating time was 170±45 mins; the average and after the case 86 the rate of the operating time appears to be similar. The conversion rate decrease from 13% in group one to 8% in group two.
Conclusions: There is a gradual reduction in the operating time and rate conversion with increasing experience. Lessons from our initial experience in the learning curve period in SVATS helps to create this trouble shooting guide that offers “tips and tricks” to both avoid and manage numerous intra-operative technical difficulties that commonly arise during the SVATS initial experience.
... Conventional VATS requires one camera port and two or three working ports [3,4]. Recently, single incision, single-port VATS has been introduced and gradually adopted worldwide [5][6][7]. Chen et al. [8] reported a case using a single 35-mm incision, Gigirey Castro et al. [9] reported a case in which single-port VATS was used with a single 20-25-mm incision for laparoscopic surgery, and Kang et al. [10] reported the use of single-port VATS with a 20-mm incision and a small wound protector. ...
Background:
Video-assisted thoracoscopic surgery (VATS) pulmonary wedge resection has emerged as the standard treatment for primary spontaneous pneumothorax. Recently, single-port VATS has been introduced and is now widely performed. This study aimed to evaluate the outcomes of the Tower crane technique as novel technique using a 15-mm trocar and anchoring suture in primary spontaneous pneumothorax.
Methods:
Patients who underwent single-port VATS wedge resection in Chungnam National University Hospital from April 2012 to March 2014 were enrolled. The medical records of the enrolled patients were reviewed retrospectively.
Results:
A total of 1,251 patients were diagnosed with pneumothorax during this period, 270 of whom underwent VATS wedge resection. Fifty-two of those operations were single-port VATS wedge resections for primary spontaneous pneumothorax performed by a single surgeon. The median age of the patients was 19.3±11.5 years old, and 43 of the patients were male. The median duration of chest tube drainage following the operation was 2.3±1.3 days, and mean postoperative hospital stay was 3.2±1.3 days. Prolonged air leakage for more than three days following the operation was observed in one patient. The mean duration of follow-up was 18.7±6.1 months, with a recurrence rate of 3.8%.
Conclusion:
The tower crane technique with a 15-mm trocar may be a promising treatment modality for patients presenting with primary spontaneous pneumothorax.
... Therefore, single port access VATS is actually simply the next step in the evolution of minimally invasive thoracic surgery itself (1). The development of single port VATS has come a long way, from the beginning, when it was employed for performing simple procedures (such as sympathectomy and pleurodesis), to the rapid progression in the last years of complex major lung resections (2). ...
... Changing the order of the instruments along the single port incision can sometimes help facilitate these manoeuvres, without the need to enlarge the incision or exert force onto the ribs. To improve ergonomics and to avoid meddling between individual instruments placed through the small incision of single-port VATS, a rapid progress in the instrument design has taken place (2). ...
... A qualified assistant must have flexible camera-holding skills, be familiar with the detailed surgical procedures, understand and support the operational habits of the operator, and have complete, long lasting teamwork experiences (19,20). The single port VATS approach may further reduce access trauma and has brought about a new line of thought on the role of an awake non-intubated technique in fast-tracking patients postoperatively (2). Technologic advancements aimed at manufacturing custommade instrumentation for thoracoscopic surgery will be equally decisive in facilitating the single-port technique under local or loco regional anaesthesia (12). ...
One of the greatest advances in Thoracic Surgery in our generation has been the advent of video assisted thoracic surgery (VATS). The more recent advance in VATS is the increasing use of Uniportal surgery. The development of single-port VATS has come a long way, from the beginning, when it was employed for performing simple procedures, to the last years with complex major lung resections. Nowadays, Uniportal VATS is not a Manichean law because there are several steps between open thoracotomy and Uniportal VATS. In thoracic surgery, a skilled surgeon alone cannot sustain new approaches or techniques; it is natural that minimally invasive thoracic surgery continues to evolve, since VATS is a never-ending story and Uniportal VATS is not the end of this history.
Pneumonectomy is usually indicated for more complex or advanced lung cancers, that are centrally located. The decision to proceed with pneumonectomy should not be done lightly as the surgical procedure itself is often considered a disease in itself that can be associated with potentially severe and life-threatening complications [1–3]. A sleeve resection procedure to preserve a lobe should be the operation of choice when circumstances allow [4–6]. The general principles for lung cancer surgery regarding patient having adequate lung function to tolerate the procedure and adequate lung cancer staging is paramount when preparing a patient for pneumonectomy.
