Clinical applications of minimally invasive uniportal video-assisted thoracic surgery

Abstract

Background

In recent years, the field of minimally invasive thoracic surgery has experienced significant advancements driven by improvements in video-assisted thoracoscopic surgery (VATS) techniques and surgical instruments. These advances have given rise to uniportal VATS as a new area of exploration in minimally invasive thoracic surgery. This technique presents several potential advantages, including reduced access trauma, less postoperative pain, improved cosmesis, fewer complications, shorter hospital stays, and faster rehabilitation, ultimately leading to an improvement in patient quality of life.

Purpose

This article reviews the evolutionary history of minimally invasive thoracic surgery, highlights novel techniques, explores possible applications and obtained results, and discusses future prospects of uniportal VATS.

Conclusion

Experienced thoracic surgeons have demonstrated the capacity to perform uniportal VATS with a high level of safety and efficacy. Further studies are necessary to assess its long-term efficacy, address limitations, and enhance clinical decision-making for optimal treatment of thoracic conditions.

Introduction

The rapid progress of surgical technology has enabled thoracic surgery to become increasingly minimally invasive, with faster postoperative rehabilitation (Gonzalez-Rivas 2016). Minimally invasive thoracoscopic surgery relies on video technology and avoids rib spreading. Thanks to recent improvements in VATS techniques and surgical instruments, uniportal VATS lobectomy has emerged as a new area of exploration in minimally invasive thoracic surgery since 2010 (Gonzalez-Rivas et al. 2011). Uniportal VATS offers several potential advantages, including reduced access trauma, less postoperative pain, faster rehabilitation, greater patient satisfaction, and a less invasive approach than conventional VATS techniques (Wang et al. 2017, 2023). Despite these advantages, the surgical procedure is infrequently performed due to concerns regarding operative risks, technical challenges, and a lack of studied outcomes in uniportal VATS lobectomies.

The evolution of uniportal VATS

Minimally invasive thoracic surgery dates back to 1910 when Dr. Hans Christian Jacobaeus performed the first procedure using a laparoscope to visualize the thoracic cavity and conduct a pleural biopsy (Donnelly et al. 1992). However, it was not until the 1990s when VATS techniques were introduced that minimally invasive thoracic surgery gained popularity (Sihoe 2014). Dr. Jacques Perissat performed one of the earliest VATS procedures in 1992, but the technique was first described by Dr. Giancarlo Roviaro in 1991, who used only three small incisions, leading to improved postoperative recovery for patients (Périssat et al.1992; McKenna et al. 1994; Gonzalez-Rivas et al. 2014). Since then, VATS has become a standard technique in thoracic surgery, with increasing numbers of surgeons performing VATS procedures for various thoracic conditions. With the development of endoscopic instrumentation, uniportal VATS has emerged as a minimally invasive procedure performed through a single incision. Initially used for sympathectomy, pleural procedures, mediastinal biopsies, pulmonary wedge resections, and mediastinal pathologies, uniportal VATS techniques have advanced considerably, and more complex procedures, such as segmentectomy, bronchial sleeve resection, pneumonectomy, pulmonary artery reconstruction, and chest wall resection, have been developed (Gonzalez-Rivas et al. 2011; Rocco et al. 2013; Paradela et al. 2023; Dai et al. 2022; Ng 2016; Gonzalez-Rivas et al. 2016a, b; Xie et al. 2021). Gonzalez Rivas and colleagues even carried out a uniportal thoracoscopic major pulmonary resection in a patient with non-intubated anesthesia, expanding the use of this technique further (Gonzalez-Rivas et al. 2016a, b). The potential of uniportal VATS to reduce the invasiveness of the procedure and improve patient outcomes is clear. In recent studies, subxiphoid uniportal VATS was used to treat bilateral pulmonary lesions, and the long-term results of this approach are eagerly awaited (Abdellateef et al. 2020; Yang et al. 2019; Negi et al. 2020). Overall, the evolution of uniportal VATS has expanded the capabilities of minimally invasive thoracic surgery, allowing for more advanced and complex procedures to be performed with improved patient outcomes.

Surgery technique

In the past two decades, the traditional VATS technique for pulmonary lobectomy has typically required three incisions and a video thoracoscopic approach visualized on screen. The incisions involved an incision in the seventh intercostal space in the midaxillary line, an incision anterior to the tip of the scapula, and an incision of approximately 4 cm placed in the fourth intercostal space anteriorly with no rib spreading. In 2004, Rocco and colleagues (Rocco et al. 2004) conducted a study on pulmonary wedge resection using single-port VATS, and since then, the field of surgery has undergone significant technological advancements. Uniportal VATS, a relatively new approach to minimally invasive thoracic surgery, has gained popularity in recent years.

The technique involves a single incision in the chest wall through which all surgical instruments are inserted and the procedure is performed using a high-definition 30° thoracoscope. For single-port VATS lobectomy, the patient is positioned in the lateral decubitus position, and after general anesthesia with double lumen endotracheal tube intubation, a single incision of approximately 4.0 cm is made in the fourth or fifth intercostal space at the anterior axillary line. Both the surgeon and assistant stand at the anterior side of the patient, with the thoracoscope usually placed at the upper channel and the instruments in the lower channel. The locations of the thoracoscope and instruments can be flexibly transposed. The surgical instrumentation used for the single-port approach is similar to that of conventional thoracoscopic surgery, including long curved endoscopic surgical instruments with double articulation, curved suction, and a higher resolution 30º thoracoscope.

The entire pleural cavity is first inspected, and adhesions are taken down using the hook cautery. Surgical procedures involve individual dissection of veins, arteries, and lobar bronchi. For lung cancer patients, complete mediastinal lymphadenectomy is performed, removing as many accessible lymph node stations as possible with uniportal VATS.

Uniportal VATS: advantages and characteristics

Uniportal VATS is a minimally invasive thoracic surgical technique that has gained popularity in recent years. This approach involves making a single incision in the chest wall, through which all surgical instruments are inserted and the procedure is performed using a high-definition 30° thoracoscope. Compared to traditional VATS or open thoracotomy, uniportal VATS offers several advantages and characteristics that make it a safe and effective alternative for many thoracic procedures.

One of the key advantages of uniportal VATS is enhanced visualization. The use of a single incision allows for direct visualization of target tissues and provides a larger field of view for the 30° thoracoscope and operating instruments. This approach mimics open surgery and preserves visual depth, which enhances the accuracy of surgical procedures. Additionally, the surgeon's operating fulcrum moves from the chest wall to the thoracic cavity, increasing comfort and ease of access to the targeted area. Furthermore, the uniportal approach eliminates the creation of torsional or dihedral angles by the instruments, which is a problem inherent to conventional multi-port VATS.

Another advantage of uniportal VATS is the single-incision approach, which reduces the number of incisions needed and minimizes trauma to the patient. This technique is associated with lower levels of postoperative pain due to the smaller incision and less manipulation of tissues (Tian et al. 2021). Patients who undergo uniportal VATS also typically have shorter hospital stays compared to traditional VATS or open thoracotomy, and faster recovery times due to reduced pain and faster mobilization (Chen et al. 2022; Bertolaccini et al. 2019).

Uniportal VATS also results in improved cosmetic outcomes (Yang et al. 2018), as it leads to a smaller surgical scar compared to traditional VATS or open thoracotomy. Moreover, it is associated with a lower risk of complications (Homma et al. 2022) such as bleeding, infection, and nerve damage. This technique can be used to safely and effectively perform a wide range of thoracic surgeries, including lobectomy, segmentectomy, sleeve resection, and pulmonary artery reconstruction, mediastinal mass resection, and esophageal (Zhai et al. 2022; Tang et al. 2022; Han et al. 2020; Fiorelli et al. 2018).

Finally, uniportal VATS involves less manipulation and dissection of tissues, resulting in less tissue trauma and improved preservation of lung function (Gonzalez-Rivas et al. 2016a, b). This characteristic makes it a favorable alternative to traditional VATS or open thoracotomy for many thoracic procedures.

Limitations and drawbacks of uniportal VATS

Uniportal VATS offers several advantages for thoracic surgeries, but there are some potential drawbacks and limitations to consider.

First, performing uniportal VATS requires advanced surgical skills and specialized training. This technique may be challenging for inexperienced surgeons and may require a longer learning curve to become proficient.

Second, the single-incision approach of uniportal VATS may limit the range of motion of surgical instruments, making some procedures more difficult to perform. This can be especially problematic for complex surgeries that require a higher degree of precision and manipulation.

Third, the single-incision approach may also result in reduced working space, which can further limit the surgeon's ability to manipulate tissues and perform complex procedures.

Fourth, uniportal VATS may be associated with a slightly increased risk of bleeding compared to traditional VATS or open thoracotomy due to the limited access and reduced visualization (Gonzalez-Rivas et al. 2020).

Fifth, uniportal VATS may have longer operative times compared to traditional VATS or open thoracotomy, particularly for more complex procedures.

Sixth, the specialized instruments and equipment required for uniportal VATS may be more expensive compared to traditional VATS or open thoracotomy, resulting in higher costs for patients.

Finally, uniportal VATS is not widely available in all centers, and patients may need to travel to a specialized center to undergo the procedure, which can be inconvenient and costly.

Learning curve, education, and training in uniportal VATS

Uniportal VATS is a technically demanding procedure that requires specialized training and experience. The learning curve for this technique is steeper than for traditional or multi-port VATS, and the success rate is closely linked to the surgeon's experience and skill level. To become proficient in uniportal VATS, thoracic surgeons typically undergo specialized training programs that focus on this technique. These programs may include hands-on training with cadavers or simulators, as well as observation and assistance with experienced uniportal VATS surgeons. Some institutions also offer formal uniportal VATS training programs or fellowships, which may include didactic instruction, live surgery observation, and hands-on practice with real patients under the supervision of experienced faculty.

Ongoing education and practice are essential for maintaining proficiency in uniportal VATS. This may include participation in continuing medical education courses, attending conferences and workshops, and regular review of surgical techniques and outcomes. A commitment to ongoing education and training is crucial for successful adoption of uniportal VATS and for providing the highest quality care to patients.

Our experience with uniportal VATS began in January 2015, after building upon our prior experience with conventional and double-port VATS. We transitioned to a uniportal approach without rib spreading, following the successful technique of Gonzalez Rivas. Prior to 2014, we utilized a traditional VATS technique for pulmonary lobectomy that involved a video thoracoscopic approach visualized on screen and required three incisions. Later, we switched to a two-port VATS approach, using a video thoracoscope inserted in the seventh intercostal space in the midaxillary line and a 4 cm incision in the fourth or fifth intercostal space anteriorly for instrument passage and specimen extraction without rib spreading.

Future prospects of uniportal VATS

Uniportal VATS is a minimally invasive surgical technique that has been increasingly used to treat a variety of thoracic conditions. However, with the development of innovative techniques and technologies such as 3D thoracoscopy, robotic-assisted thoracic surgery, and navigation-guided procedures, the safety and effectiveness of uniportal VATS are expected to further improve.

One of these innovative techniques is 3D thoracoscopy. This technique uses a 3D video camera to provide a more detailed and accurate view of the surgical site, allowing for greater depth perception and spatial orientation. Early studies indicate that 3D thoracoscopic surgery has led to better outcomes and reduced morbidity and mortality when compared to traditional 2D thoracoscopy (Liang et al. 2018; Yang et al. 2016; Dong et al. 2016; Li et al. 2019).

Another innovative technique is robotic-assisted thoracic surgery, which uses robotic arms to perform the surgery, allowing for greater precision and control. This technique has been used to treat a range of thoracic conditions and has shown improved surgical outcomes and reduced morbidity and mortality rates compared to traditional open surgery (Kent et al. 2023; Paradela et al. 2023; Kneuertz et al. 2019).

Navigation-guided uniportal VATS is another promising technique that combines VATS with image-guided navigation technology to guide the surgeon to the surgical site, improving accuracy and reducing the risk of complications. This technique has been used to treat pulmonary nodules (Hung et al. 2020; Hsu et al. 2020) and has shown improved accuracy, reduced risk of injury, shorter surgical time, and reduced pain and scarring.

With the continued development of these innovative techniques and technologies, uniportal VATS is expected to become a potential standard of care for multiple thoracic surgeries.

Conclusion

Uniportal VATS has emerged as a promising technique for the treatment of thoracic diseases, offering comparable oncologic outcomes and lower complication rates than traditional thoracic surgery. Despite its potential benefits, it is important to note that uniportal VATS may not be suitable for all patients and that the decision to use this technique should be made by a skilled thoracic surgeon on a case-by-case basis. Moreover, there is a need for further studies to determine the long-term efficacy of uniportal VATS and to address its limitations and drawbacks. This ongoing research will help to inform clinical practice and ensure that patients receive the most appropriate and effective treatment for their thoracic conditions.

Author contributions

WLL drafted the manuscript. GLH and SSY participated in editing the manuscript and revised the article. WLL and RY conceptualized the study and revised the article. All authors have read and approved the final manuscript.

Funding

This study was supported by the Natural Science Foundation of Liaoning Province (2022-MS-433).

Data availability

Not applicable.

Code availability

Not applicable.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not applicable.