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Ann Thorac Surg 2004;77:726-728
© 2004 The Society of Thoracic Surgeons

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How to do it

Uniportal VATS wedge pulmonary resections

^a The Price-Thomas Thoracic Unit, Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, United Kingdom

Accepted for publication April 1, 2003.

^* Address reprint requests to Dr Rocco, The Price-Thomas Unit, Northern General Hospital, Herries Rd, S5 7AU, Sheffield, UK
e-mail: gaetano.rocco{at}btopenworld.com

	Abstract

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Since 2000, 15 patients have undergone single port (uniportal) video-assisted thoracic surgery for wedge pulmonary resection either for diagnosis of interstitial lung diseases (10 patients) or for treatment of primary spontaneous pneumothoraces (5 patients). Diagnosis was obtained in all patients and no recurrences of pneumothorax were seen at follow-up. This initial experience shows that, for specific indications, uniportal video-assisted thoracic surgery for wedge pulmonary resections can be safe and effective.

	Introduction

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In the recent literature, numerous attempts at performing diagnostic or therapeutic video-assisted thoracic surgery (VATS) procedures through a single port (uniportal VATS) have been reported [1]. Although a two-port technique for pulmonary resections has been described [2], the feasibility of wedge pulmonary resections through uniportal VATS has not yet been investigated.

	Technique

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Between January 1, 2000, and December 31, 2002, 180 patients underwent VATS procedures at one thoracic surgical service of our institution (GR). Of these, 71 VATS (39%) were performed using the standard three-port approach. Of the remaining 109, 75 (42%) were uniportal VATS pleural biopsies, 12 (7%) were uniportal bilateral VATS sympathectomies, and 7 (4%) were uniportal VATS debridements of early-stage empyema.

Fifteen patients (8%; 6 women and 9 men; median age 48 years) underwent uniportal VATS wedge resections of the lung for diagnosis of a pulmonary condition (10 patients) or, more recently, received a combined wedge resection and pleurectomy or pleural abrasion for treatment of a primary spontaneous pneumothorax (5 patients).

Unlike the classic three-port approach, in which the "baseball diamond" geometric configuration allows for maximal convergence of the operative instruments from each side of the target lesion with minimal interference with the optical source, the uniportal approach requires rotating the thoracoscope instruments 90° along a sagittal plane, thus bringing the operative instruments to address the target lesion from a vertical, cranio-caudal perspective (Fig 1). To avoid mutual interference, the use of roticulating instruments is of paramount importance for their ability to rotate the stem and the jaws independently on different planes and with multiple angles.

View larger version (21K): [in this window] [in a new window]   Fig 1. Diagram representing the different geometric approach to the pulmonary lesion by (A) standard three-port video-assisted thoracic surgery (VATS) compared with (B) uniportal VATS. See text for explanation.

View larger version (74K): [in this window] [in a new window]   Fig 2. The port incision used for uniportal video-assisted thoracic surgery.

When blebs or small bullae are found, the apex is mobilized with a roticulating lung endograsper (Fig 3) and the endostapler is positioned on healthy tissue caudal to the blebs with the jaws facing upward (Fig 4).

View larger version (113K): [in this window] [in a new window]   Fig 3. A roticulating grasper is used for lung mobilization.

View larger version (57K): [in this window] [in a new window]   Fig 4. A roticulating endostapler is used to complete the wedge resection along a sagittal plane.

In this series, the median operative time was 62.5 minutes (range 45 to 75 minutes). In no instances was the uniportal VATS procedure converted to a standard three-port VATS procedure or to thoracotomy. No major complications were observed and only 1 patient developed a superficial wound infection after treatment of primary pneumothorax.

The diagnostic yield of uniportal VATS wedge resections for interstitial lung disease was as follows: cryptogenic fibrosing alveolitis (5 patients), extrinsic allergic alveolitis (3 patients), and sarcoidosis (2 patients).

No recurrences were observed within 10 months (range 2 to 20 months) of the surgical treatment of spontaneous pneumothorax. All patients were discharged after a median hospital stay of 2 days (range 1 to 4 days).

	Comment

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Our major concern was to verify whether it was possible to perform the same operation through one incision as safely as with the standard three-port technique. Although the numbers in this initial experience were small, uniportal VATS pulmonary wedge resections seem to be technically comparable to standard VATS in terms of diagnostic accuracy and therapeutic efficacy.

The potential advantages of uniportal VATS are obvious. As an example, the involvement of only one intercostal space, instead of two or three, may reduce postoperative pain, thereby speeding recovery and return to work. In this setting, the vexata quaestio of how to approach first-time primary spontaneous pneumothorax may find an adequate answer in a surgical procedure performed through the same incision as the one used for the chest drain [3]. In the future, a prospective study will be needed to compare postoperative pain after uniportal and traditional VATS pulmonary wedge resections.

One disadvantage of uniportal VATS procedures is represented by the higher costs of the roticulating instruments. However, previous studies have demonstrated that the increased costs of VATS operations may be compensated by the reduced length of hospitalization [4, 5].

There are some technical issues with uniportal VATS wedge lung resections still to be addressed. The field vision obtained with a uniportal compared with standard three-port VATS can at times be restricted but, as the learning curve reaches the plateau, and with the use of roticulating instruments and 30° video thoracoscopes, blind areas do not usually represent a problem. The absence of the protecting sleeve may result in an injury to the overlying intercostal nerve and an increased need for cleaning the lens, which will increase the operative time. To avoid intercostal nerve injury, it is advisable to take full advantage of laterality given by the intercostal space incision without applying an excessive leverage on the thoracoscope-instruments ensemble.

In the future, the routine use of 2-mm video thoracoscopes (needlescopy) [6] will make uniportal VATS wedge pulmonary resections even easier to perform and to teach. Postoperatively, the current strategies of early mobilization of the patient and the use of flutter bags will possibly turn uniportal VATS lung wedge resections for diagnosis of lung conditions or for treatment of primary spontaneous pneumothoraces into a day case [7].

	Acknowledgments

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We thank Robert Salthouse and Heather Allen, from Medical Illustration, for their invaluable help.

	References

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1. Lin T.S., Kuo S.J., Chou M.C. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery 2002;51(Suppl):84-87.
2. Kaga K., Park J., Nishiumi N., Iwasaki M., Inoue H. Usefulness of video-assisted thoracic surgery (Two Windows Method) in the treatment of lung cancer for elderly patients. J Cardiovasc Surg (Torino) 1999;40:721-723.[Medline]
3. Baumann M.H., Strange C., Heffner J.E., et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590-602.[Abstract/Free Full Text]
4. Sugi K., Kaneda Y., Nawata K., et al. Cost analysis for thoracoscopy: thoracoscopic wedge resection and lobectomy. Surg Today 1998;28:41-45.[Medline]
5. Maruyama R., Oka T., Anai H. Video-assisted thoracoscopic treatment for spontaneous pneumothorax as two-day surgery. Am J Surg 2000;180:171-173.[Medline]
6. Kim B.Y., Oh B.S., Park Y.K., Jang W.C., Suh H.J., Im Y.H. Microinvasive video-assisted thoracoscopic sympathicotomy for primary palmar hyperhidrosis. Am J Surg 2001;181:540-542.[Medline]
7. Preventza O., Hui H.Z., Hramiec J. Fast track video-assisted thoracic surgery. Am Surg 2002;68:309-311.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gaetano Rocco Antonio Martin-Ucar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rocco, G. Articles by Passera, E. Search for Related Content PubMed PubMed Citation Articles by Rocco, G. Articles by Passera, E. Related Collections Lung - cancer