Ann Thorac Surg 2009;88:2069. doi:10.1016/j.athoracsur.2009.04.117
© 2009 The Society of Thoracic Surgeons
Correspondence
The One and Only
Gaetano Rocco, MD, FRCS(Ed)
Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Via Semmola 81, Naples, 80131 Italy
(Email: gaetano.rocco{at}btopenworld.com).
To the Editor:
I read with interest the contribution by Drs Iwazaki and Inoue [1] regarding their video-assisted thoracic surgery (VATS) "one-port method" to perform lobectomy and mediastinal nodal dissection for early stage lung cancer [1]. I would like to congratulate the authors for having accomplished a procedure that as a rule requires multiple ports of variable sizes and a utility thoracotomy, or both. Likewise, I concur with them on the versatility of a single-port approach for "a wide variety of intrathoracic diseases" [1] for the same reasons listed in their current article and in a previous article describing their "two-port" technique (ie, less pain and prompt recovery and return to daily life activities, thus also achieving a potential cost-effectiveness balance) [2]. In this setting, the "uniportal" approach was devised in the year 2000 and was published in 2004 to address the need for minimal invasiveness in routine thoracoscopic surgery by addressing target lesions inside the chest through a novel spatial concept enabling the surgeon to effect (through the same minimal incision) the thoracoscopic visualization and necessary surgical maneuvers [3–6]. If the philosophy of a single thoracoscopic incision (and the attendant dogma: "one intercostal space-one intercostal nerve") is followed, then Iwazaki and Inoue [1] are actually presenting a technique that is directly derived from the needlescopic approach [7]; indeed, at least two stab incisions through different intercostal spaces and one in the auscultatory triangle are used by the authors to inspect the pleural cavity and provide an intraoperative view. Strictly speaking, the authors are working through at least two ports, and the figure in their article confirms this impression. Moreover, why place lateral needlescopic ports when the same task (ie, exploration and visualization of the pleural cavity) can be accomplished through the central operative one? In the description of the "one port method" by Iwazaki and Inoue [1] many technical details are missing that should be clearly delineated for this procedure to be reproducible. For example, different surgical targets (ie, different lobectomies) may dictate individual variations of the port placement strategy, which does not seem to be contemplated by the authors who claim to use surgical instruments through the 2-cm port, only always in the same position. In this context, their original two-port technique and the alternation of endoscopic instrumentation and thoracoscope through the ports could better substantiate the actual feasibility of any pulmonary lobectomy. Also, details of the extent of leverage on the intercostal bundles, the possible reciprocal interference of the operative instruments, and on the extraction of an entire lobe through a 2-cm port are not given.
In conclusion, I agree with Iwazaki and Inoue [1] that rigorously performed, one port, or a uniportal technique should be added to the surgical armamentarium [4]. However, I suspect that although the authors need to be commended for their strenuous search for refinements of minimally invasive thoracoscopic surgery, this technique of VATS lobectomy may not be realistically labelled as the "one-port method."
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References
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- Iwazaki M, Inoue H. Microthoracoscopic one-port method for lung cancer Ann Thorac Surg 2009;87:1250-1252.[Abstract/Free Full Text]
- Iwasaki M, Nishiumi N, Maitani F, Kaga K, Ogawa J, Inoue H. Thoracoscopic surgery for lung cancer using the two small skin incisional method J Cardiovasc Surg 1996;37:79-81.[Medline]
- Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections Ann Thorac Surg 2004;77:726-728.[Abstract/Free Full Text]
- Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions Thorac Surg Clin 2008;18:305-310.[Medline]
- Rocco G, Brunelli A, Jutley R, et al. Uniportal VATS for mediastinal nodal diagnosis and staging Interact Cardiovasc Thorac Surg 2006;5:430-432.[Abstract/Free Full Text]
- Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases J Thorac Cardiovasc Surg 2005;129:947-948.[Free Full Text]
- Ikeda Y, Miyoshi S, Seki N, Kobayashi S, Umezu H, Tamura M. Needlescopic operation for partial lung resection Ann Thorac Surg 2003;75:599-601.[Abstract/Free Full Text]
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