Technical aspects of uniportal video-assisted thoracoscopic sleeve resections: Where are the limits?

Abstract

Central MessageA single running suture using 1 thread with 2 needles makes end-to-end bronchovascular anastomosis faster and easier by minimally invasive thoracic surgery, especially with uniportal VATS.See Commentaries on pages 165 and 167. A single running suture using 1 thread with 2 needles makes end-to-end bronchovascular anastomosis faster and easier by minimally invasive thoracic surgery, especially with uniportal VATS. See Commentaries on pages 165 and 167. Feature Editor's Note—Global enthusiasm for a uniportal approach to video-assisted thoracoscopic (VATS) resection of thoracic neoplasms has seen a surge during the past decade subsequent to the first reported case in 2010. Proponents of the approach argue for diminished postoperative pain, reduced hospital length of stay, and more rapid recovery compared with a 3-hole VATS technique. Of note, in the only published randomized study that compared uniportal with other VATS techniques for lobectomy, there was no difference in postoperative outcomes including pain, length of stay, or complications (Perna et al. Eur J Cardiothorac Surg. 2016;50:411-5). Nevertheless, safety and feasibility of the technique are well established and the adoption of more advanced resections by champions of the modality are being explored as depicted in this technical report by Gonzalez-Rivas and colleagues. Bronchial and/or vascular sleeve resections during pulmonary resection are challenging even in the presence of a thoracotomy, so achieving this operation through VATS or robotic assisted surgery and now uniportal VATS is noteworthy. This has been greatly facilitated by improved instrumentation and refinement of the uniportal technique that optimizes the parallel nature of visualization and surgical dissection. Importantly, this technique should only be implemented in the hands of surgeons familiar with the method in which appropriate oncologic resection can be achieved. As the authors emphasize incision placement is critical and many surgical pearls are described in this report including avoidance of polymer clips for arterial vessel ligation and eliminating instruments that crowd the small access incision. Because sleeve resections require anastomoses of airway or vasculature, multiple sutures in an already crowded field is cumbersome. Conversion from the previous technique of interrupted suture on the cartilaginous wall and continuous running suture on the membranous wall to a single double-armed monofilament running suture to complete the entire 360 degrees of the anastomosis with a single knot appears to be a significant step forward. Among the many reported improvements to permit advanced pulmonary or carinal resection via a uniportal technique, the most important contribution of these authors is the dedication to teaching this technique to a wide spectrum of thoracic surgeons all over the world. Michael Lanuti, MD In recent years, experience gained through video-assisted thoracoscopic surgery (VATS), the development of better and adapted surgical instruments, and improvements in thoracoscopic cameras have greatly contributed to the ability to perform more challenging cases by VATS, such as parenchyma-sparing (sleeve) pulmonary resections.1Chen H. Huang L. Xu G. Zheng B. Zheng W. Zhu Y. et al.Modified bronchial anastomosis in video-assisted thoracoscopic sleeve lobectomy: a report of 32 cases.J Thorac Dis. 2016; 8: 2233-2240Crossref PubMed Scopus (12) Google Scholar,2Zhou S. Pei G. Han Y. Yu D. Song X. Li Y. et al.Sleeve lobectomy by video-assisted thoracic surgery versus thoracotomy for non-small cell lung cancer.J Cardiothorac Surg. 2015; 10: 116Crossref PubMed Scopus (31) Google Scholar These procedures are recommended for the treatment of central tumors involving the origin of the lobar bronchus or extending into the main bronchus and in the case that the hilar lymph nodes are infiltrated, regardless of the patient's capacity to tolerate a pneumonectomy. Data accumulated over the