17

Uniportal video-assisted thoracoscopic surgery (VATS)

Gaetano Rocco

INTRODUCTION

Single-port (uniportal) video-assisted thoracoscopic surgery (VATS) represents an evolution of traditional VATS principles and, at the same time, a formidable return to the geometric configuration of classic open thoracotomies. ¹ – ³ . In a way, the uniportal concept is the center of a star system whose satellites exchange technical aspects with the other known thoracic surgical approaches (see Figure 17.1). The main feature of the uniportal VATS approach consists of targeting, through a caudocranial (sagittal) plane, any area of surgical interest inside the chest (see Figure 17.2). Two advantages result from such a perspective: (1) the procedure allows for a similar approach as is used for open surgery and (2) the reacquisition of the depth of visualization lost with conventional three-port VATS. ³ The latter is based on the development of a transversal latero-lateral (or anteroposterior) plane, along which the operative instruments are deployed to address the target area. ³ With the current 2-D technology, the surgical maneuvers impede in-depth visualization through a centrally located videothoracoscope because of the torsion angle created by the operative instruments (see Figure 17.3). ³ , ⁴ As a result, traditional three-port VATS demands an extent of hand-eye coordination to overcome the geometrical obstacle originating from this torsion angle (see Figure 17.4a). ⁴ This hand-eye coordination represents an added difficulty, especially during hilar dissection during VATS lobectomy, and this has possibly undermined the more universal acceptance of the procedure, which is otherwise appealing. Conversely, in the uniportal approach, the eye “accompanies” in depth the stems of the instruments, which are deployed parallel to each other along the sagittal plane, and effectively represents an extension of the surgeon’s hands (see Figure 17.4b). ⁴ At present, the similarity between open and uniportal VATS is as close as it can get. In addition, the articulated jaws or graspers can be positioned so as to avoid bite closure on the target area, which could, in turn, obstruct the in-depth view. Furthermore, the fulcrum of the operative instruments is inside the chest—at a short distance from the actual lesion. This characteristic assimilates uniportal VATS to robotic surgery; indeed, robotic surgery is considered to be the minimally invasive surgical approach that most closely duplicates the technical features of open thoracotomy (see Figure 17.1).

The concept of using a thoracoscope and instrumentation through the same small incision dates back to a report by Singer in 1924. ⁵ Uniportal VATS has since been described for sympathectomy and the diagnosis of pleural conditions. ⁶ , ⁷ The general consensus is that the main advantage of uniportal VATS is to provide a minimally invasive approach that can be used in conjunction with loco-regional anesthesia to fast track surgical candidates to diagnostic or therapeutic procedures. ¹ In this setting, the triad one port-one intercostal-less pain seems justified, albeit that definitive evidence (i.e., a prospective, randomized trial) has yet to be published. ⁸ , ⁹

PREOPERATIVE PLANNING

The technical feasibility of uniportal VATS is heavily dependent on preoperative planning of the surgical coordinates necessary to identify the location of the single incision. In this setting, the scapular angle line—that is, longitude—defines the distinction between anteriorly and posteriorly located incisions. The latitude is defined by the intercostal space at a level that must warrant sufficient distance between the single port and target lesion to avoid videothoracoscope-instrument interference. ² Longitudinal and latitudinal coordinates usually allow for placing the incision so as to “face” the target area inside the chest. Accordingly, lesions located in the middle lobe are best approached through incisions located posterior to the scapular angle line; conversely, lesions located in the apical segment of the lower lobe are best addressed from incisions located anterior to the scapular angle line. The intercostal space selected depends on the caudocranial level where the lesion is found in the lung. As an example, if the lesion is in the apex of the right upper lobe, an incision should be placed at the fourth or fifth intercostal space. Once the incision is made (see Figure 17.5 a), the distribution of the surgical personnel varies so that the first surgeon and his/ her assistant work from the same side, looking at the same monitor (see Figure 17.5 b).

UNIPORTAL VATS FOR DIAGNOSTIC PURPOSES

Recurrent pleural or pericardial effusions, early empyemas, interstitial lung disease, peripheral pulmonary nodules, or ground glass opacities, as well as pleural or mediastinal masses and lymph node biopsy, are all amenable to uniportal VATS, yielding precise histological diagnosis and short hospitalizations. ² , ⁶ , ¹⁰ , ¹¹ Interestingly, selected awake patients can be operated on under a combination of loco-regional anesthesia and sedation. ¹² Typically, an epidural catheter is positioned at the T5-6 level and a single shot of 1% Ropivacain solution (10 mg/mL diluted to 5 mg/mL, for a total dose of 15 mL = 75 mg) is administered. ¹² , ¹³ In addition, the patient is given intravenous (IV) midazolam (4 mg), fentanyl (100 mcg) and propofol (0.5 mg/kg/h up to a total of 30 mg in 1 hour), along with supplemental oxygen by nasal prongs in order to maintain arterial oxygen saturation above 90%. ¹² , ¹³

SURGICAL TECHNIQUE FOR UNIPORTAL VATS FOR PLEURAL CONDITIONS

As a rule, diagnostic uniportal VATS is performed through a single 1.0–1.5 cm incision located along a virtual thoracotomy line in the fifth intercostal space, usually anterior to the scapular line if the pleural effusion occupies two-thirds or more of the chest cavity. ¹⁴ When the pleural effusion is less significant, needle probing is used to identify the most recumbent site compatible with safe performance of the procedure and convenient chest drain placement. A 24 Fr chest drain is passed through a 10 mm trocar inserted through the single incision and the pleural fluid aspirated and routinely sent for cytology. As a rule, a 5 mm trocar is then used to introduce a 5 mm 0-degree videothoracoscope to explore the posterior chest wall and the diaphragm. The trocar is removed along the stem of the videothoracoscope to gain more operative space at the incision level. Later, the videothoracoscope is tilted toward the assistant’s side, and the anterior chest wall, pericardium, and diaphragm are visualized. At this point, biopsy forceps are introduced parallel to the videothoracoscope. If talc pleurodesis is needed, the insufflator is inserted parallel to the thoracoscope, which is slightly retracted to visualize the tip of the insufflators in order to better direct talc aspersion. Talc poudrage is completed by rotating the thoracoscope and insufflator ensemble to cover all areas of the chest cavity.

SURGICAL TECHNIQUE FOR UNIPORTAL VATS WEDGE RESECTION

The perfect size for single-port VATS—in line with the extreme minimally invasive philosophy behind this technique—is one fingerbreadth measured at the knuckle—that is, 2.5 cm (see Figures 17.6 and 17.7). ³ The intercostal space is opened flush to the superior border of the underlying rib so as to allow for 1 cm lateral movements on each side. The following step is the introduction of a 0or 30-degree 5 mm videothoracoscope without trocar, which is retracted along the thoracoscope stem. ³ Next, articulating endograspers and an endostapler are inserted to suspend and resect the pulmonary target area along a craniocaudal (sagittal) plane (see Figures 17.8 and 17.9). The reciprocal position of the instruments and the thoracoscope can vary during the procedure to facilitate surgical maneuvers. ³ The placement of soft tissue retractors is discouraged, to avoid subtracting room for the instruments and thoracoscope. Once the nodule is visualized or identified with an ultrasound probe, ¹⁵ the area of parenchyma containing the nodule is marked and resected (see Figure 17.10).

Stay updated, free articles. Join our Telegram channel

Join