Chapter 74: Uniportal VATS Lobectomy

INTRODUCTION

One of the most important breakthroughs in thoracic surgery has been the development of video-assisted thoracic surgery (VATS) for major pulmonary resections.^1,2 This technique has revolutionized how surgeons treat thoracic diseases, evolving from three or four incisions to a uniportal VATS approach during the past several years.

Since it was first performed in 2010,³ lobectomy through a single hole—uniportal VATS—has become increasingly popular among surgeons from all over the world.^4–6 However, this minimally invasive surgical approach requires a different skill set even compared to conventional multiportal VATS. For those beginning to learn uniportal VATS, the technical challenges can seem considerable. Since only one intercostal space is involved without rib spreading, normally more anteriorly than with conventional VATS, some authors have reported less postoperative pain, faster postoperative recovery, reduced hospital stay, and potentially earlier administration of adjuvant therapy when necessary.^7–9 This chapter describes the most important technical details of uniportal VATS.

BASIC CONCEPTS

The uniportal approach permits direct visualization of the target tissue and of the pulmonary hilum from the anterior view. The parallel instrumentation achieved through this access mimics the maneuvers performed during open surgery, and this makes the movements of the surgeon more natural and ergonomic.¹⁰ Therefore, surgeons experienced with the two-port technique or with the anterior thoracotomy approach will probably adopt the uniportal concept more rapidly than surgeons more used to the three-port technique.^11,12 The most important aspect of uniportal VATS is the exposure. Consequently, the tips and tricks related to this are more important than for other VATS approaches. Because only one hole is available, learning these small details and tricks is a big step toward improving exposure.

The technique evolved over time with the introduction of adapted instruments, improvements in imaging systems, and experience. We have further refined the technique by introducing the concept of advanced instrumentation. The idea is to modify existing instrumentation to enable the use of fewer instruments through the uniportal incision. Most uniportal VATS surgery is now performed with a long, curved suction device in the left hand, and an energy device in the right hand. The suction device is a versatile instrument that can perform multiple functions, including aspirating, holding, exposing, compressing, and releasing adhesions¹³ (Fig. 74-1).

The shape of the long curved suction is ideally suited for use via a small uniport, allowing compression of structures, blunt dissection, retraction of tissues, and even support and movement of the lymph node package during lymphadenectomy. The endoscopic energy devices (ultrasonic and/or diathermy energy) can be used to dissect vessels, retract tissues, coagulate and cut structures, and even grasp organs in ...