The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery

Abstract

The history of Minimally Invasive Surgery in the thorax is one of evolution, not revolution. The concept of video-assisted thoracic surgery (VATS) to greatly reduce the trauma of chest operations was born over two decades ago. Since then, it has undergone a series of step-wise modifications and improvement. The original practice of three access ports in a 'baseball diamond' pattern was modified to suit operational needs, and gradually developed into 'next generation' approaches, including Needlescopic and 2-port VATS. The logical, incremental progression has culminated in the Uniportal VATS approach which has stirred considerable interest within the field of Thoracic Surgery in recent years. This measured, evolutionary process has significant implications on how the surgeon should approach, master and realize the full potential of the Uniportal technique. This article gives a précis of the evolutionary history of minimally invasive thoracic surgery, and highlights the lessons it provides about its future.

Keywords: Single-port VATS; Uniportal VATS; thoracoscopic surgery; video assisted thoracic surgery (VATS).

Figure 1

Schematic of the right thorax, showing approximate relative locations of the main hilar structures.

Figure 2

The ‘classic’ 3-port VATS lobectomy. In a right-side operation, the ‘baseball diamond’ (dotted blue line) has a 10 cmm camera port at ‘home base’, a 3-5 cm utility port at ‘first base’, and a 10 mm posterior port at ‘third base’. The axis of the operation (red arrow) is a straight line from ‘home base’ through the ‘second base’—and in this classic early VATS approach the axis is essentially in a hip-to-head direction along the patient’s body’s longitudinal axis. VATS, video-assisted thoracic surgery.

Figure 3

The ‘modified’ 3-port VATS lobectomy. The ‘baseball diamond’ (dotted blue line) and axis of the operation (red arrow) have essentially been rotated in a posterior direction—and the axis direction is now umbilicus-to-shoulder, better reflecting the fact that in reality the surgeon stands anterior to the patient (rather than sits on the patient’s hip!). VATS, video-assisted thoracic surgery.

Figure 4

The Needlescopic VATS lobectomy. The ports positions (purple) and axis of the operation (red arrow) are the same as for the ‘modified’ 3-port VATS approach. However, the posterior and camera ports have been reduced in size to 3 mm in diameter only. VATS, video-assisted thoracic surgery.

Figure 5

The 2-port VATS lobectomy. The utility and camera ports are identical to the Needlescopic approach, but the posterior port has been eliminated. VATS, video-assisted thoracic surgery.

Figure 6

The Uniportal VATS lobectomy. Compared to the 2-port approach, the camera port has been eliminated. The Uniport is in the 5^th intercostal space and is largely unchanged from the utility port of all previous iterations of VATS lobectomies. VATS, video-assisted thoracic surgery.

Figure 7

Example of manoeuvring the lung to enable the correct angulation for stapling. (A) If the lung is simply retracted upwards (green arrow) or towards the Uniport (yellow ring), the stapler is inserted downwards near-vertically (blue arrow) and even with reticulation of the stapler head the stapler tip will impinge against the mediastinal or hilar structures, impeding passage of the stapler around the vessel branch; (B) if the lung is instead distracted away (green arrow) from the Uniport (yellow ring), the target vessel branch is better displayed, allowing the reticulated stapler to approach perpendicularly at a ‘flatter’ angle (blue arrow) and avoid impingement against any structures on the far side.

Figure 8

The issue of perspective. (A) With classic 3-port VATS, the surgeon looks out onto a flat, horizontal baseball field. With the surgeon at ‘home base’, the right and left hand instruments at ‘first and third bases’ are in front of the surgeon and farther along that flat field. This translates into a camera port positioned ‘lower’ (closer to the surgeon) than the right and left ports; (B) with Uniportal VATS, the view is more like looking downwards into a mine shaft. As the surgeon looks into the mine shaft, the eyes are naturally at a higher level than the right and left hands. This translates into the camera placed in the Uniport ‘higher’ (father from the surgeon) than the right and left hand instruments. For a surgeon standing anterior to the patient, this means the camera is placed towards the posterior end of the wound. VATS, video-assisted thoracic surgery.