Uniportal video-assisted thoracic surgery for major lung resections: pitfalls, tips and tricks

Abstract

Nearly six years since inception, uniportal video-assisted thoracic surgery (VATS) has become a growing part of major lung resections and has revolutionized the way thoracic surgeons treat pulmonary lesions. This technique is being touted for various benefits. It ensures direct visualization together with a better exposure of the lung and allows the chance of a digital palpation of the lesion through a small incision. Postoperative pain is reduced due to the involvement of only one intercostal space without rib spreading and muscle disruption. The comfort and aesthetics factors are improved significantly since the oncological principles and radicality of open surgery are restored. As the surgeons gain more experience in uniportal-VATS lobectomy, more complex cases can be managed by this technique. The objectives of this work are to set the basic steps for performing major lung resections (lobectomy, bilobectomy and pneumonectomy) by utilizing uniportal-VATS and to analyze some common pitfalls that thoracic surgeons face when practicing this technique and provide practical tips and tricks on how to avoid.

Keywords: Video-assisted thoracic surgery (VATS); lobectomy; pneumonectomy; uniportal-VATS, less invasive approach.

Figure 1

Position of the patient on the surgical table.

Figure 2

Muscle-sparing incision: the parietal pleura is well visible before being incised.

Figure 3

Operative settings during uniportal VATS. (A) Both surgeons positioned in front of the patient watching the same monitor, with scrub nurse opposite to them; (B) 10 mm 30° thoracoscope placed in the upper part of the incision; the camera shank is as lateralized as possible and not more tilted than 30°–40° on the horizontal plane. VATS, video-assisted thoracic surgery.

Figure 4

Intercostal nerve blockade. (A) Kit for performing intercostal nerve block; (B) intrapleural paravertebral intercostal nerve block with ropivacaine (R: ribs, TP: transverse processes of vertebrae).

Figure 5

Uniportal VATS incision; (A) chest tube fixed in the posterior part of skin incision; (B) scar after chest tube removal.

Figure 6

Right upper lobectomy steps. (A) Division of the anterior trunk; (B) division of the upper vein; (C) preparation of A2 by dissector; (D) division of the upper bronchus.

Figure 7

Right upper lobectomy following steps for dissection of parenchyma. (A) Dissection of the anterior parenchyma between upper and middle lobes; (B) dissection of the posterior parenchyma between upper and lower lobes.

Figure 8

Lower right lobectomy steps. (A) dissection of the anterior parenchyma between lower and middle lobe; (B) division of arterial branches of basal pyramid and A6; (C) division of the posterior parenchyma by stapler; (D) lower vein exposed with the right angle for introduction of the stapler; (E) division of the lower vein; (F) division of the lower bronchus.

Figure 9

Middle lobectomy steps. (A) Dissection of the fissure between middle and lower lobes; (B) division of the middle vein; (C) division of A4–5; (D) division of the bronchus.

Figure 10

Lower bilobectomy steps for cutting veins. (A) Preparation of the inferior vein by dissector; (B) division of inferior vein; (C) middle vein exposed and inferior vein cut; (D) division of middle vein.

Figure 11

Lower bilobectomy following steps. (A) Dissection of anterior parenchyma between upper and middle lobes; (B) dissection of intermediate artery; (C) division of the posterior side of the fissure; (D) dissection of the intermediate bronchus.

Figure 12

Left upper lobectomy steps. (A) Dissection of anterior artery; (B) dissection of the upper vein; (C) division of the anterior parenchyma between upper and lower lobes; (D) division of the posterior side of the fissure; (E) dissection of remain arterial branches for upper lobe; (F) dissection of upper bronchus.

Figure 13

Left lower lobectomy steps. (A) Dissection of anterior parenchyma between upper and lower lobes; (B) division of the posterior parenchyma after identification and dissection of A6 and arterial branches to basal pyramid; (C) stapler angle for dissection of the lower vein; (D) division of the lower bronchus.

Figure 14

Closure of bronchial stump in case of central tumors. (A) The bronchus in cut upstream the tumor—on free borders—by scalpel; (B) bronchial stump closed by stapler, after holding and pulling it by two traction stitches.

Figure 15

Left pneumonectomy main steps. (A) Division of the main artery; (B) division of the main bronchus.

Figure 16

Left pneumonectomy, intrapericardial dissection of the hilum. (A) Opening of the pericardium by energy device; (B) dissection of the upper vein; (C) dissection of the lower vein.