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Surgical procedures of pleural cavity are crucial to complete the diagnoses or planning treatment of pleural effusions with an unknown aetiology. Traditionally, the transthoracic approach has been the most used procedure to study the pleural cavity. The subxiphoid video-thoracoscopy is becoming an alternative to the transthoracic approach. Subxiphoid video-thoracoscopy is a minimally invasive technique that allows us to study both pleural cavities with a single subxiphoid incision. In the supine decubitus, through a small subxiphoid incision, a rigid video-mediastinoscope is introduced. Once all the tissues are dissected, mediastinal pleura can be identified and incised. A 30° thoracoscopy is then inserted into the pleural cavity through the video-mediastinoscope to obtain samples of pleural fluid and biopsies of the parietal pleura and lung nodules if present. Subxiphoid approach has some advantages compared with the traditional transthoracic approach. On the one hand, contrary to traditional thoracoscopy, in subxiphoid video-thoracoscopy it is not necessary to do a transthoracic approach even for the insertion of a chest tube.Avoidance of intercostal ports probably decreases the risk of post-operative pain and the patients can be discharged 24 hours after surgery with no increase in surgical risk. On the other hand, we can explore both pleural cavities at the same time through a single incision, in case of bilateral pleural effusion. If malignancy is confirmed by frozen-section or by macroscopic evidence of intrapleural tumour infiltration or implants, a pleurodesis to avoid recurrence can be performed prior to tube insertion and closure.

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Introduction: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). Methods: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". Results: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR = 0.61 (p = 0.081), 90-day mortality OR = 0.46 (p = 0.051). Conclusions: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.

Surgical techniques remain the gold standard to diagnose and staging lung and pleural tumours. Non-invasive techniques have become more accurate but actually they are not enough to plan and evaluating prognosis of lung and pleural tumours. In some cases, we need to explore the pleural cavity and the mediastinal lymph node status to confirm or rule out tumour dissemination. The combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy through a single transcervical incision allows the surgeon to widen the range of the exploration and to improve the staging for lung and pleural cancers. VAMLA allows to perform a complete lymphadenectomy of the subcarinal space, the right and pretracheal areas. We consider sampling more safety on the left side to avoid left recurrent nerve injuries. Once this mediastinal tissue is removed, the right mediastinal pleura can be identified and incised. Once mediastinal pleura is opened, a 5 mm 30º thoracoscope is inserted through the video- mediastinoscope into the pleural cavity. It allows to obtain samples of parietal or visceral pleural, pleural fluid or lung nodules if present. In case of left-sided thoracoscopy the access to the left pleural cavity is anterior to the aortic arch as for extended cervical mediastinoscopy. The combination of VAMLA and thoracoscopy is useful to explore the mediastinum and the pleural space from a single incision and in the same surgical setting through the transcervical approach.

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