anatomical lung resection with U-VATS (2,3), and it has developed to more complex surgery, such as segmentectomy and sleeve resection (4). We started U-VATS in February 2019 and have performed more than 80 anatomical lung resections so far. In U-VATS, we use special curved forceps and a suction tube, and we have devised a length and angle so that the instruments do not interfere with each other.

Background: Few studies have reported on the effects of intraoperative complications, such as vessel injury, during thoracoscopic anatomic pulmonary resection. We evaluated intraoperative vessel injury and assessed troubleshooting methods for thoracoscopic anatomic pulmonary resection. Methods: A total of 378 patients underwent thoracoscopic anatomic pulmonary resection between April 2012 and March 2018, 40 of whom were identified as having an intraoperative vessel injury. In our department, we treat significant bleeding based on the algorithm shown in Figure 1. We analyzed the injured vessels and hemostatic procedures employed and compared perioperative outcomes in patients with (n=40) or without (n=338) a vessel injury. Additionally, we examined the data on a year-by-year basis from April 2012, and perioperative results were compared in each year. Results: The vessel injured was a branch of the pulmonary artery in 22 cases (55%). Hemostasis was achieved by applying a thrombostatic sealant in 26 cases (65%). Although patients without a vessel injury had a shorter operation time, less intraoperative blood loss, and shorter duration of chest tube drainage, no significant differences in the length of postoperative hospitalization or morbidity were observed. The occurrence rate of significant intraoperative bleeding in the last year measured was similar to that in the first year measured. Conclusions: Thoracoscopic anatomic pulmonary resection is feasible and safe if the surgeon performs appropriate hemostasis, although vascular hazards might be inherent during thoracoscopic anatomic pulmonary resection, regardless of the surgeon's experience.

Background: In recent years, opportunities to conduct anatomical segmentectomies for early stage lung cancer, metastatic lung tumor, and so on have been increasing. Generally, uniportal video-assisted thoracoscopic surgery (U-VATS) uncommon segmentectomy is technically more complicated because of limited angulation compared to multiportal VATS (M-VATS) and the need to treat peripheral vessels/ bronchi compared to common segmentectomy. This study aimed to determine the safety and feasibility of U-VATS uncommon segmentectomy compared with U-VATS common segmentectomy and M-VATS uncommon segmentectomy. Methods: We retrospectively reviewed the medical records of 76 patients in the M-VATS group and 45 patients in the U-VATS group who underwent VATS segmentectomy from January 2015 to December 2020. During that period, the perioperative results of U-VATS uncommon (n=22) segmentectomy were compared with those of U-VATS common (n=23) and M-VATS uncommon (n=37) segmentectomy. Uncommon segmentectomy was defined as any segmentectomy other than segmentectomies of the lingual, basilar, or superior segment of the lower lobe (S6), and upper division of the left upper lobe. All patients in our department underwent preoperative three-dimensional computed tomography (3D-CT) angiography and bronchography to image bronchovascular structures and determine the resection line. Results: Patients characteristics were similar between the U-VATS uncommon segmentectomy group and the U-VATS common segmentectomy group or the M-VATS uncommon segmentectomy group. In U-VATS, there were no significant differences between common and uncommon segmentectomy in operation time, postoperative drainage, postoperative hospitalization, and postoperative complications. Comparing M-VATS and U-VATS uncommon segmentectomies, operation time (145±35 vs. 185±44 min, P<0.001) and postoperative hospitalization (3.1±1.6 vs. 4.2±1.8 days, P=0.02) were significantly shorter in the U-VATS group than in the M-VATS group. There were no significant differences in blood loss, intraoperative bleeding, duration of postoperative drainage and postoperative complications. Conclusions: In U-VATS, both types of segmentectomies can be achieved with similar results. Moreover, U-VATS shortened operation time and postoperative hospitalization in uncommon segmentectomy compared with conventional M-VATS. U-VATS is a useful approach for uncommon segmentectomy.

Background: Although video-assisted thoracoscopic surgery (VATS) segmentectomy has become widespread, the advantage of uniportal VATS (U-VATS) segmentectomy over multiportal VATS (M-VATS) remains controversial. The purpose of this study was to verify the safety and usefulness of U-VATS segmentectomy compared with conventional hybrid/multiportal segmentectomy.Methods: Here, we retrospectively reviewed the data from anatomical pulmonary segmentectomy cases in a single institution from March 2010 to March 2021. Patients were divided into the U-VATS and hybrid/ multiportal VATS (H/M-VATS) groups. Perioperative results were compared between the groups after matching for patient background characteristics. In addition, cases of complex segmentectomy were selected from each group and compared in terms of perioperative results.Results: A total of 180 patients underwent pulmonary segmentectomy during the study period at this institution, comprising 57 cases in the U-VATS group and 123 cases in the H/M-VATS group. After matching for age, sex, disease, tumor location, and type of segmentectomy, no significant differences between the groups were seen in blood loss, major intraoperative bleeding, rate of conversion to thoracotomy, postoperative complications, or re-hospitalization within 30 days after discharge. Operation time (141±46 vs.174±45 min, P<0.001), postoperative drainage duration (1.5±1.2 vs. 2.3±1.8 days, P=0.007), and postoperative hospital stay (3.4±2.0 vs. 4.6±2.5 days, P=0.006) were significantly lower in the U-VATS group. Subgroup analysis of the complex segmentectomy cases also revealed that operation time (146±34 vs. 185±47 min, P<0.001), postoperative drainage duration (1.5±1.3 vs. 2.2±1.2 days, P=0.021), and postoperative hospital stay (3.0±1.4 vs. 4.9±2.1 days, P<0.001) were significantly reduced in the U-VATS group.Conclusions: U-VATS segmentectomy appears as safe and feasible as H/M-VATS segmentectomy. An experienced surgeon can make a smooth transition to U-VATS.

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