The uniportal approach for major pulmonary resections began in 2010, with the first case being reported by D González-Rivas and colleagues in La Coruña, Spain. Since then, in different countries, thoracic surgeons had been performing hundreds of cases, with more advanced and complex procedures. Nowadays, there are reports of uniportal tracheal resection and reconstruction, carinal resection, bronchoplastic procedures, lobectomies with chest wall excision, and vascular reconstruction with optimal outcomes. The development of technologies and the potential benefits of a direct view, anatomic instrumentation, better cosmesis, and, potentially, less postoperative pain have led uniportal video-assisted thoracic surgery to grow exponentially worldwide.

Surgical treatment for non-small cell lung cancer (NSCLC) involving trachea and carina is one of the most infrequent and challenging procedures for a thoracic surgeon, requiring careful preoperative assessment, high level management of the airway, advanced surgical technique and appropriate postoperative care. Carinal and tracheal resections with lung sparing, and carinal sleeve pneumonectomy are part of these complex techniques, with a variable rate of morbidity and mortality. To prevent complications, the most important aspect of the technique is for reconstruction to be performed without tension and with a good blood supply. If a complication is suspected, it must be diagnosed at an early stage, and the problem must be handled aggressively to avoid further progression. The majority of cases are performed with an open approach, but under the care of surgeons and anesthesiologists experienced in minimally invasive thoracic procedures, with advanced airway management skills, in high volume referral centers, these procedures can be performed safely with video-assisted thoracic surgery to obtain good postoperative results. In recent years, with the rapid development of uniportal video assisted thoracic surgery (VATS), this approach resulted in shorter postoperative stays, less postoperative pain and faster recovery after surgery, maintaining oncological principles, becoming an excellent alternative for these difficult cases. This article aims to review the specific considerations that involve this kind of tumors, surgical technique and anesthesiology options, and the recent shift to a minimally invasive approach.

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Bolaños-Cubillo A. Minimally invasive thoracic surgery in lung cancer: respecting oncologic principles is the key. Ann Transl

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Despite the widespread adoption of uniportal video-assisted thoracoscopic surgery (UniVATS) for lung cancer, some procedures are still rarely performed with this approach. A minimally invasive approach is seldom selected to perform a pneumonectomy for a number of different reasons, usually involving the experience of the surgeon and the specific characteristics of cases requiring pneumonectomy as a treatment. Some surgeons believe that because of the complexity of such cases involving large tumors and usually some sort of hilum compromise, a minimally invasive technique cannot be safely performed.Safety involved in performing this procedure is more related to the surgeon experience in the approach than to the procedure itself, and it mostly depends on prior exposure to complex uniportal cases. In a time when several groups around the world are performing bronchovascular reconstructions, carinal resections by UniVATS the question should not be if is possible to perform UniVATS pneumonectomy, but what are the factors and considerations the surgeon must take into account in order to perform these cases. This review aims to provide an update on current status of uniportal VATS pneumonectomy and to provide guidance for surgeons who face this sort of cases.

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