Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Abstract

Pulmonary lobectomy has been considered as the standard surgical procedure for lung cancer, since the prospective randomized controlled study published by the U.S. Lung Cancer Study Group in 1995 (1) showed a lower local recurrence rate and a better long-term survival rate when performing lobectomies compared to sublobectomies.Nevertheless, technical advances in non small cell lung cancer (NSCLC) early diagnosis and in thoracic surgery techniques have changed the treatment approach to early stage NSCLC (2,3). The extensive application of highresolution computed tomography (HRCT) in NSCLC screening programmes for high-risk former smokers has increased the detection of an even greater number of tiny NSCLC (<2 cm) and pure ground-glass opacity (GGO) lesions (4). This phenomenon has led to a modification of the 8th Edition of TNM classification of lung cancer (5), introducing tumors of ≤1 cm that are classified into a new T1a group, and had also led to the inclusion of the presence of GGO lesions as a radiological classification criterium suggestive of minimally invasive or noninvasive NSCLC (6).This scenario has renewed surgeons' interest in sublobar resections, not only for high-risk but also for fitting patients with early stage I NSCLC.Simultaneously, anatomical segmentectomies (introduced as a surgical approach to benign lesions in 1939) has reemerged as a treatment option for such less-invasive NSCLC.Compared with wedge resections, typical segmentectomies can ensure an adequate distance of the lesion from the margins, thereby reducing tumor recurrence and improving long-term survival (7) resulting in the most tailored surgical approach in the landscape of personalized medicine.

An aberrant medial basal segmental pulmonary artery (A7b) behind the superior segmental pulmonary vein (V6) in a patient undergoing right superior segment (S6) segmentectomy

“…The uVATS is a less invasive procedure with minimal postoperative pain compared with mVATS; however, more technical skills are required to perform lobectomies and segmentectomies via uVATS than via mVATS [ 5 ]. One disadvantage of uVATS using the anterior approach is poor visibility of the dorsal side of the lung compared with mVATS [ 6 ].…”

Decreased postoperative complications, neuropathic pain and epidural anesthesia-free effect of uniportal video-assisted thoracoscopic anatomical lung resection: a single-center initial experience of 100 cases

“…Among surgical approaches, U-VATS is expected to reduce postoperative neuropathic pain compared to conventional multiportal VATS (M-VATS); therefore, we have introduced U-VATS lobectomy and segmentectomy since July 2018 (18). Many reports on U-VATS have been related to safety and feasibility (2)(3)(4)(5)(6)(7)(8)(9)(10), and few studies have strictly evaluated postoperative neuropathic pain, time effects, and the necessity of epidural anesthesia.…”

“…Uniportal video-assisted thoracoscopic surgery (VATS) for major lung resections is a novel upcoming and promising approach that is gaining popularity worldwide (1)(2)(3)(4)(5)(6)(7)(8)(9)(10). It has already been introduced not only in standard operations, but also in complex techniques such as bronchoplasty or pulmonary angioplasty (11,12).…”

Uniportal video-assisted thoracic surgery basal segmentectomy: a single-center retrospective cohort study

“…Intentional lung sparing resection, such as anatomic segmentectomy, is increasingly indicated for ground-glass opacity (GGO) dominant lung cancer and comparable longterm outcomes can be achieved (1)(2)(3)(4)(5)(6). Since the earliest report of uniportal video-assisted thoracic surgery (VATS) segmentectomy published by Gonzalez-Rivas in 2012 (7), the feasibility and the potential advantages of uniportal VATS segmentectomy have been examined by various surgical groups worldwide (8)(9)(10). Basal segmentectomies (of segments 7-10) are much more technically challenging than other kinds of segmentectomies because, due to the deeper hilar structures, more frequent variations, and more complex intersegmental planes, the surgeon has to identify dominant pulmonary vein branches located deep in the lung parenchyma and find simpler methods (11).…”