Introduction
Rapid technological progress has decreased the invasiveness of thoracic surgeries, as well as the duration of postoperative rehabilitation [
1]. Since 2010, uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a new area of exploration and evolution for minimally invasive thoracic surgery [
2]. Because of excellent results, uniportal VATS lobectomy is becoming increasingly accepted [
3,
4]. We started using this surgical procedure in 2015 [
5]. However, nearly all reported uniportal VATS lobectomies were performed via an intercostal route, and intercostal incisions can result in postoperative intercostal neuralgia and chronic thoracotomy pain [
6]. Here, we report the use of a novel uniportal VATS technique involving a subxiphoid route for pulmonary lobectomy prevents these outcomes and better preserves pulmonary function. This study aims to assess the feasibility and applicability of the subxiphoid uniportal VATS approach for pulmonary lobectomy and to compare perioperative outcomes of subxiphoid uniportal and traditional three-port VATS lobectomies.
Discussion
The field of thoracic surgery is continually evolving [
9]. Since the first uniportal VATS lobectomy was performed by Gonzalez Rivas in 2011, there have been considerable improvements in techniques and reliability [
4,
10]. The advantages of uniportal VATS over traditional three-port VATS include less postoperative pain, speedier recovery, and superior cosmetic results [
11,
12]. Although postoperative pain and chest wall paresthesias can be reduced with uniportal VATS due to its minimally invasive nature, they often still occur when an incision through the intercostal space is utilized. Technological advances and innovative devices have led to the development of a novel uniportal VATS involving a subxiphoid approach [
10]. Initially, this procedure was applied to pneumothorax operations, metastasectomies, and mediastinal tumor resections [
11‐
13]. However, as demonstrated here, the use of novel uniportal VATS approaches for lobectomies has proved quite successful.
In this study, we compared the outcomes of pulmonary lobectomy via subxiphoid uniportal VATS with traditional three-port VATS. We found no significant between-group differences in the number of retrieved lymph nodes, number of explored nodal stations, blood loss, drainage time, postoperative complications, or length of hospital stay. Compared with other reports [
14], the average number of resected lymph nodes was lower in our study. This can be explained by our routine performance of en-bloc resection of lymph nodes during mediastinal lymphadenectomy. During our procedures, we dissected and investigated over six stations of lymph nodes during mediastinal lymphadenectomy, including at least three mediastinal lymph node stations. Specifically, in our center, we conventionally dissect stations #2, 4, 7, 9, 10, 11, and 12 during right pneumonectomies, and stations #5, 6, 7, 9, 10, 11, and 12 lymph nodes during left pneumonectomies. Dissection of #7 lymph nodes is often relatively difficult. During our procedures, we pulled the lobes forward along the mediastinum below the bronchus and resected lymph nodes en-bloc. We feel this is an effective approach; as previously noted, the two groups did not differ in the number of retrieved lymph nodes or the number of explored nodal stations.
Besides the number of resected lymph nodes, other surgical outcomes in our center, including blood loss, drainage time, postoperative complications, and length of hospital stay, were mostly in accordance with other published results [
15‐
17]. The positioning of patients and general surgical techniques followed Dr. Chia-Chuan Liu’s subxiphoid incision approach [
16]. His techniques helped us to adapt to the new approach, and complete the operation proficiently. However, we used some extended laparoscopic instruments to better access to certain surgical regions. Our retrospective study had a limited sample size, and the next step is to expand surgical cases via subxiphoid VATS. These experiences will be summarized in future publications.
In early surgeries at our hospital, we utilized three ports by conventional thoracoscopic access. With increased technical proficiency, we were eventually able to complete the operation using one port through the thoracic cage. Now the majority of thoracic surgeries are performed with single-port VATS at our center. More importantly, we have found that the intensity of postoperative pain following the single-port approach is indeed lower than after the three-port approach. We have compared the results of procedures performed through the thoracic cage using either three ports or one port in a previous study [
5]; despite the number of ports, patients continued to experience intercostal neuralgia. Thus, we began to explore uniportal subxiphoid VATS and to investigate advantages of the uniportal approach over the three-port conventional VATS. Because this technique and approach were new to us and synchronous bilateral pulmonectomies were performed in the subxiphoid uniportal VATS group, operative times for this group were somewhat prolonged. Substantially less time will likely be required for subxiphoid uniportal VATS lobectomies with increased experience and enhanced instrumentation. Finally, we found that VAS pain scores were significantly lower after surgery in the subxiphoid uniportal VATS lobectomy group than in the other group. We attributed this difference to decreased incidence of intercostal nerve injury and access trauma.
We have noted several advantages of the uniportal subxiphoid approach in this study. First, there was no limitation of shoulder movement after subxiphoid uniportal VATS, because thoracic integrity was maintained. Second, this approach involves a low risk of pulmonary complications. All the advantages above have overt benefits for enhanced recovery after surgery (ERAS) [
18]. Third, for patients with bilateral pulmonary lesions, subxiphoid uniportal VATS allows synchronous bilateral pulmonectomies. Furthermore, compared with other approaches, subxiphoid uniportal VATS has superior aesthetic outcomes, with no visible chest scars.
Subxiphoid uniportal VATS lobectomy may have certain limitations under certain technical conditions. First, it is difficult to use this approach to perform complex thoracic procedures, such as surgeries in patients who have received prior thoracic irradiation and induction therapy, sleeve lobectomies, and vascular reconstructions. Second, bleeding control for vascular injuries may be significantly harder to achieve when using this approach. Third, the heart may be compressed, or arrhythmias may be encountered when passing instruments into the left chest. However, we are convinced that these weaknesses will be overcome with the continuous development of videoendoscopic instruments and endosurgical techniques.
In our study, we retrospectively analyzed the advantages and disadvantages of uniportal subxiphoid VATS in pulmonectomies compared to traditional VATS. Our recent experience demonstrates that subxiphoid uniportal VATS lobectomy is a safe and feasible surgical procedure with excellent postoperative results, particularly for patients with bilateral pulmonary lesions. However, subxiphoid uniportal VATS lobectomy is a relatively complex procedure, and appropriate expertise and instruments are critical to its success. Moreover, further analyses of subxiphoid uniportal VATS lobectomy should be conducted with more patients to better evaluate the potential and promise of this approach.
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