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ingle-Port Video-Assistedhoracic Surgery (Uniportal) in theoutine General Thoracic Surgical Practice

aetano Rocco, MD, FRCS(Ed), FETCS

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n the last 15 years, video-assisted thoracic surgery (VATS)has rapidly become a milestone in the thoracic surgical

rmamentarium because it enables the surgeon to offer min-mally invasive procedures as part of structured diagnosticnd therapeutic pathways of intrathoracic diseases with theame outcomes as after open techniques. In turn, minimalnvasiveness is reported to yield reduced postoperative mor-idity, duration of hospitalizations, and prompt return tooutine daily activities. VATS performed through a singleort (“uniportal”) pursues the same objectives of standardATS with even less invasiveness due to the involvement ofnly 1 intercostal space,1 thereby potentially resulting in re-uced pain and paraesthesia and shortened hospitalizationompared with traditional VATS. Currently, there are severalndications for uniportal VATS summarized in Table 1. Thiseview focuses on operative uniportal VATS, for which theontraindications are the same as for a conventional VATSpproach.2

atient Positioningnd Anesthetic Techniquesepsis is obtained as per routine thoracotomy. Usually, theatient is under general anesthesia with one-lung ventilationnd in the lateral decubitus position (Fig. 1). Uniportal VATSor undetermined pleural effusions can also be performed inhe awake patient under locoregional anesthesia through sin-le-shot epidural (see below). Once the pleural cavity is en-ered, the surgical team distributes in a convenient fashion tohe target area (Fig. 2A). The assistant—whose main role is tonsure adequate visualization of the intraoperative field—isositioned between the operating surgeon and the scruburse3 (Fig. 2B).

ivision of Thoracic Surgery, Department of Thoracic Surgery and Oncol-ogy, National Cancer Institute, Pascale Foundation, Naples, Italy.

r. Rocco reports receiving advisory board fees and honoraria from USSurgical, Norwalk, CT.

ddress reprint requests to Gaetano Rocco, MD, FRCS(Ed), FETCS, Divisionof Thoracic Surgery, Department of Thoracic Surgery and Oncology,National Cancer Institute, Pascale Foundation, Via Semmola 81, 80131

Naples, Italy. E-mail: Gaetano.Rocco@btopenworld.com

T

26 1522-2942/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1053/j.optechstcvs.2009.08.002

urgical Techniqueareful preoperative planning of the procedure is of para-ount importance. Imaging studies need to be evaluated toecide the location of the single port.1

The usual incision is 2.0- to 2.5-cm-long for operativeniportal VATS but could be shorter (halved) for diagnos-ic procedures or for sympathectomy (Fig. 3A). Access tohe intercostal space is gained by blunt dissection in aashion similar to chest drain insertion to accommodatehe surgeon’s index fingerbreadth (Fig. 3B). Care is takeno ensure adequate hemostasis at all times to avoid fre-uent cleansing of the videothoracoscope lens during therocedure.1

With uniportal VATS, the target lesion in the chest cav-ty is addressed along a craniocaudal approach, whichnables the surgeon to obtain thoracoscopic visualizationnd operate through a single port. Compared with stan-ard VATS with the attendant “baseball diamond” place-ent of ports to achieve a laterolateral approach, the en-

emble of thoracoscope and operative instruments isotated 90° on the vertical— or sagittal—axis.1 This prin-iple is maintained in all applications of this procedurend is facilitated by the utilization of articulating devices“roticulator”), which offer the ability to deploy and rotateheir intrathoracic parts so that mutual interference of theperative instruments is avoided and a 360° maneuver-bility is obtained. Similar to robotic arms, articulating

able 1 Indications for Uniportal VATS

iopsy of parietal pleura (ie, undetermined effusions)leural abrasion or pleurectomyesection of blebs/bullaeesection of peripheral (ie, outer third) pulmonary nodulesedge biopsy for diagnosis of interstitial lung diseaseediastinal lymph node biopsy and removal

horacic sympathectomyericardial windowissection of intrathoracic component of extrathoracicmasses

rauma

Single-port VATS in thoracic surgery 327

Figure 1 Patient’s positioning for uniportal VATS.

Figure 2 Distribution of the members of the surgical team during uniportal VATS (see text).

328 G. Rocco

Figure 3 (A) Typical incision measuring 2-2.5 cm, usually accommodating 1 surgeon’s fingerbreadth (B).

Single-port VATS in thoracic surgery 329

Figure 4 Initial positioning of instrumentation for uniportal VATS wedge resection of the lung.

Figure 5 Intraoperativeviewof sequence leading touniportalVATSapicalbleb resectionwith initial instrumentpositioning (A)andsubsequent completion of parenchymal stapling (B). (C) Schematic of pleurodesis obtained with pleural abrasion through a

scratchpad mounted on an articulating endograsper (see text).

330 G. Rocco

Figure 6 (A) Example of positioning of the videothoracoscope relative to target nodule in the lung (see text). Details onthe use of articulating grasping (B) and stapling (C) instrumentation for uniportal VATS wedge resection (D) andsubsequent extraction of the specimen with an endobag (E).

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Single-port VATS in thoracic surgery 331

nstruments may transfer a significant degree of the humananual dexterity inside the chest—in this case through

nly 1 VATS incision—without impairing either visualiza-ion or operative ability. An additional technical principleor this technique entails paying attention at ensuring aufficient distance between the port site and the target area

Figure 6 (Continued)

o prevent thoracoscope instruments’ interference.1 p

ocation of the Incisionhe placement of the incision is crucial to success of therocedure. For the majority of target lesions in the chest, theelected intercostal space is between the fourth and the sixth.ongitudinally, the midscapular line represents a fundamen-al anatomical reference in positioning the trocar incision.1,4

sually, posteriorly located lesions are approached throughncisions located anterior to the midscapular line—generallylong the midaxillary line. The intercostal space (as a rule, 4o 6) is selected based on the lobe on which the target lesions situated. When the middle lobe and the lobar anterioregments need to be addressed, an incision along or evenlightly (1 cm) posterior to the midscapular line is chosen.his incision will be used for chest drain placement at the endf the procedure. In particular, to facilitate placement ofrains through incisions located posterior to the mid-scapu-

ar line, a supporting roll is used alongside the patient spineo avoid kinking and to facilitate a 15 to 20° recumbentosition.

nstrumentshe operative instruments and the videothoracoscope are

nserted through the same incision, as an ensemble or se-uentially, by taking complete advantage of the laterality ofhe intercostal entry site. The intrathoracic placement of theulcrum of the articulating instruments (“roticulator”; USurgical, Norwalk, CT) prevents undue leverage on the in-ercostal bundle and allows for full adaptation to the dome-haped, curvilinear, and confined thoracoscopic space.1 As aule, the videothoracoscope is situated between the operativenstruments, but their position may be frequently changeduring the procedure1,4 (Fig. 4).For intrathoracic visualization, a 5-mm, 0° or 30° video-

horacoscope is used.1,4 For sympathectomy or sympathi-otomy, a 2.7-mm thoracoscope can be utilized. Lung sus-ension along the sagittal plane is performed with 5-mmoticulating endoscopic graspers. Likewise, roticulating en-ostaplers are used to divide the parenchyma during diag-ostic or therapeutic uniportal procedures. As a rule, 3.5-m, 45- or 60-mm-long, blue cartridges are utilized and the

nvil is articulated outside the chest. The endostapler is han-led and inserted in a way similar to the “mediastinoscopelid under the pretracheal fascia.” Articulating endograspersnd endostaplers are inserted parallel to the videothoraco-cope, taking care to retract the 5-mm trocar along the stemf the thoracoscope to increase the available maneuveringpace.

Other standard thoracoscopic instruments should beade available for use along with a long and thin Roberts’

lamp. In addition, a thoracotomy tray should be available atll times in the theater.

niportal VATS forneumothorax, Wedgeiopsy, and Pulmonary Nodules

f the patient to be treated presents with a chest drain in

lace, the same incision should be used to perform the pro-

332 G. Rocco

Figure 7 Details of uniportal VATS right sympa-thectomy begun over the second rib (A) and com-pleted over the third rib (B).

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Single-port VATS in thoracic surgery 333

edure. When the target area on the lung is easily identified,ung manipulation is reduced to a minimum but enough tonspect the lung for other emphysematous changes.5 Thendograsper is positioned on the bleb/bullae and the articu-ating arm is deployed to fully expose the diseased area1,5

Fig. 5A). The jaws of the endostapler are opened inside thehest and positioned, facing upward, just caudal to the bleb/ullae to be removed1,5 (Fig. 5B). To this purpose, the en-ograsper has to “accommodate” the parenchymal area in-ide the endostapler jaws, which can then be gently pushednto position before firing.1,5 The endostapler is fired and thendograsper repositioned more distally onto the remainingung to be resected. As a rule, up to 3 firings are usuallyeeded to complete the procedure. The specimen is thenxtracted through the same incision using an endobag orirectly with a long Roberts’ clamp.1,5

Pleural abrasion can be performed by mounting on a Rob-rts’ clamp or on the same roticulating endograsper an elec-rocautery scratchpad cut down to fit the port incision.5 Oneployment of the articulating arm of the endograsper, thecratchpad will conveniently adapt to the convexity of thenner chest cavity to start an abrasion (Fig. 5C). Alternatively,n apical pleurectomy can also be performed with the aid ofn endo kittner (endopeanut).5

When the lung is biopsied for the diagnosis of an intersti-ial parenchymal process, the selected target area is usuallyhosen based on preoperative workup imaging.6 The lung isuspended by an endograsper and “presented” to the openndostapler jaws, which are advanced as needed. The staplers closed and fired and the pulmonary edges are checked forir leaks and bleeding. This sequence is repeated as needed toemove the diseased parenchyma.6

Using the same technique,1,6 visible peripheral noduleseasuring up to 2 cm in diameter can be easily addressed

Fig. 6A) and removed through an endobag (Fig. 6B-D). Vir-ually all peripheral nodules in the lung can be resected by

uniportal VATS approach.7 Coupled with mediastinalodal sampling, the uniportal VATS wedge resection of aulmonary nodule on adequate margins is feasible in se-

ected patients with borderline cardiopulmonary functionr single metastatic deposits from extrathoracic neo-lasms.1,8 As with traditional 3-port VATS, palpation ofhe lung is hindered. However, the use of articulating en-ograspers and gentle traction enables the surgeon to mo-ilize for finger palpation areas not limited to the lungnderlying the port incision.

niportal VATSediastinal Nodaliopsy and Pericardial Window

s to the location of the incision and the insertion of theniportal operative ensemble, the same principles apply.8

owever, for masses in the anterior mediastinal compart-ent or to create a pericardial window,9 an alternative ap-

roach could be with the patient in the supine position whilehe port is located along the posterior axillary line with theperated side elevated (45°) by an axillary roll. Once theargeted nodal station is identified, it is exposed by dividing

he overlying mediastinal pleural using a roticulating grasper t

nd endoscissors.8 Moreover, an endopeanut is utilized toissect the mediastinal fat around the node, which is theniopsied in a fashion similar to standard mediastinoscopy.8

lternatively, the entire lymph node is grasped and sus-ended while an endoclip is fired at the base of the vascularedicle to secure hemostasis.8

As to the pericardial window, the side of the uniportalpproach is selected based on the most prominent pericardialulging as indicated by preoperative ultrasound and com-uted tomographic scan evidence.9 The incision is placed inhe fifth interspace along the axillary line with the patientupine or with the selected hemithorax elevated (45°) by anxillary roll. For this procedure, a 2.7- or 5-mm videothora-oscope is inserted and the pleural cavity is inspected. Anrea of the pericardium anterior to the phrenic nerve is iden-ified and a limited amount of fluid is evacuated though aericardiocenthesis under endoscopic visualization throughlong spinal needle inserted along the videothoracoscope toecompress the pericardium and to facilitate subsequentrasping. In my experience, the creation of a window anterioro the phrenic nerve is usually sufficient to ensure adequateericardial drainage. To this purpose, the parietal pericar-ium is lifted cranially with thin forceps or endograspers andpened with endoscissors inserted parallel to the videotho-acoscope. The window is completed by circumferential in-isions of the pericardium. If needed, additional diagnosticnd/or therapeutic tasks can be accomplished through theingle port. A chest tube inserted through the same incision iseft at the end of the procedure.9

niportal VATSor Sympathectomy,rauma, and Special Situations

he patient is sequentially placed on both semilateral decu-itus positions. The right side is approached first.10 The in-ision is placed at the base of the hairline in the axilla and aong 5-mm trocar is inserted to accommodate the thoraco-cope.10 The trocar sleeve is retracted along the thoraco-cope shaft and a diathermy hook is inserted. If adhesions aredentified, these are taken down using an endograsper andndoscissors as indicated. Otherwise, the resort to an en-ograsper is necessary only when the lung is incompletelyollapsed to accommodate the thoracoscope, which isushed onto the lung apex to access the sympathetic chain.10

nce the desired level of resection is selected and the corre-ponding ganglia is identified, monopolar cautery is used ondiathermy hook to divide the pleura on the rib. The heel of

he diathermy hook is gently pressed against the ganglionnd onto the rib down to the periosteum10 (Fig. 7). Care isaken at not pointing the diathermy toward sizable venousranches, which can be injured by inadvertent current trans-ission. The nerve stumps are then checked for residual

onnecting nerve bridges and further applications of theook are warranted to avoid possible future nerve regenera-ion.10 The division of all tissue down to the periosteum iserformed laterally (at least 5 cm) to include possible Kuntz’sbers responsible for symptom recurrence.10

Uniportal VATS can be utilized in patients with thoracic

rauma under stable cardiorespiratory conditions to diagnose

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leeding sources and/or remove foreign bodies.11 Throughhe same incision used for the chest drain, a 5-mm thoraco-cope may be introduced to explore the cavity and make aecision on whether a more aggressive approach is needed.n the event of a minor bleeder, hemostasis can be achievedy inserting an endoclip applier parallel to the videothoraco-cope as well as other vessel sealing instruments. The resorto a fan retractor and an endobabcock grasper (US Surgical)ay serve the purpose of removing retained objects hidden

n costophrenic recesses.11

Uniportal VATS represents a valid addition to the mini-ally invasive surgical armamentarium when a mass lesion

nvolves the cervicomediastinal area.12 While 1 surgical teamissects the neck component, the thoracic surgeon, throughsmall, strategically placed incision, can free the intrathoracic

art, thus avoiding the thoracotomy-related morbidity.12 Like-ise, uniportal VATS has also been used to dissect the ex-

raforaminal component of a dumbbell neurinoma as a partf a combined approach with the neurosurgeon (unpub-ished data).

niportal VATS forndetermined Pleuralffusions and Early Empyemas

ecent use of VATS to diagnose pleural effusions through oneort dates back to the work of several authors who, since the

ate 1980s, used the mediastinoscope to obtain histologicaliagnosis from undetermined effusions.13 With the advent ofhoracoscopy, the use of a single incision to manage pleuralffusions became more widespread.14 In brief, the biopsyorceps is inserted parallel to the videothoracoscope and thisnsemble is maneuvered consensually inside the chest cavity.he procedure can be performed under either general or localnesthesia. However, a locoregional analgesia through a sin-le shot of anesthetic agent in the epidural space at the T3-4evel allows a 3-hour pain-free interval for thoracoscopic ma-euvering (Video 1; supplementary video is available onlinet http://www.optechtcs.com). In some circumstances (ie,arly empyemas), the videothoracoscope can be used as aissector to break loculations, thereby permitting a moreffective drainage. Preferentially, nodules on the parietal/iaphragmatic pleura should be biopsied. Biopsy of smallodules on the visceral pleura may be complicated by persis-ent air leaks. Special attention should be used to avoid thentercostal bundles while obtaining a pleural biopsy. Frozenection should be available to confirm sample adequacy andature. For talc pleurodesis, the stem of the insufflators is in-erted inside the chest under direct thoracoscopic view. Perfectemostasis of the port site is mandatory to avoid wetting the tipf the insufflator. The two crucial areas for talc pleurodesis arehe diaphragm and the apex of the chest cavity, which are easilyeached through the single-port incision.

onclusionshe uniportal VATS approach is feasible, safe, and reproduc-

ble.1,4 It is meant to emphasize the clinical acumen of theurgeon in the interpretation of preoperative imaging to de-

ermine the best location for the single incision. In fact, com-

ared with traditional VATS, the use of only one port and-mm (or smaller) instruments introduced in the chest with-ut trocars may avoid multiple intercostal nerve injury.4 As aonsequence, operative or diagnostic uniportal VATS can betilized in a substantial proportion of the routine clinicalractice because its use may lead to decreased pain and par-esthesia and an attendant reduced hospitalization.15 Theatter is a major factor concurring at offsetting potential ad-itional costs generated by the use of articulating instru-ents.16

As a diagnostic tool, uniportal VATS can be used to obtainistological diagnosis of virtually all pathologic conditions inhe chest. It may obviate the need for multiple or more ex-ended incisions to diagnose/treat concomitant intrathoracicesions and can be planned at the bedside of the intensive carenit patient. As an operative procedure, uniportal VATSeems to present a variety of applications where the intratho-acic target is easily identified. A more reliable, user-friendlyreoperative marking of pulmonary nodules as well as these of flexible videothoracoscopes and the development ofmaller instrumentation for parenchymal or vessel sealingill make uniportal VATS even more appealing as a first-line

urgical approach to intrathoracic conditions in the future.

upplementary Dataupplementary data associated with this article can be found,n the online version, at doi: 10.1053/j.optechstcvs.2009.8.002.

eferences1. Rocco G, Martin-Ucar A, Passera E: Uniportal VATS wedge pulmonary

resections. Ann Thorac Surg 77:726-728, 20042. Pham DK, Balderson S, D’Amico TA: Technique of thoracoscopic seg-

mentectomy. Op Tech Thorac Cardiovasc Surg 13:188-203, 20083. Rocco G: VATS lung biopsy. The uniportal technique. Multimed Man

Cardiothor Surg 2005; doi:10.1510/mmcts.2004.0003564. Salati M, Brunelli A, Rocco G: Uniportal video-assisted thoracic surgery

for diagnosis and treatment of intrathoracic conditions. Thorac SurgClin 18:305-310, 2008

5. Calvin SH, Rocco G, Yim APC: Video-assisted thoracoscopic surgery(VATS) pleurodesis for pneumothorax. Multimed Man Cardiothor Surg2005; doi:10.1510/mmcts.2004.000349

6. Rocco G, Khalil M, Jutley R: Uniportal video-assisted thoracoscopicsurgery wedge lung biopsy in the diagnosis of interstitial lung diseases.J Thorac Cardiovasc Surg 129:947-948, 2005

7. Brunelli A, Xiume F, Refai M, et al: Bilateral staged uniportal VATS forsynchronous lung cancers. Interact Cardiovasc Thorac Surg 5:658-659,2006

8. Rocco G, Brunelli A, Jutley R, et al: Uniportal VATS for mediastinalnodal diagnosis and staging. Interact Cardiovasc Thorac Surg 5:430-432, 2006

9. Rocco G, La Rocca A, La Manna C, et al: Uniportal video-assistedthoracoscopic surgery pericardial window. J Thorac Cardiovasc Surg131:921-922, 2006

0. Rocco G: Endoscopic VATS sympathectomy: The uniportal technique.Multimed Man Cardiothorac Surg 2007; doi:10.1510/mmcts.2004.000323

1. Jutley RS, Cooper G, Rocco G: Extending video-assisted thoracoscopicsurgery for trauma: The uniportal approach. J Thorac Cardiovasc Surg131:1424, 2006

2. Givigliano F, La Rocca A, La Manna C, et al: Minimally invasive com-bined approach for an hourglass-shaped mass at the thoracic inlet.

J Thorac Cardiovasc Surg 134:528-529, 2007

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Single-port VATS in thoracic surgery 335

3. Rusch VW, Mountain C: Thoracoscopy under regional anesthesia forthe diagnosis and management of pleural disease. Am J Surg 154:274-278, 1987

4. Migliore M: Efficacy and safety of single-trocar technique for minimallyinvasive surgery of the chest in the treatment of non-complex pleuraldisease. J Thorac Cardiovasc Surg 126:1618-1623, 2003

5. Jutley RS, Khalil MW, Rocco G: Uniportal vs standard three-port

VATS technique for spontaneous pneumothorax: Comparison ofpost-operative pain and residual paraesthesia. Eur J CardiothoracSurg 28:43-46, 2005

6. Salati M, Brunelli A, Xiumè F, et al: Uniportal video-assisted thoracicsurgery for primary spontaneous pneumothorax: Clinical and eco-nomic analysis in comparison to the traditional approach. Interact Car-

diovasc Thorac Surg 7:63-66, 2008