Portal de Periódicos da CAPES

One-port (uniportal) video-assisted thoracic surgical resections—A clear advance

2012; Elsevier BV; Volume: 144; Issue: 3 Linguagem: Inglês

10.1016/j.jtcvs.2012.06.006

1097-685X

Gaetano Rocco,

Gastric Cancer Management and Outcomes

One-port (uniportal) video-assisted thoracic surgery (VATS) consists of approaching an intrathoracic target lesion through a sagittal, craniocaudal plane through 1 single-port incision. The use of articulating instruments inserted parallel to the videothoracoscope enables the surgeon to mimic inside the chest the maneuvers that are usually performed during open surgery. Through this VATS approach, several thoracic conditions can be addressed, including lung cancer in selected patients. Unlike conventional, 3-port VATS, the uniportal VATS technique enables the surgeon to bring the operative fulcrum inside the chest when the target lunge lesion is approached through a sagittal plan, thanks to articulating instruments. Uniportal wedge VATS resections of peripheral nodules can help in solving diagnostic dilemmas, be of therapeutic benefit, and provide tissue for biomolecular studies. One-port (uniportal) video-assisted thoracic surgery (VATS) consists of approaching an intrathoracic target lesion through a sagittal, craniocaudal plane through 1 single-port incision. The use of articulating instruments inserted parallel to the videothoracoscope enables the surgeon to mimic inside the chest the maneuvers that are usually performed during open surgery. Through this VATS approach, several thoracic conditions can be addressed, including lung cancer in selected patients. Unlike conventional, 3-port VATS, the uniportal VATS technique enables the surgeon to bring the operative fulcrum inside the chest when the target lunge lesion is approached through a sagittal plan, thanks to articulating instruments. Uniportal wedge VATS resections of peripheral nodules can help in solving diagnostic dilemmas, be of therapeutic benefit, and provide tissue for biomolecular studies. A MEDLINE search of the term "single port surgery" performed in August 2011 revealed more than 1200 results. In particular, several general surgical, urologic, and gynecologic papers are focused on the technique and instrumentation of single-port laparoscopic surgery.1Curcillo 2nd, P.G. Podolsky E.R. King S.A. The road to reduced port surgery: from single big incisions to single small incisions, and beyond.World J Surg. 2011; 35: 1526-1531Crossref PubMed Scopus (37) Google Scholar Single-access concept merges with natural-orifice transluminal endoscopic surgery by virtue of the transumbilical abdominal procedures recently performed and described in detail.2Lee Y.S. Kim J.H. Moon E.J. Kim J.J. Lee K.H. Oh S.J. et al.Comparative study on surgical outcomes and operative costs of transumbilical single-port laparoscopic appendectomy versus conventional laparoscopic appendectomy in adult patients.Surg Laparosc Endosc Percutan Tech. 2009; 19: 493-496Crossref PubMed Scopus (57) Google Scholar Furthermore, single-port robotic devices are being tested for use in abdominal robot-assisted surgery.3Wren S.M. Curet M.J. Single-port robotic cholecystectomy: results from a first human use clinical study of the new da Vinci single-site surgical platform.Arch Surg. 2011; 146: 1122-1127Crossref PubMed Scopus (96) Google Scholar In this setting, the latest technologic refinements aim at facilitating concomitant introduction and operative use of more than one instrument at a time in addition to the selected visualization system. Specific devices have been studied for tie-knotting, stapling, and tissue handling with superb results in terms of maneuverability and user-friendliness. When it comes to single-port (or uniportal) thoracoscopic surgery, the technologic gap is obvious. The surgical technique and current indications for single-port (uniportal) operative video-assisted thoracic surgery (VATS) have been described in detail elsewhere.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar Nevertheless, thoracic surgeons still use adapted instruments from general surgery despite the potential use of single-port operative VATS for many purposes.6Berlanga L.A. Gigirey O. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single-incision laparoscopic surgery port: a feasible and safe procedure.Surg Endosc. 2011; 25: 2044-2047Crossref PubMed Scopus (45) Google Scholar Indeed, diagnostic uses of uniportal VATS include diagnosis and treatment of pleural, mediastinal, and chest wall conditions.7Rocco G. La Rocca A. La Manna C. Scognamiglio F. D'Aiuto M. Jutley R. et al.Uniportal video-assisted thoracoscopic surgery pericardial window.J Thorac Cardiovasc Surg. 2006; 131: 921-922Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 8Jutley R.S. Khalil M.W. Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia.Eur J Cardiothorac Surg. 2005; 28: 43-46Crossref PubMed Scopus (195) Google Scholar, 9Rocco G. Khalil M. Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases.J Thorac Cardiovasc Surg. 2005; 129: 947-948Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 10Rocco G. Brunelli A. Jutley R. Salati M. Scognamiglio F. La Manna C. et al.Uniportal VATS for mediastinal nodal diagnosis and staging.Interact Cardiovasc Thorac Surg. 2006; 5: 430-432Crossref PubMed Scopus (36) Google Scholar, 11Givigliano F. La Rocca A. La Manna C. Busiello L. Longo F. Scognamiglio F. et al.Minimally invasive combined approach for an hourglass-shaped mass at the thoracic inlet.J Thorac Cardiovasc Surg. 2007; 134: 528-529Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 12Jutley R.S. Cooper G. Rocco G. Extending video-assisted thoracoscopic surgery for trauma: the uniportal approach.J Thorac Cardiovasc Surg. 2006; 131: 1424Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Uniportal pulmonary resections vary from wedge resections for diagnostic purposes to wedge for pneumothorax and solitary pulmonary nodules located in the outer third of the lung.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar Technical mainstays of operative uniportal VATS include a single incision anywhere from 0.5 to 1 cm (ie, sympathectomy) up to 2.5 cm wide, blunt dissection to the pleural plane, and simultaneous introduction of articulating operative instruments parallel to a 5-mm (or lesser size) 0° or 30° videothoracoscope.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar The placement of the incision depends on the location of the target area in the chest. In this setting, careful interpretation of chest computed tomography is mandatory, bearing in mind that an adequate distance between the single port and the target area needs to be allowed to avoid instrument–videothoracoscope interference.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar As a rule, the most appropriate intercostal space identified at a latitudinal, horizontal level is between the fourth and the sixth. The vertical, longitudinal line is selected either anterior or posterior to the midscapular line.1Curcillo 2nd, P.G. Podolsky E.R. King S.A. The road to reduced port surgery: from single big incisions to single small incisions, and beyond.World J Surg. 2011; 35: 1526-1531Crossref PubMed Scopus (37) Google Scholar, 4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar Usually, posteriorly located lesions are approached through incisions located anterior to the midscapular line—generally along the midaxillary line (Table 1).Table 1Criteria for single-port locationAdapted with permission from Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin. 2008;18:305-10.ProcedureIntercostal spaceLineDecubitusBullectomyFifthPostero–median axillary lineLateralLung biopsy–lung resection Upper lobesFifthMedian axillary lineLateral Middle lobe - LingulaFifth–sixthPosterior axillary–scapular lineLateral Lower lobesFourthMedian–posterior axillary laneLateralMediastinal node biopsy Middle mediastinumFifthScapular lineLateral Posterior mediastinumFifthPosterior axillary lineSupineSympathectomyThirdAxillary hair lineLateralPericardial windowFifthAxillary lineSupine, semilateral Open table in a new tab Uniportal VATS wedge pulmonary resection technique is based on a completely different geometric concept compared with conventional 3-port VATS (Figure 1). In fact, the approach to the target lesion in the lung is substantially similar to the approach that the surgeon would use in open surgery. In the latter scenario, the visualization of the target lesion and its surgical removal would occur along the same axis. Therefore, the target lesion in the lung would be elevated with forceps perpendicularly from the parenchymal profile and resected by applying a stapler (or a curved clamp and oversewn) at the base of this newly created, cone-shaped parenchymal area. A pure geometric explanation of the potential advantage of uniportal VATS compared with conventional 3-port VATS lies in the projective plane of the sagittal approach to the target lesion, which preserves the depth of intraoperative visualization provided by the currently available 2-dimensional video monitors.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar, 13Bertolaccini L. Rizzardi G. Terzi A. Single-port video-assisted thoracic surgery resection: the Copernican revolution of a geometrical approach in thoracic surgery?.Interact Cardiovasc Thorac Surg. 2011; 12: 516Crossref PubMed Google Scholar Conversely, the torsion plane created along the lozenge obtained with conventional VATS using the laterolateral approach hampers a distinct visualization of the perspective, deep operative field.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar, 13Bertolaccini L. Rizzardi G. Terzi A. Single-port video-assisted thoracic surgery resection: the Copernican revolution of a geometrical approach in thoracic surgery?.Interact Cardiovasc Thorac Surg. 2011; 12: 516Crossref PubMed Google Scholar The single incision needs to be placed on a direct line leading to the target area but at a distance sufficient to allow for deploying articulating arms of endograsps and endostaplers.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar In fact, in the lateral decubitus position, these articulating instruments, like robotic arms, clearly adapt to the fixed dome-shaped volumetry of the pleural cavity.5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar More recently, following the geometric principles of uniportal VATS wedge resection, single-access lobectomies have been described as a part of the surgical armamentarium of a VATS lobectomy program in Spain.14Gonzalez-Rivas D. Paradela M. Fieira E. Velasco C. Single-incision video-assisted thoracoscopic lobectomy: initial results.J Thorac Cardiovasc Surg. 2012; 143: 745-747Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Traditional VATS can be performed safely under local anesthesia and sedation.15Katlic M.R. Facktor M.A. Video-assisted thoracic surgery utilizing local anesthesia and sedation: 384 consecutive cases.Ann Thorac Surg. 2010; 90: 240-245Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Uniportal VATS can be done under locoregional anesthesia and without intubation in the awake patient for most of the already reported indications, including wedge pulmonary resection.16Rocco G. Romano V. Accardo R. Tempesta A. La Manna C. La Rocca A. et al.Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting.Ann Thorac Surg. 2010; 89: 1625-1627Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Furthermore, a no-drain policy can be adopted for straightforward wedge resections along the same line as for uniportal sympathectomy or uniportal biopsy or removal of mediastinal lymph nodes.16Rocco G. Romano V. Accardo R. Tempesta A. La Manna C. La Rocca A. et al.Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting.Ann Thorac Surg. 2010; 89: 1625-1627Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 17Rocco G. Cicalese M. La Manna C. La Rocca A. Martucci N. Salvi R. Ultasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery.Ann Thorac Surg. 2011; 92: 1099-1101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Locoregional anesthesia is usually administered through an epidural catheter introduced at the level of the fourth to fifth thoracic vertebrae. The catheter is left in place even though only a single-shot injection of local anesthetic is injected, which is supposed to ensure pain control for at least 3 hours. In addition, the epidural catheter may contribute to pain management in the event of an unanticipated conversion to thoracotomy.16Rocco G. Romano V. Accardo R. Tempesta A. La Manna C. La Rocca A. et al.Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting.Ann Thorac Surg. 2010; 89: 1625-1627Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 18Rocco G. La Rocca A. Martucci N. Accardo R. Awake single-access (uniportal) video-assisted thoracoscopic surgery for spontaneous pneumothorax.J Thorac Cardiovasc Surg. 2011; 142: 944-945Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Although no prospective, randomized trials have been generated so far to compare uniportal versus conventional VATS, the evidence in the literature is growing as to the lesser impact of uniportal VATS in terms of postoperative pain and paresthesia.8Jutley R.S. Khalil M.W. Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia.Eur J Cardiothorac Surg. 2005; 28: 43-46Crossref PubMed Scopus (195) Google Scholar, 19Salati M. Brunelli A. Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions.Thorac Surg Clin. 2008; 18: 305-310Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 20Atkinson J.L. Fode-Thomas N.C. Fealey R.D. Eisenach J.H. Goerss S.J. Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period.Mayo Clin Proc. 2011; 86: 721-729Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Conventional VATS seems to induce less postoperative pain than do thoracotomy or hybrid procedures.21Miyazaki T. Sakai T. Tsuchiya T. Yamasaki N. Tagawa T. Mine M. et al.Assessment and follow-up of intercostal nerve damage after video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2011; 39: 1033-1039Crossref PubMed Scopus (45) Google Scholar Reportedly, residual pain after VATS may subside in 12 weeks after surgery.21Miyazaki T. Sakai T. Tsuchiya T. Yamasaki N. Tagawa T. Mine M. et al.Assessment and follow-up of intercostal nerve damage after video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2011; 39: 1033-1039Crossref PubMed Scopus (45) Google Scholar Injury of the intercostal neurovascular bundle is the major determinant of postoperative complaints,21Miyazaki T. Sakai T. Tsuchiya T. Yamasaki N. Tagawa T. Mine M. et al.Assessment and follow-up of intercostal nerve damage after video-assisted thoracic surgery.Eur J Cardiothorac Surg. 2011; 39: 1033-1039Crossref PubMed Scopus (45) Google Scholar no matter how big the port incision compared with conventional port size.22Sihoe A.D. Cheung C.S. Lai H.K. Lee T.W. Thung K.H. Yim A.P. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis.Eur J Cardiothorac Surg. 2005; 27: 313-319Crossref PubMed Scopus (28) Google Scholar Indeed, 50% of the patients subjected to needlescopic VATS for palmar hyperhydrosis had significant paresthesia, especially for the incisions placed in the mammary fold.22Sihoe A.D. Cheung C.S. Lai H.K. Lee T.W. Thung K.H. Yim A.P. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis.Eur J Cardiothorac Surg. 2005; 27: 313-319Crossref PubMed Scopus (28) Google Scholar After 1 year, 17% of the patients in the series reported by Sihoe and colleagues22Sihoe A.D. Cheung C.S. Lai H.K. Lee T.W. Thung K.H. Yim A.P. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis.Eur J Cardiothorac Surg. 2005; 27: 313-319Crossref PubMed Scopus (28) Google Scholar still had residual paresthesia. The authors concluded that there was no difference between needlescopic and conventional 3-port VATS in terms of postoperative paresthesia.22Sihoe A.D. Cheung C.S. Lai H.K. Lee T.W. Thung K.H. Yim A.P. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis.Eur J Cardiothorac Surg. 2005; 27: 313-319Crossref PubMed Scopus (28) Google Scholar Passlick and associates23Passlick B. Born C. Sienel W. Thetter O. Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax.Eur J Cardiothorac Surg. 2001; 19: 355-358Crossref PubMed Scopus (92) Google Scholar reported on chronic postoperative pain after 3-port VATS in the management of pneumothorax. In the reported series, 12-mm, 10-mm, and 5-mm trocars had been used in their patients; 32% of them reported residual chronic pain particularly at the port sites.23Passlick B. Born C. Sienel W. Thetter O. Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax.Eur J Cardiothorac Surg. 2001; 19: 355-358Crossref PubMed Scopus (92) Google Scholar The authors concluded that these findings had to be taken into consideration when offering pneumothorax patients the option of chest drain or minimally invasive procedure.23Passlick B. Born C. Sienel W. Thetter O. Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax.Eur J Cardiothorac Surg. 2001; 19: 355-358Crossref PubMed Scopus (92) Google Scholar In this setting, the awake uniportal technique may settle the issue of whether to surgically manage first episodes of pneumothorax.18Rocco G. La Rocca A. Martucci N. Accardo R. Awake single-access (uniportal) video-assisted thoracoscopic surgery for spontaneous pneumothorax.J Thorac Cardiovasc Surg. 2011; 142: 944-945Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Uniportal VATS could be performed through the same incision of the chest drain placed in the accident and emergency department or, in young female patients, a cosmetically acceptable port site can be selected avoiding the mammary area and the attendant paresthesia.22Sihoe A.D. Cheung C.S. Lai H.K. Lee T.W. Thung K.H. Yim A.P. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis.Eur J Cardiothorac Surg. 2005; 27: 313-319Crossref PubMed Scopus (28) Google Scholar In an era of managed care, uniportal VATS needed to be compared with conventional VATS as to duration of hospitalization and postoperative costs.24Salati M. Brunelli A. Xiumè F. Refai M. Sciarra V. Soccetti A. et al.Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach.Interact Cardiovasc Thorac Surg. 2008; 7: 63-66Crossref PubMed Scopus (91) Google Scholar In this setting, Salati and colleagues24Salati M. Brunelli A. Xiumè F. Refai M. Sciarra V. Soccetti A. et al.Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach.Interact Cardiovasc Thorac Surg. 2008; 7: 63-66Crossref PubMed Scopus (91) Google Scholar analyzed a small selected series of patients subjected to uniportal VATS for pneumothorax. Besides a significant difference in the incidence of postoperative paresthesia (P < .0001), uniportal VATS patients had a shorter hospital stay (P = .03) and generated lower postoperative costs (P = .03).24Salati M. Brunelli A. Xiumè F. Refai M. Sciarra V. Soccetti A. et al.Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach.Interact Cardiovasc Thorac Surg. 2008; 7: 63-66Crossref PubMed Scopus (91) Google Scholar In addition, in a series from the Mayo Clinic of 155 patients subjected to sympathotomy at the level of the first or second thoracic vertebrae, no intercostal neuralgia was noted perioperatively or at 34 months' median follow-up.20Atkinson J.L. Fode-Thomas N.C. Fealey R.D. Eisenach J.H. Goerss S.J. Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period.Mayo Clin Proc. 2011; 86: 721-729Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar As with conventional VATS, the ability to palpate the lung is limited—but not impossible—through uniportal VATS.4Rocco G. Martin-Ucar A. Passera E. Uniportal VATS wedge pulmonary resections.Ann Thorac Surg. 2004; 77: 726-728Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 5Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice.Op Tech Thorac Cardiovasc Surg. 2009; 14: 326-335Abstract Full Text Full Text PDF Scopus (18) Google Scholar Accordingly, the identification of peripheral pulmonary nodules must rely on visual inspection or on their preoperative or intraoperative marking.17Rocco G. Cicalese M. La Manna C. La Rocca A. Martucci N. Salvi R. Ultasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery.Ann Thorac Surg. 2011; 92: 1099-1101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Recently, an articulating endoscopic ultrasound probe was used to detect peripheral nodules during uniportal VATS.17Rocco G. Cicalese M. La Manna C. La Rocca A. Martucci N. Salvi R. Ultasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery.Ann Thorac Surg. 2011; 92: 1099-1101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Endoscopic ultrasounds have proved useful in outlining ground glass opacities in the pulmonary parenchyma.17Rocco G. Cicalese M. La Manna C. La Rocca A. Martucci N. Salvi R. Ultasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery.Ann Thorac Surg. 2011; 92: 1099-1101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The addition, the articulating endoscopic ultrasound probe of an echo Doppler device allows for assessing the vascular supply (hence, a hint on the malignant nature of the lesion) and the depth of the nodule.17Rocco G. Cicalese M. La Manna C. La Rocca A. Martucci N. Salvi R. Ultasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery.Ann Thorac Surg. 2011; 92: 1099-1101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In this context, operative uniportal VATS can be an interesting approach to primary and secondary lung cancers, with both a diagnostic and therapeutic intention in patients with borderline cardiorespiratory function or advanced age.16Rocco G. Romano V. Accardo R. Tempesta A. La Manna C. La Rocca A. et al.Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting.Ann Thorac Surg. 2010; 89: 1625-1627Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 17Rocco G. Cicalese M. La Manna C. La Rocca A. Martucci N. Salvi R. Ultasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery.Ann Thorac Surg. 2011; 92: 1099-1101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 24Salati M. Brunelli A. Xiumè F. Refai M. Sciarra V. Soccetti A. et al.Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach.Interact Cardiovasc Thorac Surg. 2008; 7: 63-66Crossref PubMed Scopus (91) Google Scholar However, the established concept of targeted therapy for patients with non–small cell lung cancer based on new clinical and biomolecular evidence has prompted the resurgence of interest for sublobar pulmonary resections for early-stage non–small cell lung cancer.25Ettinger D.S. Akerley W. Bepler G. Blum M.G. Chang A. Cheney R.T. NCCN Non-Small Cell Lung Cancer Panel Members et al.Non-small cell lung cancer.J Natl Compr Canc Netw. 2010; 8: 740-801PubMed Google Scholar In this context, operative uniportal VATS could be considered as a means to resect nodules located in the outer third of the lung and less than 2 cm in diameter provided that the following are true: (1) pure bronchoalveolar carcinoma histology, (2) ground glass opacity appearance for more than 50% of the lesion as per computed tomographic scan assessment, (3) extended doubling time (>400 days), and (4) resection margin of at least 2 cm or equal to/greater than the size of the nodule.25Ettinger D.S. Akerley W. Bepler G. Blum M.G. Chang A. Cheney R.T. NCCN Non-Small Cell Lung Cancer Panel Members et al.Non-small cell lung cancer.J Natl Compr Canc Netw. 2010; 8: 740-801PubMed Google Scholar In conclusion, uniportal VATS represents a clear advantage for selected indications and a valuable addition to the surgical armamentarium complementing other single-port/single-access procedures, such as endobronchial ultrasound biopsy of mediastinal masses, video-assisted mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy, and transcervical extended mediastinal lymphadenectomy (Table 2). Technologic advancements aimed at manufacturing custom-made instrumentation for thoracoscopic surgery will be equally decisive in facilitating the single-port technique under local or locoregional anesthesia. However, further developments in the use of uniportal VATS will be represented by its use as the minimally invasive technique of choice for pulmonary tissue procurement aimed at biomolecular investigations, as the geometric approach to the chest cavity useful to minimize surgical trauma during robotic procedures, and, possibly, as the procedure paving the way to natural-orifice transluminal endoscopic surgery—intuitively, a single-access procedure—in our domain.Table 2Intrathoracic conditions, suggested anesthetic management, chest drain policy, and operative settings for uniportal VATSConditionUniportal VATSAnesthetic modalityDrainSettingNotesPleural effusionDiagnosticLocalLocoregionalYesOutpatient—TraumaDiagnosticGeneralYesIn HospitalHemodynamic stabilityPericardial effusionOperative (window)LocoregionalGeneralYesIn HospitalHemodynamic stabilityStage I/II empyemaDiagnostic/operative (loculations)LocalLocoregionalYesIn Hospital—Interstitial lung diseaseOperative (wedge)LocoregionalNoOutpatient—SympathectomyOperativeLocoregionalNoOutpatientBilateralNodal biopsyDiagnosticGeneralLocoregionalNoIn Hospital—LymphadenectomyOperativeGeneralYesIn Hospital—Primary pneumothoraxOperative (pleurectomy/abrasion)LocoregionalYesIn hospitalOutpatient—Peripheral subpleural noduleOperativeLocoregionalNoIn hospitalOutpatientIntraoperative ultrasoundPeripheral nodule (outer third of the lung)OperativeGeneralLocoregionalNoIn hospitalOutpatientIntraoperative ultrasoundChest wall lesionOperativeGeneralYesIn hospital—VATS, Video-assisted thoracic surgery. Open table in a new tab VATS, Video-assisted thoracic surgery.