What is the current evidence for the use of uniportal Video-Assisted Thoracic Surgery (VATS)?

Evidence for Uniportal VATS: Outcomes and Clinical Applications

Uniportal video-assisted thoracic surgery (VATS) is a safe and effective alternative to conventional multiport VATS, offering comparable clinical outcomes with potential benefits of reduced postoperative pain while maintaining equivalent mortality and morbidity rates. 1

Comparison of Uniportal vs. Conventional VATS

Clinical Outcomes

Uniportal VATS demonstrates several advantages when compared to traditional open thoracotomy and multiport VATS approaches:

• Mortality: Slightly lower with VATS compared to thoracotomy (35/1000 vs 47/1000 patients) 1
• Length of hospital stay: 2.3 days shorter with VATS compared to thoracotomy 1
• Complications: Fewer with VATS (152/1000 vs 197/1000 patients) compared to thoracotomy 1
• Postoperative pain: Less with VATS compared to thoracotomy 1

When comparing uniportal to multiport VATS specifically:

• Pain scores: Significantly lower visual analogue scale (VAS) pain scores in uniportal VATS patients after surgery 2
• Operative time: No significant differences between uniportal and multiport approaches 2, 3, 4
• Blood loss: Comparable between techniques 2
• Lymph node retrieval: Similar number of lymph nodes retrieved and nodal stations explored 2, 4
• Drainage time and hospital stay: No significant differences 2, 3

Specific Applications

Lobectomy

Uniportal VATS lobectomy has been validated as a feasible alternative to conventional multiport approaches:

• The American College of Chest Physicians guidelines acknowledge that VATS lobectomy (including uniportal) is associated with fewer complications, lower blood loss, and shorter hospital length of stay compared to open procedures 1
• Completion rates vary, with studies showing 64.5% of uniportal VATS lobectomies completed without conversion 4

Pleural Disease Management

For pleural infections and other pleural diseases:

• The British Thoracic Society guidelines recognize VATS as an effective approach for managing pleural infections 1
• VATS access should be considered over thoracotomy for the surgical management of pleural infection 1

Technical Considerations

Conversion Rates

• Conversion rates from uniportal to multiport VATS or open thoracotomy vary across studies:
  • One study reported 35.5% conversion rate from uniportal VATS, including conversions to two-port VATS (18 cases), three-port VATS (4 cases), and open thoracotomy (10 cases) 4
  • Patient selection is critical to reduce conversion rates

Learning Curve

• Thoracic surgeons experienced with other thoracic surgical approaches can safely transition to performing uniportal VATS 5
• The technique is most suitable for selected patients, particularly those with early peripheral lung cancer with good anatomy and in good general condition 4

Patient Selection Considerations

The ideal candidates for uniportal VATS include:

1. Patients with early-stage lung cancer (particularly peripheral lesions)
2. Patients without extensive pleural adhesions
3. Patients with good pulmonary function
4. Patients without previous thoracic surgery

Potential Advantages of Uniportal VATS

• Reduced surgical trauma: Single incision may result in less chest wall paresthesia 2
• Cosmetic benefits: Better cosmetic results reported in some studies 6
• Postoperative pain: Some studies report lower pain scores, though not all studies confirm this finding 2, 3

Limitations and Caveats

1. Technical challenges: Uniportal VATS may be technically more demanding due to instrument crowding through a single port
2. Learning curve: Requires specific training and experience
3. Patient selection: Not all patients are suitable candidates
4. Evidence quality: Most studies are retrospective or observational with limited long-term follow-up data
5. Conversion rates: Higher conversion rates in some studies suggest careful case selection is necessary

Conclusion

Uniportal VATS represents an evolution in minimally invasive thoracic surgery that maintains the clinical benefits of conventional VATS while potentially reducing surgical trauma. While the evidence suggests comparable outcomes to multiport VATS in terms of mortality, morbidity, and oncological results, the potential advantages in postoperative pain and cosmesis require further validation through larger prospective studies with longer follow-up periods.

For centers considering implementation of uniportal VATS, appropriate patient selection, surgeon experience, and proper instrumentation are critical factors for success.