C Schroeder, J Kim, P Linden
C Schroeder, J Kim, P Linden. Single Incision (Uniport) Videoscopic Lung Resection (UNIVATS). The Internet Journal of Thoracic and Cardiovascular Surgery. 2009 Volume 14 Number 2.
Thoracoscopy has become the standard for lung wedge resection and is commonly used for anatomic resection. Typically three incisions are used. Although perioperative pain may be lessened, chronic neuralgia is not uncommon. For many patients, three incisions may not be necessary. We describe a single incision method for performing lung resections which we term “UNIVATS”. All patients were discharged on postoperative day one without complication. This technique may lessen periosteal and intercostal nerve trauma and might further decrease hospital stay.
Video-Assisted Thoracoscopic Surgery (VATS) for lung resection is typically performed via three small incisions for wedge resections with enlargement of the anterior port to 4-6 cm for anatomic resections. Prior authors  have described two port techniques for both wedge and anatomic resection. Rocco and colleagues have described a single incision technique for lung resection, [2,3]. Since their initial description, little more has been published, and there are no descriptions of this technique being used in North America. With the recent interest in uniport abdominal surgery, we have re-examined the use of a Uniport VATS technique and describe our methods that have the potential to decrease the incidence of postoperative neuralgia.
Three patients underwent a Uniport VATS lung resection in our institution in January and Febuary 2009. The first patient was a 45 year old male with a history of hypertension and previous nephrectomy for a clear cell renal carcinoma.. He presented with slow and gradual enlargement of two left upper lobe nodules over the ensuing year, and a biopsy was required. The second patient was a 74 year old female, former smoker, with a history of diabetes who had an incidental finding of a lobulated 2cm nodular density in the right middle lobe. It was positron emission tomography (PET) positive and a needle-guided biopsy was non-diagnostic. The third patient was a 63 year old male who had completed neoadjuvant chemo-radiation for treatment of a distal esophageal cancer. A follow up PET scan showed a new, positive 1cm left lower lobe nodule, suspicious for a metastatic focus.
After institution of single lung ventilation in the respective lateral decubitus position, a 10 mm incision was made in the seventh interspace, anterior axillary line for both lower lobe targets and a more lateral to posterior axillary line was chosen for the middle lobe lesion. The incision site was chosen with the intention of being at least 10 cm away from the target lesion, but still anterior to the midaxillary line. Thoracoscopy of the chest was performed and the targeted areas were visualized. The 10 mm port was enlarged to 3 cm in length, with division of the intercostal muscle. Using a 5 mm 30 degree thoracoscope and a sliding action extended length curved ring clamp, an articulating 45 mm in length stapler was used to perform wedge resections. The 30 degree camera was placed laterally, looking back onto the nodule, and the stapler was articulated maximally into the lung beginning the wedge resection, and maximally in the opposite direction when finishing the wedge resection (Figure 1).
Intraoperative set up for Uniport wedge resection, using a 5 mm 30 degree thoracoscope, a sliding action extended length curved ring clamp, and an articulating 45 mm in length stapler. Since all instruments are angled and rotating, advantage is taken to optimize endoscopic view and 3-dimentional work space.
Each specimen was placed in a small endoscopic bag and removed. A 28 F chest tube was directed posteriorly to the apex and was secured with a #1 polypropelene stitch (Figure 2). The reminder of the incision was closed with two 2-0 absorbable layers and a 3-0 subcuticular layer. The chest tube was placed to waterseal later that night and was removed the next morning.
Uniport incision (3 cm) after wedge resection and chest tube placement, before skin closure.
All three patients were discharged home on postoperative day one without complication. In each patient, a single wedge resection through a single incision established the diagnosis on frozen section. Patient one was found to have disseminated metastatic renal cell carcinoma, patient two had necrotizing granuloma, and patient three was found to have a focus of organizing pneumonia and later underwent esophagectomy without complication.
Single site surgery has recently been described in a variety of abdominal procedures, and is now commonly employed in various centers throughout the United States . Thoracoscopic surgery is ideally suited to this approach as angled instruments are routinely employed to gain advantage in the setting of the rigid chest wall. After adapting the technique from single incision sympathectomy, Rocco and colleagues initially published these techniques in 2004 for a variety of intrathoracic procedures [2,3]. The reports show feasibility, and further reduction in pain, paraesthesia, immunologic injury, hospital stay, time to return to work and hospital costs in Uniport VATS compared to standard (three-portal) VATS.
We have adapted the techniques from Rocco et al. in our VATS oriented practice. In these cases, nodules were easily visible and near the surface of the lung. Nodules were chosen that were approximately 15 cm away from the incision in order to allow complete introduction of the articulated stapler and a good field of vision with the 30 degree camera. Palpitation of the nodules was not possible at this distance. Use of the articulating stapler and manipulation of the lung with an angled sliding action ring forceps allowed an angled wedge resection to be performed through a single incision.
Thoracoscopic Surgery has been shown to produce less pain, shorter chest tube duration, earlier return to work and possibly fewer perioperative complications . Although perioperative pain is lessened, postoperative neuralgia can still occur. Neuralgia usually manifests in the distribution of the intercostal nerve as hypersensitivity, paresthesia, or sharp stabbing pains and can persist for month or years. Injury to the intercostal nerve may be worsened by large diameter ports or instruments and by levering of instruments against the nerve. While the creation of a single 3 cm incision may initially seem to be no different than the creation of 3 individual 10 mm incisions, it may offer several advantages. First, the use of a relative wide anterior interspace may decrease trauma to the periosteum and intercostal nerve. Second, postoperative pain control may be improved by the need for fewer intercostal nerve blocks. Third, the use of a relatively wide incision should help decrease the likelihood of levering against the intercostal nerve. With a single incision instead of three, the incidence of postoperative neuralgia may be one-third or less than that seen with three separate intercostal incisions.