15-year Experience With Anterior Single-port Video-assisted Thoracoscopy
Joseph M. Arcidi1, Richard E. Davis2, Paul Samm3, Wendy J. Sharp3, V. Anand Gottumukkala3, Mohanad A. Alfaqih3.
1Michigan Center for Heart Valve Surgery, Grand Blanc, MI, USA, 2Creighton University Medical Center, Omaha, NE, USA, 3Poplar Bluff Regional Medical Center, Poplar Bluff, MO, USA.
OBJECTIVE: Uniportal thoracoscopy (VATS) through a 2.5cm incision in the posterior-mid axillary line has been demonstrated to produce less postoperative pain compared to 3 ports. Since 2002, however, we have favored an anterior approach because of wider interspaces and less bucket-handle respiratory motion, and we recently updated our evolving experience.
METHODS: The clinical records of 127 consecutive anterior uniportal VATS procedures were reviewed without exclusions for surgical acuity. Mean age (±SD) was 52.7±19.9yrs (range 13-92) and 72% were male. Patients were positioned supine with double-lumen intubation unless already intubated preoperatively. A 2.5cm incision was placed just lateral to the midclavicular line, a soft tissue retractor inserted, and a 5mm-30° rigid telescope and thin-shafted instruments used simultaneously with endoscopic staplers. Spinal needles were used for endoscopic intercostal nerve blockade. Channel drains exiting through the working interspace were tunneled subpectorally or omitted if preexisting chest drains were sufficient.
RESULTS: Procedures included wedge resection in all except basilar segments (48; 26 for apical blebs/bullae with abrasion), evacuation of effusion/hemothorax (33; 9 with lateral rib fractures/flail segments), talc pleurodesis (10), decortication (9), exploration/miscellaneous biopsy (23), and extended resection for lung volume reduction (2). No repositioning for dislodgement of double-lumen tubes was needed in 98.4% of patients (125/127). There were no urgent conversions to thoracotomy. 2 of 5 patients intubated preoperatively died from their pathology. Complications in 6 patients (4.7%) included reexplorations in 4, prolonged air leak in 1, and no lung hernias. Length of stay following resection in recent spontaneous pneumothorax patients was 3.3±1.1days; 2 patients with previous contralateral 3-port operations (image) for this same indication experienced less postoperative discomfort following anterior single-port VATS and discharge on day 2 to immediate full activity.
CONCLUSIONS: Our 15-year experience with sublobar resection and drainage procedures confirms the complementary advantages of anterior and posterior single-port VATS over 3-port approaches. The anterior approach is anatomically favorable for upper and middle chest pathology, lateral chest trauma, or patients too unstable to tolerate lateral positioning.
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