• Carlos Galvez Muñoz

How to start with the Uniportal VATS

This post is focused on those who haven't started yet their learning with Uniportal VATS or have minimal experience with it. Many people who usually perform open approach or multiportal VATS, feel unsafe and less confident with only one incision where all the instruments and the camera should get in at the same time. I just want to show some basic trick to make it more comfortable.


First of all, the reasons I love uniportal VATS are the minimal pain patients report, and the view through the anterior incision, where all the tools get inside the pleural cavity from the same point, which coincides with the camera direction, so your mind doesn't need any mental process as in the biportal or multiportal VATS.


Usually the skin incision doesn't need to be longer than 4-5 cm (maybe 1 cm longer in obese patients), but you can get a bit more incision below the skin in the intercostal space: you are going to compress during the procedure only 1 intercostal nerve, no matter how long the incision, so start with longer incisions and decrease it progressively as you get more confident (I usually perform it 3-4 cm).

Although some expertise surgeons reject soft surgical wound retractors, I find them really useful and always use one (Alexis Wound Protector, Applied Medical; SurgiSleeve Wound Protector, Medtronic). They are useful to avoid the annoying fatty tissue that dirties the camera many times.


One of the main principles of uniportal VATS, although there are some steps to break this rule, is that the best position for the thoracoscope is the superior part of the incision, so the assistant should take care of this during all the procedure. This superior position, lets the surgeon work more comfortable through almost the whole incision with the remaining instruments.



Which are the exceptions? For releasing adhesions in the most anterolateral part of the cavity, if you put the thoracoscope in the lower part, the surgeons feels glad with the energy devices because he/she gets a better angle to release them. Other exception could be when I'm performing lobectomies or anatomical segmentectomies, I find very useful for dividing the fissure, to attach 2 crossed graspers at both sides of the fissure, put the endostapler in the lower part of the incision to embrace the fissure, and after checing its right position with the thoracoscope above, then I swift it towards the lower part of the incision, just below the thoracoscope, so as using the 30º degrees you can check the anvil position in relation to the hilum structures.



Other aspect many uniportal beginners find troublesome is that many times, camera assistant and the surgeon get in conflict with the space, by hitting their hands with their instruments. There are some tricks to meake it easier, but remember that these are not easy procedures, sometimes it's unavoidable. First, use a 30º degree thoracoscope, so as the camera assistant will be able to direct the tip of the scope far from the surgeon's instruments, and then just rotate the degrees to give the surgeon his desired view.



Second, if you use energy devices such as Maryland LigaSure (Medtronic) or Harmonic Ace (Ethicon), you can choose the longer instrument (for example the 37 cm and the 36 cm respectively). This way, your dominant hand is located in a position further position to the incision that the not dominant hand usually handling a grasper or suction that are not so longer instruments. For this purpose, lower the operating bed as much as possible, and if you need it, use some kind of step to get positioned in a higher position so as you can use the energy device in an ergonomic position.


Although sometimes you will feel that it's impossible to perform a specific step, specially in difficult cases, with this approach, it is always possible, just need to train and find your way. For example, surgeons used to multiportal VATS, find very hard to put the vascular endostaplers in some situations, but there is always a way for it. As I will show in future posts, and as I always say, surgical steps are not always the same; you have to develop your own resources and adapt to every specific procedure. In the RULobectomy, I find much more comfortable to divide first the arterial superior trunk, then the RUL bronchus, and then you can divide the RUL vein easier than if you want to do it before the bronchus; it's just a matter of angles and risks.


Due to this, uniportal VATS surgeons develop many resources that make safer and cheaper the procedures: as you find some steps difficult because of the angle for dividing a specific structure, you begin to perform endoscopic ligatures, using endoclips so as your resources increase while your confidence settles.


Finally, closing the uniportal wound is easy but there are some importants aspects. When I finish my procedure, I remove everything, including the wound protector, and put a absorbable 1-0 suture in the muscle in the superior part of the incision. Before tying it, I introduce the chest tube above it, so as when you tye the suture, the tube remains in the superior part of the incision. I position it inside the chest in a apical posterolateral position, to remove air from the surgical pneumothorax and to drain liquid in the supine decubitus.

Then I close the muscle layer with separated absorbable 1-0 sutures (ususally 3-4), and then I suture the fatty tissue with continuous absorbable 2-0 suture, and the skin with intradermal suture.


Hope you find these essential tricks useful for beginning with this amazing approach!! Let me know all your comments and doubts in the Community.


(Author declares no conflict of interest)

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Designed, edited and published in Alicante, Spain

Diseñada, editada y publicada en Alicante, España

ISSN 2603-963X

Background

Medicine Degree at Miguel Hernández University, Elche, Spain, 2001-2007.

Extraordinary University Award in Medicine Degree, 2001-2007.

Thoracic Surgery Residency at University General Hospital Alicante, 2008- 2013.

Thoracic Surgeon Consultant at University General Hospital Alicante, from 2013-nowadays.

Thoracic Surgeon Consultant and Cofounder at CITMIA, Minimally Invasive Thoracic Surgery Unit, from 2013-nowadays.

PhD in Medicine, Miguel Hernández University, Elche, Spain, 2013-2017.

Tutor of Residents at University General Hospital Alicante, 2018-nowadays

Member of Teaching Committee of the Spanish Society of Thoracic Surgery (SECT), 2018-nowadays

Member of Thoracic Surgery Section at Spanish Association of Surgeons (AEC), 2019.

Thoracic Surgeon Observer at Massachussets General Hospital, Boston (USA), 2012.

Thoracic Surgeon Observer at Memorial Sloan-Kettering Cancer Center, Nueva York (USA), 2012.

Thoracic Surgeon Observer at National Taiwan University Hospital, Taipei (Taiwan), 2016.

Thoracic Surgery Director, XIV Congress of the Spanish Society of Laparoscopic and Robotic Surgery (SECLA). 2016 

Reviewer of “European Journal of Cardiothoracic Surgery”, "Revista Española de Anestesiologia y Reanimacion" and "Journal of Thoracic Disease".

Editorial Board Member of “Journal of Respiratory Research”.

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