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Page 2 of 8 Sathiamurthy et al. Mini-invasive Surg 2020;4:38 I http://dx.doi.org/10.20517/2574-1225.2020.25

INTRODUCTION
Since Giancarlo Roviaro performed the first lung resection with video assistance through small incisions
without rib spreading in 1992, the evolution of video technology and instrumentation have revolutionised
[1]
the way lung resections are performed without compromising outcomes . Diego Gonzales-Rivas
popularised the uniportal video assisted thoracoscopic surgery (U-VATS) technique by demonstrating
reproducibility of the surgeries and improving patient outcomes. He also performed many complex
[2]
procedures like segmentectomies and bronchial and arterial sleeves through U-VATS . In a new thoracic
surgery setup, we adopted the U-VATS technique for lung resections in most of our cases. This article
will describe our experience through the learning curve of adaptating the U-VATS approach in thoracic
surgery.

MATERIALS AND METHODS
Operative records of all thoracic surgeries performed from July 2017 till June 2019 in Hospital Kuala
Lumpur (HKL) were retrospectively reviewed. All surgeries were performed by a single thoracic surgeon in
a newly established thoracic surgery unit. The unit consists of a thoracic surgeon, two thoracic fellows and
a surgical house officer. Indications for surgery were mainly infective pleural diseases and tumors (benign
and malignant). This and the surgical approach were explained to the patient in detail and consent was
taken both for the procedure itself and its recording.

All surgeries were performed under general anaesthesia with single-lung ventilation using a double-lumen
endotracheal tube. All patients were positioned in the right or left lateral position, or supine and then
cleaned and square draped. The surgeon and assistant would then stand in front of the patient. A 3 to 4 cm
incision would be made in the 4th or 5th intercostal space, just medial to the anterior axillary line. No rib
o
spreading manoeuvres were required. A wound protector was applied in all cases. A 10 mm 30 telescope
with a high definition video system was used in all patients. VATS instruments were used to assist with the
surgeries and up to four instruments could be placed through the uniportal access. Resected tumors were
removed with an endobag and a 24 Fr chest drain was then inserted through the same incision for non-
infective cases. Two drains, a 24 Fr to the apex and a 28 Fr to the base were inserted for infective cases.

A digitally monitored negative pressure closed drainage system (Topaz Medela) was used for all cases.
Drains were removed when the amount of effluent was less than 100 mL. All patients were given patient-
controlled anaesthesia with morphine infusion after surgery.

Data analysis was conducted using IBM SPSS Statistics for Windows, Version 21.0 software. The means and
standard deviation were calculated for the various parameters. The paired t-test was used to compare the
means between cases performed in the first and second year after establishment of the unit for the three
commonest procedures - bullectomy and pleurodesis, lobectomy and thymectomy.

RESULTS
From July 2017 to June 2019, 320 thoracic surgeries were performed and 169 (53%) were U-VATS surgeries.
No biportal or multiportal VATS were performed. The mean age of the patients was 41-years and most
(104 of 169, 61%) were males. Amongst the 169 patients, only 57 had no co-morbidities (34%), while the
rest had at least one with the commonest being hypertension followed by diabetes mellitus and previous
tuberculosis infection.

The most common indication for U-VATS surgery was malignant lung tumors (21%) followed by ruptured
bullae (20%) and empyema thoracis (15%). Malignant lung tumors included non-small cell lung cancer
(NSCLC) and lung metastasis [Table 1].