Page 325 - Read Online

Sathiamurthy et al. Mini-invasive Surg 2020;4:38 I http://dx.doi.org/10.20517/2574-1225.2020.25 Page 5 of 8

Rocco from Italy has evolved from using three to two and now, a single port for thoracic surgery,
[8]
performing mediastinal biopsies, wedge resections and bullectomies . In 2010, Diego Gonzales Rivaz
was the first to perform a lobectomy through the uniportal approach and went on to execute complex
[2]
[9]
lung resections over the next few years, including carinal resections . Perna et al. then performed a
randomised trial comparing U-VATS and multiportal VATS procedures in 2016 and found no difference
in post-operative pain and analgesia intake, duration of chest drain and length of hospital stay. In the meta
[7]
analysis by Abouarab et al. , it was demonstrated that U-VATS provides superior post-operative outcomes
over multiportal VATS.

The advantages of U-VATS are mainly seen in positioning of the videoscope in the utility port to provide
an end on view to the surgeon, similar to open surgery. Insertion of instruments parallel to the videoscope
also simulates the manner of dissections done in open surgery. Having all instruments inserted via a single
incision also reduces post-operative pain by reducing the number of ports and prevents compression of
the intercostal nerves by not using thoracoports [4,10] . Nevertheless, the crowding of instruments inserted
[11]
through the same port can be an obstacle . The usage of curved instruments of variable length inserted
at different angles can prevent this. Thinner instruments designed specifically for U-VATS allow up to four
[1,4]
instruments to be inserted with the videoscope [Figure 1A].
The thoracic unit in HKL was established in July 2017. Thoracic surgeons in Malaysia have vast exposure in
laparoscopic surgeries during general surgery training and with this experience, performing VATS becomes
easier. In our unit, we perform around six to seven thoracic surgeries a week with almost half performed by
U-VATS and the rest were open thoracotomies. No multiportal VATS were performed, hence we are unable
to compare with these methods. In our unit, surgeons must be familiar with open thoracotomy first and
able to handle emergency situations such as bleeding before performing VATS.

The learning curve of U-VATS could be steeper than multiportal VATS [11,12] . Attending U-VATS workshops,
attachments in high volume centres such as the Shanghai Pulmonary Hospital and watching surgical videos
can assist with the improvement of developing U-VATS techniques for beginners and advanced level
surgeons [13,14] . These approaches were adopted by our centre to enhance performance of U-VATS. During
the learning process, we developed the U-VATS learning pyramid as a guide for trainees [Figure 2]. The
U-VATS learning pyramid gradually increases the complexity of cases from the bottom up. Adapting the
U-VATS learning pyramid in a stepwise manner as per the caseload in the centre may allow the learning
experience to be smoother and safer for both the patient and the surgeon alike. The initial U-VATS cases
that were performed were less complex, such as bullectomy with pleurodesis, traumatic hemothorax
evacuation, biopsies and wedge resections. The surgeon should not perform U-VATS lobectomy if he/she
has not performed U-VATS wedge resections or bullectomies comfortably before. In the first three months
of performing U-VATS, most cases are from the bottom of the pyramid. Attempts to perform U-VATS
lobectomy were only made once familiarity with the basic procedures were achieved. This learning pattern
[3-5]
is seen in many other centres worldwide in learning uniportal VATS .
The effectiveness of the learning pyramid for U-VATS is reflected in our centre having no mortalities in 169
cases performed so far. Although there was no significant difference between cases performed in the first
and second year, the duration of surgery appeared to be less for cases in the second year group. This could
be due to increased familiarity with handling of instruments and positioning of the camera as more cases
[14]
are performed. Liu et al. showed that a minimum of 30 cases of U-VATS lobectomy are needed to reach
performance plateau.

Our first uniportal lobectomy performed was a left lower lobectomy for lung adenocarcinoma with a
nodule measuring 3 cm, however an assistant port was inserted halfway through surgery for retraction