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Sathiamurthy et al. Mini-invasive Surg 2020;4:38 I http://dx.doi.org/10.20517/2574-1225.2020.25 Page 7 of 8

a stapler, completion of lymph node dissection and in some cases, enlargement of the wound to deliver
[3]
the resected specimen in one piece. Ismail et al. from Germany also reported operating times of around
250 min in their early experience of performing U-VATS for lobectomy.

The average lymph node yield in our U-VATS lobectomy for NSCLC was 20 and this allows adequate
staging assessment by the oncologist to decide on adjuvant treatment. This was similarly reported by
[5]
the Koreans in their midterm outcome of U-VATS for lung cancer . Crucially, one must not hesitate to
introduce a second port during lymph node dissection to achieve adequate yield in the early stages of
performing U-VATS lobectomy. Oncological outcomes supersede any chosen approach.

The duration of drain placement usually coincides with the length of hospital stay. Most non-infective
cases were discharged by POD 3 or 4 after surgery whereas the infective cases stayed longer. The infective
cases also had a higher amount of blood loss compared to lung cancer cases because of the higher degree
of adhesion and inflammation and thus, the tendency to bleed more. Compared to open thoracotomy
[15]
however, the blood loss difference is not significant .

Within two years of performing U-VATS, we have gradually increased the complexities of the surgeries,
taking care to minimise morbidities. In the last 6 months, we have performed a left segment 9 and 10
resection for a metastatic lung nodule, and a right upper bronchial sleeve resection for a right main
bronchus mucoepidermoid carcinoma successfully. These cases were performed after more than 100
U-VATS cases were logged.

This review was for the first two years since setting up the thoracic surgical services in HKL. We have had
a small number of patients involving all procedures, malignant and non-malignant alike. A subsequent
review of patients with NSCLC with larger numbers at the 5-year mark will shed clearer light on the
advantages of U-VATS in HKL, Malaysia.

CONCLUSION
U-VATS is a promising, alternative approach which is fast gaining popularity amongst thoracic surgeons
worldwide. The learning of U-VATS procedures should be in a stepwise manner as suggested in our
learning pyramid. Patient safety and oncological principles must always be adhered to in any form of
surgery and failing to do so will require an alternative approach. The U-VATS technique may be safely
adopted in a new thoracic centre if such a stepwise learning method is enforced.

DECLARATIONS
Authors’ contributions
Collected and selected articles: Sathiamurthy N
Participated in manuscript, writing and review: Sathiamurthy N, Diong NC, Dharmaraj B
Participated in reviewing: Sathiamurthy N, Dharmaraj B

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.