This document summarizes a presentation on uniportal anatomic pulmonary resection. It describes the technical aspects of single-port video-assisted thoracic surgery (VATS) and provides early experience from a study comparing outcomes of 50 patients who underwent single-port VATS to 50 patients who underwent multi-port VATS. The study found no significant differences in patient demographics, operations performed, intraoperative outcomes, post-operative outcomes including length of stay and complications, or post-operative pain between the two groups. This suggests that short term results of single-port VATS are comparable to multi-port VATS for pulmonary resection.

1. Sebastien Gilbert MD
Associate Professor of Surgery
Chief, Division of Thoracic Surgery
The Ottawa Hospital
University of Ottawa
Uniportal Anatomic Pulmonary
Resection
General Thoracic Surgical Club
Tucson, USA
Mar 10-13, 2016

2. Disclosures
 None

3. Outline
Background
Review Technical Aspects
Share Early Experience
Case Videos

4. Reducing Chest Wall Trauma
Thoracic Operations

5. Reducing Chest Wall Trauma
Thoracic Operations
Rib Spreading Non-Rib Spreading (VATS)

6. Reducing Chest Wall Trauma
Thoracic Operations
Rib Spreading
Postero-
lateral
Muscle
sparing,
Anterior,
“French
window”
Non-Rib Spreading (VATS)

7. Reducing Chest Wall Trauma
Thoracic Operations
Rib Spreading
Postero-
lateral
Muscle
sparing,
Anterior,
“French
window”
Non-Rib Spreading (VATS)
Multi-port Single-port

8. Reducing Chest Wall Trauma
Thoracic Operations
Rib Spreading
Postero-
lateral
Muscle
sparing,
Anterior,
“French
window”
Non-Rib Spreading (VATS)
Multi-port Single-port
Intercostal
Access
Minimal or No
Intercostal Access

9. Reducing Chest Wall Trauma
Thoracic Operations
Rib Spreading
Postero-
lateral
Muscle
sparing,
Anterior,
“French
window”
Non-Rib Spreading (VATS)
Multi-port Single-port
Intercostal
Access
Minimal or No
Intercostal Access
Subxyphoid,
Subcostal*,
Cervical*
*May include one 5 mm intercostal port

10. Reducing Chest Wall Trauma
Thoracic Operations
Rib Spreading
Postero-
lateral
Muscle
sparing,
Anterior,
“French
window”
Non-Rib Spreading (VATS)
Multi-port Single-port
Intercostal
Access
Minimal or No
Intercostal Access
Subxyphoid,
Subcostal*,
Cervical*
*May include one 5 mm intercostal port

11. Is VATS superior to OPEN?
 Common answer = “Yes”
 Equivalent oncologic outcomes1,3
 Similar chest tube drainage, LOS, pain2
 Similar pneumonia, air leak,
arrhythmia, mortality3
1. Sugi et al. WJS 2000; 24, 27–31
2. Kirby et al. JCTVS 1995;109:997-1002
3. Yan et al. JCO 2009; 27:2553-2562

12. Transition from OPEN to VATS
 How far have we come?
Limited adoption of VATS lobectomy:
STS data = 28-35%1-2 of cases
ESTS data = 11%3 of cases
Why?
1. Boffa et al. JTCVS 2008; 135:247-54
2. Ceppa et al. Ann Surg 2012; Sep;256(3):487-93
3. Begum et al. JTD 2014; 6 Suppl 2:S203-10

13. Single-port or Uniportal VATS
 Early publications:
2000: Migliore M
2004: Rocco G
2011: Gonzalez-Rivas D
 Popular topic:
Last 10 years: 1000 cases reported
Last 6 months: >400 cases reported

14.  Only 3 retrospective comparisons:
n≈200 cases
Early outcomes are similar
Is Multi-port superior to Single-Port?
1. Mu et al. Chin Med J 2015;128:2731-5
2. Shen et al. EJCTS 2016; 49 (suppl 1): i48-i53
3. French et al. Ann Cardiothorac Surg 2016 (in press)

15. Planning the Transition
 Focus on Patient Safety
 Maintain Surgical Quality
 Preserve/Enhance Educational Experience

16. Port Placement

17. Technical Aspects
Posterior axillary
Anterior axillary

18. Single Port: Anterior Hilar Dissection
Camera Head Controls
at 12 o’clock
Camera Post at 6
o’clock “30o up”Retracting Hand
(Surgeon or Assistant)
Operating Hand
Additional
Operating Hand
(Optional)
Surgeon

19. Single Port: Posterior Hilar Dissection
Camera Head and Post
at 12 o’clock
“30o down”
Retracting Hand
(Surgeon or Assistant)
Operating Hand
Additional
Operating Hand
(Optional)
Surgeon

20. Incision Plane
Camera Line of Sight
Instruments
Camera Post facing Surgeon

21. Incision Plane
Camera Line of Sight
Instruments
Camera Post facing Surgeon

22. Incision Plane
Camera Line of Sight
Instruments
Camera Post facing Surgeon

23. Incision Plane
Camera Line of Sight
Instruments
Camera Post away from Surgeon

24. Ergonomics

25. Ergonomics
Camera
Instruments
Instruments Camera

26. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Median [interquartile range]
University of Ottawa: Early Experience

27. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
Median [interquartile range]
University of Ottawa: Early Experience

28. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
BMI 27 [24-30] 27 [22-30] 0.844
Median [interquartile range]
University of Ottawa: Early Experience

29. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
BMI 27 [24-30] 27 [22-30] 0.844
Smokers 38 (76%) 38 (76%) 1.000
Median [interquartile range]
University of Ottawa: Early Experience

30. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
BMI 27 [24-30] 27 [22-30] 0.844
Smokers 38 (76%) 38 (76%) 1.000
Charlson Score 2 [1-3] 2 [1-3] 0.615
Median [interquartile range]
University of Ottawa: Early Experience

31. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
BMI 27 [24-30] 27 [22-30] 0.844
Smokers 38 (76%) 38 (76%) 1.000
Charlson Score 2 [1-3] 2 [1-3] 0.615
FEV1% 85 [69-101] 79 [69-89] 0.072
Median [interquartile range]
University of Ottawa: Early Experience

32. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
BMI 27 [24-30] 27 [22-30] 0.844
Smokers 38 (76%) 38 (76%) 1.000
Charlson Score 2 [1-3] 2 [1-3] 0.615
FEV1% 85 [69-101] 79 [69-89] 0.072
DLCO% 74 [63-85] 73 [64-81] 0.958
Median [interquartile range]
University of Ottawa: Early Experience

33. VATS (n=50) S-VATS (n=50) p
Gender (M:F) 11:39 15:35 0.362
Age (years) 67 67 0.820
BMI 27 [24-30] 27 [22-30] 0.844
Smokers 38 (76%) 38 (76%) 1.000
Charlson Score 2 [1-3] 2 [1-3] 0.615
FEV1% 85 [69-101] 79 [69-89] 0.072
DLCO% 74 [63-85] 73 [64-81] 0.958
Tumor Size (cm) 2.8 [1.8-3.8] 2.5 [1.6-3.5] 0.332
Median [interquartile range]
University of Ottawa: Early Experience

34. Operations Performed
Operations VATS (n=50) S-VATS (n=50) p
Lobectomy 42 (84%) 39 (78%) 0.764

35. Operations Performed
Operations VATS (n=50) S-VATS (n=50) p
Lobectomy 42 (84%) 39 (78%) 0.764
Bilobectomy 0 1 (2%)

36. Operations Performed
Operations VATS (n=50) S-VATS (n=50) p
Lobectomy 42 (84%) 39 (78%) 0.764
Bilobectomy 0 1 (2%)
Segmentectomy 8 (16%) 10 (20%) 0.603

37. Operations Performed
Operations VATS (n=50) S-VATS (n=50) p
Lobectomy 42 (84%) 39 (78%) 0.764
Bilobectomy 0 1 (2%)
Segmentectomy 8 (16%) 10 (20%) 0.603
Laterality (right:left) 23:27 26:24 0.548

38. Intraoperative Outcomes
Outcome VATS (n=50) S-VATS (n=50) p
R0 Resection 50 (100%) 50 (100%) 1.000

39. Intraoperative Outcomes
Outcome VATS (n=50) S-VATS (n=50) p
R0 Resection 50 (100%) 50 (100%) 1.000
Conversion to Open 1 (2%) 2 (4%) 0.558

40. Intraoperative Outcomes
Outcome VATS (n=50) S-VATS (n=50) p
R0 Resection 50 (100%) 50 (100%) 1.000
Conversion to Open 1 (2%) 2 (4%) 0.558
Operating Time (min) 146 [121-178] 154 [142-175] 0.081

41. Intraoperative Outcomes
Outcome VATS (n=50) S-VATS (n=50) p
R0 Resection 50 (100%) 50 (100%) 1.000
Conversion to Open 1 (2%) 2 (4%) 0.558
Operating Time (min) 146 [121-178] 154 [142-175] 0.081
Staplers 8 [6-10] 9 [8-10] 0.577

42. Intraoperative Outcomes
Outcome VATS (n=50) S-VATS (n=50) p
R0 Resection 50 (100%) 50 (100%) 1.000
Conversion to Open 1 (2%) 2 (4%) 0.558
Operating Time (min) 146 [121-178] 154 [142-175] 0.081
Staplers 8 [6-10] 9 [8-10] 0.577
Chest Tube(s) 1 2 <0.001

43. Post-Operative Outcomes
Outcomes VATS (n=50) S-VATS (n=50) p
Chest tube drainage (days) 3 [3-5] 3 [2-5] 0.394
‡Ottawa TMM system (https://ottawatmm.org) Seely AJE et al. Ann Thor Surg 2010;90(3):936-42

44. Post-Operative Outcomes
Outcomes VATS (n=50) S-VATS (n=50) p
Chest tube drainage (days) 3 [3-5] 3 [2-5] 0.394
LOS (days) 4 [3-7] 4 [3-7] 0.992
‡Ottawa TMM system (https://ottawatmm.org) Seely AJE et al. Ann Thor Surg 2010;90(3):936-42

45. Post-Operative Outcomes
Outcomes VATS (n=50) S-VATS (n=50) p
Chest tube drainage (days) 3 [3-5] 3 [2-5] 0.394
LOS (days) 4 [3-7] 4 [3-7] 0.992
Complications:‡
None 32 (64%) 30 (60%) 0.680
‡Ottawa TMM system (https://ottawatmm.org) Seely AJE et al. Ann Thor Surg 2010;90(3):936-42

46. Post-Operative Outcomes
Outcomes VATS (n=50) S-VATS (n=50) p
Chest tube drainage (days) 3 [3-5] 3 [2-5] 0.394
LOS (days) 4 [3-7] 4 [3-7] 0.992
Complications:‡
None 32 (64%) 30 (60%) 0.680
Grade I-II 13 (26%) 9 (18%) 0.334
‡Ottawa TMM system (https://ottawatmm.org) Seely AJE et al. Ann Thor Surg 2010;90(3):936-42

47. Post-Operative Outcomes
Outcomes VATS (n=50) S-VATS (n=50) p
Chest tube drainage (days) 3 [3-5] 3 [2-5] 0.394
LOS (days) 4 [3-7] 4 [3-7] 0.992
Complications:‡
None 32 (64%) 30 (60%) 0.680
Grade I-II 13 (26%) 9 (18%) 0.334
Grade III 4 (8%) 8 (16%) 0.357
‡Ottawa TMM system (https://ottawatmm.org) Seely AJE et al. Ann Thor Surg 2010;90(3):936-42

48. Post-Operative Outcomes
Outcomes VATS (n=50) S-VATS (n=50) p
Chest tube drainage (days) 3 [3-5] 3 [2-5] 0.394
LOS (days) 4 [3-7] 4 [3-7] 0.992
Complications:‡
None 32 (64%) 30 (60%) 0.680
Grade I-II 13 (26%) 9 (18%) 0.334
Grade III 4 (8%) 8 (16%) 0.357
Grade IV 1 (2%) 2 (4%) 0.558
‡Ottawa TMM system (https://ottawatmm.org) Seely AJE et al. Ann Thor Surg 2010;90(3):936-42

49. Post-Operative Pain
Outcomes VATS (n=50) S-VATS (n=50) p
Time on PCA (days) 3 [3-3] 3 [2-3] 0.559

50. Post-Operative Pain
Outcomes VATS (n=50) S-VATS (n=50) p
Time on PCA (days) 3 [3-3] 3 [2-3] 0.559
Total PCA Dose (mg) 3.4 [2.6-8.0] 5.4 [1.6-8.0] 0.209

51. Post-Operative Pain
Outcomes VATS (n=50) S-VATS (n=50) p
Time on PCA (days) 3 [3-3] 3 [2-3] 0.559
Total PCA Dose (mg) 3.4 [2.6-8.0] 5.4 [1.6-8.0] 0.209
VAS @ 1 hour 3 [0-4] 1 [0-3] 0.009

52. Post-Operative Pain
Outcomes VATS (n=50) S-VATS (n=50) p
Time on PCA (days) 3 [3-3] 3 [2-3] 0.559
Total PCA Dose (mg) 3.4 [2.6-8.0] 5.4 [1.6-8.0] 0.209
VAS @ 1 hour 3 [0-4] 1 [0-3] 0.009
VAS @ 24 hours 4 [2-5] 4 [3-5] 0.625

53. Post-Operative Pain
Outcomes VATS (n=50) S-VATS (n=50) p
Time on PCA (days) 3 [3-3] 3 [2-3] 0.559
Total PCA Dose (mg) 3.4 [2.6-8.0] 5.4 [1.6-8.0] 0.209
VAS @ 1 hour 3 [0-4] 1 [0-3] 0.009
VAS @ 24 hours 4 [2-5] 4 [3-5] 0.625
Satisfied with Pain
Control @ 24 hours
48 (96%) 47 (94%) 0.743

54. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?

55. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes

56. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes

57. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace

58. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace
Articulating staplers Optional Required

59. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace
Articulating staplers Optional Required
Dividing PA before vein Optional Required

60. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace
Articulating staplers Optional Required
Dividing PA before vein Optional Required
Clipping PA Optional Recommended

61. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace
Articulating staplers Optional Required
Dividing PA before vein Optional Required
Clipping PA Optional Recommended
Wound protector Optional Recommended

62. Comparing Approaches
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace
Articulating staplers Optional Required
Dividing PA before vein Optional Required
Clipping PA Optional Recommended
Wound protector Optional Recommended
Special instrumentation Optional Optional

63. Summary
Multiport Single Port
MIS training/experience Important ?
Viewing angle similar to open No Yes
Alignment No Yes
Access incision 4th interspace 5th interspace
Articulating staplers Optional Required
Dividing PA before vein Optional Required
Clipping PA Optional Recommended
Wound protector Optional Recommended
Special instrumentation Optional Optional
Assistant 1 0-1

64. Thank You!