Converting uniportal video-assisted thoracic surgery: multiport or open?

Introduction

In 2010, about 2 years and 6 months after Diego Gonzalez Rivas reported video-assisted thoracic surgery (VATS) lobectomy for lung cancer (1), our institution performed the first case of minimally invasive anatomical lung resection in Japan. Since then, we have reported the surgical outcomes in Japan for about 6 years until now (2,3). The pursuit of minimally invasive surgery is a proposition for surgeons. Among existing surgical treatments, the accuracy of the procedure of this surgery has been improved when it is simply considered with regard to chest wall invasion. If prevention of intercostal nerve injury can be demonstrated, it may be an ultimate minimally invasive surgery. Although this is thoracoscopic surgery, technically, it contains many elements of thoracotomy compared with the procedure of 2- or 3-port VATS. We experienced cases in which uniportal VATS (U-VATS) was inevitably converted. In this review, the cause of conversion of U-VATS is discussed.

Cause of conversion

Before discussing conversion of U-VATS, the cause of conversion of Multiport VATS (M-VATS) to open thoracotomy is discussed based on the literature (4-16). The rate of conversion of M-VATS is shown in Table 1 (4-16). Their mean rates were approximately 8.5%, and hemorrhage and adhesion due to vascular injury, tumor size, anatomical problems, such as fissureless lung, firm fixation of lymph nodes to the pulmonary artery and bronchus, and technical problems, such as the use of an automatic suture device and differential lung ventilation failure in anesthesia, were presented as the causes in several reports. In contrast, reported cases of lobectomy for lung cancer in which U-VATS was converted to open thoracotomy are presented in Table 2 (17-22). On meta-analysis, the mean conversion rate was 3.6%, being not significantly different from that of M-VATS, and on comparison of the overall mortality in the same report, it was significantly lower in patients treated with U-VATS than M-VATS (17). Furthermore, the rates of conversion of U-VATS and M-VATS to thoracotomy were 1.0% and 1.6%, respectively, in propensity-matched patient cohorts, showing no significant difference in both procedures (17).

The cause of conversion of U-VATS was analyzed using data of detailed reports from 3 institutions (3,18,23) including patients of our institution. Strictly speaking, there are 2 patterns of conversion of U-VATS: (I) conversion to open thoracotomy; and (II) conversion to 2- or 3-port M-VATS. Cases are shown by the cause in Tables 3,4. Although further verification is necessary because the number of cases analyzed was small, no technical problem, such as the use of an automatic suture device or differential lung ventilation failure in anesthesia, was noted, being a characteristic, in cases with conversion to open thoracotomy, and hemorrhage was the cause in 0.7 and 1.7% in the data from 2 institutions (3,23), respectively, being within the acceptable range. Anatomical problems were the causes of conversion to M-VATS in relatively many cases in the 3 institutions, being characteristic. Cases with conversion to M-VATS accounted for more than 70% of all cases in all 3 institutions, suggesting that if the operator learned the M-VATS procedure and is familiar with the U-VATS technique to some extent, most cases can be dealt with by M-VATS before conversion to open thoracotomy in the future.

Conversion during U-VATS, especially for dealing with hemorrhage

All surgeons have difficulty in carefully preparing a visual field at the beginning of the use of U-VATS and they have similar feeling to that when they learned M-VATS from thoracotomy. Scopists also require some techniques because they have to secure a visual field from the same direction as that of surgical instruments. The surgical procedure proceeds while devising avoidance of interference with the scope by forceps and scissors mainly by the operator. When unexpected hemorrhage and anatomical problems occur during the procedure, these have to be dealt with by calmly making a judgment as in M-VATS. Since intraoperative hemorrhage may lead to endanger the life of the patient, it is necessary to always pay attention during surgery applied through a small wound, such as U-VATS, more closely than that in M-VATS. In our institution, a polyurethane sponge, Secrea (HOGY TM), is always prepared for hemorrhage, and the hemorrhagic point is carefully pressed (Figures 1,2) (24,25). In U-VATS applied through an about 3–4-cm sized small wound, depressors, such as Securea, can be easily inserted and placed on the hemostasis point compared with inserting and placing it in M-VATS, especially in surgery using only cylindrical trocar, so that hemorrhage can be dealt with by calmly making judgment and conversion to open thoracotomy and M-VATS as needed. Of course, simulation of hemorrhagic cases is sufficiently performed with nursing staff regularly to promote communication.

Figure 1 Secrea (Hogy TM).

Figure 2 Hemostasis using the Secrea to it. A6 bleeding (24). Available online: http://www.asvide.com/article/view/30351

Judgement criteria for conversion

Conversion is an event that operators want to avoid, but strong a feeling of the operator to provide minimally invasive surgery to the patient and excessively sticking to U-VATS may lead to disadvantages for the patient, such as prolongation of the operative time (more than 4 hours) and unexpected massive hemorrhage (more than 500 mL). Generally, in cases that the lung is firmly adhered to diaphragm, aorta and superior vena cava (SVC), the operator should convert to M-VATS or thoracotomy. Furthermore, tumor invading main bronchus, main PA, SVC and aorta is also a contraindication of U-VATS. Considering my experience of M-VATS, it is desirable to prepare the criteria to indicate conversion in each institution, perform surgery following it, and convert the procedure to M-VATS and open thoracotomy as needed. In our department, U-VATS was indicated only for curative surgery for stage I lung cancer early after its introduction, but original indication criteria of conversion were prepared and surgery is routinely performed following it (Table 5).

Conclusions

Although U-VATS is complex and difficult compared with that of M-VATS at present, when it is performed by a thoracic surgeon familiar with M-VATS, the frequency of conversion may be almost the same as that of M-VATS (17). In the literature, the mortality rate of patients treated with U-VATS is still 0%, but serious complications may be reported with spread of this surgical procedure in the future, as it occurred in M-VATS, for which further evaluation of the surgical outcomes and investigation of problems are essential. Close investigation of cases with conversion of U-VATS is especially important.

The task concerning conversion of U-VATS, which is the theme of this report, is improvement of the technical aspects of the surgical procedure by U-VATS surgeons so as to avoid open thoracotomy as much as possible and convert the procedure to multiport VATS even in the worst cases. In addition, acquisition of the ability to smoothly convert the procedure from U-VATS to M-VATS, from U-VATS to open thoracotomy, or from U-VATS to open thoracotomy through M-VATS may be a task for U-VATS surgeons in the future.

The history of U-VATS is still short and the, the surgical procedure performed by U-VATS surgeons has been improving steadily and new surgical instruments may be developed in the future. The analysis of conversion cases from U-VATS to M-VATS or thoracotomy is essential to do U-VATS safer. Eventually, devising to reduce U-VATS conversion rate is still the key to the development and spread of this surgical procedure.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Jose Luis Danguilan) for the series “Dedicated to the 6th Asian Single-port VATS Symposium 2018” published in Journal of Visualized Surgery. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jovs.2019.03.01). The series “Dedicated to the 6th Asian Single-port VATS Symposium 2018” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12:514-5. [Crossref] [PubMed]
2. Hirai K, Takeuchi S, Usuda J. Single-port video-assisted thoracic surgery for early lung cancer: initial experience in Japan. J Thorac Dis 2016;8:S344-50. [PubMed]
3. Hirai K, Takeuchi S, Usuda J. Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: a retrospective comparative study of perioperative clinical outcomes. Eur J Cardiothorac Surg 2016;49:i37-41. [PubMed]
4. Safdie FM, Sanchez MV, Sarkaria IS. Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion. J Vis Surg 2017;3:87. [Crossref] [PubMed]
5. Sugi K, Kaneda Y, Esato K. Video-assisted thoracosopic lobectomy schieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 2000;24:27-30; discussion 30-1. [Crossref] [PubMed]
6. Solaini L, Pruscinao F, Bagioni P, et al. long-term results of video-assisted thoracic surgery lobectomy for stage I non-small lung cancer:a single-center study of 104 cases. Interact Cardiovasc Thorac Surg 2004;3:57-62. [Crossref] [PubMed]
7. Walker WS, Codispoti M. Long-term outcomes following VATS lobectomy for non-small cell lung carcinoma. Eur J Cardiothorac Surg 2003;23:397-402. [Crossref] [PubMed]
8. Roviaro G, Varoli F, Vergani C, et al. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 2004;126:725-32. [Crossref] [PubMed]
9. Ohtsuka T, Nomori H, Horio H, et al. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer? Chest 2004;125:1742-6. [Crossref] [PubMed]
10. Shiraishi T, Shirakusa T, Hiratsuka M, et al. Video-assisted thoracoscopic surgery lobectomy for c-T1N0M0 primary lung cancer: its impact on locoregional control. Ann Thorac Surg 2006;82:1021-6. [Crossref] [PubMed]
11. Swanson SJ, Miller DL, McKenna RJ Jr, et al. Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: results from a multihospital database (Premier). J Thorac Cardiovasc Surg 2014;147:929-37. [Crossref] [PubMed]
12. Jones RO, Casali G, Walker WS. Does failed video-assisted lobectomy for lung cancer prejudice immediate and long-term outcomes? Ann Thorac Surg 2008;86:235-9. [Crossref] [PubMed]
13. Li Y, Wang J, Yang F, et al. Indications for conversion of thoracoscopic to open thoracotomy in video-assisted thoracoscopic lobectomy. ANZ J Surg 2012;82:245-50. [Crossref] [PubMed]
14. Puri V, Patel A, Majumder K, et al. Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications. J Thorac Cardiovasc Surg 2015;149:55-61, 62.e1.
15. Byun CS, Lee S, Kim DJ, et al. Analysis of unexpected conversion to thoracotomy during thoracoscopic lobectomy in lung cancer. Ann Thorac Surg 2015;100:968-73. [Crossref] [PubMed]
16. Vallance A, Tcherveniakov P, Bogdan C, et al. The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy. Ann R Coll Surg Engl 2017;99:129-33. [Crossref] [PubMed]
17. Christopher GH, Rebecca SJ, David HT, et al. Systematic review and mata-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer. Ann Cardiothoracic Surg 2016;5:76-84. [Crossref]
18. Chung JH, Choi YS, Cho JH, et al. Uniportal video-assisted thoracoscopic lobectomy: an alternative to conventional thoracoscopic lobectomy in lung cancer surgery? Interact Cardiovasc Thorac Surg 2015;20:813-9. [Crossref] [PubMed]
19. Mu JW, Gao SG, Xue Q, et al. A Matched Comparison Study of Uniportal Versus Triportal Thoracoscopic Lobectomy and Sublobectomy for Early-stage Nonsmall Cell Lung Cancer. Chin Med J (Engl) 2015;128:2731-5. [Crossref] [PubMed]
20. Shen Y, Wang H, Feng M, et al. Single- versus multiple-port thoracoscopic lobectomy for lung cancer: a propensity-matched study†. Eur J Cardiothorac Surg 2016;49:i48-53. [PubMed]
21. Wang BY, Liu CY, Hsu PK, et al. Single-incision versus multiple-incision thoracoscopic lobectomy and segmentectomy: a propensity-matched analysis. Ann Surg 2015;261:793-9. [Crossref] [PubMed]
22. Zhu Y, Liang M, Wu W, et al. Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer. Ann Transl Med 2015;3:92. [PubMed]
23. Ng CS, Kim KH, Wong RH, et al. Single-port video-assisted thoracoscopic major lung resections:Experience with 150 consecutive cases. Thorac Cardiovasc Surg 2016;64:348-53. [Crossref] [PubMed]
24. Hirai K, Enomoto Y, Usuda J. Hemostasis using the Secrea to it. A6 bleeding. Asvide 2019;6:058. Available online: http://www.asvide.com/article/view/30351
25. Hirai K, Ibi T, Besso R, et al. Use of the “Secrea (Hogy™)” sponge spacer in thoracoscopic surgery for lung cancer. J Surg Oncol 2011;104:857-8. [Crossref] [PubMed]