Is uniport thoracoscopic surgery less painful than multiple port approaches?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In patients undergoing Video-Assisted Thoracoscopic Surgery (VATS), does a uniport (single-port) or multiport technique convey benefit in terms of postoperative pain?' Altogether, 255 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studies, study type, relevant outcomes and results of these tables are tabulated. All the available evidence is from small, non-randomized studies. Many were retrospective and methodologically weak. Most studied minor thoracic surgical procedures and a few compare the two approaches in major pulmonary resections. One of the studies compared pain at 24 h for uniport [mean Visual Analogue Scale (VAS) >4.4] and three-port VATS (mean VAS 6.2), for different procedures including lung biopsy and surgery for pneumothorax (P = 0.035). Another study compared pain in the first 36-h post-sympathectomy and found mean pain scores of 0.8 in the uniport group and 1.2 in the two-port group (P = 0.025). Six studies exclusively compared the VAS between uniport and three-port VATS for primary spontaneous pneumothorax. Two studies found no significant difference in pain scores and four found a statistically significant reduction in early postoperative pain scores. One study found that pain scores were similar for lung volume reduction surgery. Two studies compared the mean VAS and morphine use between uniportal and multiportal lobectomies; however, there were no statistically significant differences. From the papers identified in our search, we conclude that uniport VATS may have a small clinical effect in reducing postoperative pain, with the majority of papers looking at the first 72 h following surgery. Often the VAS score was only improved in the uniport patients by 1-2 points, and the studies did not find statistically significant results throughout their investigations, especially when looking at follow-up pain scores. Around one-third of the chosen papers did not find any statistically significant results. Further studies are needed before single-port can be recommended as less painful than multiport thoracoscopic surgery.