Modified uniportal video-assisted thoracic surgery in children.

Video-assisted thoracic surgery (VATS) has been traditionally performed by a multi-port approach, but uniportal VATS is gaining popularity among thoracic surgeons. The use of only one intercostal space may result in less pain, but competition among camera and operating instruments may be a disadvantage. In children, the limited space in the thorax makes the uniportal VATS difficult to accomplish. We present a modification of the uniportal VATS, using a single skin incision but placing the thoracoscope in the superior or inferior intercostal space relative to the working instruments to increase instrument range of motion within a single intercostal space.

INTRODUCTION

Uniportal video-assisted thoracic surgery (VATS) has become an important innovation in the field of thoracic surgery over the last decade. This surgical approach utilizes only one intercostal space with no rib spreading.[123] The same approach for thoracic procedures in children is not well-established. This may be secondary to the relatively low number of thoracic procedures performed in children, limited space in the thorax and the challenge of single-lung ventilation in this age group. We present a modification of the uniportal VATS technique that uses a single incision with the thoracoscope in the superior intercostal space relative to the working instruments. This reduces the clash that can occur when only one intercostal space is used.

CASE REPORT

A 14-year-old male with liver mass and bilateral lung nodules was referred to our institution. Pulmonary lesions were concerning for metastatic disease and a lung nodule biopsy was required. Following implementation of one-lung ventilation, the patient was placed in the lateral decubitus position. A 2.5-3 cm incision was made in the 5th intercostal space to accommodate the thoracoscopic instruments; a 5 mm 30° endoscope was passed through the superior intercostal space relative to the working instruments [Figures 1 and 2]. The lung nodule was identified and an endostapler was used for the wedge resection. A thoracostomy tube was then introduced through the superior muscular defect, where the endoscope had been and was brought out of the incision anteriorly. The chest wall was closed and the thoracostomy tube secured with a suture. No complications were observed. Pathology was consistent with necrotising granulomatous inflammation related to Histoplasma Capsulatum infection.

Figure 1

(A) Thoracoscope (1) in the superior intercostal space with grasper (2) and stapler (3) in the inferior space. (B) Diagram of the thoracoscope and instruments locations

Figure 2

(A) Long thoracoscope relative to working instruments avoids interaction between hands of the assistant and operating surgeon. (B) Thoracoscopic view of grasper and stapler (asterisk)

DISCUSSION

Single-port or uniportal VATS was first described by Lin et al.[1] in 2002 for the treatment of palmar and axillary hyperhidrosis. In 2004, Rocco et al.,[2] reported uniportal VATS pulmonary wedge resection in 15 patients. In 2011, Gonzalez-Rivas et al.,[3] reported the first upper lobectomy performed by uniportal VATS. This surgical group has since applied the uniportal VATS technique to major resections, including complex cases and advanced tumours. Based on their experience, several other groups have recently started their own programs using uniportal VATS. While single-site laparoscopy in paediatric patients is becoming more common, with publications increasing in number,[4] the same approach is not as well-established for the thorax. Very few uniportal VATS reports exist for paediatric patients. These include sympathectomy, lung biopsy and empyema debridement. The first report of uniportal middle lobectomy in a paediatric patient, for the treatment of a pulmonary aspergilloma, was recently published.[5] Lack of experience with uniportal thoracic procedures in paediatric surgery is secondary to fewer pathologic processes requiring surgical intervention relative to those affecting adults, namely cancer. Limited space in the thorax of these young patients makes uniportal VATS difficult to perform. Single lung ventilation in neonatal and paediatric patients is also challenging, which may represent an important barrier for the implementation of uniportal VATS. Advantages associated with uniportal VATS include parallel instrumentation that mimics the manoeuvres performed during open surgery, less incisional pain and paraesthesia and improved cosmesis.[45] A disadvantage includes competition among camera and operating instruments within the same intercostal space. We present a modification to uniportal VATS, using a single skin incision, but placing the thoracoscope in the superior intercostal space relative to the working instruments. This allows increased instrument range of motion within a single intercostal space [Figure 1]. Furthermore, use of a long thoracoscope allows the hands of an assistant to be remote relative to those of the operating surgeon [Figure 2]. The scope intercostal incision can be utilised as an exit site for the thoracostomy tube which permits a better closure of the larger intercostal incision. Possible risks include increased pain incidence, since two intercostal spaces are entered. Furthermore, tissue trauma may be greater, since multiple instruments are being passed through a limited space. This raises the theoretical risk for wound complications. In summary, we describe a modification to uniportal VATS that may help facilitate operations in children by increasing degrees of freedom with regard to the range of motion. Further development of instruments scaled to size, such as endoscopic staplers, will expand opportunities for utilisation of uniportal VATS in small children.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.