uVATS has a history spanning over more than 1 decade and, more recently, has become an increasingly popular approach for surgical treatment of thoracic diseases (5-8). The potential advantages of uVATS include less postoperative pain, fewer paraesthesias, and better cosmetic results (7-12). Nevertheless, uVATS still draws less attention because there are still some unclear points in terms of the safety in terms of mortality and morbidity associated with this technique.
Being the largest series of uVATS, this study repeats previous findings regarding the safety of uVATS (5,6,8-10,12,13). It is clear that this technique can be used in selected patients with minimal in hospital mortality and morbidity.
Possible clinical advantages include the single-port approach with the potential of reducing postoperative chest pain due to the involvement of only one ICS and the avoidance of trocar use, which avoids intercostal nerve compression. It has been reported that fewer paraesthesias and less postoperative pain occurred with the single-port approach compared with the multiport approach (14,15).
Evaluation of the undiagnosed pleural effusion, undiagnosed pulmonary nodules, interstitial lung disease, malignant tumor invasion, secondary cancer in lymph nodes, and staging of primary extrathoracic tumors are the known diagnostic indications for uVATS (16).
uVATS not only enables to take biopsies from any region but also to observe the entire pleural, mediastinal, and diaphragmal surfaces, and to obtain biopsies from the most problematic locations (5). Alar and Ozcelik (17) and Kara et al. (18) reported the facile and reliable application of uVATS with a low incidence of recurrence in patients with pleural effusion. In all of our 140 patients who could not be diagnosed by thoracentesis or closed pleural biopsy, uVATS was used to diagnose mesothelioma (n=25), squamous cell carcinoma (n=13), breast cancer metastasis (n=5), active chronic pleurisy (n=77), and granulomatous reaction (n=20). Kürkçüoğlu et al. (19) and Kurul et al. (20) obtained similar results with us in 47 and 23 patients, respectively, with pleural effusion.
With the development of minimally invasive surgical techniques, thoracoscopic wedge resections were frequently recommended for diagnostic purposes in interstitial lung diseases, solitary pulmonary nodules, and for therapeutic reasons in some lung pathologies including bullous diseases, metastasectomies, peripherally located hamartoma and pulmonary aspergilloma, especially because patient comfort is not impaired in the postoperative period (21).
uVATS also has a high capability in the diagnosis of nodular and interstitial lesions which could not be diagnosed with bronchoscopy and transthoracic biopsy. Kurul et al. (20) used uVATS in patients with single or multiple nodules imaged by CT to diagnose malignant pathologies in four cases and benign pathologies in nine cases. We also applied uVATS in 42 cases and diagnosed 15 of the cases with malignant pathologies including squamous cell carcinoma (n=6), adenocarcinoma (n=3) and bronchoalveolar carcinoma (n=1), and lymphoma (n=5); 17 cases were diagnosed with benign pathologies including granulomatous reaction (n=15) and hamartoma (n=12). After using uVATS in 15 patients with an interstitial pattern on CT, we were able to diagnose granulomatous reaction (n=2), sarcoidosis (n=2), and squamous metaplasia (22).
uVATS can be performed in cases of primary or secondary spontaneous pneumothorax (23). One point requiring attention is the localization of all pulmonary air leaks, blebs and bullae by scanning. Another important point is the requirement of pleural abrasion or pleurectomy procedures after wedge resection, with or without air leakage, in order to ensure the removal of all blebs and bullae, overlooked or likely to recur post operatively, and thereby to prevent repetition of pneumothorax by means of the adhesion of the visceral and parietal pleura (24,25). In our clinic, uVATS-assisted wedge resection and pleural abrasion were performed in 56 cases consulting with spontaneous pneumothorax. There were no incidences of recurrence within the 12-month follow-up of all cases.
Giant bullous lung disease large enough to fill at least 1/3 of a hemithorax, presenting as a complication of emphysema, can be operated with uVATS. Development of symptoms, such as shortness of breath related to the bulla, pneumothorax, infection, empyema, and massive haemoptysis are the indications for surgery (25). The place of preventive surgery in asymptomatic patients is a subject of debate, and the advantages and risks of surgery need to be carefully considered. When there are problems related with the patient and the surgical treatment, selecting the right patient, and evaluating the likely postoperative complications are important issues (25). When selecting a surgical procedure, a surgeon has to consider the factors least likely to impair the current respiratory function of the patient, and choose a procedure with the best outcomes. uVATS is therefore preferred to open surgery for patients with limited respiratory function. Here the aim is to excise the bulla without causing air leakage and to achieve the expansion of the lung (25). Ten of our patients with giant bullous lung disease suffered shortness of breath adversely affecting daily life. In order to prevent or minimize the formation of air leakage, staple line reinforcement was used and the bullae were excised followed by pleural abrasion. No recurrence was observed during a mean period of 16 months of follow-up. Linear and circular stapling devices enable surgeons to perform minimally invasive surgery allowing simultaneous stapling and sealing of the tissue, thus giving surgeons the ability to divide and transect a variety of tissues with ease. However, there are two major drawbacks of the stapling technology: the development of staple line bleeding and leaks. These potential complications can lead to significant postoperative morbidity and even mortality, which were not experienced during the relatively shortened course of uVATS.
