Evidence - Uniportal VATS lobectomy lower lobe right

Indication for Lobectomy According to Current Guidelines (2022)

According to current guidelines, lobectomy is the treatment of choice in UICC Stage I, Stage II, and Stage IIIA (T3N1), provided there is sufficient cardiopulmonary reserve. While open surgery via thoracotomy was previously recommended, the advantages of a minimally invasive approach with equivalent oncological outcomes have been sufficiently demonstrated. Therefore, the revised S3 guideline for the treatment of lung cancer (2022) explicitly recommends a minimally invasive approach for tumor stages I and II.

After initial concerns regarding oncological and surgical safety, acceptance of a minimally invasive approach has significantly improved following positive results from large case series. Ultimately, the choice of surgical procedure also strongly depends on the experience and technical skills of the surgical team and should be assessed by them. (1)

Development of Minimally Invasive Thoracic Surgery

Beginning in the 1990s, there has been significant development in the field of minimally invasive thoracic surgery over the past decades. Following the dissemination of the method and increasing scientific interest, several studies (2, 3) have demonstrated that VATS lobectomy offers the following advantages over thoracotomy in early tumor stages:

• less postoperative pain (4)
• reduced blood loss (5)
• shorter hospital stay with quicker resumption of daily activities (5)
• fewer postoperative complications (6)
• better postoperative lung function
• equivalent oncological outcomes and mediastinal staging quality
• better 5-year survival rate (7)

Development of Uniportal VATS

The aforementioned research results suggest a correlation between the mentioned advantages and operative trauma. Therefore, the next developmental step was to further reduce the 3-port VATS technique. Over the past 10 years, uniportal VATS surgery, particularly for complex anatomical resections in lung cancer, has been developed and advanced by Gonzalez-Rivas et al. (7)

At present, scientific evidence for the superiority of uniportal VATS over 3-port VATS is still pending, although at least equivalence has been extensively investigated and proven. It remains exciting to see how thoracic surgery will continue to evolve.

(1) Expertise in Thoracic Surgery. Müller M, Wanka S, Inderbitzi R, Kiefer T, Stubenberger E, Eds. 1st Edition. Stuttgart: Thieme; 2015.

(2) Bulgarelli Maqueda, L., García-Pérez, A., Minasyan, A. et al. Uniportal VATS for non-small cell lung cancer. Gen Thorac Cardiovasc Surg 68, 707–715 (2020).

(3) Shigemura N, Akashi A, Funaki S, Nakagiri T, Inoue M, Sawabata N, Shiono H, Minami M, Takeuchi Y, Okumura M, Sawa Y. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg. 2006;132:507–12

(4) Bendixen M, Jørgensen O, Kronborg C, Andersen C, Licht P. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early-stage lung cancer: a randomized controlled trial. Lancet Oncol. 2016;17(6):836-844.

(5) Long H, Tan Q, Luo Q, Wang Z, Jiang G, Situ D, et al. Thoracoscopic Surgery Versus Thoracotomy for Lung Cancer: Short-Term Outcomes of a Randomized Trial. Ann Thorac Surg. 2018;105(2):386-392.

(6) Palade E, Passlick B, Osei-Agyemang T, Günter J, Wiesemann S. Video-assisted vs open mediastinal lymphadenectomy for Stage I non-small-cell lung cancer: results of a prospective randomized trial. Eur J Cardiothorac Surg. 2013;44(2):244-9; discussion 249.

(7) Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27:2553–62)

(8) Gonzalez D, Paradela M, Garcia J, de la Torre M. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg. 2011;12:514–5.