Single-Incision Thoracoscopic Surgery in Children: Equivalent Results with Fewer Scars When Compared with Traditional Multiple-Incision Thoracoscopy

Introduction

Single-incision pediatric endosurgery is rapidly gaining popularity. There are now several studies in the literature supporting the feasibility of the single-incision approach in pediatric laparoscopy.^1–7 Our group began to apply single-incision techniques not only to abdominal operations but also for thoracoscopic procedures. Previously, we reported our early experience with single-incision thoracoscopic surgery (SITS) in the pediatric population, concluding that the technique is feasible. ⁸ In this study we compare the results of our current experience with SITS to traditional multiple-incision video-assisted thoracoscopic surgery (VATS) in children.

Materials and Methods

With IRB approval under protocol #18587, we conducted a retrospective chart review of all patients who underwent SITS at our institution between October 2008 and July 2010. An equal number of traditional multiple-incision VATS cases performed during the same time period and for similar conditions as the SITS procedures matched for age, sex, and weight were selected to represent the control group. For both SITS and VATS groups, the mean operative time, time until chest tube removal, and length hospital of stay were recorded. Any procedure conversion (either SITS to VATS or SITS/VATS to open), intraoperative or postoperative complication, or need for reoperation was noted. Statistical analysis was performed by Student's t-test using InStat Version 3.10 (Graphpad Software, La Jolla, CA). A P value of <.05 was considered statistically significant.

Results

Twelve patients (9 males and 3 females) underwent 14 SITS procedures during the study period (2 patients had bilateral procedures performed under 2 different anesthetics each). These patients were compared with 14 patients (10 males and 4 females) who had undergone similar procedures using traditional multiple-incision VATS. The average age and weight of the patients in the SITS group were 13.3±4.9 years and 46.9±16.8 kg, respectively. The traditional multiple-incision VATS case controls were statistically similar with regard to age (P=.06) and weight (P=.58; Table 1). The procedures performed in the SITS group were similar to those done in the VATS group and included 10 wedge resections, 1 mediastinal biopsy, 1 chest wall biopsy, 1 resection of an apical extrapulmonary neuroblastoma, and 1 drainage of an empyema. The mean operative time in the SITS group was 84±43 minutes when compared with 64±30 minutes in the VATS group (P=.18). Days until chest tube removal was 4±2.2 in the SITS group when compared with 2.8±1.4 in the VATS group (P=.09). Patients who underwent SITS were discharged on average 1.7 days sooner than VATS patients, but this was not statistically significant (SITS 5.5±4.4 days, VATS 7.2±8.6 days; P=.51; Table 2). There were no intraoperative complications in either group. No SITS patient required conversion to VATS, and no patient in either group required conversion to open. One SITS patient who underwent an apical wedge resection and mechanical pleurodesis for a spontaneous pneumothorax was readmitted 1 week after discharge for a recurrent pneumothorax and persistent air leak. The patient required a reoperation and ultimately recovered fully. Notably, the patient was found to have an occult pulmonary Aspergillus infection diagnosed on tissue culture of the resected specimen.

Discussion

The single-incision approach to abdominal surgery was first reported in 1992 by Pelosi and coworker for a laparoscopic appendectomy in an adult. ⁹ In 1997, Navarra et al. performed the first modified single-incision laparoscopic cholecystectomy using two trocars passed through a single-umbilical incision and three transabdominal stay sutures for retraction. ¹⁰ Podolsky et al. subsequently reported a completely transumbilical approach to cholecystectomy in adults, and Solomon et al. described the short learning curve required to attain proficiency with the technique.^11,12 Others have reported on the use of a single-incision approach to nephrectomy, adrenalectomy, and colorectal procedures.^13–15 The concept of single-incision laparoscopy was naturally applied to surgery in children.^16,17 There are now several studies in the literature supporting the feasibility of the single-incision approach to pediatric appendectomy, pyloromyotomy, and pull-through procedures, among others.^1–7 Single-incision surgery in children offers several potential advantages over traditional multiple-port surgery, including less pain, reduced port-site complications, and less scarring. Single-incision laparoscopy has the added advantage of utilizing the umbilicus, the natural cicatrix of the body, allowing for “scarless” surgery.

There are very few reports in the literature regarding single-incision surgery for thoracic conditions in children. Previously, we reported our early experience with SITS in the pediatric population. ⁸ In this technique, multiple trocars are passed through a single small incision in the chest, where either a thoracostomy tube was in place or would be placed (Fig. 1). In our initial operations, the incision measured between 2.5 and 3 cm. Since then we generally keep the incision 2.5 cm or shorter. We concluded that the single-incision approach is a feasible option to consider in children requiring thoracoscopy. Further, the in-line positioning of the telescope and instruments often proved to be an advantage in the smaller chest cavity of a child, where triangulation toward a target and articulation of instruments can be difficult (Fig. 2). In this present case–control study, we compared our current experience with SITS to traditional multiple-incision VATS in children. This includes our additional experience since our first report and compares our results to statistically matched patients having undergone VATS. We found that there was no statistical difference in operative time, time until chest tube removal, and length of hospital stay between patients who have undergone SITS or VATS. We believe that this indicates that the learning curve is short. Further, because the time until chest tube removal and the length of hospital stay were similar between the groups, we feel that SITS is a safe and efficacious procedure. Because only one small lateral incision is necessary, SITS may be cosmetically more appealing than traditional VATS, which requires an array of multiple small incisions across the chest wall.

OPEN IN VIEWER

FIG. 1.

A 12-mm trocar for the endostapler, a 5-mm trocar for the telescope, and an unsheathed 3-mm instrument passed within the same interspace through the single small incision where the patient already had a chest tube placed preoperatively.

OPEN IN VIEWER

FIG. 2.

Intraoperative view demonstrating the in-line positioning of the telescope, grasper, and endoscopic stapler achieved during an apical wedge resection via a single incision.

One noticeable difference between the groups was that there was a single postoperative complication in the SITS group in a patient who underwent an apical wedge resection and mechanical pleurodesis for a recurrent spontaneous pneumothorax (there were no complications in the VATS group). After an initial uneventful postoperative course, this patient returned 1 week following discharge with a recurrent pneumothorax. An air leak persisted despite chest tube placement, and the patient required a reoperation. Postoperatively, it was discovered that the patient had an occult pulmonary Aspergillus infection. Although this complication can be possibly attributed to the technique and, hence, to the single-incision approach, it is reasonable to believe that an initial multiple-incision VATS approach would also have failed because of the Aspergillus infection. Further, the patient's mother reported a similar personal experience in the past herself when she suffered an infectious complication after a thoracotomy for a spontaneous pneumothorax that resulted in a prolonged hospital stay. We believe that there may be an underlying undiagnosed immunologic condition in this family.

We conclude that SITS is an ergonomically efficient operation with a short learning curve for a pediatric surgeon already adept at traditional VATS. There is no difference in time until chest tube removal or length of hospital stay, indicating that the operation is as safe and effective as VATS, although no clear benefit is evident. However, because only a single small lateral incision is required, SITS may be cosmetically superior to multiple-incision VATS, as the end result in SITS is a single small scar at the thoracostomy tube site, which is appealing to both patients and parents. A prospective, randomized study is necessary to confirm our preliminary findings.