Uniportal Video-Assisted Thoracic Surgery in a Pediatric Hospital: Early Results and Review of the Literature

Abstract

Background:

Uniportal video-assisted thoracic surgery (U-VATS) is an implemented technique in adult surgery that may aid to extend offer the benefits of thoracoscopy to a wide number of pediatric patients.

Materials and Methods:

Consecutive cases treated between July 2019 and July 2021 were retrospectively analyzed. Simultaneously, a MEDLINE systematic search was conducted.

Results:

Twelve patients (median age 13 years, median weight 44.5 kg) underwent 4 major procedures (n = 2 lobectomy, n = 2 segmentectomy) and 11 minor procedures (n = 1 bronchogenic cyst resection, n = 4 apical wedge resections and pleurodesis for pneumothorax, n = 4 wedge resections for lung nodules, and n = 2 debridement for empyema). The median observed operative time was 77 minutes. We recorded one conversion to biportal VATS. No intraoperative complications or 30-day morbidity–mortality was reported. A rate of 40% adverse postoperative events was observed (Clavien–Dindo grade I-IVa). Visual analog scale for postoperative pain recorded a median value of 0 on days 1, 2, and 3. The systematic review provided 15 full-text articles reporting 76 pediatric interventions (4 major and 72 minor procedures); among them, 1 biportal conversion, 3 mild postoperative complications, and 1 redo surgery are presented.

Conclusions:

As emerged from the literature review, U-VATS remains scarcely adopted by pediatric surgeons. Its feasibility is supported by the four reported major lung resections plus the four cases added on by our series. Thanks to a more rapid learning curve over conventional VATS, the uniportal technique could be accessible to a wider number of centers.

Introduction

Uniportal video-assisted thoracoscopic surgery (U-VATS) has been rapidly implemented by adult surgeons within the past two decades^1–3: it is performed through a 3-cm single incision in the fifth intercostal space with the camera and operative instruments entering the pleural cavity in a parallel manner. Procedure, specimen retrieval, chest drain insertion are all carried out from the single port.¹ In adults, U-VATS has demonstrated to be safe and feasible, and many publications have highlighted its benefits, including shorter hospital stay, earlier chest tube removal, reduced complication rates, and equivalent cancer-free survival. However, U-VATS remains poorly adopted in pediatric patients, not only for major lung resections, but also in case of minor procedures. We present the preliminary results of a U-VATS program in a pediatric hospital and a review of the available literature.

Materials and Methods

This study is based on information routinely collected during normal clinical care, no additional data were collected for the purposes of the study, and no additional intervention/medication was given solely for the purposes of the study. All the patients, as declared, have signed the consent form for clinical data utilisation in reasearch, with the clear intent of retrospective analysis and no personal information showing. Therefore, institutional review board approval was waived.

Population, procedures, and outcome

We retrospectively reviewed data about U-VATS procedures performed at our department between July 2019 and July 2021: demographics (gender, age, and weight), preoperative clinical presentation, perioperative features (anesthesia and operative time, intraoperative complications, and conversion rate), and postoperative outcomes (chest tube duration, length of hospital stay, infections, air leak, need for redo surgery, and postoperative pain) were recorded. For all the patients, a written consent was received and archived. Descriptive statistics were used to present features of the population (median and range). Depending on technical expertise, and related intraoperative risk, procedures were classified as minor or major. Minor procedures included debridement and decortication, wedge lung resection and biopsy, pleurodesis, bronchogenic cyst resection, and extralobar sequestration excision; major procedures were lobectomy, segmentectomy, and pneumonectomy.

Patients were also stratified depending on patient weight: <10 kg, between 10 and 30 kg, and >30 kg. The postoperative pain at days 1, 2, and 3 was determined by the visual analog scale (VAS), ranging from 0 to 10.⁴ Outcome in terms of operative time, total anesthesia time, chest tube duration, length of postoperative hospital stay, and postoperative pain are presented by median values. Surgical complications were retrospectively reviewed according to the thoracic morbidity and mortality (TMM) reporting system based on the Clavien–Dindo classification.⁵

U-VATS program

The U-VATS program was set following the Harvard Business School report⁶: a U-VATS-lobectomy experienced thoracic surgeon was designed as team leader; 2 pediatric surgeons were involved as members to be trained in U-VATS. In addition, 2 anesthesiologists, 2 scrub nurses, and 3 members of operating theater staff were identified. Before assembling the surgical team, hospital administration and operating theaters provided the resources and permission for the new procedure.

Technique

Single-lung ventilation was established in all cases, either with a double-lumen endotracheal tube or, depending on the size of the patient (below or above 25–27 kg), with a single-lumen and bronchial blocker. Patients were placed in lateral decubitus, with a tissue roll under the chest to avoid the hip curve. A 30- or 40-mm single access was entered in the fourth–fifth intercostal space with no carbon dioxide (CO₂) insufflation. A wound retractor (Alexis S or XS, Applied Medical, California) was positioned to achieve the best field exposure with the minimum associated local tissue trauma. In cases of severe parenchymal inflammation, parietal adhesions, or fissure obliteration, the dissection was carried out using an Ultracision harmonic scalpel device (Ethicon Endo-Surgery, Inc., Cincinnati, OH).

Before securing and dividing the vessels with the device, a laparoscopic titanium clip was placed proximally. Furthermore, an endoscopic linear stapler (Echelon Flex™ Powered Vascular Stapler) was preferred both for a vessel diameter >7 mm and for bronchus closure. Once excised, the separated parenchyma was extracted by specimen bag through the single incision. Before wound closure and under thoracoscopic view, four to five intercostal spaces around the level of the incision were injected with 2 mL of Levobupivacaine at 2.5 mg/mL to reduce immediate postoperative pain. In all cases, a chest tube was positioned through the port.

Systematic literature search

A MEDLINE/PubMed systematic search was conducted by the following MeSH terms and keywords. Mesh: “Thoracoscopy,” “Thoracic Surgery, Video-Assisted,” “Adolescent,” “Child,” “Child, Preschool,” “Infant,” “Pediatrics”; keywords: “UVATS,” “VATS,” “Single port,” “Uniportal,” “Single incision,” “One trocar,” “Single site,” “One port,” “One incision.” After duplicates search, abstracts were screened according to inclusion criteria (“Pediatric/adolescent population < 18 years-old,” “Thoracic conditions,” “English language,” and “Human”) and exclusion criteria (“Chest wall conditions,” “Sympathectomies,” and “Extra-thoracic chest conditions”). Full-text articles were then included, and references were checked for relevant studies. Included articles were examined for population/procedure relevant features. Procedures were then classified following the cited system (minor and major).

Results

Eleven minor and four major procedures were performed following the described technique (Table 1): n = 2 lobectomy, n = 2 segmentectomy, n = 1 bronchogenic cyst excision, n = 4 surgical treatment of pneumothorax (meaning apical wedge and pleurodesis), n = 4 wedge resection for lung nodule, n = 2 treatment of empyema. Out of the 12 patients, 2 were treated at a distance of 3 months for contralateral pneumothorax and 1 for bilateral lung metastasis of osteosarcoma. Among all the patients studied, 2 were <10 kg, 3 were between 10 and 30 kg, and the remaining 7 > 30 kg; median overall weight was 44.5 kg (range 10–75).

Table 1.

Case Management of the Patients Treated at Our Center for Thoracic Surgical Diseases by Means of Uniportal Video-Assisted Thoracic Surgery

Diagnosis	Intralobar bronchopulmonary sequestration n = 2 Congenital pulmonary airway malformation n = 1 Bronchiectasis n = 1 Mediastinal bronchogenic cyst n = 1 Primary spontaneous pneumothorax n = 4 Lung nodule n = 4 Empyema n = 2
Surgery	Lobectomy n = 2 Segmentectomy n = 2 Bronchogenic cyst excision n = 1 Apical wedge resection and pleurodesis n = 4 Wedge resection n = 4 Debridement n = 2
Procedures (n)	15
Minor procedures	11
Major procedures	4
Patients (n)	12
Patients ≤10 kg	2
Patients 10–30 Kg	3
Patients ≥30 kg	7
Median weight (kg)	44.5 (10–75)
Median age (years)	13 (1–17)
Median time under anesthesia (minutes)	188 (87–335)
Median operative time (minutes)	77 (30–203)
Conversion (n)	1 biportal conversion
Intraoperative complications	0
Postoperative short-term complications	40%
Median grade of the TMM reporting system (I–V)	II (I–IVa)
Median VAS for pain at POD 1, 2, and 3 (0–10)	0 (0–6), 0 (0–6), 0 (0–6)
Median chest tube duration time (days)	3 (1–24)
Median length of postoperative stay (days)	5 (2–26)

POD, postoperative day; TMM, thoracic morbidity and mortality; VAS, visual analog scale.

We recorded a median operative time and a median total time under anesthesia: 77 minutes (30–203) and 188 minutes (87–335), respectively. Outcomes were described in terms of (1) median VAS at postoperative day (POD) 1, 2, and 3 of 0 (range 0–6), 0 (range 0–6), and 0 (range 0–6), respectively; (2) median chest tube duration of 3 days (range 1–24); (3) median length of postoperative hospital stay of 5 days (range 2–26). No intraoperative complications occurred and, overall, no 30-day morbidity and mortality were reported.

In one 10-kg patient, a biportal conversion was needed due to the dimensions of the 60-mm stapler.

During postoperative stay, we experienced a total of six (40%) undesired short-term events with a median grade of severity according to the TMM of II (range I–IVa). Specifically, among the major procedures we recorded a prolonged air leak in a 26-kg patient with mental retardation and low compliance with respiratory physiotherapy protocols. In this patient, who underwent an inferior right lobectomy, chest tube duration was 8 days. In addition, a 45-kg patient operated by segmentectomy for bronchiectasis experienced a postoperative pleural effusion, which significantly prolonged the postoperative stay until POD 26.

The patient had a history of long-gap esophageal atresia at birth and residual laryngeal stenosis due to prolonged intubation with recurrent airway infections and bronchiectasis. After chest tube ablation on POD 2 and elective fulguration of a laryngeal granuloma on POD 4, the patient complained of thoracic pain on POD 6 with no associated dyspnea or fever; a contextual rise of white blood cell count of 16 × 10³/μL, C-reactive protein level of 10.7 mg/dL, and stable hemoglobin levels were found. The pleural effusion was successfully treated conservatively by respiratory physiotherapy and intravenous antibiotics. Furthermore, this patient experienced a central vein catheter thrombosis requiring curative anticoagulation.

At follow-up on POD 34, the patient presented in good general condition, with no reported pain or respiratory symptoms, and a chest X-ray showing no residual effusion. Among minor procedures we recorded (1) one postoperative pleural effusion in a 10-kg patient needing drain repositioning; (2) one postoperative respiratory failure requiring ventilatory support in a 19-kg child treated for a pleuropneumopathy; (3) two postoperative pneumothoraxes in the same 50-kg patient operated bilaterally at 3-month distance: the residual mild postop pneumothorax after the first surgery was treated conservatively, whereas for the second event a drain repositioning was deemed necessary.

The systematic MEDLINE search provided a total number of 96 abstracts (Fig. 1); one adjunctive article matching the research query was found as cited from another article and was thus included in the screening process, but was then excluded with reason. No duplicates were found. A total number of 53 out of 97 abstracts were rejected according to the mentioned inclusion/exclusion criteria. After the retrieval/screening processes, a comprehensive number of 44 articles matched eligibility parameters. A total number of 29 full-text articles were then excluded as they regarded large and mainly adult populations with no specific data about any sparse pediatric cases.

FIG. 1.

MEDLINE/PubMed systematic search process⁶ of identification, screening, and inclusion of previously published articles about uniportal video-assisted thoracic surgery performed in pediatrics. A total amount of 15 full-text articles were found reporting about case reports/case series. Color images are available online.

Among the 15 included articles,^7–22 case reports/series presented a total of 76 procedures performed within pediatric age (4 major and 72 minor procedures). It is worth noting that only four reports on MEDLINE provided information about major lung resections: left upper lobectomy (n = 1),⁹ right upper sleeve lobectomy (n = 1),¹⁵ middle lobectomy (n = 1),¹⁶ and right lower lobectomy with lymphadenectomy (n = 1).¹⁷ Only four articles were found that reported application of the technique in a small child <5 years^9,13,19,21 and, within this cohort, only one referred to a major resection.⁹

Among the 15 articles, technical safety and feasibility were advocated by all authors. The reported conversion rate was low: 1 case, among the minor procedures, recorded a biportal conversion²¹ out of 76 total cases, whereas no major resection required conversion. When looking at the postoperative complications, three minor procedures registered a mild event (i.e., air leak) and one minor procedure needed redo surgery (Table 2). Stratification by patient's weight and adverse event reclassification following TMM was not feasible due to missing data.

Table 2.

Systematic Literature Review About Pediatric Uniportal Video-Assisted Thoracic Surgery: 15 Reports Have Been Published Reporting a Total of 76 Procedures Done Within Pediatric Age (4 Major and 72 Minor Procedures)

	Patients (n)	Age	Weight	Condition	Surgery	One-lung ventilation (yes/no/type)	Technique	Operative time	Complication/conversion	Technical aspects	Notes	Follow-up
Vasconcelos-Castro et al.⁸	1	16	65 kg	Bilateral pneumonia complicated with right empyema	Thoracoscopic debridement and decortication	Not reported	10-mm, 0° thoracoscope, single, intercostal incision below the scapula tip	180 minutes	No	—	—	Not reported
Shaqqura et al.⁹	1	9 weeks	4.5 kg	Congenital lobar emphysema	Left upper lobectomy	Yes/3.5-mm single-lumen endotracheal tube	2.5-cm intercostal incision in the anterior axillary line (5th intercostal space). 30° 5-mm scope	Not reported	No	Puncture in the lung parenchyma to deflate the lobe	The narrow space and the available size of thoracoscopic instruments required the conventional open instruments that increased the difficulty.	Not reported
Fernandez-Pineda¹⁰	11	7–21 years	Not reported	Peripheral lung nodule in cancer patients	Lung biopsy (wedge resection)	Yes/not reported	Modified U-VATS: thoracoscope in the superior intercostal space relative to the working instruments	54 minutes (38–84)	No	The superior intercostal incision as exit site for chest tube may permit better closure of the larger incision.	Tissue trauma in U-VATS may be greater because of multiple instruments are passed through a limited space.	Not reported
Wang et al.¹¹	1	14 years	Not reported	Bilateral lung metastases (previous osteosarcoma)	Simultaneous bilateral wedge resection	Yes/double-lumen endotracheal tube	RLL nodule: 3-cm subxiphoid incision, 45-mm stapler. LUL nodule: 4-cm incision in the 5th intercostal space, 45-mm stapler.	85 minutes	No	—	—	Not reported
Kim¹²	2	17 and 18 years	Not reported	Simultaneous bilateral primary spontaneous pneumothorax	Single-staged simultaneous bilateral wedge resection	Yes, sequential/double-lumen endotracheal tube	Sequential procedure on both sides: supine position, 2.5-cm incision in the 4th intercostal space, 5-mm, 30° thoracoscope. 60-mm stapler	65 and 79 minutes	No	The supine position (with tilting of the operation table) removes the need of changing patient's position in bilateral procedures.	—	24 and 19 months
Halezeroğlu et al.¹³	1	14 months	Not reported	Extralobar sequestration	Extralobar sequestration resection	Yes/bronchial blocker	3-cm incision, 7^th intercostal space. The vascular bundle was freed by 5-mm vascular sealing device; Tied with 1–0 silk suture and plastic vascular clip was placed.	105 minutes	No	30-mm stapler not possible to open because of the limited distance between the incision and the vascular bundle.	—	Not reported
Fernandez-Pineda and Seims¹⁴	1	14 years	Not reported	Lung nodules (histoplasma capsulatum infection)	Wedge resection	Yes/not reported	Modified U-VATS: thoracoscope in the superior intercostal space relative to the working instruments	Not reported	No	Long thoracoscope avoids interaction between hands.	Possible increased postop pain, since two intercostal spaces are entered.	Not reported
Gonzalez-Rivas et al.¹⁵	1	10 years	Not reported	Low-grade right upper lobe carcinoid tumor	Right upper sleeve lobectomy	Yes/double-lumen intubation	3-cm incision, 4° intercostal space, anterior axillary line	Not reported	No	—	—	Not reported
Aragón and Méndez¹⁶	1	11 years	Not reported	Pulmonary aspergilloma secondary to lymphoblastic leukemia	Middle lobectomy and right lower lobe wedge resection	Yes/double-lumen endotracheal left tube	4-cm single incision in the 5th intercostal space. Stapler	Not reported	No	—	—	Not reported
Nakagawa et al.¹⁷	1	15 years	50 kg	Lung cancer (adenocarcinoma, stage pT1aN0M0)	Right lower lobectomy and lymphadenectomy	Yes/not reported	2-cm incision in the 5th intercostal space, 30°, 5-mm thoracoscope. 30-mm stapler	107 minutes	No	—	All the surgical instruments currently used for thoracoscopy are manufactured for adults.	2 years
Katz et al.¹⁸	12	13.3 ± 4.9 years	46.9 ± 16.8 kg	—	14 procedures: wedge resection (10), mediastinal biopsy (1), chest wall biopsy (1), empyema (1), resection apical extrapulmonary neuroblastoma (1).	Not reported	—	84 ± 43 minutes	1 readmission for recurrent pneumothorax/No	—	Hypothesis of shorter learning curve when compared with conventional VATS.	Not reported
Prasad et al.¹⁹	8	13.5 years (3–18)	47 kg (16–63)	Spontaneous pneumothorax, lymphoma, chronic granulomatous disease, apical extrapulmonary neuroblastoma	10 procedures: wedge resection and pleurodesis (7), wedge biopsy (2), resection of apical extrapulmonary neuroblastoma (1)	Yes/double-lumen endotracheal tube	2.5–3cm incision. Two trocars (12-mm and 5-mm), one unsheathed 3/5 mm instrument directly through the intercostal muscle. Wedge resections performed by stapler through the 12-mm trocar.	64 minutes (50–201)	1 readmission for recurrent pneumothorax/No	—	—	7 months (3–12)
Cobellis et al.²⁰	19	<17 years	Not reported	Multiloculated empyema	Thoracoscopic debridement ± decortication	Yes, not mandatory/not reported	10-mm Hasson trocar at the 4th–5th space. CO₂ insufflation at 4 mmHg	93.8 minutes (60–160)	No	—	Hospital stay: 21.2 days (8–35)	Not reported
Tander et al.²¹	12	4.5 years (4 months–14 years)	Not reported	Late-stage empyema	Thoracoscopic debridement	Not reported	A balloon connected to a 12F tube was inflated first to enhance the vision. Debridement done with the scope as dissecting tool. CO₂ insufflation.	Not reported	Secondary debridement (biportal) after 12 days (1), continuous fever (1)/biportal conversion (1)	—	—	Not reported
Martínez-Ferro et al.²²	10	6.9 years (2–13)	Not reported	Empyema	Thoracoscopic debridement	Yes/double-lumen endotracheal tubes if >25kg and selective intubation with monolumen tubes if <25 kg	11.5-mm thoracoport insertion after balloon insufflation technique	70 minutes (60–140)	Mild 48-hour air leak (1)/No	—	—	Not reported

POD, postoperative day; LUL, left upper lobe; RLL, right lower lobe; U-VATS, uniportal video-assisted thoracic surgery.

Discussion

Despite the widespread adoption of U-VATS in adults starting 20 years ago, there are few reports of its use in the pediatric population. Current available data concerning major procedures are scarce: eight cases worldwide (four previously described in the literature and four added on by our series).^9,15–17 We believe that the division in major and minor procedures could be useful to reflect the level of expertise required to complete the surgery by means of VATS. Potential obstacles for the use of U-VATS in small children concern space limitations within the pediatric chest, as declared in 3 out of the 15 articles reviewed (Table 2).^10,13,14 In our series, a biportal conversion was necessary mainly due to the dimensions of the 60-mm stapler and conceivably not for the single-port technique itself.

The same issue related to stapler length was also experienced by Halezeroğlu et al.,¹³ suggesting that there is a need for dedicated pediatric surgical instruments to facilitate the diffusion of the technique, just as previously reported for conventional video-assisted thoracic surgery (VATS).²³ An additional barrier to U-VATS pediatric translation could be the challenges of obtaining an optimal selective intubation due to the absence of double-lumen tubes available for subjects weighing <25–30 kg. In fact, we attribute the excessive length of anesthesia of our series to the establishment of a selective intubation achieved by a double lumen tube in 5 out of 7 patients and by a bronchial blocker in 2 out of 7 patients. Exclusion of ventilation of the affected lung is a crucial aspect for U-VATS feasibility since there is open-air communication with the pleural cavity through the retractor.

Nonetheless, well-established one-lung ventilation could support gas-free VATS procedures, especially in a small child where CO₂ brain absorption is associated with a higher risk of sequelae. Other advantages of the technique over conventional VATS include the coaxial position of the instruments, which mimics an open thoracotomy with a more rapid learning curve and greater accessibility to more of centers. This is an interesting aspect if we take into consideration the fact that nowadays still <50% of surgeries for congenital lung lesions are done thoracoscopically.²⁴ It has also been suggested that parallel positioning of the instruments in U-VATS could be even more useful in children where there is limited working space.¹⁸ Moreover, a lower rate of competition among instruments, could be associated with a reduced incidence of neuralgia/paresthesia due to lower angle rib stress and nerve compression.

A limitation of our study is mainly due to the retrospective nature of the analysis of a heterogenous population without the benefit of further statistical considerations. Looking at the incidence of adverse postoperative events, a multi-institutional, perhaps supranational, group of study would be needed to properly quantify the real rate of complications after thoracic surgery in the pediatric population. To this aim, a standardized reporting system and focus on the thoracic subspecialty (rather than including confounding factors from abdominal surgery) is mandatory. In fact, thoracic surgery has specific features and is associated to a higher rate of adverse events (which in adults settles in between 15% and 57%^25–27), even if the majority are at a low grade of severity.

We believe that even if the pediatric population does not suffer from the risks associated with chronic obstructive pulmonary disease or tobacco exposure, other factors could significantly impact outcomes, such as operating on an inflamed field (i.e., bronchiectasis or infected congenital pulmonary airway malformation). Another limitation of our study is that in all the cases the final cosmetic result was perceived as satisfactory by the patients or parents, but no validated score has been employed as an objective measure in that regard. Furthermore, we were not able to determine the exact impact of the technique on chest wall function, which would require years of follow-up.

Conclusions

In our experience, as confirmed from previously published cases, U-VATS could be a feasible and safe surgical option for the treatment of lung diseases. Conversions to biportal VATS were due to the inadequacy of surgical instruments only. Despite very few publications on the subject, U-VATS has been used in major lung resections with no morbidity or mortality related to the technique. Potential extra advantages over conventional VATS could be a better postoperative outcome in terms of pain due to the avoidance of intercostal nerve stress and greater accessibility for other centers, thanks to a more rapid learning curve when used to open surgery. Further research is warranted to confirm our experience.

Footnotes

Authors' Contributions

S.U., F.D.O., R.L.P., and R.C. collected data; S.U., A.M., and A.G. analyzed data; L.V. gave technical support and conceptual advice; S.U. and A.M. wrote the article; L.V., A.M., and A.G. participated in the final critical review process; A.M. and A.G. supervised the whole drafting process; all authors read and approved the final article.

Acknowledgments

The authors declare that the material has not been published or submitted for publication elsewhere.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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