Video-Assisted Thoracic Surgery (VATS) is conventionally performed through multiple small incisions (C-VATS). Recent studies have reported encouraging results with the single-incision VATS (S-VATS) over the conventional technique. However, these studies were either small in size, unfocused, nonuniform, retrospective, lacking follow-up information, or focused on pain. We aim to validate previously reported results in a single large meta-analysis, including only the best evidence studies available.
Methods:
Systematic review of the PubMed archive was conducted to include only full English articles with Newcastle Ottawa Scale score ≥7. The primary outcome was the complications rate while secondary outcomes were operative time, resected lymph nodes (LNs), chest tube duration, estimated blood loss, length of postoperative stay (LOS), and postoperative pain on day 1 after surgery. Odds ratio and standard mean difference were used as effect estimates. Random model and leave-one-out analysis were used.
Results:
A total of 39 studies were included with 4635 patients (1686 S-VATS versus 2949 C-VATS). S-VATS has resulted in significantly less postoperative pain (P < .001), blood loss (P = .006), LOS (P < .001), and chest tube duration (P < .001). In lung cancer patients, the number of retrieved LNs was similar to that of C-VATS (P > .05). Subgroup comparison of the rate of complications between lung resections versus other intrathoracic procedures, lung cancer versus pneumothorax, and lung cancer versus other lung-only lesions did not show any significant differences between the groups.
Conclusion:
Performing S-VATS technique has shown superior postoperative outcomes over the C-VATS technique in the treatment of thoracic disorders. Substantial benefit was confirmed in terms of less postoperative pain, blood loss, drainage time, and postoperative hospital stay.
RahoumaM, KamelM, GhalyG, NasarA, HarrisonS, StilesB, et al.PS01.44: 1,000 Video-assisted thoracoscopic lobectomies: A single institution's experience: Topic: Surgery. J Thorac Oncol, 2016; 11:S296–S297.
3.
RahoumaM, KamelM, HarrisonS, NasarA, StilesB, AltorkiN, et al.MINI01.07: Predictors of conversion to thoracotomy in VATS lobectomy patients: Topic: Surgery. J Thorac Oncol, 2016; 11:S260.
4.
Gonzalez-RivasD. Uniportal thoracoscopic surgery: From medical thoracoscopy to non-intubated uniportal video-assisted major pulmonary resections. Ann Cardiothorac Surg, 2016; 5:85–91.
5.
LujánJA, SorianoMT, AbrisquetaJ, PérezD, ParrillaP. Single-port colectomy vs multi-port laparoscopic colectomy. Systematic review and meta-analysis of more than 2800 procedures. Cir Esp, 2015; 93:307–319.
6.
EversL, BouvyN, BranjeD, PeetersA. Single-incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: A systematic review and meta-analysis. Surg Endosc, 2016; 30:1–12.
7.
NagahiroI, AndouA, AoeM, SanoY, DateH, ShimizuN. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: A comparison of VATS and conventional procedure. Ann Thorac Surg, 2001; 72:362–365.
8.
YangY, DongJ, HuangY. Single-incision versus conventional three-port video-assisted surgery in the treatment of pneumothorax: A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg, 2016; 23:722–728.
9.
LiberatiA, AltmanDG, TetzlaffJ, MulrowC, GøtzschePC, IoannidisJPA, et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration. BMJ, 2009; 339:b2700.
10.
DerSimonianR, LairdN. Meta-analysis in clinical trials. Control Clin Trials, 1986; 7:177–188.
11.
WellsG, SheaB, O'ConnellD, et al.The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, ON: Ottawa Hospital Research Institute. 2011. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (last accessed May15, 2017).
12.
BorroJM, RegueiroF, PértegaS, ConstenlaM, PitaS. Comparative study of survival following videothoracoscopic lobectomy procedures for lung cancer: single-versus multiple-port approaches. Archivos de Bronconeumología (English Edition). 2017; 53:199–205.
13.
ChangJ-M, KamK-H, YenY-T, HuangW-L, ChenW, TsengY-L, et al.From biportal to uniportal video-assisted thoracoscopic anatomical lung resection: A single-institute experience. Medicine (Baltimore), 2016; 95:40.
14.
ChenP-R, ChenC-K, LinY-S, HuangH-C, TsaiJ-S, ChenC-Y, et al.Single-incision thoracoscopic surgery for primary spontaneous pneumothorax. J Cardiothorac Surg, 2011; 6:58.
15.
ChenC-H, LeeS-Y, ChangH, LiuH-C, HungT-T, ChenC-H. The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: A retrospective study. J Cardiothorac Surg, 2012; 7:99.
16.
ChungJH, ChoiYS, ChoJH, KimHK, KimJ, ZoJI, et al.Uniportal video-assisted thoracoscopic lobectomy: An alternative to conventional thoracoscopic lobectomy in lung cancer surgery?. Interact Cardiovasc Thorac Surg, 2015; 20:813–819.
17.
ClarkJJ, JohnsonSM. Single incision Nuss procedure for pectus excavatum. Pediatr Surg Int, 2011; 27:733–736.
18.
DaiF, MengS, MeiL, GuanC, MaZ. Single-port video-assisted thoracic surgery in the treatment of non-small cell lung cancer: A propensity-matched comparative analysis. J Thorac Dis, 2016; 8:2872.
19.
FrenchDG, ThompsonC, GilbertS. Transition from multiple port to single port video-assisted thoracoscopic anatomic pulmonary resection: Early experience and comparison of perioperative outcomes. Ann Cardiothorac Surg, 2016; 5:92.
20.
GuoW, MaL, ZhangY, MaX, YangS, ZhuX, et al.Totally minimally invasive Ivor-Lewis esophagectomy with single-utility incision video-assisted thoracoscopic surgery for treatment of mid-lower esophageal cancer. Dis Esophagus, 2016; 29:139–145.
21.
HanKN, KimHK, ChoiYH. Comparison of single port versus multiport thoracoscopic segmentectomy. J Thorac Dis, 2016; 8:S279.
22.
HiraiK, TakeuchiS, UsudaJ. Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: A retrospective comparative study of perioperative clinical outcomes. Eur J Cardiothorac Surg, 2015; 49:i37–i41.
23.
IbrahimM, AllamA. Comparing two methods of thoracoscopic sympathectomy for palmar hyperhidrosis. J Am Acad Physician Assist, 2014; 27:1–4.
24.
IgaiH, KamiyoshiharaM, IbeT, KawataniN, ShimizuK. Single-incision thoracoscopic surgery for spontaneous pneumothorax using multi-degrees of freedom forceps. Ann Thorac Cardiovasc Surg, 2014; 20:974–979.
25.
JeonHW, KimY-D. Does 11.5 mm guided single port surgery has clinical advantage than multi-port thoracoscopic surgery in spontaneous pneumothorax?. J Thorac Dis, 2016; 8:2924.
26.
JutleyRS, KhalilMW, RoccoG. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: Comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg, 2005; 28:43–46.
27.
KangHD, JunHJ, HwangYH, KangM-K. Early outcomes of single-port video-assisted thoracic surgery for primary spontaneous pneumothorax. Korean J Thorac Cardiovasc Surg, 2014; 47:384.
28.
KatzMS, SchwartzMZ, MorontML, ArthurLG, TimmapuriSJ, NagyBK, et al.Single-incision thoracoscopic surgery in children: Equivalent results with fewer scars when compared with traditional multiple-incision thoracoscopy. J Laparoendosc Adv Surg Tech, 2012; 22:180–183.
29.
KimM-S, YangHC, BaeM-K, ChoS, KimK, JheonS. Single-port video-assisted thoracic surgery for secondary spontaneous pneumothorax: Preliminary results. Korean J Thorac Cardiovasc Surg, 2015; 48:387.
30.
LinF, ZhangC, ZhangQ, ChengK, ZhaoY. Uniportal video-assisted thoracoscopic lobectomy: An alternative surgical method for pulmonary carcinoma. Pak J Med Sci, 2016; 32:1283.
31.
LiuC-C, ShihC-S, PennarunN, ChengC-T. Transition from a multiport technique to a single-port technique for lung cancer surgery: Is lymph node dissection inferior using the single-port technique?. Eur J Cardiothorac Surg, 2015; 49:i64–i72.
32.
McElnayPJ, MolyneuxM, KrishnadasR, BatchelorTJ, WestD, CasaliG. Pain and recovery are comparable after either uniportal or multiport video-assisted thoracoscopic lobectomy: An observation study. Eur J Cardiothorac Surg, 2014; 47:912–915.
33.
MierJM, ChavarinA, Izquierdo-VidalC, FiblaJJ, MolinsL. A prospective study comparing three-port video-assisted thoracoscopy with the single-incision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: A pilot study. Surg Endosc, 2013; 27:2557–2560.
34.
MuJ-W, GaoS-G, XueQ, ZhaoJ, LiN, YangK, et al.A matched comparison study of uniportal versus triportal thoracoscopic lobectomy and sublobectomy for early-stage nonsmall cell lung cancer. Chin Med J (Engl), 2015; 128:2731.
35.
MurphyMO, GhoshJ, KhwajaN, MurrayD, HalkaAT, CarterA, et al.Upper dorsal endoscopic thoracic sympathectomy: A comparison of one-and two-port ablation techniques. Eur J Cardiothorac Surg, 2006; 30:223–227.
36.
OcakciogluI, AlpayL, DemirM, KiralH, AkyilM, DogruyolT, et al.Is single port enough in minimally surgery for pneumothorax?. Surg Endosc, 2016; 30:59–64.
37.
SalatiM, BrunelliA, XiumeF, RefaiM, SciarraV, SoccettiA, et al.Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: Clinical and economic analysis in comparison to the traditional approach. Interact Cardiovasc Thorac Surg, 2008; 7:63–66.
ShihC-S, LiuC-C, LiuZ-Y, PennarunN, ChengC-T. Comparing the postoperative outcomes of video-assisted thoracoscopic surgery (VATS) segmentectomy using a multi-port technique versus a single-port technique for primary lung cancer. J Thorac Dis, 2016; 8:S287.
40.
SongI-H, LeeSY, LeeSJ. Can single-incision thoracoscopic surgery using a wound protector be used as a first-line approach for the surgical treatment of primary spontaneous pneumothorax? A comparison with three-port video-assisted thoracoscopic surgery. Gen Thorac Cardiovasc Surg, 2015; 63:284–289.
TamuraM, ShimizuY, HashizumeY. Pain following thoracoscopic surgery: Retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg, 2013; 8:153.
43.
TsuboshimaK, WakaharaT, MatobaY, MiyauchiH, HayashiC, KobayashiI, et al.Single-incision thoracoscopic surgery using a chest wall pulley for lung excision in patients with primary spontaneous pneumothorax. Surg Today, 2015; 45:595–599.
44.
WangB-Y, LiuC-Y, HsuP-K, ShihC-S, LiuC-C. Single-incision versus multiple-incision thoracoscopic lobectomy and segmentectomy: A propensity-matched analysis. Ann Surg, 2015; 261:793–799.
45.
WangL, LiuD, LuJ, ZhangS, YangX. The feasibility and advantage of uniportal video-assisted thoracoscopic surgery (VATS) in pulmonary lobectomy. BMC Cancer, 2017; 17:75.
46.
WuH-H, ChenC-H, ChangH, LiuH-C, HungT-T, LeeS-Y. A preliminary report on the feasibility of single-port thoracoscopic surgery for diaphragm plication in the treatment of diaphragm eventration. J Cardiothorac Surg, 2013; 8:224.
47.
WuC-F, Gonzalez-RivasD, WenC-T, LiuY-H, WuY-C, ChaoY-K, et al.Comparative short-term clinical outcomes of mediastinum tumor excision performed by conventional VATS and single-port VATS: Is it worthwhile?. Medicine (Baltimore), 2015; 94:45.
YangHC, ChoS, JheonS. Single-incision thoracoscopic surgery for primary spontaneous pneumothorax using the SILS port compared with conventional three-port surgery. Surg Endosc, 2013; 27:139–145.
50.
ZhuY, LiangM, WuW, ZhengJ, ZhengW, GuoZ, et al.Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer. Ann Transl Med, 2015; 3;(7).
51.
AkterF, RoutledgeT, ToufektzianL, AttiaR. In minor and major thoracic procedures is uniport superior to multiport video-assisted thoracoscopic surgery?. Interact Cardiovasc Thorac Surg, 2015; 20:550–555.
52.
YoungR, McElnayP, LeslieR, WestD. Is uniport thoracoscopic surgery less painful than multiple port approaches?. Interact Cardiovasc Thorac Surg, 2014; 20:409–414.
53.
XuW, WangY, SongJ, MoL, JiangT. One-port video-assisted thoracic surgery versus three-port video-assisted thoracic surgery for primary spontaneous pneumothorax: A meta-analysis. Surg Endosc, 2017; 31:17–24.
54.
QinS-L, HuangJ-B, YangY-L, XianL. Uniportal versus three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: A meta-analysis. J Thorac Dis, 2015; 7:2274.
55.
HarrisCG, JamesRS, TianDH, YanTD, DoyleMP, Gonzalez-RivasD, et al.Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer. Ann Cardiothorac Surg, 2016; 5:76.
56.
ChengK, ZhengB, ZhangS, ZhengW, GuoZ, ZhuY, et al.Feasibility and learning curve of uniportal video-assisted thoracoscopic segmentectomy. J Thorac Dis, 2016; 8:S229.
57.
TanakaM, SagawaM, UsudaK, MachidaY, UenoM, MotonoN, et al.Postoperative drainage with one chest tube is appropriate for pulmonary lobectomy: A randomized trial. Tohoku J Exp Med, 2014; 232:55–61.
58.
CerfolioRJ, BryantAS. Does minimally invasive thoracic surgery warrant fast tracking of thoracic surgical patients?. Thorac Surg Clin, 2008; 18:301–304.
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
