ABSTRACT

Single-port (uniportal) video-assisted thoracoscopic surgery (VATS) represents an evolution of traditional VATS principles and, at the same time, a formidable return to the geometric configuration of classic open thoracotomies. 13 . In a way, the uniportal concept is the center of a star system whose satellites exchange technical aspects with the other known thoracic surgical approaches (see Figure 17.1). The main feature of the uniportal VATS approach consists of targeting, through a caudocranial (sagittal) plane, any area of surgical interest inside the chest (see Figure 17.2). Two advantages result from such a perspective: (1) the procedure allows for a similar approach as is used for open surgery and (2) the reacquisition of the depth of visualization lost with conventional three-port VATS. 3 The latter is based on the 206development of a transversal latero-lateral (or anteroposterior) plane, along which the operative instruments are deployed to address the target area. 3 With the current 2-D technology, the surgical maneuvers impede in-depth visualization through a centrally located videothoracoscope because of the torsion angle created by the operative instruments (see Figure 17.3). 3 , 4 As a result, traditional three-port VATS demands an extent of hand-eye coordination to overcome the geometrical obstacle originating from this torsion angle (see Figure 17.4a). 4 This hand-eye coordination represents an added difficulty, especially during hilar dissection during VATS lobectomy, and this has possibly undermined the more universal acceptance of the procedure, which is otherwise appealing. Conversely, in the uniportal approach, the eye “accompanies” in depth the stems of the instruments, which are deployed parallel to each other along the sagittal plane, and effectively represents an extension of the surgeon's hands (see Figure 17.4b). 4 At present, the similarity between open and uniportal VATS is as close as it can get. In addition, the articulated jaws or graspers can be positioned so as to avoid bite closure on the target area, which could, in turn, obstruct the in-depth view. Furthermore, the fulcrum of the operative instruments is inside the chest—at a short distance from the actual lesion. This characteristic assimilates uniportal VATS to robotic surgery; indeed, robotic surgery is considered to be the minimally invasive surgical approach that most closely duplicates the technical features of open thoracotomy (see Figure 17.1).