OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Background: In recent years, many factors have revamped the interest in segmentectomies as preferred procedure for stage I non-small cell lung cancer (NSCLC). The aim of this systematic review and meta-analysis is to compare the outcomes of segmentectomy versus lobectomy regarding overall survival (OS) in the surgical treatment of stage I NSCLC, as stated in the conclusions of the largest studies conducted in this field and reported to date. Methods: The searching strategy was developed in EMBASE, MEDLINE and Cochrane CENTRAL from 1990 until December 2016. The meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random effect model. The OS of the lobectomy group was compared with the segmentectomy group alone. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method. Results: Regarding the results, most of these studies were based on the retrospective data. The size of the cohorts varied from 17 to 11,520, with a total number of 24,542 patients. The pooled HR was 1.04 [95% confidence interval (CI), 0.92–1.18; P=0.50]. Conclusions: The survival in the segmentectomy group was not inferior to patients treated with lobectomy. In conclusion, the current meta-analysis disclosed that segmentectomies produce similar survival compared to lobectomy for patients with stage I NSCLC. To establish the role of segmentectomy in early NSCLC, more evidence is needed, in particular, a large numbered, prospective, randomised trials, which should dissolve the uncertainties and the questions raised by retrospective data.

Background: Uniportal video-assisted thoracoscopy (VATS) has increasingly gained importance in the thoracic surgery scenario. The use of this technique can reduce postoperative pain and length of stay and gives the surgeon the same operative perspective as open surgery. Methods: We retrospectively analysed the data of 73 patients who underwent uniportal VATS lobectomies from November 2014 to December 2015 in our institution. We divided the patients in two groups (group 1: first 30 patients vs. group 2: established phase, 43 patients) to compare and evaluate the data regarding the learning curve. To explore evolution of learning curve, data were plotted to calculate Spearman’s Rank-Order Correlation. R (version 3.2.3) was used for statistical analysis. Results: The median age was 69.9 (group 1) and 68.8 (group 2) years. Mean operative time was 84.9±33.0 (group 1) and 84.8±31.5 (group 2) minutes. The conversion rate was 13.3% in group 1 vs. 9.3% in group 2, showing a significant learning reduction (rho=0.590). Overall morbidity rate was 15.1%. The most common complication consisted in prolonged air leak. Interpolation line of complications showed a significant decrease due to learning curve (rho=0.676). The median length of stay was 4 days in group 1 vs. 3 days in group 2. The 30-day mortality was 3.3% in group 1 and 0% in group 2. Conclusions: The comparison between the groups showed that the median length of stay, operative time, conversion rate and 30-day mortality statistically significantly improved in the established phase. Also, complications like prolonged air leak were decreasing in the established phase. In conclusion, the uniportal VATS lobectomy technique can be performed safely from experienced surgeons without major complications and with an acceptable mortality rate.

Enhanced recovery pathway for thoracic surgery in the UK

Background: Three-dimensional reconstructions of state-of-the-art high-resolution imaging are progressively being used more for preprocedural assessment in thoracic surgery. It is a promising tool that aims to improve patient-specific treatment planning, for example, for minimally invasive or robotic-assisted lung resections. Increasingly available mixed-reality hardware based on video pass-through technology enables the projection of image data as a hologram onto the patient. We describe the novel method of real-time 3D surgical planning in a mixed-reality setting by presenting three representative cases utilizing volume rendering. Materials: A mixed-reality system was set up using a high-performance workstation running a video pass-through-based head-mounted display. Image data from computer tomography were imported and volume-rendered in real-time to be customized through live editing. The image-based hologram was projected onto the patient, highlighting the regions of interest. Results: Three oncological cases were selected to explore the potentials of the mixed-reality system. Two of them presented large tumor masses in the thoracic cavity, while a third case presented an unclear lesion of the chest wall. We aligned real-time rendered 3D holographic image data onto the patient allowing us to investigate the relationship between anatomical structures and their respective body position. Conclusions: The exploration of holographic overlay has proven to be promising in improving preprocedural surgical planning, particularly for complex oncological tasks in the thoracic surgical field. Further studies on outcome-related surgical planning and navigation should therefore be conducted. Ongoing technological progress of extended reality hardware and intelligent software features will most likely enhance applicability and the range of use in surgical fields within the near future.