Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach.

Minimally invasive thoracic surgery has emerged as a significant advancement in the surgical field, offering numerous advantages over traditional open procedures. Over the past few decades, there has been a shift towards minimally invasive approaches for treating thoracic diseases.[ 1 ] This shift has been driven by advances in surgical techniques and the availability of better instruments and devices.[ 2 ] The uniportal approach provides new opportunities for developing innovative technological tools.[ 3 ] Advances in surgical techniques have made it possible to perform most thoracic surgical procedures, even in complex cases, using minimally invasive approaches.[ 4 ] The shift towards minimally invasive thoracic surgery is driven by the desire to reduce post-operative complications and improve patient outcomes.[ 5 ] Video-assisted thoracoscopic surgery (VATS) offers several advantages over the traditional open thoracotomy for the management of various thoracic conditions. Studies have consistently highlighted the benefits of VATS, including reduced chest wall trauma, faster remission of post-operative pain, faster recovery, less bleeding, better preservation of cardiopulmonary function and fewer post-operative complications.[ 6 ] In addition, VATS is associated with a shorter hospitalisation, lower cost, better lung function, improved visualisation and a higher detection rate of small injuries.[ 7 ] Furthermore, VATS has also resulted in fewer post-operative complications, shorter duration of chest tube placement, more cosmetically appealing incisions, less post-operative pain, better post-operative quality of life and similar overall survival rates in oncological cases compared with open thoracotomy.[ 8 ] The subxiphoid and subcostal approaches have gained attention in thoracic surgery owing to their potential advantages. These approaches have been used in various myasthenia gravis procedures, including thymectomy. Studies have shown that the subxiphoid approach improves patient satisfaction, reduces pain and provides better aesthetic outcomes.[ 9 ] It has been shown to be technically feasible and safe, making it a viable option for thoracic surgery.[ 10 ] The uniportal subxiphoid VATS approach has been increasingly used in various thoracic surgeries, including thymectomy, lobectomy and resection of giant solitary fibrous tumours of the pleura.[ 11 ] The subxiphoid approach has also been studied as an alternative to traditional approaches to reduce complications and improve surgical outcomes. During subxiphoid uniportal VATS, intercostal irritation and nerve injury are avoided, resulting in reduced post-operative pain compared with classical lateral uniportal VATS.[ 12 ] The subcostal incision represents a further variation of the thoracoscopic approach, avoiding possible irritation of the intercostal nerves present in the standard transthoracic approach. Only a few case reports have described the subcostal approach for thymectomy.[ 13 ] In lung resections, subcostal VATS has only been reported in combination with two further incisions to perform large wedge resections[ 14 ] or middle lobe resections in obese patients.[ 15 ] The first experimental uniportal subcostal lung resections were reported only by Gonzalez-Rivas using a robotic approach.[ 16 ] In this study, we report our first clinical experience with the subcostal uniportal VATS approach for different thoracic surgical procedures, excluding anatomical lung resection.

All adult patients who underwent subcostal uniportal VATS (suVATS) between January 1, 2019, and April 30, 2020, were included. All patients scheduled for non-anatomical resections, mainly lung volume reduction surgery (LVRS), wedge resections and pleural procedures, were included in the suVATS group. The control group comprised patients who underwent standard lateral uniportal VATS (luVATS) for similar indications. Under general anaesthesia (propofol, remifentanil, rocuronium, sevoflurane and oxycodone, according to the manufacturer’s recommendations and national guidelines), single-lung ventilation was initiated using a left-sided Robertson Shaw double-lumen endobronchial tube. None of the patients underwent pre-operative thoracic epidural catheter placement. The patients were placed in the lateral decubitus position using a vacuum mattress. For luVATS, a 2–4 cm incision in the fifth intercostal space was used. For suVATS, an incision 2–4 cm in length was made parallel to the costal arch and lateral to the subxiphoid [ Figure 1 ]. The pleural cavity was entered through the subcostal space and an Alexis O Wound Protector-Retractor ® (Applied Medical, Rancho Santa Margarita, CA, USA) was used. At the end of the procedure, a 28F chest tube was inserted through an intercostal or subcostal incision. Wound closure was performed using absorbable running sutures in the muscle, subcutaneous and skin layers. The chest tube was connected to a digital suction system (Thopaz+; Medela, Dietersheim, Germany). An intercostal block with 10 mL of ropivacaine (7.5 mg/mL) was applied intraoperatively under direct vision in the luVATS group. Local infiltration of the subcostal incision in the suVATS group was performed using 10 mL of ropivacaine (7.5 mg/mL). Visual Analogue Scale (VAS) scores and analgesic consumption were documented routinely every day after surgery until discharge. The figure demonstrates the position of the incision for the subcostal approach and placement of the chest tube through the incision All patients received basic analgesia with metamizole (500 mg) four times daily. Oxycodone (5 or 10 mg, twice daily) was administered to all patients. After the removal of the chest tube, metamizole was administered for analgesia. Opioid medication with oxycodone was discontinued in all patients. For each patient, cumulative oxycodone consumption was calculated on the first post-operative day (POD) and the day of chest tube removal. The oxycodone dosage was reduced during the hospital stay according to the daily reported VAS values and patient needs. The initial suction applied to the chest tube after surgery was −8 cmH 2 O. In all patients, suction was reduced to −6 cmH 2 O on POD 2. The chest tube was removed when no air leakage was detected for 24 h, and the amount of fluid drained from the tube was <400 mL daily. This represented standard practice at our institution. Chest radiography was performed 24 h after chest tube removal, and the patients were discharged when complete expansion of the lungs was confirmed, and no clinical complaints were reported. Patient demographics, comorbidities, surgeries performed, laboratory values, examination results, VAS values, analgesic consumption and clinical course, including post-operative complications, were documented in electronic health records. Two digital systems were used at our hospital. In regular wards, iMedOne ® (Deutsche Telekom Healthcare Solutions GmbH, Bonn, Germany) and in the intensive care unit, LowTeq IntensiveCare ® (LOWTeq GmbH, Cologne, Germany) were used. Excel sheets (Microsoft Excel ® , Microsoft Corporation, Redmond, WA, USA) were used for the data collection. The data were saved in a pseudonymised format. The data were presented as the mean ± standard deviation. An unpaired t -test was performed to evaluate intergroup differences in the VAS because the data showed a normal distribution. Prism (version 10; GraphPad Software, CA, USA) was used for all statistical analyses. The authors are accountable for all aspects of this work and ensure that questions related to the accuracy or integrity of any part of the study are appropriately investigated and resolved. All procedures were performed in accordance with the ethical standards of the Institutional and National Research Committees and the Declaration of Helsinki (revised in 2013). Ethical approval was waived by the local ethics committee because of the retrospective nature of the study, and all procedures were part of routine care.

Patient demographics and surgical procedures are summarised in Table 1 . The suVATS group included 38 patients (21 males) with a mean age of 61 (30–83) years. The luVATS group included 33 patients (23 males) with a mean age of 69 (46–89) years. In the suVATS group, LVRS ( n = 15), bulla resection with subtotal pleurectomy for pneumothorax ( n = 11), thymectomy ( n = 4), local pleurectomy with talc pleurodesis for malignant pleural effusion ( n = 3) and diagnostic atypical wedge resections ( n = 5) were performed. The procedures in the luVATS group included LVRS ( n = 13), diagnostic atypical wedge resection ( n = 12), hematoma evacuation ( n = 1), lymph node dissection ( n = 1) and local pleurectomy with talc pleurodesis for malignant pleural effusion ( n = 6). Demographics of the study groups suVATS: Subcostal uniportal VATS, luVATS: Lateral uniportal VATS, LVRS: Lung volume reduction surgery The mean duration of surgery in the suVATS group was 82.6 ± 41 min, which was significantly longer than that in the luVATS group (52.3 ± 24.2 min ( P = 0.002) [ Table 2 and Figure 2 ]. Intra- and post-operative outcomes * P value of <0.05 is considered significant. luVATS: Lateral uniportal VATS, VAS: Visual Analogue Scale, POD: Post-operative day, POC: Post-operative oxycodone consumption, suVATS: Subcostal uniportal VATS Surgery time for the subcostal (suVATS) and lateral (luVATS) approach. suVATS: Subcostal uniportal VATS, luVATS: Lateral uniportal VATS Both chest tube treatment duration (6.2 ± 3.6 days suVATS vs. 9.1 ± 4.7 days luVATS, P = 0.03) [ Figure 3 ] and length of hospital stay (6.9 ± 3 days suVATS vs. 14.1 ± 13.3 days luVATS, P = 0.02) [ Table 2 and Figure 4 ] were significantly shorter in the suVATS group. Duration of chest tube therapy for the subcostal (suVATS) and lateral (luVATS) approach. suVATS: Subcostal uniportal VATS, luVATS: Lateral uniportal VATS Hospital stay for the subcostal (suVATS) and lateral (luVATS) approach. suVATS: Subcostal uniportal VATS, luVATS: Lateral uniportal VATS In the luVATS group, post-operative complications occurred in seven patients. These included prolonged post-operative air leak ( n = 3), acute exacerbation of chronic obstructive pulmonary disease requiring systemic corticosteroid and antibiotic therapy ( n = 1), post-operative pneumonia requiring systemic antibiotic therapy ( n = 1), mucus retention requiring bronchoscopy ( n = 1) and post-operative bleeding in a patient receiving systemic anticoagulation for atrial fibrillation, which required repeat VATS. Four complications were observed in the suVATS group; a total of n = 4 complications were observed. These included two cases of prolonged air leak and two of post-operative pneumonia requiring systemic antibiotic treatment. In both the groups, 30-day mortality was 0% in both the groups. No relevant surgical complications occurred during surgery in either group. In none of the cases was the procedure converted to an open procedure and neither technique had to be switched to another surgical approach. No incisional hernias were observed during the post-operative period. Regarding post-operative pain, the routinely recorded VAS on the first POD (1.6 ± 1.3 suVATS vs. 2.9 ± 1.2 luVATS, P = 0.002) [ Table 2 and Figure 5 ] and on the day of discharge (0.2 ± 0.5 suVATS vs. 0.7 ± 0.8 luVATS, P = 0.03) were significantly lower in the suVATS group [ Table 2 and Figure 6 ]. Visual Analogue Scale on 1 st post-operative day for the subcostal (suVATS) and lateral (luVATS) approach. VAS: Visual Analogue Scale, suVATS: Subcostal uniportal VATS, luVATS: Lateral uniportal VATS Visual Analogue Scale on the day of discharge for the subcostal (suVATS) and lateral (luVATS) approach. VAS: Visual Analogue Scale, suVATS: Subcostal uniportal VATS, luVATS: Lateral uniportal VATS On POD 1, cumulative oxycodone consumption for the suVATS group was 15 ± 5.1 mg versus 15.86 ± 5 mg for the luVATS group ( P = 0.57). On the day of chest tube removal, cumulative oxycodone consumption for the suVATS group was 12.22 ± 4.2 mg versus 13.1 ± 4.7 mg for the luVATS group ( P = 0.52) [ Table 2 ].

Subcostal video thoracoscopy is a valuable alternative to conventional thoracoscopy because it reduces the risk of intercostal nerve injury. Our initial experience shows that this approach can be considered in patients requiring pleural biopsies, talc pleurodesis or wedge resection of the middle, lingula and basal lower lobes. Given the effects of intercostal nerve damage on post-operative pain and functional outcomes, the adoption of techniques that minimise nerve injury is crucial in thoracic surgical practice. Nil. There are no conflicts of interest.

Our retrospective analysis of the comparison of suVATS with luVATS provides evidence of the superiority of the subcostal approach in terms of resource consumption and pain therapy for selected indications, although both must be considered safe procedures in our cohort. The standard uniportal and subcostal thoracoscopic approaches are two commonly used techniques in thoracic surgery. Although both approaches aim to achieve minimally invasive surgery, some differences can affect their applicability and outcomes. The incision location is the key difference between the two approaches. In the standard uniportal approach, a single incision is made between the ribs, typically in the fourth or fifth intercostal spaces. This allows access to the chest cavity and enables the performance of various procedures. In contrast, the subcostal approach involves an incision below the costal margin, typically in the subcostal region. This approach provides a different access angle for the thoracic cavity. The choice between the standard uniportal and subcostal approaches may depend on the specific procedure performed and the surgeon’s preference. The subcostal approach may be preferred in cases where a different angle of access is required, such as the resection of anterior mediastinal tumours, access to pre-pericardial lymph nodes or middle lobe resection.[ 15 ] Chen et al . published their experience with the resection of anterior mediastinal masses through subxiphoid and subcostal thoracoscopic approaches.[ 17 ] The authors concluded, just like in our cohort, that these approaches offer a safe and feasible alternative to the standard lateral approach. Although several pulmonary resections using the subxiphoid approach have been published,[ 18 ] only a few cases have reported subcostal incisions for lung resection. In cases of middle lobe resection, the subcostal approach may provide better accessibility because of the localisation of the middle lobe.[ 15 ] In the present study, we report our clinical experiences with the subcostal approach for various thoracic surgical procedures, including non-anatomical lung resections. The subcostal approach provided an excellent overview of the thoracic cavity in all the cases. Owing to the new implementation of this technique, the operation time was expected to be longer than that of lateral uniportal VATS, which represents the standard minimally invasive approach at our institution. However, our results demonstrated a significant improvement in post-operative recovery in the subcostal group. This was reflected by the shorter chest tube treatment, reduced post-operative pain and shorter hospital stay in this group than in the standard lateral uniportal VATS group. Interestingly, the benefits were not overshadowed by an increased intra- or post-operative risk of complications. The implementation of an enhanced recovery after surgery (ERAS) programme in thoracic surgery has been shown to significantly influence patient outcomes and perioperative care. Studies have demonstrated that adopting ERAS protocols in thoracic surgery significantly improves clinical outcomes, including accelerated post-operative recovery, reduced post-operative complications and decreased length of hospital stay.[ 19 20 21 22 ] Furthermore, the implementation of ERAS programmes has been associated with cost savings without compromising patient safety, making them an important example of value-based surgical care.[ 23 24 ] ERAS protocols in thoracic surgery encompass a multidisciplinary and evidence-based approach to perioperative care, focusing on components such as pre-operative assessment, anaesthetic techniques, surgical techniques and post-operative care, including early mobilisation, pain management and prevention of post-operative complications.[ 25 ] Using the uniportal VATS technique, a very important milestone towards the implementation of modern enhanced recovery programmes in thoracic surgery was achieved. By refining surgical techniques aimed at reducing surgical trauma and post-operative pain, further improvements in the perioperative management of patients and enhanced recovery may be accomplished. In the present study, the subcostal approach was associated with a significant reduction in the duration of hospital stay. This results from the reduction in the required length of chest tube therapy. Therefore, this surgical approach may be useful for achieving better recovery after surgery. Intercostal nerve irritation after thoracoscopy can lead to chronic pain and sensory abnormalities. Intercostal nerve damage during thoracic surgery can result in the loss of intercostal nerve conduction and abdominal reflexes, both of which are associated with post-operative pain.[ 26 ] While most intercostal nerve injuries caused by thoracic surgery lead to sensory abnormalities and pain that recover within months, some may result in permanent nerve damage and chronic pain.[ 27 ] Various techniques have been proposed to manage intercostal nerve irritation. First, regional analgesia techniques, such as rhomboid intercostal and subserratus plane blocks, have been investigated and have shown potential for chest wall and upper abdominal analgesia.[ 28 ] Second, bony decompression of the chronically painful intercostal nerves has been suggested as an effective management strategy when conservative treatment fails.[ 29 ] Intercostal cryoneurolysis has been investigated as a potential intervention for intercostal nerve-related pain.[ 30 ] Therefore, avoiding the cause of chronic pain should be considered superior to sophisticated treatment strategies. Thus, because inserting equipment between the ribs is the cause of injuries, subxiphoid and subcostal video thoracoscopy offer an advantage over traditional thoracoscopy by avoiding potential injury to the intercostal nerves and subsequent intercostal neuralgia. This represents an important aspect in enhancing recovery after thoracic surgical procedures and is supported by the findings of our study. Several factors may influence the development of incisional hernias after subcostal thoracoscopic procedures. Studies have shown that the location and type of incision can affect the incidence of incisional hernias, with rates varying between incision types. For example, Gastaca et al . reported a lower incisional hernia rate of 1.7% in patients with bilateral subcostal incisions than in those with other incision types.[ 31 ] In addition, the size of the hernia defect has been highlighted as a significant factor, with the modified sublay technique used for large incisional subcostal hernias with specific defect sizes.[ 32 ] In addition, the timing of hernia occurrence after surgery is critical, with incisional hernias typically defined as hernias occurring within a certain period after surgery, such as within 3 years in some studies.[ 33 ] Risk factors for incisional hernias include patient characteristics such as smoking, body mass index and comorbidities.[ 34 ] In our series, no incisional hernias were observed. This may be due to the small size of the incision (2–4 cm). In all cases, wound closure was performed using absorbable running sutures in the muscle, subcutaneous and skin layers. The subcostal approach is comparable to the subxiphoid approach and has gained attention because of its potential advantages in various thoracic surgical procedures. Studies have highlighted the feasibility and benefits of the subxiphoidal uniportal VATS approach for pulmonary lobectomy,[ 35 ] anterior mediastinal tumour resection[ 36 ] and surgical resection of retrosternal goitre.[ 37 ] The subxiphoidal approach is associated with decreased post-operative pain, better cosmesis and easier specimen retrieval compared to the transthoracic approach.[ 38 ] In addition, it has been reported that the subxiphoidal VATS approach is feasible with similar intraoperative and post-operative outcomes as conventional approaches.[ 39 ] Furthermore, the subxiphoidal VATS approach has been explored in thymectomy, with studies indicating its safety and less invasive nature.[ 40 ] It has also been associated with reduced intraoperative blood loss, earlier removal of chest drains, reduced requirement for blood products, reduced inflammatory cytokine response, shorter hospital stay and superior cosmesis compared to traditional approaches.[ 41 ] In accordance with our findings, the subxiphoidal approach has been found to result in lower post-operative pain scores than other approaches.[ 39 ] The subxiphoidal uniportal VATS approach has been used in various thoracic procedures, including lobectomy, resection of giant pleural fibroids and combined lung and thymus resection.[ 42 43 ] Studies have also indicated that the extent of resection achieved using the subxiphoidal VATS approach is comparable to that achieved using open surgery, suggesting its reliability in achieving satisfactory resection and good prognosis.[ 44 ] In our practice, the subcostal approach provides all these advantages, with better exposure of the thoracic cavity owing to the different angles from the subxiphoid incision. Unlike the subxiphoidal approach, a subcostal incision offers access to a single thoracic cavity. This may be a disadvantage when performing thymectomy, as access to both thoracic cavities is required for safe and precise surgery. Therefore, subxiphoid approach might be more appropriate than the subcostal approach for thymectomy or any other procedure requiring bilateral access to the thorax. The most important limitation of this study is its retrospective design. Therefore, further prospective randomised studies should be conducted to highlight the advantages of the subcostal approach over the transthoracic uniportal VATS.