Uniportal Versus Biportal VATS for Anatomical Lung Resections: Is Perioperative Safety Comparable and Postoperative Pain Reduced?

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Mustafa Vedat Doğru, Gizem Özçıbık Işık, Dilekhan Kizir, Umut Kilimci, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8579392/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Introduction: Minimally invasive techniques are increasingly used in anatomical lung resections; however, the impact of different video-assisted thoracic surgery (VATS) port strategies on perioperative outcomes remains controversial. Evidence comparing uniportal and biportal VATS in terms of safety and postoperative pain is still limited. This study aimed to compare clinical and surgical outcomes of anatomical lung resections performed using uniportal and biportal VATS approaches. Methods Patients who underwent anatomical lung resection with minimally invasive techniques between January 2024 and September 2025 were retrospectively analyzed. Patients were grouped according to the surgical approach as uniportal VATS (U-VATS) or biportal VATS (B-VATS). Demographic data, comorbidities, operative variables, perioperative complications, conversion rates, postoperative pain scores, and length of hospital stay were compared. Results A total of 241 patients were included (131 U-VATS, 110 B-VATS). Age and sex distribution were similar between groups. Charlson comorbidity index scores, neoadjuvant treatment rates, and segmentectomy rates were significantly higher in the U-VATS group. Operative time, intraoperative and postoperative complications, conversion to thoracotomy, hospital stay, and 30- and 90-day mortality rates were comparable. Postoperative VAS pain scores on days 0, 3, and 14 were significantly lower in the U-VATS group. Conclusion Uniportal and biportal VATS provide similar perioperative safety in anatomical lung resections. U-VATS offers superior postoperative pain control and can be safely applied in patients with higher comorbidity burdens. Minimally invasive techniques Uniportal VATS Biportal VATS Posteperative VAS Introduction With increasing technological advancements, lung resections can be performed using minimally invasive methods [ 1 , 2 ]. Video-assisted thoracic surgery (VATS) can be carried out using one or more port incisions [ 3 – 6 ]. Compared to thoracotomy, VATS has been reported to be associated with less postoperative pain, improved wound healing, earlier mobilization, shorter hospital stay, and fewer complications, without compromising oncological outcomes [ 7 – 9 ]. Consequently, the use of VATS in clinical practice has increased over the years [ 7 – 9 ]. Nevertheless, thoracotomy remains necessary in certain situations, such as large tumor size, the need for bleeding control, and the presence of extensive pleural adhesions [ 7 – 9 ]. From a historical perspective, lung resections using VATS were initially performed with three ports and a camera system [ 3 – 6 ]. The main objective has been to further reduce surgical trauma by minimizing the number of incisions [ 10 – 13 ]. When uniportal VATS (U-VATS) was introduced in 2010, it emerged as a step toward maximizing the minimal invasiveness of thoracic surgical techniques [ 10 – 13 ]. However, the transition from multiport to single-port VATS posed several challenges in terms of surgical training and technical proficiency [ 10 – 13 ]. In particular, the use of the camera and working instruments through the same incision led to difficulties related to instrument crowding and angulation [ 10 – 13 ]. Previous studies have suggested that uniportal VATS lung resections may offer advantages over multiport VATS in several perioperative outcomes, including operative time, intraoperative blood loss, complication rates, and length of hospital stay. However, no significant differences have been demonstrated when uniportal VATS is compared specifically with biportal VATS resections [ 3 – 6 , 14 , 15 ]. Therefore, the aim of this study was to evaluate and compare the clinical and surgical outcomes of patients who underwent lung resection using single-port and two-port VATS techniques. Materials and Methods Ethical committee approval was obtained for the study (Decision No: 2023 − 347; Date: 25.05.2023). Patients who underwent surgery in our clinic between January 2024 and September 2025 were included in the study. The inclusion criteria were having undergone anatomical lung resection during this period and having been operated on using one- or two-port video-assisted thoracic surgery (VATS) as a minimally invasive approach. Patients who underwent thoracotomy or did not undergo anatomical lung resection were excluded from the study. In our clinic, uniportal VATS lung resections are performed through a 4-cm incision at the intersection of the fifth intercostal space and the midaxillary line. In biportal VATS lung resections, an additional incision is made at the seventh intercostal space for camera placement, in addition to the primary incision. Patient data were evaluated retrospectively. A total of 241 patients met the inclusion criteria; 131 patients (54.4%) underwent lung resection via uniportal VATS, and 110 patients (45.6%) via biportal VATS. The uniportal VATS (U-VATS) and biportal VATS (B-VATS) groups were compared in terms of clinical and surgical characteristics. Statistical analyses were performed using SPSS software (version 27.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as numbers and percentages for categorical variables and as mean, standard deviation, minimum, and maximum values for parametric variables. Associations between categorical variables were analyzed using the chi-square (χ²) test or Fisher’s exact test, as appropriate. Student’s t-test or the Mann–Whitney U test was used for comparisons of continuous variables. A p-value of less than 0.05 was considered statistically significant. Results A total of 241 patients were included in the study; 131 patients (54.4%) underwent lung resection using uniportal VATS, and 110 patients (45.6%) using biportal VATS. The mean age was 60.0 ± 11.9 years in the U-VATS group and 59.6 ± 11.5 years in the B-VATS group, with no statistically significant difference between the groups (p = 0.438). The U-VATS group consisted of 89 men (67.9%) and 42 women (32.1%), while the B-VATS group included 72 men (70.0%) and 38 women (30.0%). There was no statistically significant difference in gender distribution between the groups (p = 0.683) (Table 1). The Charlson comorbidity index was statistically significantly higher in the U-VATS group (p < 0.001). The rate of segmentectomy was also significantly higher in the U-VATS group (p = 0.010). In addition, a history of neoadjuvant treatment was statistically significantly more frequent in the U-VATS group (p = 0.007) (Table 2). No statistically significant differences were observed between the groups with regard to operative time, intraoperative complications, intraoperative blood loss, conversion from VATS to thoracotomy, postoperative complications, length of postoperative hospital stay, postoperative drainage volume, or drain duration (Table 2 and 3). No mortality was observed at either 30 or 90 days in either group. However, Visual Analog Scale (VAS) pain scores assessed on postoperative days 0, 3, and 14 were statistically significantly lower in the U-VATS group (p = 0.020, p = 0.028, and p = 0.045, respectively) (Table 2 and 3). Discussion In the present study, although no statistically significant differences were observed between anatomical lung resections performed using uniportal (U-VATS) and biportal (B-VATS) approaches with regard to operative time, intraoperative complications, conversion rates from VATS to thoracotomy, postoperative complications, or length of hospital stay, postoperative pain scores evaluated in both the early and late postoperative periods were significantly lower in the U-VATS group. Postoperative pain is a critical parameter that directly influences patient comfort, respiratory function, and time to mobilization following thoracic surgery [ 16 , 17 ]. The reduced intercostal nerve trauma and limited muscle dissection associated with a single intercostal incision in the uniportal VATS approach may explain the lower pain scores observed with this technique [ 10 , 15 ]. The significantly lower VAS scores recorded in the U-VATS group on postoperative days 0, 3, and 14 indicate that this approach offers an advantage in pain control not only during the early postoperative period but also in the mid-term period. Sudarma et al. reported lower VAS scores on postoperative days 0 and 3 in patients who underwent U-VATS [ 14 ]. In the present study, the lower VAS score observed on postoperative day 14 in the U-VATS group further suggests that postoperative pain and analgesic requirements may be reduced over a longer duration. The absence of significant differences between the groups in terms of operative time, intraoperative complication rates, and conversion from VATS to thoracotomy, as well as the lack of mortality at 30 and 90 days, indicates that both U-VATS and B-VATS are effective and safe minimally invasive surgical approaches and can yield comparable surgical outcomes in experienced centers. Moreover, the standardization of surgical techniques in our clinic and the increasing experience of the surgical team may have minimized the impact of port number on perioperative outcomes. Additionally, although the Charlson comorbidity index and the rate of neoadjuvant treatment were significantly higher in the U-VATS group, no differences were observed between the groups with respect to complication rates or length of hospital stay. These findings suggest that the uniportal VATS approach can be safely applied even in patients with a higher comorbidity burden and in those who have received neoadjuvant therapy [ 15 , 18 ]. Achieving acceptable surgical outcomes with U-VATS despite potential challenges such as hilar fibrosis and lymph node adhesions following neoadjuvant treatment supports the feasibility of this approach in complex cases when appropriate patient selection is combined with surgical expertise. The higher segmentectomy rate observed in the U-VATS group may be attributed to the ability of the uniportal approach to facilitate parenchyma-sparing surgery [ 13 , 16 ]. In recent years, the increasing role of anatomical segmentectomy in early-stage lung cancer and small pulmonary lesions has heightened interest in minimally invasive and parenchyma-sparing techniques. The improved field of view and ease of dissection provided by U-VATS may explain its preference in technically demanding anatomical resections such as segmentectomy. The absence of 30- and 90-day mortality in both groups in our study further demonstrates the safety of minimally invasive approaches when appropriate patient selection is ensured [ 3 – 6 ]. In addition, similar conversion rates from VATS to thoracotomy indicate that the uniportal approach does not compromise surgical safety, and it should be emphasized that conversion should not be regarded as a failure but rather as a deliberate surgical decision made in the interest of patient safety [ 9 ]. The main limitations of this study include its retrospective and single-center design, as well as the potential for selection bias related to patient and surgeon factors. Furthermore, long-term oncological outcomes and quality-of-life assessments were not evaluated. Nevertheless, the relatively large sample size and the use of standardized surgical techniques represent notable strengths of the study. In conclusion, anatomical lung resections performed using U-VATS and B-VATS demonstrate similar perioperative safety profiles. The uniportal VATS approach offers a significant advantage, particularly in terms of postoperative pain control, and can be safely applied even in patients with higher comorbidity burdens. These findings support the role of U-VATS as an effective minimally invasive surgical option when appropriate patient selection is ensured by experienced surgical teams. Declarations Ethics approval and consent to participate: Ethical committee approval was obtained for the study (Decision No: 2023-347; Date: 25.05.2023). Consent for publication: Not applicable. Funding: No source of funding or research and/or publication. Authors declare they have nothing to disclose. Conflicts of interest/Competing interests: Authors have no conflicts of interest or financial ties to disclose. Data availability: The data in the study are available for consultation. Authors' contributions: MVD, GÖI, DK, UK, CBS, and ÖS designed the study, acquired and analyzed data and approved its final version. 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Trabalza Marinucci B, Siciliani A, Andreetti C, Tiracorrendo M, Messa F, Piccioni G, Maurizi G, D'Andrilli A, Menna C, Ciccone AM, Vanni C, Argento G, Rendina EA, Ibrahim M. Mini-Invasive Thoracic Surgery for Early-Stage Lung Cancer: Which Is the Surgeon's Best Approach for Video-Assisted Thoracic Surgery? J Clin Med. 2024 Oct 28;13(21):6447. doi: 10.3390/jcm13216447. Sudarma IW, Pertiwi PFK, Yasa KP, Harta IKAP. Outcomes of Uniportal Video-Assisted Thoracoscopic Surgery in the Management of Lobectomy and Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis of Propensity Score-Matched Cohorts. Ann Thorac Cardiovasc Surg. 2025;31(1):24-00137. doi: 10.5761/atcs.ra.24-00137. Xiang Z, Wu B, Zhang X, Wei Y, Xu J, Zhang W. Uniportal versus multiportal video-assisted thoracoscopic segmentectomy for non-small cell lung cancer: a systematic review and meta-analysis. Surg Today. 2023 Mar;53(3):293-305. doi: 10.1007/s00595-021-02442-y. Sun J, Sheng Y, Yang T. The impact of VATS anatomic segmentectomy on postoperative stress response and respiratory function in early-stage NSCLC patients. Medicine (Baltimore). 2025 Dec 5;104(49):e46356. doi: 10.1097/MD.0000000000046356. Walsh LC, Seitlinger J, Gold MS, Sorin M, Fermi F, Tankel J, Rokah M, Rayes R, Mulder D, Sirois C, Cools-Lartigue J, Najmeh S, Ferri L, Fiore JF Jr, Spicer JD. The effect of lobar versus sublobar video-assisted thoracoscopic surgery lung resection on patient quality of life. J Thorac Dis. 2025 Nov 30;17(11):10138-10148. doi: 10.21037/jtd-2025-260. Gonzalez-Rivas D, Stupnik T, Fernandez R, de la Torre M, Velasco C, Yang Y, Lee W, Jiang G. Intraoperative bleeding control by uniportal video-assisted thoracoscopic surgery†. Eur J Cardiothorac Surg. 2016 Jan;49 Suppl 1:i17-24. doi: 10.1093/ejcts/ezv333. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviewers agreed at journal 28 Mar, 2026 Reviewers invited by journal 13 Jan, 2026 Editor assigned by journal 12 Jan, 2026 Submission checks completed at journal 12 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8579392","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":575203099,"identity":"6e896fdb-80ee-4e6a-bd31-86f6965b00aa","order_by":0,"name":"Mustafa Vedat 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Video-assisted thoracic surgery (VATS) can be carried out using one or more port incisions [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Compared to thoracotomy, VATS has been reported to be associated with less postoperative pain, improved wound healing, earlier mobilization, shorter hospital stay, and fewer complications, without compromising oncological outcomes [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Consequently, the use of VATS in clinical practice has increased over the years [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Nevertheless, thoracotomy remains necessary in certain situations, such as large tumor size, the need for bleeding control, and the presence of extensive pleural adhesions [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a historical perspective, lung resections using VATS were initially performed with three ports and a camera system [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The main objective has been to further reduce surgical trauma by minimizing the number of incisions [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. When uniportal VATS (U-VATS) was introduced in 2010, it emerged as a step toward maximizing the minimal invasiveness of thoracic surgical techniques [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the transition from multiport to single-port VATS posed several challenges in terms of surgical training and technical proficiency [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In particular, the use of the camera and working instruments through the same incision led to difficulties related to instrument crowding and angulation [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have suggested that uniportal VATS lung resections may offer advantages over multiport VATS in several perioperative outcomes, including operative time, intraoperative blood loss, complication rates, and length of hospital stay. However, no significant differences have been demonstrated when uniportal VATS is compared specifically with biportal VATS resections [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the aim of this study was to evaluate and compare the clinical and surgical outcomes of patients who underwent lung resection using single-port and two-port VATS techniques.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eEthical committee approval was obtained for the study (Decision No: 2023\u0026thinsp;\u0026minus;\u0026thinsp;347; Date: 25.05.2023). Patients who underwent surgery in our clinic between January 2024 and September 2025 were included in the study. The inclusion criteria were having undergone anatomical lung resection during this period and having been operated on using one- or two-port video-assisted thoracic surgery (VATS) as a minimally invasive approach. Patients who underwent thoracotomy or did not undergo anatomical lung resection were excluded from the study.\u003c/p\u003e \u003cp\u003eIn our clinic, uniportal VATS lung resections are performed through a 4-cm incision at the intersection of the fifth intercostal space and the midaxillary line. In biportal VATS lung resections, an additional incision is made at the seventh intercostal space for camera placement, in addition to the primary incision. Patient data were evaluated retrospectively. A total of 241 patients met the inclusion criteria; 131 patients (54.4%) underwent lung resection via uniportal VATS, and 110 patients (45.6%) via biportal VATS. The uniportal VATS (U-VATS) and biportal VATS (B-VATS) groups were compared in terms of clinical and surgical characteristics.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using SPSS software (version 27.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as numbers and percentages for categorical variables and as mean, standard deviation, minimum, and maximum values for parametric variables. Associations between categorical variables were analyzed using the chi-square (χ\u0026sup2;) test or Fisher\u0026rsquo;s exact test, as appropriate. Student\u0026rsquo;s t-test or the Mann\u0026ndash;Whitney U test was used for comparisons of continuous variables. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 241 patients were included in the study; 131 patients (54.4%) underwent lung resection using uniportal VATS, and 110 patients (45.6%) using biportal VATS. The mean age was 60.0 ± 11.9 years in the U-VATS group and 59.6 ± 11.5 years in the B-VATS group, with no statistically significant difference between the groups (p = 0.438). The U-VATS group consisted of 89 men (67.9%) and 42 women (32.1%), while the B-VATS group included 72 men (70.0%) and 38 women (30.0%). There was no statistically significant difference in gender distribution between the groups (p = 0.683) (Table 1).\u003c/p\u003e\n\u003cp\u003eThe Charlson comorbidity index was statistically significantly higher in the U-VATS group (p \u0026lt; 0.001). The rate of segmentectomy was also significantly higher in the U-VATS group (p = 0.010). In addition, a history of neoadjuvant treatment was statistically significantly more frequent in the U-VATS group (p = 0.007) (Table 2).\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were observed between the groups with regard to operative time, intraoperative complications, intraoperative blood loss, conversion from VATS to thoracotomy, postoperative complications, length of postoperative hospital stay, postoperative drainage volume, or drain duration (Table 2 and 3). No mortality was observed at either 30 or 90 days in either group. However, Visual Analog Scale (VAS) pain scores assessed on postoperative days 0, 3, and 14 were statistically significantly lower in the U-VATS group (p = 0.020, p = 0.028, and p = 0.045, respectively) (Table 2 and 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, although no statistically significant differences were observed between anatomical lung resections performed using uniportal (U-VATS) and biportal (B-VATS) approaches with regard to operative time, intraoperative complications, conversion rates from VATS to thoracotomy, postoperative complications, or length of hospital stay, postoperative pain scores evaluated in both the early and late postoperative periods were significantly lower in the U-VATS group.\u003c/p\u003e \u003cp\u003ePostoperative pain is a critical parameter that directly influences patient comfort, respiratory function, and time to mobilization following thoracic surgery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The reduced intercostal nerve trauma and limited muscle dissection associated with a single intercostal incision in the uniportal VATS approach may explain the lower pain scores observed with this technique [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The significantly lower VAS scores recorded in the U-VATS group on postoperative days 0, 3, and 14 indicate that this approach offers an advantage in pain control not only during the early postoperative period but also in the mid-term period. Sudarma et al. reported lower VAS scores on postoperative days 0 and 3 in patients who underwent U-VATS [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the present study, the lower VAS score observed on postoperative day 14 in the U-VATS group further suggests that postoperative pain and analgesic requirements may be reduced over a longer duration.\u003c/p\u003e \u003cp\u003eThe absence of significant differences between the groups in terms of operative time, intraoperative complication rates, and conversion from VATS to thoracotomy, as well as the lack of mortality at 30 and 90 days, indicates that both U-VATS and B-VATS are effective and safe minimally invasive surgical approaches and can yield comparable surgical outcomes in experienced centers. Moreover, the standardization of surgical techniques in our clinic and the increasing experience of the surgical team may have minimized the impact of port number on perioperative outcomes.\u003c/p\u003e \u003cp\u003eAdditionally, although the Charlson comorbidity index and the rate of neoadjuvant treatment were significantly higher in the U-VATS group, no differences were observed between the groups with respect to complication rates or length of hospital stay. These findings suggest that the uniportal VATS approach can be safely applied even in patients with a higher comorbidity burden and in those who have received neoadjuvant therapy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Achieving acceptable surgical outcomes with U-VATS despite potential challenges such as hilar fibrosis and lymph node adhesions following neoadjuvant treatment supports the feasibility of this approach in complex cases when appropriate patient selection is combined with surgical expertise. The higher segmentectomy rate observed in the U-VATS group may be attributed to the ability of the uniportal approach to facilitate parenchyma-sparing surgery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In recent years, the increasing role of anatomical segmentectomy in early-stage lung cancer and small pulmonary lesions has heightened interest in minimally invasive and parenchyma-sparing techniques. The improved field of view and ease of dissection provided by U-VATS may explain its preference in technically demanding anatomical resections such as segmentectomy. The absence of 30- and 90-day mortality in both groups in our study further demonstrates the safety of minimally invasive approaches when appropriate patient selection is ensured [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition, similar conversion rates from VATS to thoracotomy indicate that the uniportal approach does not compromise surgical safety, and it should be emphasized that conversion should not be regarded as a failure but rather as a deliberate surgical decision made in the interest of patient safety [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main limitations of this study include its retrospective and single-center design, as well as the potential for selection bias related to patient and surgeon factors. Furthermore, long-term oncological outcomes and quality-of-life assessments were not evaluated. Nevertheless, the relatively large sample size and the use of standardized surgical techniques represent notable strengths of the study. In conclusion, anatomical lung resections performed using U-VATS and B-VATS demonstrate similar perioperative safety profiles. The uniportal VATS approach offers a significant advantage, particularly in terms of postoperative pain control, and can be safely applied even in patients with higher comorbidity burdens. These findings support the role of U-VATS as an effective minimally invasive surgical option when appropriate patient selection is ensured by experienced surgical teams.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical committee approval was obtained for the study (Decision No: 2023-347; Date: 25.05.2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003eNo source of funding or research and/or publication. Authors declare they have nothing to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests:\u003c/strong\u003eAuthors have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003eThe data in the study are available for consultation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003eMVD, GÖI, DK, UK, CBS, and ÖS designed the study, acquired and analyzed data and approved its final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKubouchi Y, Wada T, Yasuda R, Nozaka Y, Fujiwara W, Matsui S, Tanaka Y. Comparison of thoracotomy conversion rates and causes between VATS and RATS for primary lung cancer: a retrospective cohort study. Gen Thorac Cardiovasc Surg. 2025 Nov 4. doi: 10.1007/s11748-025-02217-z.\u003c/li\u003e\n\u003cli\u003eMirza W, Javid A, Khan ME, Uneeb M, Khan A, Khan HM, Dadan S, Yasmin S, Hanif H. Robotic-assisted vs video-assisted thoracoscopic lobectomy for non-small cell lung cancer: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials on surgical quality, perioperative, and oncologic outcomes. J Robot Surg. 2025 Oct 1;19(1):651. doi: 10.1007/s11701-025-02852-x. \u003c/li\u003e\n\u003cli\u003ePajala FB, Tanadi C, Aribowo RH. The Impact of the Number of Ports on Perioperative Outcomes Following Video-Assisted Thoracoscopic Surgery for Non-Small-Cell Lung Cancer: A Systematic Review and Meta-Analysis. J Chest Surg. 2025 Aug 11. doi: 10.5090/jcs.25.037.\u003c/li\u003e\n\u003cli\u003eWatanabe T, Tanahashi M, Chiba M, Hashimoto K, Sakakura N, Okazaki M, Mori S, Hashimoto M, Chen-Yoshikawa TF, Miyajima M, Matsumoto I, Shitara M, Takao M, Ogura T, Kawaguchi K. Postoperative Pain Reduction and Clinical Value of Uniportal Video-Assisted Thoracic Surgery: A Secondary Analysis of the J-RATSIG 01 Study. Clin Lung Cancer. 2025 Sep;26(6):e413-e419.e2. doi: 10.1016/j.cllc.2025.05.001. \u003c/li\u003e\n\u003cli\u003eLi Y, Dai T. Meta-analysis comparing the perioperative efficacy of single-port versus two and multi-port video-assisted thoracoscopic surgical anatomical lung resection for lung cancer. Medicine (Baltimore). 2023 Jan 13;102(2):e32636. doi: 10.1097/MD.0000000000032636.\u003c/li\u003e\n\u003cli\u003eKosiński S, Putowski Z, Stachowicz J, Czajkowski W, Wiłkojć M, Ziętkiewicz M, Zieliński M. Postoperative Pain Intensity After Single-port, Double-port, and Triple-port Video-assisted Lung Lobectomy: A Three-arm Parallel Randomized Clinical Trial. J Cardiothorac Vasc Anesth. 2025 Jul;39(7):1755-1762. doi: 10.1053/j.jvca.2025.02.051.\u003c/li\u003e\n\u003cli\u003eTsubokawa N, Tsutani Y, Hishida T, Saji H, Wakabayashi M, Endo M, Mimae T, Miyoshi T, Isaka T, Isaka M, Hattori A, Yoshioka H, Nakajima R, Yotsukura M, Maniwa T, Sekino Y, Fukuda H, Nakagawa K, Aokage K, Watanabe SI, Okada M. Quality comparison of mediastinal lymph node dissection between video-assisted thoracic surgery and open thoracotomy: a supplementary analysis of the phase 3 Japan Clinical Oncology Group 1413 trial\u0026dagger;. Eur J Cardiothorac Surg. 2025 Jul 1;67(7):ezaf206. doi: 10.1093/ejcts/ezaf206.\u003c/li\u003e\n\u003cli\u003eKent MS, Hartwig MG, Valli\u0026egrave;res E, Abbas AE, Cerfolio RJ, Dylewski MR, Fabian T, Herrera LJ, Jett KG, Lazzaro RS, Meyers B, Reddy RM, Reed MF, Rice DC, Ross P, Sarkaria IS, Schumacher LY, Spier LN, Tisol WB, Wigle DA, Zervos M. Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases. Ann Surg. 2023 Jun 1;277(6):1002-1009. doi: 10.1097/SLA.0000000000005820. \u003c/li\u003e\n\u003cli\u003eHerrera LJ, Schumacher LY, Hartwig MG, Bakhos CT, Reddy RM, Valli\u0026egrave;res E, Kent MS. Pulmonary Open, Robotic, and Thoracoscopic Lobectomy study: Outcomes and risk factors of conversion during minimally invasive lobectomy. J Thorac Cardiovasc Surg. 2023 Jul;166(1):251-262.e3. doi: 10.1016/j.jtcvs.2022.10.050.\u003c/li\u003e\n\u003cli\u003eGonzalez-Rivas D, Sihoe ADL. Important Technical Details During Uniportal Video-Assisted Thoracoscopic Major Resections. Thorac Surg Clin. 2017 Nov;27(4):357-372. doi: 10.1016/j.thorsurg.2017.06.004.\u003c/li\u003e\n\u003cli\u003eGonzalez-Rivas D, Damico TA, Jiang G, Sihoe A. Uniportal video-assisted thoracic surgery: a call for better evidence, not just more evidence. Eur J Cardiothorac Surg. 2016 Sep;50(3):416-7. doi: 10.1093/ejcts/ezw187.\u003c/li\u003e\n\u003cli\u003eGonzalez-Rivas D, Yang Y, Ng C. Advances in Uniportal Video-Assisted Thoracoscopic Surgery: Pushing the Envelope. Thorac Surg Clin. 2016 May;26(2):187-201. doi: 10.1016/j.thorsurg.2015.12.007.\u003c/li\u003e\n\u003cli\u003eTrabalza Marinucci B, Siciliani A, Andreetti C, Tiracorrendo M, Messa F, Piccioni G, Maurizi G, D\u0026apos;Andrilli A, Menna C, Ciccone AM, Vanni C, Argento G, Rendina EA, Ibrahim M. Mini-Invasive Thoracic Surgery for Early-Stage Lung Cancer: Which Is the Surgeon\u0026apos;s Best Approach for Video-Assisted Thoracic Surgery? J Clin Med. 2024 Oct 28;13(21):6447. doi: 10.3390/jcm13216447.\u003c/li\u003e\n\u003cli\u003eSudarma IW, Pertiwi PFK, Yasa KP, Harta IKAP. Outcomes of Uniportal Video-Assisted Thoracoscopic Surgery in the Management of Lobectomy and Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis of Propensity Score-Matched Cohorts. Ann Thorac Cardiovasc Surg. 2025;31(1):24-00137. doi: 10.5761/atcs.ra.24-00137. \u003c/li\u003e\n\u003cli\u003eXiang Z, Wu B, Zhang X, Wei Y, Xu J, Zhang W. Uniportal versus multiportal video-assisted thoracoscopic segmentectomy for non-small cell lung cancer: a systematic review and meta-analysis. Surg Today. 2023 Mar;53(3):293-305. doi: 10.1007/s00595-021-02442-y. \u003c/li\u003e\n\u003cli\u003eSun J, Sheng Y, Yang T. The impact of VATS anatomic segmentectomy on postoperative stress response and respiratory function in early-stage NSCLC patients. Medicine (Baltimore). 2025 Dec 5;104(49):e46356. doi: 10.1097/MD.0000000000046356.\u003c/li\u003e\n\u003cli\u003eWalsh LC, Seitlinger J, Gold MS, Sorin M, Fermi F, Tankel J, Rokah M, Rayes R, Mulder D, Sirois C, Cools-Lartigue J, Najmeh S, Ferri L, Fiore JF Jr, Spicer JD. The effect of lobar versus sublobar video-assisted thoracoscopic surgery lung resection on patient quality of life. J Thorac Dis. 2025 Nov 30;17(11):10138-10148. doi: 10.21037/jtd-2025-260.\u003c/li\u003e\n\u003cli\u003eGonzalez-Rivas D, Stupnik T, Fernandez R, de la Torre M, Velasco C, Yang Y, Lee W, Jiang G. Intraoperative bleeding control by uniportal video-assisted thoracoscopic surgery\u0026dagger;. Eur J Cardiothorac Surg. 2016 Jan;49 Suppl 1:i17-24. doi: 10.1093/ejcts/ezv333. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bratislava-medical-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Bratislava Medical Journal](https://link.springer.com/journal/44411)","snPcode":"44411","submissionUrl":"https://submission.springernature.com/new-submission/44411/3","title":"Bratislava Medical Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Minimally invasive techniques, Uniportal VATS, Biportal VATS, Posteperative VAS","lastPublishedDoi":"10.21203/rs.3.rs-8579392/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8579392/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eMinimally invasive techniques are increasingly used in anatomical lung resections; however, the impact of different video-assisted thoracic surgery (VATS) port strategies on perioperative outcomes remains controversial. Evidence comparing uniportal and biportal VATS in terms of safety and postoperative pain is still limited. This study aimed to compare clinical and surgical outcomes of anatomical lung resections performed using uniportal and biportal VATS approaches.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent anatomical lung resection with minimally invasive techniques between January 2024 and September 2025 were retrospectively analyzed. Patients were grouped according to the surgical approach as uniportal VATS (U-VATS) or biportal VATS (B-VATS). Demographic data, comorbidities, operative variables, perioperative complications, conversion rates, postoperative pain scores, and length of hospital stay were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 241 patients were included (131 U-VATS, 110 B-VATS). Age and sex distribution were similar between groups. Charlson comorbidity index scores, neoadjuvant treatment rates, and segmentectomy rates were significantly higher in the U-VATS group. Operative time, intraoperative and postoperative complications, conversion to thoracotomy, hospital stay, and 30- and 90-day mortality rates were comparable. Postoperative VAS pain scores on days 0, 3, and 14 were significantly lower in the U-VATS group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eUniportal and biportal VATS provide similar perioperative safety in anatomical lung resections. U-VATS offers superior postoperative pain control and can be safely applied in patients with higher comorbidity burdens.\u003c/p\u003e","manuscriptTitle":"Uniportal Versus Biportal VATS for Anatomical Lung Resections: Is Perioperative Safety Comparable and Postoperative Pain Reduced?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 15:48:24","doi":"10.21203/rs.3.rs-8579392/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-04T06:49:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T23:43:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55126683328299504083165253408345728352","date":"2026-03-28T15:49:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T16:08:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-12T11:33:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-12T11:32:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Bratislava Medical Journal","date":"2026-01-12T08:36:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bratislava-medical-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Bratislava Medical Journal](https://link.springer.com/journal/44411)","snPcode":"44411","submissionUrl":"https://submission.springernature.com/new-submission/44411/3","title":"Bratislava Medical Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8a19e944-78ea-4543-b514-422f899051ff","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T20:09:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 15:48:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8579392","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8579392","identity":"rs-8579392","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}