CONCEPT

Hans Christian Jacobaeus (1879 –1937) provided the first description of a thoracoscopy in 1910. During decades the role of thoracocopy was only related to diagnostic and minor therapeutic procedures. Since the past two decades, thoracoscopic procedures have increasingly gained acceptance specially with the introduction of VATS major pulmonary resections. Although there is no standardised technique for the thoracoscopic approach used in this type of procedure, most groups use a utility incision of about 4-6 cm, and add between 1-3 ancillary incisions, i.e., there is variability in the number of incisions used, depending on the centre in question. The most common approach comprises a utility incision plus two supporting incisions, i.e., three ports, and a very important consideration is the obviation of rib-spreading . We started to perform major pulmonary resections by uniportal approach in 2010 in our department. Actually we apply the single-port technique for most major resections including advanced and complex cases. The advantage of using the camera in coordination with the instruments is that the vision is directed to the target tissue, bringing the instruments to address the target lesion from a straight perspective, thus we can obtain similar angle of view as for open surgery. Coventional three port triangulation makes a forward motion of VATS camera to the vanishing point. This triangulation creates a new optical plane with genesis of dihedral or torsional angle that is not favorable with standard two-dimension monitors. Instruments inserted parallel to the videothoracoscope also mimic inside the chest maneuvers performed during open surgery. There is a physical and mathematical demonstration about better geometry obtained for instrumentation and view in the uniportal VATS over conventional approach (Luca Bertolaccini study). Other potential advantage could be less postoperative pain: only one intercostal space is involved and avoiding the use of a trocar could minimize the risk of intercostal nerve injury. Further studies will be required to demonstrate other geometric aspects like ergonomy and that there is less pain with single incision techniques, compared to conventional VATS for lobectomy. We truly believe on the use of the single port technique for major pulmonary resections because we understand that the future goes in that direction, i.e., robotics and single-port. The instruments that would be necessary in the next future for single port robotic surgery should be vessel and bronchus sealer devices, snake-like arms inside the chest for instrumentation, wireless cameras and feedback robotic tactile Systems