A study from Taiwan (April 2011) highlights the surgeons’ experience using single incision thoracoscopic surgery (SITS) for the treatment of spontaneous pneumothorax. While the study is small – involving 30 patients, with just ten patients receiving treatment via single incision thoracoscopy, it’s a useful study in demonstrating that SITS is not only possible but feasible for uncomplicated thoracic procedures.
The major advantage of using this procedure in the spontaneous pneumothorax population is the low level of underlying thoracic disease, or co-morbidities necessitating conversion to VATS or open surgery. In general, true spontaneous pneumothoraces occur in younger patients (teens and twenties) in the absence of other conditions such as infection, emphysema or effusion. The benefits of using this procedure in such a young, mobile population is reduced pain, and a speedier recovery – and returning these patients to work/ life faster, with less post-operative limitations.
As the authors noted, a consistent obstacle to widespread adoption of this surgical technique is the lack of specialized surgical instruments. This has also plagued single incision laparoscopy to some extent, with several minor modifications being made by practicing surgeons to overcome these problems, primarily of positioning several instruments thru a single port*. This is more problematic in thoracic surgery than general surgery due to patient positioning. (In general surgery the patient is usually laying supine, allowing for a flat surface).
In thoracic surgery, the patient’s side lying positioning puts the operator at greater disadvantage, with gravity working against the surgeon. As mentioned in a previous post – there is a commercial port of multiple instruments available, however it is costly, unwieldly and requires larger incisions (making SITS more of a mini-thoracotomy). The other mechanical problem is the instruments themselves – when placed in a single incision, care has to be taken to prevent the instruments from obstructing the movements of each other. The authors were able to overcome this obstacle thru practice, but suggest needed modifications to existing instruments.
Despite frequently cited concerns about visibility with this technique, in the article (and confirmed by my own observations in the operating room), properly done single incision thoracoscopy offers the same visibility as multi-port (VATS) thoracoscopy. (See the original article full text for photos of procedure illustrating visibility.)
More recently, (June 2011) Berlanga & Gigirey in Caceres, Spain reported the use of SITS for spontaneous pneumothorax in 13 patients. They reported similar findings, and came to the same conclusions as Chen et. al. However, these researchers used the commercially available port and reported satisfactory results.
There is a place for single incision thoracoscopy within thoracic surgery. However, it will take continued research to further delineate its role, and surgical innovation to adapt the current instrumentation for more effective and surgeon friendly use.