Keywords
thoracoscopy/VATS - pneumothorax - minimally invasive surgery - single-incision thoracoscopic
surgery
Introduction
Video-assisted thoracoscopic surgery (VATS) is widely used in the surgical treatment
of primary spontaneous pneumothorax (PSP) and is classically performed through several
ports. Single-incision thoracoscopic surgery (SITS) for wedge pulmonary resection
was first introduced in the early 2000s. Over time, efforts have been made to further
minimize instrument use at the incision site, while modified SITS techniques have
also been developed to enhance lesion retraction. We present a modified SITS technique
for PSP that utilizes spinal needle anchoring.
Technique Description
SITS using spinal needle anchoring involves inserting a spinal needle through a separate
intercostal space—distinct from the single-incision site, to anchor the lung within
the thoracic cavity. This procedure was originally developed and modified by Dr. Dae
Hyun Kim. Surgery was performed under general anesthesia with the patient in the lateral
decubitus position. A 1.5-cm skin incision was made along the mid-axillary line at
the level of the fifth intercostal space ([Fig.1A]). If a chest tube was already in place, the existing insertion site was utilized
as the single port for SITS. A 5-mm, 30-degree thoracoscope was inserted after placing
a wound retractor and secured to one side of the incision, allowing for the introduction
of a grasping instrument to evaluate the number, location, and condition of the lesions,
such as bullae or blebs. Subsequently, the distal 2 cm of a 20-gauge spinal needle
was bent at a 90-degree angle and inserted into the thoracic cavity, typically through
the anterior axillary line at the second intercostal space ([Video 1], available in the online version). However, the insertion site may vary depending
on the location of the lung lesion, with the needle placed at the corresponding intercostal
space as needed.
Video 1 Skin incision to insertion of the spinal needle.
Fig. 1 Surgical procedure and incision sites. (A) A 1.5-cm incision along the mid-axillary line (arrows). (B) Intraoperative view showing the single port with the thoracoscope and stapler. (C) Final wound after 20-Fr tube insertion, measuring 1.5 cm (arrows).
After inserting the spinal needle, the affected lung tissue was grasped using a grasping
instrument and carefully hooked onto the needle ([Fig. 2A]). Although a single hooking approach can be used, multiple adjustments and re-hooking
maneuvers were performed as needed to optimize the tension and alignment of the lesion
with the planned resection line ([Fig. 2B] and [Video 2], available in the online version). The lung, hooked onto the spinal needle, was
repositioned by rotating or adjusting the needle vertically under the guidance of
the grasping instrument to ensure proper orientation for stapling or cutting. Once
the lesion was adequately stabilized with the spinal needle, an endoscopic stapler
(Medtronic Endo-GIA™) was introduced through the single port ([Fig. 1B]). The stapler was positioned along the planned resection line, and the lung tissue
containing the lesion was excised ([Fig. 2A] and [Video 2], available in the online version). After completing the wedge resection, an air
leak assessment was performed using an underwater test. To minimize the risk of recurrence,
the resection site and the surrounding lung parenchyma were reinforced with polyglycolic
acid felt (Neoveil®) and fibrin glue. A 20-Fr chest tube was inserted through the
incision site ([Fig. 1C]), and the spinal needle insertion site was managed with a simple dressing.
Video 2 Multiple re-hooking maneuvers with a single needle.
Fig. 2 Spinal needle anchoring technique for lung retraction. (A) Illustration demonstrating the spinal needle anchoring technique. (B) Multiple re-hooking maneuvers using a single needle.
When the base of a bulla is broad or when multiple adjacent bullae require a larger
resection area, two or more spinal needles can be placed simultaneously at different
sites to enable a more extensive wedge resection ([Video 3], available in the online version). In some cases, multiple bullae are distributed
along the major or minor fissure, specifically along the peripheral fissure margin.
In such situations, employing multiple re-hooking maneuvers allows for effective wedge
resection while preserving the natural lung contour and avoiding deformation ([Video 4], available in the online version).
Video 3 Wedge resection of multiple bullae using two spinal needles simultaneously.
Video 4 Multiple re-hooking maneuvers along the fissure margin.
Discussion
SITS was introduced in the early 2000s for procedures like sympathectomy. In 2004,
Rocco et al. expanded their application to wedge resections, and by 2010, Gonzalez
et al. successfully performed lobectomies.[1]
[2] Over subsequent decades, SITS has advanced significantly, driven by surgical techniques,
instrumentation, and clinical experience. SITS for major anatomical lung resection
in lung cancer has been adopted by many centers but remains an emerging approach due
to challenges in vessel, bronchus, and mediastinal lymph node management, requiring
precise dissection and secure handling.[3] For minor lung resections, such as PSP or small peripheral lesions, SITS is considered
safe and feasible. It provides advantages over multiport VATS, including minimal scarring,
reduced postoperative pain, less chest wall paresthesia, and shorter hospitalization.
Its morbidity is comparable to multiport VATS, and its recurrence rate aligns with
the best outcomes reported for multiport VATS or thoracotomy.[4] However, SITS for wedge resection has not been widely accepted as standard due to
its limitations, including instrument collision, restricted field of view, and the
need for a slightly longer single incision to accommodate multiple instruments. To
overcome these limitations, a laparoscopic port (originally developed for abdominal
procedures) and articulated grasping instruments have been adapted for SITS.[5] Additionally, various techniques have been introduced to improve SITS feasibility,
including methods that facilitate lesion traction using a percutaneous loop retractor,
hook wire, or anchoring suture.[6]
[7]
[8]
Unlike previous anchoring techniques, we utilized a 90-mm spinal needle to hook the
lesion and retract the lung in an appropriate direction for stabilization. This technique
offers several advantages, as the spinal needle functions similarly to a grasping
instrument used in a second port in multiport VATS. First, multiple re-hooking maneuvers
with a single needle allow for precise traction in the optimal direction, facilitating
accurate resection while preserving lung contour and preventing deformation after
stapling. Second, since the lesion's location can vary beyond the upper lobe apex,
the needle insertion site can be selected to correspond to the lesion's position and
easily repositioned as needed. Third, in patients with bullous lung disease or multiple
large bullae, two or more spinal needles can be used simultaneously for a broader
wedge resection, enhancing procedural feasibility. Additionally, the needle insertion
site leaves no visible scar, and postoperative pain is minimal. Finally, stable lung
fixation through spinal needle traction minimizes stapler movement, allowing a reduction
in skin incision size to 1.5 cm. This technique has been previously applied in 139
patients at our institution with favorable outcomes. No conversion to multiport VATS
was required, and the recurrence rate was low (2.16%) over a mean follow-up of more
than 7 years. Postoperative complications were not observed, supporting its feasibility
and safety of this approach.[9] However, this technique has some limitations. SITS using spinal needle anchoring
offers a limited ability to explore the lung parenchyma. Therefore, it is not suitable
for wedge resection of non-visible or deep-seated pulmonary nodules. In obese patients,
needle handling may be challenging, but this can be improved by using a more rigid
19-gauge needle bent at 90 degrees over a 3-cm segment.
Conclusion
SITS for PSP utilizing a spinal needle as a substitute for the grasper is a safe and
effective technique that can be performed through a minimal incision. This approach
can facilitate precise resection while preserving lung integrity, making it a valuable
option even in anatomically challenging cases.
