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Objective The efficacy and safety of subxiphoid thoracoscopic thymectomy (SVATS) for early thymoma are unknown. The purposes of this meta-analysis were to evaluate the effectiveness and safety of SVATS for early thymoma, to compare it with unilateral intercostal approach video thoracoscopic surgery (IVATS) thymectomy, and to investigate the clinical efficacy of modified subxiphoid thoracoscopic thymectomy (MSVATS) for early anterior mediastinal thymoma. Methods Original articles describing subxiphoid and unilateral intercostal approaches for thoracoscopic thymectomy to treat early thymoma published up to March 2023 were searched from PubMed, Embase, and the Cochrane Library. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated and analyzed for heterogeneity. Clinical data were retrospectively collected from all Masaoka stage I and II thymoma patients who underwent modified subxiphoid and unilateral intercostal approach thoracoscopic thymectomies between September 2020 and March 2023. The operative time, intraoperative bleeding, postoperative drainage, extubation time, postoperative hospital stay, postoperative visual analog pain score (VAS), and postoperative complications were compared, and the clinical advantages of the modified subxiphoid approach for early-stage anterior mediastinal thymoma were analyzed. Results A total of 1607 cases were included in the seven studies in this paper. Of these, 591 cases underwent SVATS thymectomies, and 1016 cases underwent IVATS thymectomies. SVATS thymectomy was compared with IVATS thymectomy in terms of age (SMD = − 0.09, 95% CI: −0.20 to − 0.03, I 2  = 20%, p  = 0.13), body mass index (BMI; SMD = − 0.10, 95% CI: −0.21 to − 0.01, I 2  = 0%, p  = 0.08), thymoma size (SMD = − 0.01, 95% CI: −0.01, I 2  = 0%, p  = 0.08), operative time (SMD = − 0.70, 95% CI: −1.43–0.03, I 2  = 97%, p  = 0.06), intraoperative bleeding (SMD = − 0.30. 95% CI: −0.66–0.06, I 2  = 89%, p  = 0.10), time to extubation (SMD = − 0.34, 95%CI: −0.73–0.05, I 2  = 91%, p  = 0.09), postoperative hospital stay (SMD = − 0.40, 95% CI: −0.93–0.12, I 2  = 93%, p  = 0.13), and postoperative complications (odds ratio [OR] = 0.94, 95% CI: 0.42–2.12, I 2  = 57%, p  = 0.88), which were not statistically significantly different between the SVATS and IVATS groups. However, the postoperative drainage in the SVATS group was less than that in the IVATS group (SMD = − 0.43, 95%CI: −0.84 to − 0.02, I 2  = 88%, p  = 0.04), and the difference was statistically significant. More importantly, the postoperative VAS was lower in the SVATS group on days 1 (SMD = − 1.73, 95%CI: −2.27 to − 1.19, I 2  = 93%, p  < 0.00001), 3 (SMD = − 1.88, 95%CI: −2.84 to − 0.81, I 2  = 97%, p  = 0.0005), and 7 (SMD = − 1.18, 95%CI: −2.28 to − 0.08, I 2  = 97%, p  = 0.04) than in the IVATS group, and these differences were statistically significant. A total of 117 patients undergoing thoracoscopic thymectomy for early thymoma in the Department of Thoracic Surgery of the Second Hospital of Jilin University were retrospectively collected and included in the analysis, for which a modified subxiphoid approach was used in 42 cases and a unilateral intercostal approach was used in 75 cases. The differences between the two groups (MSVATS vs. IVATS) in general clinical characteristics such as age, sex, tumor diameter, Masaoka stage, Word Health Organization (WHO) stage, and intraoperative and postoperative conditions, including operative time, postoperative drainage, extubation time, postoperative hospital stay, and postoperative complication rates, were not statistically significant ( p  > 0.05), while BMI, intraoperative bleeding, and VAS on postoperative days 1, 3, and 7 were all statistically significant ( p  < 0.05) in the MSVATS group compared with the IVATS group. Conclusion The meta-analysis showed that the conventional subxiphoid approach was superior in terms of postoperative drainage and postoperative VAS pain scores compared with the unilateral intercostal approach. Moreover, the modified subxiphoid approach had significant advantages in intraoperative bleeding and postoperative VAS pain scores compared with the unilateral intercostal approach. These results indicate that MSVATS can provide more convenient operation conditions, a better pleural cavity view, and a more complete thymectomy in the treatment of early thymoma, indicating that is a safe and feasible minimally invasive surgical method.

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients’ characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients’ comfort.

This systematic review aims to provide a comprehensive evaluation of the literature on robotic video-assisted thoracoscopic surgery (VATS) pneumonectomy. To evaluate its effectiveness and safety in treating various lung diseases. A thorough search of electronic databases was conducted, and 25 studies encompassing 1,650 patients were included in the review. The review found that robotic VATS pneumonectomy surgery is a safe and effective alternative to traditional open surgery for the treatment of various lung diseases, particularly early-stage lung cancer. The surgery is associated with shorter hospitalizations, less blood loss, and less postoperative pain when compared to traditional open surgery. However, long-term survival outcomes were not significantly different between robotic and open surgery. The review also highlights the need for further studies to determine the optimal use of robotic VATS pneumonectomy surgery in different clinical scenarios and to determine whether the benefits of this technique outweigh the costs. Overall, this systematic review suggests that robotic VATS pneumonectomy surgery is a safe and effective technique that can be used as an alternative to traditional open surgery.

Background Minimally invasive sub-lobectomy is sufficient in treating small early-stage non-small cell lung cancer (NSCLC). However, comparison of the feasibility and oncologic efficacy between robot-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) in performing sub-lobectomy for early-stage NSCLC patients age 80 years or older is scarce. Methods Octogenarians with clinical stage IA NSCLC (tumor size, ≤ 2 cm) undergoing minimally invasive wedge resection or segmentectomy at Shanghai Chest Hospital from 2011 to 2020 were retrospectively reviewed from a prospectively maintained database. Propensity score-matching (PSM) with a RATS versus VATS ratio of 1:4 was performed. Perioperative and long-term outcomes were analyzed. Results The study identified 594 patients (48 RATS and 546 VATS patients), and PSM resulted in 45 cases in the RATS group and 180 cases in the VATS group. The RATS patients experienced less intraoperative bleeding (60 mL [interquartile range (IQR), 50–100 mL] vs. 80 mL [IQR, 50–100 mL]; P = 0.027) and a shorter postoperative hospital stay (4 days [IQR, 3–5 days] vs. 5 days [IQR, 4–6 days]; P = 0.041) than the VATS patients. The two surgical approaches were comparable concerning other perioperative outcomes and postoperative complications (20.00% vs. 26.11%; P = 0.396). Additionally, during a median follow-up period of 66 months, RATS and VATS achieved comparable 5-year overall survival (90.48% vs. 87.93%; P = 0.891), recurrence-free survival (83.37% vs. 83.18%; P = 0.782), and cumulative incidence of death. Further subgroup comparison also demonstrated comparable long-term outcomes between the two approaches. Finally, multivariate Cox analysis indicated that the surgical approach was not independently correlated with long-term outcomes. Conclusions The RATS approach shortened the postoperative hospital stay, reduced intraoperative bleeding by a statistically notable but clinically insignificant amount, and achieved long-term outcomes comparable with VATS in performing sub-lobectomy for octogenarians with early-stage small NSCLC.

Purpose This study compared short- and long-term outcomes of robotic-assisted thoracoscopic surgery (RATS) versus video-assisted thoracoscopic surgery (VATS) for lobectomy in young adults aged ≤ 35 years with non-small cell lung cancer (NSCLC), aiming to assess the superiority of RATS over VATS for this special group of patients. Methods A total of 1355 consecutive NSCLC cases aged 18–35 years undergoing RATS ( n =  105) or VATS ( n =  1250) between 2014 and 2021 were retrospectively identified from a prospectively maintained database. Propensity score matching (PSM) was applied to establish a 1:3 RATS versus VATS ratio. Baseline clinicopathological characteristics, perioperative outcomes, lymph node (LN) assessment, and long-term survival were investigated. Results Following PSM, 105 and 315 cases were in the RATS and VATS groups, respectively. RATS led to a shorter postoperative hospital stay than VATS (4.0 ± 1.5 vs 4.3 ± 1.7 days, p =  0.02). The two groups were comparable in other perioperative outcomes and postoperative complications (all p >  0.05). Moreover, RATS assessed more LNs (9.4 ± 4.4 vs 8.3 ± 3.6, p =  0.03), especially N1 LNs (4.2 ± 3.1 vs 3.5 ± 2.2, p =  0.02), than VATS. By comparison, no difference in 5-year recurrence-free survival (RFS), overall survival (OS), or recurrence or mortality patterns was found between the two groups (all p >  0.05). Further subgroup analyses also observed similar long-term outcomes between the two groups regarding age, gender, and smoking history. Finally, Cox’s analyses found that the surgical approach was not independently correlated with RFS or OS. Conclusion RATS shortened postoperative hospital stay, assessed more N1 and total LNs, and achieved comparable long-term outcomes to VATS for very young NSCLC patients.

BackgroundThe purpose of this study was to compare the results of the hybrid mediastino-thoracoscopic approach with that of the conventional thoracoscopic approach and to identify the advantages and disadvantages of the hybrid approach.MethodsWe retrospectively analyzed 172 patients who underwent thoracoscopic esophagectomy for esophageal cancer from July 2009 to June 2021, excluding salvage surgery. In the mediastinoscopic approach, the lymph nodes were dissected from a small incision in the left aspect of the neck to the aortic arch with supine double-lung ventilation. Thereafter, the middle-to-lower mediastinum and right superior mediastinum were dissected thoracoscopically in the prone position. The patients’ demographics, surgical outcomes, postoperative complications, and postoperative recurrence patterns were compared between 51 patients in the hybrid approach and 121 patients in the conventional approach.ResultsThe hybrid group had more elderly patients (71 years vs. 67 years; P = 0.010), more cardiovascular disease (33.3% vs. 16.7%; P = 0.021), lower rates of preoperative chemotherapy (49.0% vs. 69.4%; P = 0.015), and shorter right lung collapse time (196 min vs. 264 min; P < 0.001). Postoperative hoarseness was not different between the two groups (31.4% vs. 27.3%; P = 0.584), and there was a significant difference in the sternal-vertebral distance at the level of the sternal notch (41 mm in the hybrid group vs. 48 mm in the conventional group; P = 0.029). The sternal-vertebral distance of less than 45 mm was an independent risk factor for postoperative hoarseness in the logistic analysis (odds ratio 3.636, 95% confidence interval 1.054–12.546; P = 0.041).ConclusionThe hybrid mediastino-thoracoscopic approach could be safely adapted to elderly or cardiopulmonary diseased patients; however, short sternal-vertebral distance might be a risk factor of postoperative recurrent laryngeal nerve palsy.

We aimed to compare the outcomes and postoperative complications of patients with esophageal cancer after single-port thoracoscopic esophagectomy (SPTE) and four-port thoracoscopic esophagectomy (FPTE). We retrospectively collected data from patients who underwent surgery at the First Affiliated Hospital of Kunming Medical University from February 2019 to November 2022. In total, 86 patients were included in the SPTE group and 114 patients were included in the FPTE group. Compared to patients undergoing FPTE, significantly shorter postoperative hospital stay (13.54 ± 3.88 vs. 19.08 ± 5.09 days), shorter chest drainage time (6.06 ± 2.16 vs. 7.45 ± 1.68 days), lower estimated intraoperative blood loss (226.05 ± 94.87 vs. 363.16 ± 78.92 mL), and longer overall length of surgery (346.34 ± 53.86 vs. 332.89 ± 28.86 min) and longer length of abdominal surgery (183.46 ± 33.33 vs. 166.05 ± 22.07 min) were observed among patients undergoing SPTE; however, no significant difference was observed regarding 3-month, 6-month, and 12-month overall survival, time to start oral feeding, and length of thoracic surgery. Furthermore, postoperative intractable pain lasting for 3 months (39.5% vs. 21.0%), pneumonia (34.2% vs. 11.6%), empyema (14.9% vs. 3.5%), and chylothorax (10.5% vs. 2.3%) were significantly more frequent in the FPTE group, whereas postoperative gastrointestinal symptoms (41.9% vs. 23.7%) were significantly more frequent in the SPTE group. There was no significant difference between the groups regarding postoperative arrhythmia, recurrent laryngeal nerve injury, esophagotracheal fistula, second surgery, and intractable pain lasting for 6 and 12 months. Compared to FPTE, SPTE may improve patients’ outcomes and prevent some of the major complications.

BackgroundTo evaluate the short-term efficacy, lung function, and oxidative stress levels between the robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery group (VATS) for non-small cell lung cancer (NSCLC).MethodsWe conducted a retrospective cohort study, selecting 248 NSCLC patients who underwent minimally invasive lobectomy at the Department of Thoracic Surgery, Gansu Provincial People’s Hospital, from August 2019 to February 2023. There were 105 patients in the RATS group and 143 patients in the VATS group. The patients in the two groups were subjected to 1:1 propensity score matching analysis (PSM), and the perioperative indicators were recorded. The levels of oxidative stress factors (superoxide dismutase, SOD; malondialdehyde, MDA) and inflammatory factors were measured 1 day before surgery and 3 days after surgery, respectively. Pulmonary function and patient quality of life were measured at 1 day preoperatively and 3 months postoperatively.ResultsThere are 93 patients in each group after PSM. Compared to the VATS group, the RATS group had shorter operation time, less intraoperative blood loss, greater number and groups of lymph nodes cleared, and shorter postoperative hospital stay. The SOD level in the RATS group was higher and the MDA level was lower than that in the VATS group after surgery. Postoperative inflammatory cytokine levels were less elevated in the RATS group than in the VATS group. At 3 months postoperatively, FVC%, FEV1%, and GQOLI-74 scores were higher in the RATS group than in the VATS group.ConclusionCompared to VATS lobectomy, RATS lobectomy has the advantages of shorter operative time, lesser bleeding, more lymph node dissection, faster postoperative recovery, and lesser impact on postoperative lung function. It is also capable of reducing the postoperative oxidative stress and inflammatory response, which can improve patients’ quality of life.

The combined use of the ProSeal laryngeal mask airway and a bronchial blocker may reduce postoperative hoarseness and sore throat. We aimed to test the feasibility and efficacy of this combination technique in thoracoscopic surgery. A single-center, patient-assessor blinded, randomized controlled trial. Nagoya City University Hospital (between November 2020 and April 2022). A total of 100 adult patients undergoing lobectomy or segmentectomy by video- or robotic-assisted thoracoscopic surgery. Patients were randomly assigned to either group using a combination of the ProSeal laryngeal mask airway and a bronchial blocker (pLMA+BB group) or a double-lumen endobronchial tube (DLT group). The primary outcome was the hoarseness incidence on 1–3 postoperative days. Secondary outcomes included sore throat, intraoperative complications (hypoxemia, hypercapnia, surgical interruption, malposition of devices, unintended lung expansion, and ventilatory difficulty), lung collapse, device placement-related outcomes, and coughing during emergence. A total of 100 patients underwent randomization (51 to the pLMA+BB group and 49 to the DLT group). After drop outs, a total of 49 patients in each group were analyzed per-protocol. The incidences of hoarseness in the pLMA+BB and DLT groups were 42.9% and 53.1% (difference, −10.2%; 95% confidence interval, −30.1% to 10.3%; p = 0.419), 18.4% vs. 32.7%, and 20.4% vs. 24.5% on postoperative day 1, 2, and 3, respectively. The incidences of sore throat in the pLMA+BB and DLT groups were 16.3% vs. 34.7% (difference, −18.4%; 95% confidence interval, −35.9% to −0.9%; p = 0.063) on postoperative day 1. In the pLMA+BB group, more intraoperative complications and less coughing during emergence were observed compared to the DLT group. Lung collapse and placement-related outcomes were comparable between the groups. The combination of ProSeal laryngeal mask airway and bronchial blocker did not significantly reduce hoarseness compared to the double-lumen endobronchial tube. •Double-lumen endobronchial tubes (DLTs) sometimes cause hoarseness and sore throat.•Little is known about a combination of the LMA ProSeal and a bronchial blocker (pLMA+BB).•We compared pLMA+BB and DLT in a robotic- and video-assisted thoracoscopic surgery.•Postoperative hoarseness and sore throat were comparable between the two groups.•The pLMA+BB was feasible but had more frequent intraoperative complications.

Abstract Introduction: Uniportal video-assisted thoracoscopic surgery (U-VATS) has recently become an alternative approach for many minimally invasive thoracic procedures, but although its surgical effectiveness has been proven, still its feasibility and safety are debated and unclear. the objective of this study was to compare the safety and perioperative outcomes of U-VATS versus multiportal VATS (M-VATS). Patients and Methods: This was a comparative follow-up randomised controlled clinical trial, carried out on 36 randomly selected eligible patients, and fulfilling the inclusion and exclusion criteria for VATS, they were assigned randomly into two groups: Study Group I including 18 patients undergoing U-VATS with conventional treatment using standard chest tube drainage and Control Group II including 18 patients undergoing M-VATS) with the same conventional treatment using standard chest tube drainage and served as a comparable control group. Results: Patients in the U-VATS Group 1 had faster operation time, and with reduced blood loss, pleural drainage and post-operative hospitalisation, they also experienced lower average post-operative pain score on comparison with those in M-VATS Group II (P < 0.001), respectively. For either group, there were no hospital deaths or infections. There was no noticeable difference between the two groups in terms of the number of resected lymph nodes or the rates of intraoperative or post-operative complications (P > 0.05). Conclusion: U-VATS is feasible and safe in eligible selected patients with favourable short-term perioperative outcomes (operative time, duration of pleural drainage, post-operative pain, early ambulation, duration of hospital stay as well as the risk of perioperative complications), and it can be considered the preferred approach in minimally invasive thoracic procedures that open up for the possibility of fast-track thoracic surgeries.