Locally advanced lung tumours often require complex surgical techniques to achieve an oncological and safe procedure. Sleeve resections when operating on endobronchial lesions or hilar tumours should be attempted whenever possible rather than performing a pneumonectomy. These procedures result in improved survival, better quality of life, a reduced loss of lung function and an improved operative mortality compared with pneumonectomy. Although the most common approach is an open thoracotomy, these complex surgical techniques can be performed in a thoracoscopic way with the skills and the experience gained from major video-assisted thoracoscopic procedures (VATS). However, despite the multiple advantages of VATS compared with thoracotomy, such as decreased postoperative pain and better recovery, this minimally invasive approach is still not widely adopted for advanced stages of lung cancer and complex resections. Concerns about performing an adequate oncological resection and safe reconstruction VATS are the main reasons for the low adoption of these minimally invasive approaches. Like other thoracoscopic techniques, VATS sleeve procedures also have a steep learning curve, and should therefore be performed either by or with skilled and experienced VATS surgeons to ensure safety and avoid complications. In this article, we describe the technique of thoracoscopic sleeve procedures through a single-incision (uniportal) approach for bronchial, bronchovascular, tracheal and carinal reconstruction, and review the literature reporting sleeve resections by VATS.

OBJECTIVES Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

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Summary Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

Masters of Cardiothoracic SurgeryWith continually growing interest in video-assisted thoracoscopic surgery (VATS) sleeve procedures in the international community, mastery of uniportal VATS sleeve resections is still a complex issue for surgeons. Several articles published recently have shown that VATS sleeve procedures can be performed safely (1-3). In this article the technique of a complex uniportal VATS sleeve resection is presented. Case 1 Clinical vignetteThe patient is a 67 year-old woman with a left upper lobe squamous cell carcinoma (cT3N0M0) involving mediastinal pleura and the pulmonary artery. Her pulmonary function testing indicated 43% of her predicted forced expiratory volume in one second (FEV1). Uniportal VATS double sleeve left upper lobectomy was scheduled. Surgical techniqueThe patient was set in the lateral position. After singlelung ventilation, a 5 cm long incision was made in the fifth intercostal space (Video 1). The first step was revision and dissection of the mediastinal pleura, division of the pulmonary ligament, dissection of lymph nodes from stations 5, 6, 8 and 9 and visualization of the lower lobe vein (Video 2). The extra-pericardial part of the upper lobe vein was involved in the tumor. Therefore the pericardium was opened and both the upper lobe vein and left pulmonary artery were dissected. The upper lobe vein was divided by an endostapler. Then, the left main bronchus and lower lobe bronchus were dissected and cleared. After that, the ductus arteriosus was dissected and divided. The fissure was completed by endostaplers. After dissection of the lower lobe artery and division of the lingular artery, the possibility of resection was confirmed. Before clamping the left pulmonary artery, 5,000 units of heparin were injected intravenously. The left pulmonary artery and lower lobe artery were occluded by placing an arterial clamp and bulldog-clamp respectively. The arterial clamp was placed in the anterior portion of the incision. After that, the upper sleeve lobectomy with sleeve pulmonary artery resection en-bloc was performed. The specimen was temporarily placed in the diaphragmatic sinus. Then, after lymph node dissection from station 7, we performed bronchial and arterial anastomoses. The bronchial anastomosis was performed with a continuous suture (V-loc 3-0). The water probe was negative. The arterial anastomosis was performed with a continuous suture (prolene 4-0) and covered by oxidized regenerated cellulose (Surgicel). The specimen was removed by endo-catch. Surgery time was 300 minutes. Blood loss was 200 mL. Case 2 Clinical vignetteThe patient is a 54 year-old man with a right upper lobe squamous cell carcinoma (cT4N0M0) involving the right main bronchus and superior vena cava. After three courses of neoadjuvant chemotherapy (gemcitabine and cisplatin), the tumor size was reduced to some extent. Pulmonary function testing showed 74% of his predicted FEV1. Uniportal VATS total sleeve carinal pneumonectomy with vena cava resection was scheduled. Surgical techniqueThe pat...