Preface to the book This is life: the journey of uniportal VATS

Thoracoscopic lobectomy was introduced without the support of prospective randomized trials; however, the advantages of thoracoscopic lobectomy were demonstrated through multi-institutional and propensity-matched studies, proving the quality of life advantages, safety advantages, and cost advantages, compared to thoracotomy. Prospective randomized trials would now be difficult to complete to due lack of equipoise. Thoracoscopic lobectomy has emerged as the standard of care for early stage lung cancer and is utilized extensively for locally advanced lung cancer in centers of excellence. Throughout the investigation of the potential for thoracoscopic lobectomy to improve outcomes, the focus on technical aspects centered on limiting the size of the access incision, but more importantly, avoiding rib spreading with a retractor. Surgeons may have used 4 ports, or 3 ports or 2 ports, and robotic procedures may have employed with up to 5 ports, but the difference in the number of ports was never considered in assessing outcomes.

Is there a difference in outcomes based on the number of ports? Is an approach using 3 ports better than one using 4 ports? If minimally invasive approaches improve outcomes, would the most minimally invasive approach incrementally improve outcomes compared to other approaches? It is unlikely that this hypothesis will ever be tested in a prospective randomized trial, and it is possible that there are other considerations that are more important than the number of incisions, including the location of the incisions, avoidance of local trauma, and other strategies to reduce surgical stress. Yet the quest to improve outcomes by minimizing the number of incisions has been completed with the development of the uniportal thoracoscopic lobectomy.

This volume, “Uniportal Thoracoscopic Surgery” presents to most up to date data available regarding the use of uniportal approaches for early stage as well as locally advanced pulmonary malignancy. It is interesting to note that transition to a uniportal approach seems to have evolved relatively rapidly compared to the adoption of other minimally invasive approaches. The current evidence, relevant controversies, regional experience and results, and future directions are critically discussed by an international panel of experts, from Asia, Europe, and North America. This compilation is especially useful as the emphasis on minimally invasive approaches increases in the wake of lung cancer screening with low dose computed tomography, as more and more patients with early stage lung cancer will be treated and surgical approaches will be compared to non-surgical ablative approaches. Furthermore, as robotic technology evolves, a uniportal robotic platform may also emerge. It may not be possible to demonstrate that one incision is better than other minimally invasive approaches, but it is more likely that one and two port approaches will be considered preferable to ablative techniques than other multiport strategies.

The text is well-written and well-edited, providing relevant information for experienced uniportal surgeons as well as others interested in adopting the uniportal approach. This is an outstanding reference, one that will be extremely useful for the modern management of lung cancer in the era of lung cancer screening, as there will be an increased focus on optimizing the advantages of minimally invasive strategies.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery. The article did not undergo external peer review.

Conficts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/vats.2016.08.15). The author has no conflicts of interest to declare.

This editorial is preface of the new book This is life: the journey of uniportal VATS.

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