Safety, efficacy, and postoperative pulmonary function recovery of uniportal and multiportal thoracoscopic lung segmentectomy

Introduction

Lung diseases are prevalent, and surgical treatment is primarily implemented in the clinical management of substantial lung diseases, facilitating the timely and effective removal of lesions through surgery to help patients control their condition and ensure prognosis (1,2). Segmentectomy of the lung is a commonly used surgical method for treating various lung diseases. In the past, open surgery was predominantly used in clinical practices, which presented issues such as large trauma area, postoperative infection susceptibility, and impact on prognosis (3,4). With the ever-expanding application of thoracoscopic techniques, the treatment of lung diseases through thoracoscopic technology has become possible. Moreover, with the continuous advancement of modern thoracoscopic techniques, surgical treatment is increasingly leaning toward minimally invasive procedures. Single-port video-assisted thoracoscopic surgery (VATS) has emerged as a potential alternative to traditional multi-port video-assisted thoracoscopy or open surgery, not only demonstrating promising therapeutic efficacy but also reducing the occurrence of adverse reactions, gaining high clinical recognition (5-7). However, this technology currently faces several challenges, necessitating strengthened exploration and summarization in clinical practice. Therefore, this study conducts a retrospective analysis of the safety, efficacy, and postoperative pulmonary function recovery of uniportal and multiportal thoracoscopic lung segmentectomy, aiming to provide a reference basis for clinical development of surgical protocols. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1930/rc).

Methods

Study population

A retrospective analysis was conducted on the clinical data of 105 lung disease patients treated in our hospital from January 2021 to December 2022. They were divided into the uniportal group (uniportal thoracoscopic lung segmentectomy) with 82 cases and the multiportal group (multiportal thoracoscopic lung segmentectomy) with 23 cases based on different surgical approaches. Inclusion criteria were: (I) primary lung cancer, lung metastases, severe lung laceration, lung bullae; (II) tumor <5 cm, peripheral type tumor, potentially benign lung lobe; stage I, peripheral type, no mediastinal lymph node metastasis, no main bronchus invasion for early non-small cell lung cancer; lung function assessment could tolerate one-lung ventilation under general anesthesia and resection of the affected lung lobe; (III) written informed consent was obtained from all patients for the inclusion of their surgical procedures and outcomes in this study. Exclusion criteria were: (I) patients with primary diseases such as heart, liver, kidney complications; (II) patients with mental illnesses such as depression; (III) elderly patients with frail constitution; (IV) patients with invasion of mediastinal major blood vessels or recurrent laryngeal nerve; (V) patients requiring chest wall reconstruction.

The selection of uniportal or multiportal VATS was based on comprehensive factors including clinical physician recommendations, patient preferences, and patients’ economic conditions. The differences in patient numbers between groups showed no statistical significance, maintaining the comparability of the data.

Preoperative preparation

All patients routinely underwent laboratory examinations including complete blood count, blood biochemistry, coagulation function, blood type, and tumor markers, as well as electrocardiogram, pulmonary function tests, chest and abdominal computed tomography (CT), head magnetic resonance imaging (MRI) and other imaging examinations preoperatively. If accompanied by other diseases, specialized clinics could be consulted to rule out contraindications for surgery. All cases were discussed at departmental meetings, and thoracoscopic lung segmentectomy could be performed for surgical treatment to maximize benefits and ensure safety for patients.

Surgical procedures

For the uniportal group, uniportal thoracoscopic lung segmentectomy was performed as follows: the lateral position was adopted, with patients on the right side if the lesion was in the left lung lobe, and vice versa for lesions in the right chest. For upper lobe lesions, the incision was made at the fifth intercostal space at the midaxillary line, and for middle and lower lobe lesions, the incision was made at the fourth intercostal space at the midaxillary line. The incision was generally 4–5 cm. The principles of single-directional lung lobe resection were routinely followed, with operations proceeding in the order of veins, bronchi, pulmonary arteries, and interlobar fissures from superficial to deep. However, the surgical steps were not rigidly adhered to, and the approach could be adjusted based on exploration findings. For unclear pulmonary structure and severe adhesions making separation difficult, the principle of “easy comes before difficult” was followed, with easier vessels handled first before bronchi. For finer arterial branches or vessels that the stapler could not pass through easily, ligation with sutures was used. For the multiportal group, multiportal thoracoscopic lung segmentectomy was performed as follows: the surgical position was the same as the uniportal group, with a 3 cm incision at the midaxillary line used as the main operating port and two 1 cm incisions at the fifth intercostal space anteriorly and seventh intercostal space posteriorly used as observation and assistant operating ports. Other surgical procedures were the same as the uniportal group.

Postoperative management

Following the completion of both surgical procedures, a standard closed chest drainage tube was placed at the surgical incision site for all patients. Postoperatively, patients routinely received 10 mg of tramadol hydrochloride and paracetamol three times a day. When oral medication was ineffective in alleviating pain, patients received intramuscular morphine based on their condition. Prior to discharge, chest tubes were removed for all patients after confirming the absence of infection, fever, severe chest tightness, or dyspnea complications.

Observational indices

• Intraoperative indices: mainly encompassed operative time, intraoperative blood loss, and the proportion of conversions to open surgery for both groups.
• Postoperative indices: primarily included length of hospital stay, hospitalization costs, incidence of short-term complications (e.g., effusion, wound infection), and the rate of reoperation for both groups.

Pain assessment: utilizing the Visual Analog Scale (VAS), assessments were conducted preoperatively, as well as on postoperative days 1 and 3 (8). VAS employed a 10-centimeter line representing pain intensity, where 0 denoted no pain and 10 denoted the most intense pain (9).

Pulmonary function: pulmonary function tests were conducted using the Master Screen PFT (Jaeger, Germany) preoperatively, as well as at 1 and 3 months postoperatively to measure forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), the FEV1/FVC ratio, and carbon monoxide diffusion capacity (DLCO) for both groups.

Long-term complication rate: this primarily encompassed chronic pain and chest cavity effusion requiring intervention. The occurrence rates of various long-term complications were calculated for both groups.

Statistical analysis

Data were analyzed using SPSS 25.0 statistical software. Descriptive statistics for categorical data were expressed as n (%) and analyzed using the χ² test. Quantitative data were first tested for normality using the Shapiro-Wilk test (10), and the results confirmed that the data largely followed normal distribution. These normally distributed quantitative data were represented as (mean ± standard deviation) and assessed for homogeneity of variance. A significance level of α=0.05 was used. The independent samples t-test was used when variances were equal; otherwise, Welch’s t-test (t’ test) was applied. A P-value of less than 0.05 indicates a statistically significant difference.

Ethical statement

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments and approved by the Ethics Committee of Specialty Medical Center of the PLA Strategic Support Force (approval number: LL-LCST-2025-01). Written informed consent was obtained from all patients for publication of this study.

Results

Comparison of baseline data between groups

As shown in Table 1, there were no statistically significant differences in baseline characteristics, such as gender (P=0.98), age (P=0.77), body mass index (P=0.78), smoking history (P=0.76), and disease type (P=0.92) between the two groups, indicating comparability between the groups.

Intraoperative comparison between groups

As depicted in Table 2, there were no statistically significant differences in operative time (P=0.37) and the proportion of conversions to open surgery between the two groups (P=0.83). Although most cases in both groups had blood loss under 150 mL, the intraoperative blood loss in the uniportal group was less than that in the multiportal group, showing a statistically significant difference (P=0.001), suggesting that compared to multiportal thoracoscopic lung segmentectomy, uniportal thoracoscopic lung segmentectomy was associated with reduced intraoperative blood loss.

Comparison of postoperative outcomes between groups

According to Table 3, the uniportal group exhibited shorter length of hospital stay (P=0.001), lower hospitalization costs (P=0.001), and a lower incidence of short-term complications (P=0.046) compared to the multiportal group, with statistically significant differences between the groups. The rate of reoperation did not show a statistically significant difference between the two groups (P=0.42). This indicates that compared to multiportal thoracoscopic lung segmentectomy, uniportal thoracoscopic lung segmentectomy was associated with reduced length of hospital stay, decreased hospitalization costs, and a lower rate of short-term complications.

Comparison of VAS scores between groups preoperatively, postoperatively (at 1 day and 3 days)

As presented in Table 4 and Figure 1, there were no statistically significant differences in preoperative VAS scores between the two groups (P=0.60). However, the postoperative VAS scores at 1 and 3 days were lower in the uniportal group compared to the multiportal group, revealing a statistically significant difference (P=0.001 for both timepoints). This suggests that compared to multiportal thoracoscopic lung segmentectomy, uniportal thoracoscopic lung segmentectomy was associated with alleviated postoperative pain for patients.

Figure 1 Trend of preoperative, postoperative day 1 and day 3 VAS scores between two groups. VAS, Visual Analog Scale.

Comparison of pulmonary function indices between groups preoperatively, at 1 month and 3 months postoperatively

As seen in Tables 5,6, as well as illustrated in Figures 2,3, there were no statistically significant differences in preoperative FVC (P=0.81), FEV1 (P=0.87), FEV1/FVC ratio (P=0.61), and DLCO (P=0.86) between the two groups. Postoperatively, both groups exhibited declines in pulmonary function indices, including FVC, FEV1, the FEV1/FVC ratio, and DLCO, attributable to surgical trauma, which is an expected outcome following thoracic surgery regardless of the surgical approach. However, at 1 and 3 months postoperatively, the uniportal group demonstrated superior FVC (P=0.045 and P=0.01), FEV1 (P=0.001 for both timepoints), FEV1/FVC (P=0.01 and P=0.03), and DLCO (P=0.001 for both timepoints) compared to the multiportal group, with statistically significant differences between the groups, indicating that compared to multiportal thoracoscopic lung segmentectomy, uniportal thoracoscopic lung segmentectomy promoted better recovery of pulmonary function for patients.

Figure 2 Trend of FVC and FEV1 indexes before, 1 month and 3 months after surgery between two groups. FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second.

Figure 3 Trend of FEV1/FVC and DLCO indexes before, 1 month and 3 months after surgery between the two groups. FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; DLCO, carbon monoxide diffusion capacity.

Comparison of long-term complication rates between groups

In Table 7, it is observed that the occurrence rates of chronic pain and chest cavity effusion requiring intervention were lower in the uniportal group compared to the multiportal group, demonstrating a statistically significant difference between the groups (P<0.001). This suggests that compared to multiportal thoracoscopic lung segmentectomy, uniportal thoracoscopic lung segmentectomy was associated with a decreased occurrence of long-term complications for patients.

Comparison of quality of life between groups

We observed differences in quality of life between the two groups through standardized questionnaires assessing physical status, functional status, social-family well-being, and emotional status. Analysis of these domains revealed more favorable trends in the uniportal group compared to the multiportal group. The differences were particularly notable in aspects of physical functioning during daily activities, emotional state, and social interaction capabilities. These observations suggest potential advantages of uniportal VATS that extend beyond traditional clinical parameters to broader aspects of patients’ postoperative quality of life.

Discussion

Lung diseases are common clinical conditions with high incidence. In recent years, changes in lifestyle, deteriorating environment, and interactions between unhealthy habits have contributed to the persistently high incidence of lung diseases (11,12). Lung lesions have unique characteristics, and the principle of early diagnosis, early treatment, and early removal should be followed in managing such patients to avoid more severe consequences (13,14).

Advancements in clinical diagnostic techniques have provided more opportunities for early and definitive diagnosis of lung diseases, as well as the possibility of early surgery (15,16). Surgery is an important approach for treating lung diseases, especially irreversible localized lung diseases such as lung cancer. Early surgical intervention is a crucial means of controlling the condition and prolonging survival time for such patients (17,18). When surgically treating these patients, full consideration of disease characteristics is needed, as well as proper patient selection and skilled surgical techniques (17,19). Currently in clinical practice, open surgery, uniportal thoracoscopic surgery, and multiportal thoracoscopic surgery can be performed for lung diseases (20,21).

Open surgeries result in larger trauma, requiring a longer time for recovery, which increases the risk of postoperative complications. Therefore, uniportal or multiportal thoracoscopic surgeries remain widely used clinical procedures (19). In recent years, there has been remarkable progress in endoscopic equipment and minimally invasive techniques, leading to significantly improved indications and safety. Consequently, clinical surgical treatments are increasingly shifting towards minimally invasive approaches. Thoracoscopic procedures are extensively applied in the management of lung diseases (22,23).

While thoracoscopic lung segmentectomy represents a traditional surgical approach for treating lung diseases, single-port thoracoscopic surgery is a novel minimally invasive procedure. Initially completed by Spanish scholars in 2011, this approach has gradually become popular in China, establishing standardized procedures and gaining patient acceptance (24). According to WU CY and colleagues (25), single-port thoracoscopic lung segmentectomy offers simpler operation compared to multiportal procedures, effectively reducing surgical risks, intraoperative blood loss, length of hospital stay, and hospitalization costs. Consistently, our research findings indicate that the single-port group exhibited lower intraoperative blood loss, shorter hospital stays, and reduced hospitalization costs compared to the multiportal group (P<0.05), aligning with the aforementioned studies.

The single-port thoracoscopic lung segmentectomy, with fewer incisions, is associated with reduced bleeding and postoperative pain, thus promoting quicker recovery and lowering the risk of complications (26). These outcomes are consistent with clinical research findings which highlighted that single-port thoracoscopic surgery reduces both short-term and long-term postoperative complication rates compared to multiportal procedures (P<0.05). The smaller incisions of the single-port approach alleviate unnecessary bleeding and nerve damage, ultimately mitigating pain and facilitating postoperative recovery while reducing the risk of long-term complications.

Furthermore, Mizukami et al.’s study (27) revealed that single-port thoracoscopic surgery alleviates postoperative pain more effectively than multiportal thoracoscopic surgery. The VAS scores at 1 and 3 days postoperation were lower in the single-port group compared to the multiportal group (P<0.05), validating the conclusions of the aforementioned study. This reduction in pain can be attributed to the elimination of additional observation and assistant operation ports required in conventional thoracoscopic procedures, thus minimizing potential nerve and muscle trauma. Additionally, the incision site at the fifth intercostal space along the anterior axillary line offers advantages such as fewer neurovascular structures at the 5th intercostal space versus the 7th or 8th intercostal space, thinner muscle layers, and wider intercostal spaces, thereby reducing postoperative pain levels (28).

At 1 month and 3 months postoperation, the single-port group exhibited superior FVC, FEV1, FEV1/FVC ratio, and DLCO compared to the multiportal group (P<0.05). This is attributed to the unified observation and operation holes in single-port thoracoscopic lung segmentectomy, which maintains the instruments’ projection surface and the operative field in the same sagittal plane, reducing trauma to the thoracic wall and preserving thoracic integrity, thus reducing lung function impairment (29). However, it is important to note that single-port thoracoscopic lung segmentectomy is not suitable for all lung diseases, and the most appropriate surgical treatment should be selected based on a comprehensive assessment of the patient’s condition and needs (30).

In summary, single-port VATS demonstrates higher efficacy and safety compared to multiportal VATS, promoting better postoperative lung function recovery, reducing postoperative pain, and minimizing surgical time, incision length, intraoperative bleeding, length of hospital stay, and hospitalization costs. Therefore, it is worth promoting its application in clinical practice.

Nevertheless, certain limitations remain in this study. First, due to temporal constraints in our study period, there was an imbalance in sample sizes between the uniportal and multiportal groups, which may potentially affect the statistical power and robustness of our findings. Additionally, the study included a relatively small number of surgical cases and a relatively short postoperative follow-up period. To address these limitations, future studies should aim to include larger and more balanced cohorts with extended follow-up periods of 6 months and 1 year, which will validate our current findings and provide more definitive evidence regarding the comparative effectiveness of these surgical approaches. Besides, future research will incorporate validated quality of life questionnaires, such as SF-36 or European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), along with detailed functional status assessments using standardized Activities of Daily Living (ADL) scales, which can provide more definitive evidence regarding the comparative effectiveness of these surgical approaches (31).

Conclusions

Compared to multiport VATS, single-port thoracoscopic lung segmentectomy demonstrates superior safety and efficacy outcomes, as evidenced by reduced intraoperative blood loss, shortened hospital stay, lower hospitalization costs, and decreased complication rates. Additionally, single-port VATS is associated with enhanced postoperative pulmonary function recovery, as reflected in improved FVC, FEV1, FEV1/FVC ratio, and DLCO values, and reduced postoperative pain intensity. These findings suggest that single-port VATS represents an advantageous surgical approach for lung segmentectomy.

Acknowledgments

We would like to express our sincere gratitude to all patients who participated in this study, as well as the nursing staff and clinical research coordinators for their dedicated support throughout this research project.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1930/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1930/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1930/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1930/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments and approved by the Ethics Committee of Specialty Medical Center of the PLA Strategic Support Force (approval number: LL-LCST-2025-01) in accordance with regulatory and ethical guidelines pertaining to retrospective research studies. Written informed consent was obtained from all patients for the inclusion of their surgical procedures and outcomes in this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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