Efficacy and outcomes of total tubeless single-port thoracoscopic wedge resection for peripheral pulmonary nodules

Introduction

With the widespread adoption of early screening technologies such as low-dose spiral computed tomography (CT) scans and increased public awareness of health, the detection of pulmonary nodules, particularly early-stage lung cancers, has significantly risen (1). A significant proportion of peripheral early-stage lung cancers, primarily presenting as ground-glass opacities (GGOs), can achieve favorable therapeutic outcomes through localized wedge resection (2). As both surgical and anesthetic techniques have significantly advanced, there is growing interest in tubeless procedures (3-11). The vast majority of medical centers still commonly opt to leave chest drainage tubes postoperatively to mitigate the risk of complications. Nevertheless, for patients with peripheral pulmonary nodules undergoing localized pulmonary wedge resection, the adoption of total tubeless (TT) techniques (i.e., no preoperative urinary catheter placement, no intraoperative tracheal intubation and central venous catheterization, and no postoperative closed chest drainage tubes nor chest puncture drainage tubes) may represent an effective treatment strategy (12). This approach can further reduce trauma, accelerate the recovery process, and thereby enhance the overall treatment experience (12). However, there remains a paucity of research regarding the safety and efficacy of TT techniques in single-port thoracoscopic pulmonary wedge resection for the treatment of peripheral pulmonary nodules. This study aimed to assess the safety, short‑term efficacy, and overall patient satisfaction of TT single‑port thoracoscopic wedge resection for peripheral pulmonary nodules. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-361/rc).

Methods

Patients

This is a retrospective cohort study. This retrospective cohort study adhered to the principles of the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Fujian Medical University Union Hospital (No. 2024KY263), and individual consent for this retrospective analysis was waived.

A total of 89 consecutive patients who underwent tubeless single-port thoracoscopic pulmonary wedge resection for peripheral pulmonary nodules at the Department of Thoracic Surgery I in Fujian Medical University Union Hospital between July 2023 and September 2024 were included. Patients were divided into two groups according to whether a 12 Fr small-bore pleural catheter inserted via the Seldinger technique was employed: the TT group and the partial tubeless (PT) group. Propensity score matching (PSM) with a 1:1 matching algorithm was carried out to reduce the influence of confounders between the two groups. After matching, 68 patients were analyzed, with 34 in each group.

The following were the inclusion criteria: (I) anesthesia with laryngeal mask ventilation maintaining spontaneous respiration; (II) surgery via single-port thoracoscopic pulmonary wedge resection; (III) age between 18 and 75 years; (IV) Eastern Cooperative Oncology Group (ECOG) (13) score ≤1; (V) American Society of Anesthesiologists (ASA) (14) classification ≤ III; (VI) normal cardiopulmonary function.

The following were the exclusion criteria: (I) refusal of surgery or anesthesia; (II) coagulation disorders; (III) hypoxemia [partial pressure of oxygen (PaO₂) <60 mmHg], hypercapnia [partial pressure of carbon dioxide (PaCO₂) >50 mmHg]; (IV) increased risk of gastroesophageal reflux or comorbid gastroesophageal reflux disease (GERD); (V) extensive thoracic adhesions; (VI) contralateral phrenic nerve paralysis.

Preoperative examination

Before surgery, all patients received standard preoperative tests such as thin-slice chest CT, cranial CT or magnetic resonance imaging (MRI), electrocardiogram (ECG), echocardiography, pulmonary function tests, evaluation of supraclavicular lymph nodes, and comprehensive abdominal ultrasonography.

Anesthesia procedures

Instead of endotracheal intubation, laryngeal mask airway (LMA) is inserted to maintain the patient’s airway and facilitate spontaneous breathing. An anesthesia protocol was employed, consisting of intravenous anesthesia, paravertebral nerve blocks, pleural blockade, and thoracic vagal nerve blockade. Anesthesia induction involved administering dexmedetomidine at a rate of 1.0 µg/kg/h for 15 minutes, followed by a target-controlled infusion (TCI) of propofol at a concentration of 2–3.5 µg/mL and 0.2 µg/kg of sufentanil. The LMA was inserted and connected to the breathing circuit once the Bispectral Index (BIS) value reached 60 or lower. Respiratory function was continuously monitored, and if spontaneous breathing was absent, assisted ventilation or synchronized intermittent mandatory ventilation (SIMV) was initiated [fraction of inspired oxygen (FiO₂) 1.0, tidal volume 7–8 mL/kg, respiratory rate 10–12 breaths/min, oxygen flow rate 4–5 L/min]. The patient was then repositioned to the lateral decubitus position on the healthy side, followed by paravertebral nerve blocks 2 at the 4th, 6th, and 8th intercostal spaces, with 5 mL of ropivacaine (5 mg/mL) injected into each interspace.

During anesthesia maintenance, prior to skin incision, propofol (TCI) was administered at a concentration of 1.5–4 µg/mL, remifentanil at a rate of 0.03–0.08 µg/kg/min, and dexmedetomidine at 0.5 µg/kg/h to maintain the BIS between 45 and 60. If intraoperative blood pressure (IBP) monitoring indicated a systolic blood pressure (SBP) below 90 mmHg, intravenous dopamine was administered at a dose of 3–5 µg/kg/min (maximum dose: <8 µg/kg/min). During thoracotomy, 8 mL of 2% lidocaine was sprayed on the lung surface, and 2 mL of 2% lidocaine was injected adjacent to the thoracic vagal nerve for blockade. The dosage of remifentanil was reduced to 0.03–0.05 µg/kg/min after adequate blockade was achieved. After chest closure, dexmedetomidine was immediately discontinued, while propofol and remifentanil were tapered off postoperatively. Inhalational anesthetics were not used at any stage during the procedure.

Facilitating spontaneous breathing: assisted ventilation was employed to support the recovery of spontaneous breathing. If spontaneous breathing was not reestablished within 10 minutes, the doses of anesthetic and analgesic medications were reduced. Once spontaneous breathing was restored, the oxygen concentration was adjusted to 100% with an oxygen flow rate of 4–5 L/min.

Timing for LMA removal: the LMA was removed once the patient was awake and responsive, as evidenced by opening their eyes in response to stimulation. Optimal oxygenation was confirmed by maintaining peripheral oxygen saturation (SpO₂) above 95% for 5–10 minutes (or PaO₂ >85 mmHg, PaCO₂ <50 mmHg), achieving a tidal volume exceeding 6–8 mL/kg, and ensuring stable hemodynamic parameters.

Surgical procedures

Following anesthesia, all patients underwent surgery using a single-port thoracoscopic technique. The surgical incision was made at the fourth or fifth intercostal space along the anterior axillary line, approximately 3–4 cm in length. Pulmonary nodules were identified using three-dimensional reconstruction technology combined with tactile feedback. A linear cutter was employed for wedge resection of the lung nodules. During the surgery, the lung resection margin was visually confirmed to be well stapled. In cases where the stapling of the lung resection margin was unsatisfactory, reinforcement was performed using continuous suturing with Prolene thread. Mediastinal lymph node sampling was performed if needed. The surgical site was thoroughly inspected to confirm the absence of significant bleeding. Following surgery, two different chest tube drainage strategies were used.

A #22 silicone tube was inserted and soaked in water before closing the muscular layer of the incision. Simultaneously, the anesthesiologist was directed to fully inflate the lung (airway pressure 20 cmH₂O) until no air leakage was observed. If any leakage was detected, it was reinforced with a continuous mattress suture using 4-0 Prolene, and the water-seal test was repeated until no further bubbles were observed. Afterward, the silicone tube was promptly removed, and the incision was closed in layers. In this group, no chest drainage tube was placed in the end.

A 12 Fr small-bore pleural drainage catheter (disposable drainage catheter set) was inserted along the posterior axillary line through the seventh intercostal space before lung inflation. Aside from this, the air leak test procedures were the same as in the TT group, with a 12 Fr drainage tube left in place at the end. In the PT group, a prophylactic 12 Fr mini-pleural catheter was retained even in the absence of a leak, to reduce postoperative pneumothorax risk and to monitor fluid drainage.

Postoperative management

Post-operative management involved assessment of inflammatory markers on postoperative day (POD) 1, including complete blood count (CBC), C-reactive protein (CRP), and procalcitonin (PCT). Additional observations comprised body temperature, chest-drainage volume, pain level measured by the Numeric Rating Scale (NRS) (15), and cough severity assessed with the Visual Analogue Scale (VAS) (16). On POD 1, the extent of lung compression was independently evaluated on chest radiographs by an experienced thoracic radiologist, and the percentage was recorded accordingly. The timing for the drainage tube removal was determined based on the patient’s clinical status and removal criteria, including the absence of fever, dyspnea, or other symptoms, satisfactory lung expansion on chest X-ray, and chest drainage less than 100 mL/24 h. This conservative cut-off was chosen to minimize residual pleural fluid and reduce the risk of re-intervention within the tubeless pathway. Patients were followed up on PODs 7 and 30 to assess pain intensity, cough severity, and overall patient satisfaction.

Statistical analysis

Statistical analysis was performed using SPSS version 21.0 (IBM Corporation, Armonk, NY, USA) and R version 2.8.1 (R foundation for Statistical Computing, Vienna, Austria). Descriptive statistics were used to summarize the sample characteristics, with categorical variables presented as frequencies and percentages, and continuous variables reported as mean ± standard deviation (SD) or median with interquartile range (IQR). Before PSM, normally distributed continuous variables were compared with the independent-samples t-test, non‑normally distributed variables with the Mann-Whitney U test, and categorical variables with the χ² test or Fisher’s exact test. After PSM, paired comparisons were carried out using the paired t test or Wilcoxon signed‑rank test for continuous variables and the McNemar test for categorical variables. All tests were two-sided and P<0.05 was considered statistically significant.

Results

Clinicopathologic characteristics of patients

A total of 89 patients underwent tubeless single-port thoracoscopic pulmonary wedge resection at the Department of Thoracic Surgery I of Fujian Medical University Union Hospital, including 49 in the TT group, and 40 in the PT group. All surgeries were successfully completed without the need for open thoracotomy, tracheal intubation, secondary surgeries, or perioperative mortality. There were no significant differences between the two groups in terms of gender, body mass index (BMI), history of diabetes, hypertension, ASA classification, smoking status, alcohol use, previous surgeries, pulmonary function, nodule characteristics, or pathological types (P>0.05). However, On the contrary, for the aspect age, there was a significant difference (P<0.05). To reduce the potential influence of confounding factors, we conducted PSM analysis, which resulted in 34 matched pairs, namely the TT group (34/49, 69%) and the PT group (34/40, 85%). None of the clinicopathological parameters were statistically different between the two groups following PSM (P>0.05; Table 1). A summary of the patient characteristics is provided in Table 1.

Intraoperative characteristics of 34 matched patients after PSM analysis

An analysis of intraoperative parameters revealed no significant difference in intraoperative blood loss (10.00±2.13 vs. 11.47±4.85 mL, P>0.05). However, a significant difference in operative time was observed between the two groups (65.65±16.38 vs. 79.65±24.78 minutes, P<0.05). Further details are provided in Table 2.

Inflammatory status of 34 paired patients

There were no significant differences between the two groups in maximum temperature, blood routine, CRP, and PCT on POD 1 (P>0.05). The inflammatory status on POD 1 can be viewed in Table 3.

Postoperative complications of 34 paired patients

Analysis revealed a significantly higher level of pneumothorax compression in the TT group compared to the PT group on POD 1 (P<0.05). But no grade 2 or higher complications, as defined by the Common Terminology Criteria for Adverse Events (CTCAE) (17), were reported in either group. There were no significant differences between the two groups in terms of pleural effusion, subcutaneous emphysema, or other complications on POD 1 (P>0.05). The mean post‑operative length of stay was 2.65±1.15 days in the TT group and 2.68±0.73 days in the PT group (P=0.900). No patient in either group was readmitted for complications within 30 days after discharge. Chest X-rays on POD 30 showed no significant pneumothorax, pleural effusion, or complications in either group (P>0.05). Details of postoperative complications are presented in Table 4.

Postoperative symptomatology and patient satisfaction

The pain incidence and pain intensity in both the TT group and PT group follow a similar trend on PODs 1, 7, and 30. Both groups exhibit the highest pain incidence and intensity on POD 1, which decreases over time, with similar patterns observed in both groups. The cough incidence and cough intensity also show similar trends between the TT and PT groups on PODs 1, 7, and 30. Both groups experience the highest cough incidence and intensity on POD 7. No significant differences were observed in cough, pain, or severity on PODs 1, 7, and 30 between the two groups (P>0.05). Both groups reported high overall satisfaction with the surgery, with no significant variance between them (P>0.05). A detailed display of symptoms and patient satisfaction is presented in Figure 1.

Figure 1 Patient satisfaction and postoperative symptoms in 34 paired patients. (A) Time course of pain incidence in the TT and PT groups. (B) Time course of pain intensity in the TT and PT groups. (C) Time course of cough incidence in the TT and PT groups. (D) Time course of cough intensity in the TT and PT groups. (E) Time course of satisfaction in the TT and PT groups. (F) Summary table comparing statistical data on pain, cough, and satisfaction outcomes between the TT and PT groups at different postoperative days. Data are presented as n (%) or mean ± standard deviation. PT, partial tubeless; POD, postoperative day; TT, total tubeless.

Discussion

The “tubeless” technique aims to minimize trauma and pain associated with the use of tubes and to promote postoperative recovery (18). This method involves the use of a non-invasive airway device, such as a laryngeal mask, to prevent airway damage associated with traditional tracheal intubation and to minimize complications from mechanical ventilation. Key benefits include protecting lung function, enhanced postoperative recovery, and reduced costs (7,11,19). The tubeless technique has gained increasing popularity in thoracic surgery, particularly for the management of benign and malignant pulmonary nodules, due to its significant advantages. The TT approach represents an advanced form of this technique, eliminating the need for tracheal intubation, urinary catheterization, and chest tube placement. This reduction in procedural interventions minimizes trauma, improves patient comfort, and accelerates recovery. However, the successful implementation of TT techniques depends on the expertise of both anesthetic and surgical teams. And research on its safety and effectiveness remains limited. This study retrospectively evaluates the safety, outcomes, and patient satisfaction associated with TT single-port thoracoscopic pulmonary wedge resection for peripheral pulmonary nodules.

Our study found no significant difference in intraoperative blood loss between the TT and PT groups, suggesting that the tubeless technique does not increase the risk of bleeding during surgery. However, we observed a significantly shorter surgical duration in the TT group compared to the PT group. This difference may be attributed to the elimination of thoracentesis in the TT group, which avoids additional procedures like puncture drainage, puncture hemostasis, and air evacuation. These results suggest that the TT technique may have benefits in enhancing surgical efficiency and reducing procedural complexity in thoracic surgeries, while maintaining patient safety.

The study results indicate no significant difference in postoperative recovery between the two groups, with the exception of pneumothorax compression. The higher compression observed in the TT group may be attributed to the inability to fully remove intrathoracic gas during surgery through pulmonary inflation and the absence of thoracic puncture drains for gas removal. Despite the higher compression in the TT group, none of the cases reached grade 2 complications, and no additional treatments were required. This finding is consistent with Liu et al.’s report, where 27.3% of the TT group experienced postoperative pneumothorax, which resolved without intervention (12). In our study, pneumothorax was completely resolved by the 1-month follow-up. These results suggest that, while TT surgery may slightly increase pneumothorax compression, it remains a safe and manageable technique that does not significantly impact postoperative recovery. This supports the safety and broader applicability of tubeless surgery.

The demonstrated that the omission of pleural exudate drainage in the TT group did not result in pleural effusion or thoracic infection. No significant pleural effusion was observed in either group on the first POD, and chest radiographs at the 1-month follow-up revealed no pleural effusion. Additionally, no thoracic infections were reported following surgery. Postoperative body temperature and inflammation markers, including white blood cell count, CRP, and PCT, were similar between both groups. These findings suggest that single-port thoracoscopic lung wedge resection without drainage is safe and feasible, irrespective of mediastinal lymph node procedures.

Effective pain management post-surgery is essential for improving patient comfort and satisfaction during recovery. A previous study has shown that approximately 20% of patients experience severe pain in the first 24 hours after surgery (20). A previous study has suggested that omitting chest drains after thoracoscopic lung wedge resection may reduce postoperative pain for patients (21). In this study, no significant differences were observed in pain occurrence or intensity on days 1, 7, and 30 between the groups. The PT group utilizing chest tubes did not require additional pain relief, this may be attributed to the use of soft and thin thoracentesis drains.

Cough is a common complication following pulmonary surgery, with acute cough affecting 50–70% of patients and chronic cough affecting 30–40% (22-24). Studies have shown that postoperative cough is less prevalent with laryngeal mask anesthesia compared to endotracheal intubation, likely due to a reduction in inflammatory damage to the bronchial mucosa (24-26). In our study, both the TT and PT groups demonstrated low incidences and severity of postoperative cough, further supporting the advantage of avoiding tracheal intubation to minimize postoperative cough.

Regarding postoperative complications, no significant differences were observed in the incidence of CTCAE grade 1 and 2 complications between the two groups, suggesting that TT single-port thoracoscopic lung wedge resection does not increase the risk of surgical complications. However, performing a tubeless procedure requires precise intraoperative control and inspection. This includes ensuring strict hemostasis at the surgical site, reinforcing lung suture lines as necessary, achieving hemostasis at lymph node sampling sites, and conducting comprehensive air leakage tests. These measures not only help minimize blood loss and exudates at the lymph node surgical sites but also contribute to enhanced safety and improved clinical outcomes.

In this retrospective study, we assessed patient satisfaction on PODs 7 and 30 in both groups. The results demonstrated high levels of satisfaction during the early recovery phase as well as in the subsequent follow-up period. These findings suggest that the TT approach is not only safe but also highly satisfactory for patients, aligning with the principles of enhanced recovery after surgery (ERAS).

The impact of TT thoracoscopic surgery on healthcare workload is an important consideration. This strategy eliminates the need for traditional tracheal intubation and chest tubes, thereby simplifying equipment preparation and procedural steps. As a result, it reduces the workload for both anesthesiologists and surgeons. Furthermore, postoperative care is facilitated by the absence of chest tubes, which lessens the nursing responsibilities related to drain management, ultimately improving efficiency.

While this study highlights the advantages of TT surgery, there are also several limitations. Firstly, as a small-sample retrospective study, it is subject to limitations related to sample size and potential selection bias, which may affect the statistical power and generalizability of the findings. Secondly, the relatively short follow-up period restricts a comprehensive assessment of the long-term survival outcomes associated with this technique.

Conclusions

In conclusion, the study suggests that TT single-port thoracoscopic lung wedge resection for peripheral pulmonary nodules is a safe and effective option. Future research should focus on increasing sample size, extending follow-up periods, and conducting prospective randomized controlled trials to further validate the safety and long-term efficacy of this technique.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-361/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-361/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-361/prf

Funding: This work was supported by National Key Clinical Specialty of Thoracic Surgery, Fuzhou, China; Fujian Minimally Invasive Medical Center (Thoracic Surgery), China, and Startup Fund for Scientific Research, Fujian Medical University (No. 2020QH1072).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-361/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. The study was approved by the Ethics Committee of Fujian Medical University Union Hospital (No. 2024KY263), and individual consent for this retrospective analysis was waived.

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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