The subcutaneous tunneled periareolar approach in lung resection performed through uniportal video-assisted thoracic surgery

Introduction

With the implementation of low-dose computed tomography screening, the detection rate of pulmonary nodules has increased annually. Surgical interventions for pulmonary nodules include lobectomy, segmentectomy, and wedge resection. Nowadays, thoracic surgery is evolving towards more minimally invasive techniques. Recent advancements in video-assisted thoracoscopic surgery (VATS) have focused on reducing the number of ports. Uniportal video-assisted thoracoscopic surgery (Uni-VATS) has demonstrated benefits including shorter hospital stays, less postoperative pain, and improved cosmetic results (1). Typically, the approach for traditional Uni-VATS lobectomy is placed in the fourth or fifth intercostal spaces, between the anterior axillary line and midaxillary line, with an incision size of 3–5 cm. However, unsightly scars on the lateral chest wall often cause anxiety in an increasing number of patients who undergo Uni-VATS. Due to the inevitable postoperative pain, potent analgesics are still required. From both an aesthetic standpoint and the patient’s perspective, there is an urgent need for improvement. The traditional periareolar approach, introduced to thoracic surgery for thoracoscopic lobectomy by double-port incisions, improves both access and cosmetic outcomes (2,3). However, the double-port incisions do not significantly improve pain and aesthetic compared to traditional methods. To achieve superior aesthetic and less painful outcomes, we first report the subcutaneous tunneled periareolar approach (STPA) in lung resection performed through Uni-VATS in patients with peripheral pulmonary nodules. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1613/rc).

Preoperative preparations and requirements

From December 2023 through to June 2024, we performed the STPA Uni-VATS for five patients with peripheral pulmonary nodules (Table 1). Inclusion criteria: (I) solid nodules or solid components with a diameter greater than eight mm, and subsolid nodules with a diameter of six mm or greater; (II) the patient is capable of understanding and participating in pain assessment using a Visual Analog Scale (VAS); (III) the lesion does not extend to surrounding organs or major blood vessels. This surgical approach was approved by the Ethics Committee of the West China Hospital of Sichuan University (No. 20241589) and informed consent was taken from all the patients. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Step-by-step description

The patient is positioned in a full lateral decubitus posture with a flexed operating table. The surgeon stands in front of the patient and performs the operation, while the assistant stands on the opposite side of the surgeon. Surgery is conducted using both intravenous and inhalation anesthesia with double-lumen tracheal intubation for selective one-lung ventilation. Following successful anesthesia and intubation, the patient undergoes Uni-VATS lung resection.

Body markings are applied to the edge of the areolar-skin junction and the lateral border to delineate the approach sites (Figure 1A). The incision size is 1/3 to 1/2 of the areola’s circumference. An auxiliary retractor is used to hook the lateral border of the incision, ensuring clear exposure of the subcutaneous tissue (Figure 1B). Intraoperatively, electrocautery is used to dissect the subcutaneous tissue down to the fatty layer above the breast tissue. Dissection continues within the fatty layer between the subcutaneous fat and the breast tissue, extending toward the anterior axillary line. A subcutaneous tunnel leading to the chest wall was established without damaging the lactiferous ducts or breast tissue. It is imperative that this dissection is conducted with meticulous precision to create an expansive tunnel, facilitating subsequent dissection of the pulmonary hilum and minimizing the risk of hematoma formation within the chest wall or intrapleural space. A 3 to 5 cm incision is made in the fourth or fifth intercostal space at the anterior axillary line, followed by the application of disposable incision protectors. A 10-mm 30° thoracoscope and accompanying instruments are utilized through the incision during the entire surgery (Figure 1C). For detailed instructions on establishing the subcutaneous tunnel, refer to Video 1. The surgical technique follows the principles established in the Uni-VATS lung resection (4). Postoperatively, a small incision (about 1 cm) is made on the lateral chest wall to place a single 20-F chest drain. The tube is positioned in same intercostal space as in the previous surgical procedure, without the need for an additional intercostal incision. 2-0 absorbable sutures are used for the muscle layer, while 5-0 absorbable sutures are used for intermittent suturing of the subcutaneous and skin layers (Figure 1D). A chest band is used to compress the tunnel wound, preventing effusion formation.

Figure 1 The STPA in lung resection through Uni-VATS. (A) Body marking was made at the areola-skin junction; (B) an auxiliary retractor was used to hook the lateral border of the incision; (C) the operative port established through the periareolar approach provided ample space and a clear visual field; (D) condition of the periareolar incision after skin sutured. STPA, subcutaneous tunneled periareolar approach; Uni-VATS, uniportal video-assisted thoracic surgery.

In the event of an intraoperative emergency, such as pulmonary artery injury, requiring urgent conversion to open thoracotomy, our management protocol is consistent with traditional Uni-VATS. A skin incision is made at the fourth or fifth intercostal space along the anterior axillary line through the previously established intercostal access. Depending on the location of bleeding, the incision is extended along the intercostal space to create either a posterior-lateral or anterior thoracotomy (without extending into the periareolar incision). A retractor is used to widen the intercostal space and expose the operative field. Depending on the clinical situation, the lung, hilum, or mediastinal structures are exposed for procedures such as vascular repair or lobectomy.

Postoperative considerations and tasks

Postoperatively, patients were monitored in the public ward and received mechanical ventilation. Once the haemodynamics and spontaneous breathing were stabilized, mechanical ventilation was terminated. Postoperative care and discharge were managed according to the same criteria. Criteria for chest tube removal were no air leakage, drainage fluid of 300 mL/day or less, and complete lung expansion. After discharge, the patient was followed up for 1–3 months.

Tips and pearls

When establishing the subcutaneous tunnel, attention should be paid to the boundaries of the breast tissue. Dissection should be performed within the fatty layer between the subcutaneous tissue and the breast tissue to avoid damaging the breast tissue. Due to the unique nature of the STPA, complications such as fat liquefaction and tunnel seroma may occur. Postoperatively, it is necessary to apply compressive dressings to the subcutaneous tunnel.

Discussion

In this study, our surgical outcomes are satisfactory, five patients underwent pulmonary nodule resection, including three cases of wedge resections, one case of lobectomy, and one case of segmentectomy. The median operative time was 70 minutes (range, 60–110 minutes), and median blood loss was 15 mL (range, 10–20 mL). The median chest tube duration was 1 day (range, 0–2 days). The median postoperative hospital stay was 2 days (range,1–3 days). VAS pain scores were used to evaluate postoperative pain (Table 1). There were no postoperative complications or perioperative deaths. Postoperative wound healing was satisfactory (Figure 2). We first reported STPA Uni-VATS for pulmonary nodule resection, including lobectomy, segmentectomy, and wedge resection. According to the experience of the surgeon, this novel approach is suitable for most Uni-VATS lung resections under similar conditions.

Figure 2 Postoperative wounds after the STPA Uni-VATS. Only two small scars were left on the lateral side of the chest: one unobvious scar below the armpit and one almost invisible scar around the areola. (A) The surgical scar in a female patient one month postoperatively; (B,C) the surgical scar in two female patients two months postoperatively; (D) the surgical scar in a male patient two months postoperatively. STPA, subcutaneous tunneled periareolar approach; Uni-VATS, uniportal video-assisted thoracic surgery.

Visible postoperative scars are an increasingly important concern for patients undergoing thoracic surgery. Due to the unique anatomical location, deeper coloration, and pronounced wrinkles of the areola, which effectively conceal wound-healing scars, the periareolar approach has been reported in breast surgery, thyroid surgery, and cardiac surgery (5-7). Thoracic surgeons have employed this approach for thoracentesis, sympathectomies, mediastinoscopies, and pectus correction (8-10). In 2014, Cerezo Madueño et al. firstly reported satisfactory access and aesthetic outcomes of a double-port VATS lobectomy through the periareolar approach (2). In 2024, Mao et al. introduced a right middle lobectomy technique using a periareolar approach. Compared to Cerezo Madueño’s approach, they employed a subcutaneous tunneling technique that effectively preserves breast tissue, thereby making this approach more suitable for female patients (3). Our technique builds upon this approach by utilizing the STPA Uni-VATS method, with the goal of achieving a scarless and painless outcome.

Due to variations in areolar skin mobility stemming from differences in breast tissue size and pectoral muscle content, the incision length for male and female patients with smaller breasts typically approximates 1/2 of the areola’s circumference. In contrast, for female patients with larger breasts, the incision length ranges between 1/3 and 1/2 of the areola’s circumference. It is recommended to avoid incisions exceeding 1/2 of the areola’s circumference to preserve its blood supply. Our perioperative data showed minimal postoperative drainage, with some patients not requiring chest tube placement, superior to other minimally invasive approaches. Furthermore, this surgical technique minimizes postoperative scar visibility and reduces feelings of inferiority in patients (10).

Regarding the gender selection of surgical patients, based on our clinical experience, the STPA is applicable to all genders, with its success largely dependent on the mobility of the breast and anterior chest wall skin. A higher breast fat content facilitates the creation of the subcutaneous tunnel. For thin male patients, this technique is also applicable. Anatomical dissection through a periareolar incision risks damaging breast tissue, making it particularly suitable for married, parous women who have no further reproductive needs.

The STPA, similar to the traditional uniportal thoracoscopic approach, utilizes the same intercostal space to access the thoracic cavity. Theoretically, both techniques carry a potential risk of intercostal nerve injury, which may lead to postoperative pain. In this follow-up, the patient reported mild pain, which may be attributed to our use of the breast skin’s high mobility to perform a tension-free suture. The periareolar approach may risk capsular contracture due to unintended damage to the breast parenchyma or the nipple secretion extravasation (6,8,10). We employed meticulous sharp dissection using electrocautery and ensured rigorous hemostasis under direct visualization. Strict bleeding control is imperative to attenuate postoperative inflammation and reduce the incidence of subsequent capsular contracture. Diminished nipple sensation is a potential complication of this approach (5,7). The crucial fourth intercostal nerve is carefully preserved during thoracic entry by closely adhering to the superior rib edge and meticulously dissecting the intercostal tissues to prevent nerve damage. Under our careful surgical procedures, none of the patients experienced postoperative complications like infections, loss of nipple sensation, or capsular contracture.

While we believe the STPA offers cosmetic advantages over conventional VATS, it does have certain limitations. First, establishing a subcutaneous tunnel from the areola to the target intercostal spaces is time-consuming, taking approximately 20–30 minutes, and requires a high level of technical proficiency. With increased experience, the duration of surgery can typically be maintained at around 30 minutes. Second, the most likely explanation for the mild postoperative pain is that this is a retrospective study with a small sample size, which may have led selection bias. Third, this study included only five patients (four females and one male), and the ideal patient population for this technique still requires validation through more cases. Additionally, more research is still needed to conduct prospective, multi-center, large-sample randomized controlled trials to systematically evaluate the safety, efficacy, and applicability of this surgical technique.

Conclusions

In conclusion, the STPA for Uni-VATS is a safe and reliable method for resection of pulmonary nodules, offering significant advantages such as diminished postoperative pain and easily concealable postoperative scarring beneath the areola. This technique is particularly beneficial for married, parous women. We recommend considering this method for patients with aesthetic concerns (for both gender) and for women without reproductive needs. We recommend that this technology applies to all lung resection, including wedge resection, lobectomy, segmentectomy, and others, aligning with contemporary principles of minimally invasive surgery and the rapid recovery, and thus warrants broader adoption and dissemination.

Acknowledgments

We sincerely appreciate the invaluable technical guidance provided by Professor Bin Zheng and his team at the Department of Thoracic Surgery from Fujian Medical University Union Hospital.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1613/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1613/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-24-1613/coif). D.T. serves as an unpaid editorial board member of Journal of Thoracic Disease from March 2025 to February 2026. The authors have no other 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 (as revised in 2013). This surgical approach was approved by the Ethics Committee of the West China Hospital of Sichuan University (No. 20241589) and informed consent was taken from all the patients.

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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