Uniportal VATS and hybrid VATS en bloc lung and chest wall resection-report of surgical technique and own experience

Approximately 5% of all patients presenting with lung cancer show chest wall invasion. Due to difficulties in achieving complete resection, higher postoperative complication rates and generally lower survival rates of patients with these advanced tumors, lung cancer invading the chest wall was considered a relative contraindication for surgery for a long time. With the development of computed tomography (CT) scan and the possibility of evaluating surrounding tissue infiltration in the 1970s, thoracotomy with en bloc lung and chest wall resection became the traditional and potentially curative approach in lung cancer with chest wall invasion. With the evolution of video-assisted thoracoscopic surgery (VATS) in the early 1990s, thoracoscopy could be used as a complementary diagnostic tool for intraoperative assessment of resectability. Nowadays, VATS is the standard surgical approach for minimally invasive anatomic lung resection in earlystage lung cancer and its use is growing even for advanced lung cancer. After three decades of experience, minimally invasive procedures such as VATS can be used for extended resections including lung and chest wall resections and also for resections after neoadjuvant treatment. One of the least invasive approaches in thoracic surgery is the uniportal VATS (uVATS) approach, which is standardly used for anatomic lung resections in our institution. Through this single small incision, anatomic lung resection of almost any extent can be performed as well as chest wall resection. Moreover, a combination of a direct approach for chest wall resection with a VATS approach for anatomic lung resection (hybrid VATS) is becoming increasingly popular due to its affinity to conventional open resection and the variable size of the counter incision, which allows a bigger extent of chest wall resection and facilitates reconstruction. Additionally, the benefits of minimally invasive surgery can still apply to this hybrid VATS approach. So far, only small case series of minimally invasive en bloc lung and chest wall resection are available, which rarely describe the surgical technique and decision-making processes in detail. We describe our preferred technique for minimally invasive en bloc lung and chest wall resection step-by-step, including patient selection, preoperative planning, intraoperative decision-making, operative steps and potential pitfalls.