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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 291-300
 

The single-incision versus multiple-incision video-assisted thoracoscopic surgery in the treatment of lung cancer: A systematic review and meta-analysis


Department of Thoracic Surgery, The Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. D Lv
Department of Thoracic Surgery, The Second Affiliated Hospital, Dalian Medical University, Dalian 116023
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_229_17

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 » Abstract 

OBJECTIVE: We conducted this meta-analysis to compare the clinical outcomes of single-incision and multiple-incision video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer patients. METHODS: A literature search was conducted of the Cochrane Controlled Trials Register Databases, Medline, EMBASE, Web of Science databases, and Chinese Biomedical Literature Database. Eleven studies that compared single-incision VATS with multiple-incision VATS in the treatment of lung cancer were analyzed. Statistical analysis was carried out using RevMan 5.1 software. RESULTS: Eleven trials totaling 1273 patients were included. There were statistically significant differences in the duration of chest tube (standardized mean difference [SMD] = −0.42; 95% confidence interval [CI] [−0.78, −0.07], P < 0.02), hospital stays after surgery (SMD = −0.28; 95% CI [−0.41, −0.15], P < 0.0001), hospital stays after surgery in the subgroup analysis of lobectomy (SMD = −0.28; 95% CI [−0.42, −0.14], P < 0.0001), length of wound (P < 0.05), and pain visual analog scale (VAS) in the postoperative 1 day (SMD = −1.19; 95% CI [−1.94, −0.44], P = 0.002) between single-incision VATS group and multiple-incision VATS group. Compared with patients receiving multiple-incision VATS group, there were no statistically significant differences between the two groups with regard to the operative time (OT), blood loss (BL), rate of conversion to thoracotomy, and complication. CONCLUSION: Compared with multiple-incision VATS on the condition of same lymph nodes retrieved number, single-incision VATS reduced the length of wound, shortened the duration of chest tube, cut down the hospital stays after surgery, alleviated the pain VAS in the postoperative 1 day, did not significantly increase the OT and the BL in operation, and did not increase the rate of conversion to thoracotomy and complication.


Keywords: Lobectomy, lung cancer, multiple-incision video-assisted thoracoscopic surgery, single-incision video-assisted thoracoscopic surgery, sublobectomy


How to cite this article:
Zhang X, Yu Q, Lv D. The single-incision versus multiple-incision video-assisted thoracoscopic surgery in the treatment of lung cancer: A systematic review and meta-analysis. Indian J Cancer 2017;54:291-300

How to cite this URL:
Zhang X, Yu Q, Lv D. The single-incision versus multiple-incision video-assisted thoracoscopic surgery in the treatment of lung cancer: A systematic review and meta-analysis. Indian J Cancer [serial online] 2017 [cited 2020 Jul 6];54:291-300. Available from: http://www.indianjcancer.com/text.asp?2017/54/1/291/219570



 » Introduction Top


The incidence and mortality of lung cancer are the highest among men and the second highest among women worldwide.[1] Surgical resection is the mainstay treatment of early-stage nonsmall cell lung cancer. Over the past two decades, with the improvement of endoscopic instruments and surgical techniques, surgical management of lung cancer has been characterized by the emergence of novel minimally invasive surgical techniques. Video-assisted thoracoscopic surgery (VATS) has been shown to be associated with superior perioperative outcomes when compared to open thoracotomy, with numerous meta-analyses demonstrating reduced complication rates, shorter hospital stay, and improved long-term survival.[2],[3],[4] However, more than 50% patients treated with VATS report postoperative chest wall paresthesia related to the portal sites.[5] To decrease these complications, conventional VATS has been modified using fewer and smaller working ports for the surgical procedure.

Single-incision was first introduced as a procedure for the diagnosis of the nature of pulmonary lesions in 2005.[6] Later, uniportal thoracoscopic technique was used for more complicated thoracic procedures such as lobectomy, pneumonectomy, and bronchoplasty.[7],[8],[9],[10],[11] It has been suggested that the uniportal technique may have some benefits over multiport lobectomy. While there is a paucity of published trials comparing the two techniques, its proponents claim that it offers better ergonomics and training opportunities, with both a surgeon and an assistant surgeon on the same side of the table [12] although other approaches (such as the Copenhagen three-port anterior approach) offer similar advantages. On facing value, it may appear to be a more challenging technique than its two- to four-port counterpart. Because of having the camera and instrument inserted through the same incision, they may provide a clearer and more direct view of the operating field.[12],[13],[14]

In addition to the reduced number of surgical incisions, institutional reports have demonstrated a number of potential advantages of the uniportal VATS technique. These included a significant reduction in postoperative pain [15],[16] and paresthesia [17],[18],[19] and improved patient satisfaction.[17],[20],[21] Despite these encouraging results, comparative clinical outcomes of uniportal versus multiportal VATS remain uncertain. The present systematic review and meta-analysis aimed to compare uniportal VATS with conventional multiportal VATS in the context of lobectomy and sublobectomy for lung cancer. End-points included operative time (OT), blood loss (BL), lymph nodes retrieved (LNR), duration of chest tube, hospital stays after surgery, length of wound, pain visual analog scale (VAS) in the postoperative 1 day, as well as complication rates, and rate of conversion to open thoracotomy.


 » Patients and Methods Top


Inclusion and exclusion criteria

Inclusion criteria

  • All included trials must be human trials, in which survival data were available for patients with a diagnosis of lung cancer treated by lobectomy and sublobectomy in uniportal and multiportal VATS cohorts. Indications for surgery other than for lung malignancy, such as mediastinal tumors, primary spontaneous pneumothorax, and hyperhidrosis, were excluded (irrespective of language or publication status); multiple reports of a single study were considered as one publication, and only the most recent article was examined; abstracts or unpublished data were included only if sufficient information on interventions and outcomes was available and the final results were confirmed by contact with the first author
  • Patients were eligible for inclusion if they were 18 years of age or older, and the single-incision VATS was performed through a single incision using multiple devices through the same single skin incision
  • Trials of comparing the single-incision versus multiple-incision VATS in the treatment of lung cancer
  • In trials, at least one of the following outcomes was reported: OT, BL, LNR, duration of chest tube, hospital stays after surgery, length of wound, pain VAS in the postoperative 1 day, rate of complication, and conversion to thoracotomy. The postoperative pain was evaluated by VAS from 0 (no pain) to 10 (worst pain ever experienced)
  • Provided sufficient information to estimate odds ratio (OR) or standardized mean difference (SMD) and their 95% confidence intervals (CIs).


Exclusion criteria

  • Noncomparative studies, reviews, or meta-analyses
  • Studies in which necessary data were not provided. For overlapped studies, the most rounded study with more information was included.


Literature search

The Cochrane Central Register of Controlled Trials in the Cochrane Library, PubMed, EMBASE, Web of Science databases, and Chinese Biomedical Literature Database were searched for literature comparing the single-incision versus multiple-incision VATS in the treatment of lung cancer without language restriction. Moreover, Google Scholar and reference lists of all the included studies were searched for additional reports. Contact with the authors was initiated by e-mail or telephone if any information was not available. The search strategies used the following major terms: “Pulmonary Neoplasms OR Lung Neoplasm OR Pulmonary Neoplasm OR Lung Cancer OR Lung Cancers OR Pulmonary Cancer OR Pulmonary Cancers OR Cancer of the Lung OR Cancer of Lung” single port OR single incision OR single trocar OR uniportal.”

Data extraction and quality assessment

The search strategy described was used to obtain titles and abstracts of trials that were relevant to this review. Two reviewers independently assessed the titles and abstracts of all identified trials to confirm fulfillment of inclusion criteria; data abstraction was performed independently by two reviewers. Any difference of opinion or disagreement that arose in the course of search, data abstraction, quality assessment, or other related work between the two investigators was resolved by mutual discussions.

The quality of methodology of the included studies was assessed by the Newcastle-Ottawa Scale (NOS) recommended by the Cochrane Non-randomized Studies Methods Working Group.[22] Studies with five or more stars were defined as high-quality studies. Disagreements were resolved by referring to a third reviewer until consensus was reached. If any information was unavailable, contact with the authors was initiated through e-mail or telephone.

Statistical analysis

The statistical analysis was conducted using the Cochrane software RevMan 5.1 (Cochrane Collaboration, Software Update, Oxford, UK).[23] The OR with 95% CI for dichotomous variables and SMD with 95% CI for continuous variables were calculated using the fixed-effect model or random-effect model.[24] Heterogeneity between studies was assessed by the χ2 test with P < 0.10 used to indicate statistical significance. I2 was calculated to measure the quantity of heterogeneity, with I2 >50% indicating significant heterogeneity.[25] The meta-analysis was conducted using the fixed-effect model if there was no statistically significant heterogeneity (P ≥ 0.10, I2< 50%);

Otherwise, the possible reasons were explored or the random-effect model was used for the significant heterogeneity (P< 0.10, I2 > 50%). Sensitivity analysis was carried out by omitting poor-quality studies that have a high risk of bias. Intention-to-treat analysis was not performed because of insufficient information about loss to follow-up in treatment and control groups. The length of wound was assessed with descriptive analysis. The publication bias was analyzed using the funnel plot.[26]


 » Results Top


Description of studies

The flowchart of literature screening is presented in [Figure 1]. According to the established search strategy used, a total of 829 potentially relevant literature items were identified in the databases. After screening the titles and abstracts of the studies, 814 irrelevant studies were excluded, leaving 15 studies for further assessment. After the full-text review of the 15 studies, we excluded four of them. Therefore, 11 trials [27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37] that fulfilled the inclusion criteria were included.
Figure 1: The flowchart of literature screening

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Characteristics of included studies

The characteristics of included studies are shown in [Table 1]; most trials [30],[32],[33],[34],[35],[37] were performed in China; other trials [27],[28],[29],[31],[36] were performed in UK, Taiwan, Japan, and Spain. Both groups were well matched at baseline from the information in all of the trials.
Table 1: The characteristics of included studies

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Risk of bias in included studies

The risk of bias in the included trials is summarized in [Table 1]. All relevant studies were assessed by NOS and scored highly. Only two trials [34],[36] were randomized, one [36] of which was randomized by computer-generated numbers and the another [34] was randomized by randomized digital table; allocation concealment and blinding were not reported in any trial. Other trials were all retrospective.

Meta-analysis results

The operative time

The OT was reported in nine trials;[28],[30],[31],[32],[33],[34],[35],[36],[37] the random-effect model was used to perform meta-analysis because there was significant heterogeneity between trials (I2 = 96%, P < 0.1); the meta-analysis result of the OT showed that there was no significant difference between the two groups (SMD = 0.61; 95% CI [0.00, 1.23], P = 0.05) [Figure 2]. In the subgroup analysis of the lobectomy, the single- incision VATS prolonged the OT over multiple-incision VATS in the treatment of lung cancer (SMD = 0.82; 95% CI [0.10, 1.54], P < 0.00001) although with significant heterogeneity (I2 = 96%, P < 0.1). In the subgroup of the lobectomy and sublobectomy,[28],[30] because there was significant heterogeneity between trials (I2 = 82%, P < 0.1), the OT was assessed with descriptive analysis. Wang et al.[28] reported that the OT was 169.9 ± 39.58 min in the single-port arm and 191.2 ± 51.82 min in the multiple-port arm (P = 0.029). The single-port group has a significant shorter OT. Mu et al.[30] reported that no significant difference was found in the OT between single-port and multiple-port VATS groups (144.95 ± 65.81 min vs. 130.91 ± 46.88, P = 0.237).
Figure 2: The meta-analysis of operative time

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The blood loss

The BL was reported in six trials;[29],[30],[33],[34],[35],[37] the fixed-effect model was used to perform meta-analysis because there was no significant heterogeneity between trials (I2 = 0%, P > 0.1); the meta-analysis result of the BL showed that there was no significantly different between the two groups (SMD = 0.07; 95% CI [−0.08, 0.22], P = 0.34) [Figure 3]. In the subgroup analysis, the fixed-effect model was used to perform meta-analysis in the lobectomy group because there was no significant heterogeneity between trials (I2 = 0%, P > 0.1); the meta-analysis result of the BL showed that there was no significant difference between the two groups in the lobectomy group (SMD = 0.05; 95% CI [−0.12, 0.22], P = 0.56] so was the lobectomy and sublobectomy groups (SMD = 0.15; 95% CI [−0.17, 0.47], P = 0.35).
Figure 3: The meta-analysis of blood loss

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The lymph nodes retrieved

The LNR was reported in nine trials;[28],[29],[30],[31],[32],[33],[34],[36],[37] the fixed-effect model was used to perform meta-analysis because there was no significant heterogeneity between trials (I2 = 16%, P > 0.1); the meta-analysis result of the overall response rate showed that there was no significant difference between the two groups (SMD = 0.00; 95% CI [−0.12, 0.13], P = 0.98] [Figure 4]. In the subgroup analysis, the meta-analysis result of the LNR showed that there was no significant difference between the two groups in the lobectomy group (SMD = −0.06; 95% CI [−0.20, 0.09], P = 0.44) and the lobectomy and sublobectomy groups (SMD = 0.18; 95% CI [−0.07, 0.43], P = 0.16).
Figure 4: The meta-analysis of lymph nodes retrieved

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The duration of chest tube

The duration of chest tube was reported in five trials;[27],[31],[33],[36],[37] the random-effect model was used to perform meta-analysis because there was significant heterogeneity between trials (I2 = 72%, P < 0.1); the meta-analysis result of the duration of chest tube showed that the duration of chest tube for the single-port group was shorter than the duration of multiple-port group (SMD = −0.42; 95% CI [−0.78, −0.07], P = 0.02) [Figure 5].
Figure 5: The meta-analysis of the duration of chest tube

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The hospital stays after surgery

The hospital stays after surgery was reported in nine trials;[27],[28],[29],[31],[32],[33],[34],[36],[37] the fixed-effect model was used to perform meta-analysis because there was no significant heterogeneity between trials (I2 = 20%, P > 0.1); the meta-analysis result of the hospital stays after surgery showed that there was significant difference between the two groups (SMD = −0.28; 95% CI [−0.41, −0.15], P < 0.0001) [Figure 6]. In the subgroup analysis of the lobectomy, the single- incision VATS shortened the hospital stays after surgery over multiple-incision VATS in the treatment of lung cancer (SMD = −0.28; 95% CI [−0.42, −0.14], P < 0.0001) although with no significant heterogeneity (I2 = 39%, P > 0.1). In the subgroup analysis of the lobectomy and sublobectomy, the meta-analysis result of the hospital stays after surgery showed that there was no significant difference between the two groups (SMD = −0.27; 95% CI [−0.59, 0.05], P = 0.10).
Figure 6: The meta-analysis of hospital stays after surgery

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The length of wound

The length of wound was reported in two trials [29],[34] because there was significant heterogeneity between trials (I2 = 99%, P < 0.1); the length of wound was assessed with descriptive analysis. Shih et al.[29] reported that the length of wound was 3.71 ± 0.74 cm in the single-port arm and 4.36 ± 0.61 cm in the multiple-port arm (P< 0.001). The single-port group has a significant shorter length of wound.

Jin et al.[34] reported that the length of wound was 5.36 ± 0.22 cm in the single-port arm and 7.44 ± 0.35 cm in the multiple-port arm (P< 0.05). The single-port group has a significant shorter length of wound than the multiple-port group.

The rate of conversion to thoracotomy

Two trials [30],[32] reported the rate of conversion to thoracotomy. The fixed-effect model was used to perform meta-analysis because there was no significant heterogeneity between trials (I2 = 0%, P > 0.1); the meta-analysis result of the rate of conversion to thoracotomy showed that the single-port VATS significantly increased the rate of conversion to thoracotomy over multiple-incision VATS in the treatment of lung cancer (SMD = 0.66; 95% CI [0.11, 4.02], P = 0.65) [Figure 7].
Figure 7: The meta-analysis of rate of conversion to thoracotomy

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The pain visual analog scale in the postoperative 1 day

The pain VAS in the postoperative 1 day was reported in three trials;[33],[34],[35] the random-effect model was used to perform meta-analysis because there was significant heterogeneity between trials (I2 = 89%, P < 0.1); the meta-analysis result of the pain VAS in the postoperative 1 day showed that the single-port VATS significantly reduced the pain after surgery over multiple-incision VATS in the treatment of lung cancer (SMD = −1.19; 95% CI [−1.94, −0.44], P = 0.002) [Figure 8].
Figure 8: The meta-analysis of the pain visual analog scale in the postoperative 1 day

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The complication

The complication was reported in six trials;[30],[31],[33],[34],[36],[37] the complication in the included trials is summarized in [Table 2]. The meta-analysis result showed that single-incision VATS had not increased the complication (atelectasis, wound infection, subcutaneous emphysema, arrhythmia, pneumonia, reoperation, and air leaking) rate over multiple-incision VATS in the treatment of lung cancer.
Table 2: The meta-analysis result of the complication in included studies

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Publication bias

The publication bias of included literature was analyzed in the funnel plot; the symmetry of funnel plot is better; hence, the publication bias may be less [Figure 9].
Figure 9: Funnel plot analysis of 11 literatures

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 » Discussion Top


Lung cancer is a major cause of cancer-related mortality worldwide. Currently, the treatment of choice for lung cancer has been changed to VATS for the early treatment of lung cancer in most centers. VATS for lung cancer has rapidly spread over the last several years with the technical innovation of surgical devices worldwide. The reasons for this rapid spread may be its low invasiveness in consideration of esthetic outcomes and pain stress on the patient and health economic merits, such as shortened hospital stays. However, allodynia and hypesthesia, which have been attributed to intercostal nerve disorder, are often induced by conventional VATS and are difficult to manage following surgery, suggesting that surgery employing approaches through several intercostal regions are more stressful than expected for operators. VATS for lung cancer through an 4-cm incision only has recently been initiated in some countries.[38],[39] Thoracoscopic surgery through a single port is termed uniportal VATS or single-incision thoracoscopic surgery, and the incision size was previously reported to be 4–7 cm.

This meta-analysis was based on 11 trials that included 1273 patients. All patients in both groups were reported to be well-matched for age, sex, and type of tumor. All relevant studies were assessed by NOS and scored highly. Only two trials [34],[36] were randomized, one [36] of which was randomized by computer-generated number and the another [34] was randomized by randomized digital table; allocation concealment and blinding were not reported in any trial. It can produce selective bias, lead to unclear risk of selection bias, and cause a high risk of performance bias or detection bias. Future research should clearly spell out how to design randomized controlled trial (RCT). Although a comprehensive literature search was conducted, some published and unpublished trials might have been missed, which would lead to nonpublication bias. Publication bias might exist. No trials were multicenter; future study should pay attention to the impact of geographic differences. At the same time, we still need more high-quality, multicenter, RCTs from different countries and regions.

The meta-analysis results are as follows. In the OT, the meta-analysis result showed that there was no significant difference between the two groups (SMD = 0.61; 95% CI [0.00, 1.23], P = 0.05). In the subgroup analysis of single-incosion and multiple-incision VATS lobectomy, the songle-incision VATS prolongs the OT compared with multiple-incision VATS(SMD=0.82;95%CI[0.10,1.54], P<0.00001); in the subgroup analysis of lobectomy and sublobectomy, Wang et al.[28] reported that the OT was 169.9 ± 39.58 min in the single-port arm and 191.2 ± 51.82 min in the multiple-port arm (P = 0.029). The single-port group has a significant shorter OT. Mu et al.[30] reported that no significant difference was found in the OT between single-port and multiple-port VATS groups (144.95 ± 65.81 min vs. 130.91 ± 46.88, P = 0.237). In the BL, the meta-analysis result showed that there was no significantly different between the two groups (SMD = 0.07; 95% CI [−0.08, 0.22], P = 0.34) so were the lobectomy subgroup (SMD = 0.05; 95% CI [−0.12, 0.22], P = 0.56) and the lobectomy and sublobectomy groups (SMD = 0.15; 95% CI [−0.17, 0.47], P = 0.35). In the LNR, the meta-analysis result showed that there was no significantly different between the two groups (SMD = 0.00; 95% CI [−0.12, 0.13], P = 0.98) so were the lobectomy subgroup (SMD = −0.06; 95% CI [−0.20, 0.09], P = 0.44) and the lobectomy and sublobectomy subgroups (SMD = 0.18; 95% CI [−0.07, 0.43], P = 0.16). In the duration of chest tube, the meta-analysis result showed that the duration of chest tube for the single-port group was shorter than the duration of multiple-port group (SMD = −0.42; 95% CI [−0.78, −0.07]). In the hospital stays after surgery, the meta-analysis result of the hospital stays after surgery showed that there was significant difference between the two groups (SMD = −0.28; 95% CI [−0.41, −0.15], P < 0.0001). In the subgroup analysis of the lobectomy, the single-incision VATS shortened the hospital stays after surgery over multiple-incision VATS in the treatment of lung cancer (SMD = −0.28; 95% CI [−0.42, −0.14], P < 0.0001); in the subgroup analysis of the lobectomy and sublobectomy, the meta-analysis result of the hospital stays after surgery showed that there was no significant difference between the two groups (SMD = −0.27; 95% CI [−0.59, 0.05], P = 0.10).

The meta-analysis results of the length of wound are as follows. Shih et al.[29] reported that the length of wound was 3.71 ± 0.74 cm in the single-port arm and 4.36 ± 0.61 cm in the multiple-port arm (P< 0.001). The single-port group has a significant shorter length of wound. Jin et al.[34] reported that the length of wound was 5.36 ± 0.22 cm in the single-port arm and 7.44 ± 0.35 cm in the multiple-port arm (P< 0.05). The single-port group has a significant shorter length of wound than the multiple-port group. The meta-analysis result of the rate of conversion to thoracotomy showed that the single-port VATS significantly increased the rate of conversion to thoracotomy over multiple-incision VATS in the treatment of lung cancer (SMD = 0.66; 95% CI [0.11, 4.02], P = 0.65). The meta-analysis result of the pain VAS in the postoperative 1 day showed that the single-port VATS significantly reduced the pain after surgery over multiple-incision VATS in the treatment of lung cancer (SMD = −1.19; 95% CI [−1.94, −0.44], P = 0.002).

The meta-analysis results of complication are as follows. The single-incision VATS had not increased the complication (atelectasis [OR = 0.46; 95% CI (0.09, 2.33), P = 0.34], wound infection [OR = 0.81; 95% CI (0.22, 3.03), P = 0.75], subcutaneous emphysema [OR = 1.15; 95% CI (0.34, 3.81), P = 0.82], arrhythmia [OR = 0.74; 95% CI (0.37, 1.47), P = 0.39], pneumonia [OR = 0.73; 95% CI [0.31, 1.76], P = 0.49], reoperation [OR = 0.34; 95% CI (0.03, 3.32), P = 0.35], and air leaking [OR = 0.77; 95% CI (0.29, 2.03), P = 0.60]) rate over multiple-incision VATS group.

The OT was similar between the two groups; the early period of single-incision VATS mainly focused on minor thoracic surgeries such as sympathectomy, pleural deloculations, mediastinal biopsies, pericardial window, and lung wedge resections. In recent years, with the development and refinements in scope and instrument designs, we have seen uniportal VATS maturing and the capability of complex major lung resections. For minor thoracic surgery, most surgeons experienced in bullectomy/blebectomy and abrasion through SITS single-incision thoracic surgery showed similar OTs with multiple-incision.

It is also evident that more operating time in the early period is needed when operating a single-port VATS compared to multi-port VATS. The disadvantages of the single-port VATS are that this procedure is still technically difficult to conduct in the early learning period and might not be safe if performed by an unexperienced surgeon. The reasons included are as follows: (I) All the operating instruments and thoracoscopy went through the single port, which might interfere each other, especially when the focus located near the dorsal cavity and diaphragm; (II) single-port thoracoscopic lobectomy had a strict skill requirement of qualified camera assistant to accommodate the geometrical changes of uniportal VATS; (III) the camera assistant was supposed to know how to cooperate with the operator, how to allocate the space within the incision, and how to keep the camera stable. Hence, we believed that the operation time would be shortened with the improvement of operating instruments which can better suit single-port operation and more experience of surgeons.

Mediastinal lymph node dissection may lead to more accurate lung cancer staging and therefore influence statistical results. Patients with 15 or fewer totally lymph nodes dissected had worse survival outcomes than those with more than 15.[40] The meta-analysis result of the LNR demonstrated that the number of dissected lymph nodes in the single-incision group was same that in the multiple-incision group. With the accumulation of surgical experience, our surgical team became more familiar with mediastinal lymph node dissection, and the OT spending on mediastinal lymph node dissection would be shorter. The number of dissected lymph nodes in both groups was greater than 15 in all included trials; thus, there was no compromise when mediastinal lymph node dissection was performed in single-incision VATS.

Postoperative pain and the incidence of paresthesia may be affected by many factors. The number and the length of the incision were recognized as important factors. Single-incision VATS has only one port, the number of incisions was obviously less than that with multiple-incison VATS, and the potential intercostal nerve injury was less with one incision. Therefore, less postoperative pain and lower incidence of paresthesia might be a consequence. The postoperative pain was evaluated using the VAS. Most studies that evaluated postoperative pain at 1 day with VAS were included in our study; the meta-analysis result of the pain VAS in the postoperative one day showed that the single-port VATS significantly reduced the pain after surgery over multiple-incision VATS in the treatment of lung cancer; although it reported less pain in single-incision VATS groups, significant heterogeneity was observed in postoperative pain. Many factors may contribute to it. For example, the surgical techniques used in different centers may not be uniform. In fact, the single incision size, the type of instruments used, and the use of skin/intercostal space spreaders could be considered bias factors for the pain and paresthesia. The intersurgeon and the instrument variability should also be considered. To allow triangulation of the instruments and exposure, additional stress on the port incision, or a longer incision at the port site, might not be avoided by some surgeons. The pain from mechanical pleurodesis may also affect the patient's overall pain tolerance. In addition, different centers may use different ways to obtain adhesions. Even in this case, a different strategy could bias the analysis of pain. These factors would more or less affect the postoperative pain.

The hospital stay was shorter in the single-incision VATS group. Maybe, the length of wound was shorter in single-incision VATS, and the single-incision VATS was associated with less postoperative pain, preserving pulmonary function, and helping the patient get out of bed and do activities soon; moreover, it was beneficial for recovery. At the same time, we found that the duration of chest tube for the single-port group was shorter than the duration of multiple-port group, and we did not find that there was more complication in the single-port group. However, these parameters were hard to assess because no specific criteria were documented for chest tube removal, hospital stay, and some specific complications. It is hard to judge whether all the studies were uniform for the administration of patients, and it is not possible for different centers to manage the postoperative course with similar protocols. In fact, a different policy of chest tube management could heavily bias the results on duration of chest tube and length of stay. The meta-analysis result showed that the hospital stays after surgery in the lobectomy and sublobectomy subgroup were no significant difference between the two groups because cases of complicated subsegmental resection may have required more OT and possibly longer hospital stays due to prolonged air leaks.

Opponents of uniportal VATS have voiced concerns that this approach may be associated with longer operative duration, more BL and less LNR in operation, worse safety outcomes, and higher likelihood of conversion to open thoracotomy. However, results of the present meta-analysis have refuted these concerns, at least in the context of selected patients treated in specialized centers.

The present study had some limitations. First, we lacked RCTs. Only two trials were RCT;[34],[36] and all others were retrospective in design. There is a possibility of evident selection bias and observer bias with regard to the adoption of the operative approach. It may lead to less powerful results. To minimize patient selection bias due to the nonrandom allocation of treatment, two studies performed propensity-matched analyses to improve the matching of patients according to relevant prognostic factors.[30],[32] Second, most studies were limited to small observational studies, and the small sample size may not lead to a sound result. Third, heterogeneity was observed in some outcomes (OT, duration of chest tube, and pain VAS in the postoperative 1 day). Fourth, we did not detect publication bias; nevertheless, potential bias may exist because we did not include articles published in other databases and we did not access the articles published in languages other than English. Fifth, these findings suggested that uniportal VATS can be performed with relatively similar or improved perioperative outcomes without compromising safety or oncologic principles. However, there was a paucity of long-term clinical data and equivalent oncologic efficacy cannot be ascertained based on the existing literature. Finally, other limitations of the systematic review included the variable reporting of conversions in different studies and variable grading of postoperative morbidities. However, most studies included conversion rates (from single-port to multiportal VATS or from VATS to open thoracotomy) in their analysis of surgical outcomes. Furthermore, some studies accounted for a learning curve period by excluding the initial patients who underwent uniportal VATS from analysis to exclude the learning curve. These arbitrary exclusions may have had an impact on the surgical outcomes of the single-incision VATS treatment arm.


 » Conclusion Top


The present meta-analysis result demonstrates that single-incision VATS is a safe and efficient procedure for the treatment of lung cancer with less postoperative pain and faster recovery and does not increase significantly the OT and the BL in operation; at the same time, the number of LNR was almost the same. The rate of conversion to thoracotomy and complication is equivalent when compared with multiple-incision VATS. However, because of the limitations, heterogeneity, and bias of meta-analysis, our conclusions need to be interpreted with caution. A well-designed, prospective, multi-institutional RCT with rigorously designed methods and a longer follow-up period is required to evaluate the feasibility of single-incision VATS; at the same time, these improvements may only be minor in the clinical setting. Future studies should aim to standardize clinical outcomes with longer follow-up to assess the oncologic efficacy of the uniportal approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2]



 

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