Surgical technique of uniportal VATS for pneumothorax: the lateral and subxiphoid approaches

Uniportal video-assisted thoracoscopic surgery (VATS) is considered the optimal access method for pneumothorax surgery. Currently, uniportal VATS is used worldwide because it requires an incision in only one intercostal space, which simplifies postoperative pain control, due to reduced acute pain, and the incidence of chronic pain is also potentially lower. It is essential to tailor the surgical technique to each individual case, ensure reliable closure of air leaks, and minimize the risk of recurrence. This article introduces the practical aspects of uniportal VATS for pneumothorax, focusing on the pitfalls. Moreover, detailed methodologies for the lateral intercostal approach for uniportal lung wedge resection, and subxiphoid uniportal bilateral lung resection are provided. During lung resection (bullectomy) for primary spontaneous pneumothorax, the reinforcement-equipped cartridge is used to prevent recurrence, and an oxidized regenerated cellulose sheet is applied as a covering material. In the case of secondary spontaneous pneumothorax, in addition to the oxidized regenerated cellulose sheet, the most appropriate reinforcement material is applied after the surgical procedure. During lung resection, the planned resection line should be marked as needed to clearly define the resection area and ensure no residual lesions are left behind. When partial lung resection is challenging, or in cases of air leakage from a pedunculated bulla, suture closure or ligation may be required. The most common approaches include direct suturing of the damaged pleura or ligating the base of the bulla. Given the condition of the underlying lung, reinforcement with covering materials is essential in all cases. This article includes numerous visual materials, including figures and videos, to illustrate the uniportal VATS technique for pneumothorax. Irrespective of the technique used, it is necessary for clinicians to undergo training, refine their skills, and select the appropriate instruments.