In recent years, with the continuous improvement of equipment and continuous progress of technology, the application range of uniportal VATS is gradually expanding. Gonzalez-rivas reported uniportal sublobectomy for VATS in 2011. Subsequently, uniportal thoracoscopy was comprehensively developed and applied in lobectomy and pulmonary segmentectomy, mediastinal tumor and benign esophageal disease, etc., which proved that it had significant effect in improving postoperative incision pain and numbness of patients, and had the same surgical effect and prognosis as porous thoracoscopy and open surgery [1–6].
Compared with the above advantages, a shortcoming of small uniportal thoracoscopic surgery is that the thoracic drainage tube is directly placed in the incision. This may cause difficulty in sutures, muscles may not be easily sealed, and sutures may be sutured to the chest tube. The placement of the drainage tube may also face problems, such as position shifting during suture, peri-tube crevasse causing exudation or air into the pleural cavity, the chest tube compressing the intercostal nerve and increasing pain,etc. Placing a traditional 34F thick chest tube through a small single hole is more likely to cause the above problems. Postoperative incision exudation may have a higher incidence than three-hole thoracoscopy, and it is more likely to cause scarring.
In order to solve the above problems as much as possible and guarantee the minimally invasive advantages of uniportal thoracoscope, we have made some improvements and innovations.
The first is the choice of chest tube. When using the 34F thick chest tube, we found that it is difficult to close the muscle layer sutured after the incision is placed in the chest tube, and there is an unsealed gap between the thick chest tube and the upper and lower mating muscles, which leads to incision leakage. Compression of the intercostal nerve by the thick tube can still cause obvious pain after surgery; wound healing after thick chest tube is easy to form large scars, which reduces the aesthetic advantages of uni-VATS; the wall of the thick chest tube is hard and Poor plasticity, often difficult to adjust to the ideal drainage angle. After continuous exploration, we tried the 16F gastric tube as a closed drainage tube of the chest tube, which has a small diameter and a soft wall, which is easier to shape and has a better drainage effect. It is more suitable for uni-VATS .
However, with the accumulation of cases, we found that there were still a small number of patients with wound exudation and rare cases of air leakage. We found that the current chest tube is thin and smooth ,which may be the cause of the leak. In view of this characteristic, we further improved the incision suture and catheterization methods, and adopted the "Z" shape catheterization method to effectively control the occurrence of leakage. The exit and inlet of the chest tube in the "Z" shape catheterization method are on different planes, which significantly reduces the probability of seepage and air leakage around the chest tube. Son et al. applied similar principles to improve the treatment of incision and chest tube: The skin and subcutaneous tissue were incised at the lower margin of the 6th costal region. When it came to the muscular layer, the subcutaneous tissue and chest wall muscle were separated by stealth upward, and the protective device was placed in the incision. After the operation, a mosquito vascular clamp was used to place the drainage tube through the skin incision through the chest wall muscle to the intercostal incision.
We have tried this method before, but for the single hole of 3 cm, the incision is too small and narrow, and the exposure of the surgical field is poor. Therefore, combining with our own surgical methods, we created the original "Z" shaped catheterization method. Its characteristics are :(1) while ensuring the drainage effect, the chest tube is thinner and softer, reducing the impact on the incision, and easier to indwelling and extraction; (2) the thoracic canal runs stealthily between subcutaneous tissue and muscle tissue, so it is difficult for water leakage, air leakage, thoracic tube prolapse and other events to occur, and the incision is easier to heal; (3) suture the muscle first and then place the tube to make the suture operation easier, especially the first stitch at both ends; After the thoracic tube was identified by thoracoscopy, it was knotted directly without any more operation, which reduced the influence on the thoracic tube, and the thoracic tube was not easy to shift. It will not be sewn to the chest tube; (4) the skin and subcutaneous tissues were sutured by vertical mattress valgus to make the tissues more cohesive and the incision more beautiful.
In conclusion, the optimized suture and catheterization techniques have been proved to be easy to operate and effective by a large number of practices.