The first experience in humans in minimal thoracic invasive surgery was reported in 1910 by Jacobaeus and consisted in placing an ureteroscope into the thoracic cavity to inspect the pleura and divide the adhesions in patients with tuberculosis (1,2). Later, Jacobeus reported the first significant experience with a series of 100 patients (3). In 1992 multiportal video-assisted thoracoscopic surgery (VATS) was developed in the field of thoracic surgery and during a 20-year time-span the multiportal approach has gradually expended (1). Conventional VATS was initially performed by 3–4 ports and it has become gold standard technique for most of thoracic surgical diseases. It started to evolve from three-ports to double-port and it was in the 2000s when the uniportal technique was defined. In 2004, uniportal VATS technique was described by Rocco et al. (4), limited to diagnostic procedures and pneumothorax treatment. Nowadays, the procedure widely extended in thoracic surgery in adults. Gonzalez et al. reported in 2011 the first mayor pulmonary resection by uniportal VATS applied to a lobectomy (5). In recent years, multiple publications have confirmed that this technique is achievable for a broad variety of complex thoracic procedures such as tracheal resection and reconstruction, bronchoplastic procedures, esophagectomies, and resection of advanced lung neoplasms with satisfactory outcomes (6-10), therefore, uniportal VATS is one of the greatest advances in the history of thoracic surgery in the last 10 years (1).
Single port technique has demonstrated clear advantages in adult population about mortality, morbidity and pain control compared to thoracotomy, with a better cosmetic result if compared to multiportal approach (11-14). However, the application of this technique in paediatric population is not widespread and reports in literature are limited.
Paediatric thoracic surgery includes a high variety of congenital, infectious and tumoral pathologies. Classic approach of these paediatric diseases was open thoracotomy. In the last decades, minimal invasive procedures have demonstrated being feasible and safe in multiple pathologies. In the 1970s and 1980s the first significant thoracoscopic experience in children was reported for biopsy procedures and empyema debridement (15). Since 1990s, due to technological revolution and expansion of laparoscopic surgery in adults, more advanced diagnostic and therapeutic procedures have been performed in children (16,17). Currently a large variety of indications are recognized for thoracoscopic operations in children (18). Thoracoscopic paediatric procedures varies from decortication for empyema and biopsy of intrathoracic lesions up to advanced procedures, such as repair of oesophageal atresia and resection of mediastinal masses (19).
However, uniportal approach is not extended in paediatric surgery and there are only a few cases reported in literature with satisfactory outcomes.
We present advantages and indications of uniportal VATS in children as well as a review of reported cases. We emphasize in the reproducibility and safety of single incision VATS in paediatric population in our clinical experience.
Technical considerations and limitations of uniportal VATS in paediatric population
A good understanding of anatomical characteristics in children are mandatory for a safe surgical procedure.
The morphology of the paediatric chest changes with age (Figure 1). In neonates, the thorax has a trapezoidal morphology and the ribs are horizontal with greater length in anteroposterior diameter. In the older children, the thorax is more rectangular and the vertical diameter is greater, resembling the adult’s chest (20). In addition, the child’s thorax is more flexible than in adults (21).
The diaphragm in children is positioned at a “higher level” than in adults. For this reason, diaphragm position should be considered when incisions are planned for thoracic surgery (22).
Working space is limited for VATS in children and the lung dimensions have to be taken into consideration as an issue when performing this technique. Lungs and airway in children are not fully developed at birth. The structural integrity of the airway improves after birth as the flexible cartilage of the infant’s larynx and trachea becomes more rigid (23). Single lung ventilation is more difficult in infant or small children if compared with adults. A double lumen-tube is too prominent for patients with less than 30 kg, however different options as bronchial blocker or selective intubation of the contralateral bronchus can be achieved (24). Ventilator-dependent patients and those with significant cardiac defects can tolerate a limited period of partial lung collapse necessary to perform most of thoracic procedures (25-27). Although it is mandatory to manage the retention of CO2 by modifying ventilatory parameters, a paediatric anaesthetist has to be able to perform this kind of surgeries.
Indications and limitations of uniportal VATS in paediatric surgery
Currently in thoracic surgery, thoracoscopy is the minimally invasive technique applied in most part of thoracic surgical interventions (26-28). The lack of evolution of uniportal VATS in pediatrics is explained by a low incidence of pathologies that require thoracic surgeries (29).
Several authors have reported their experience with uniportal VATS approach in different thoracic diseases in paediatric age with satisfactory outcomes (Table 1). In 2012, Aragón et al. reported the first surgical intervention by uniportal VATS in a 11-year-old paediatric patient (30). They performed a middle right lobectomy and lower right lobe resection without technical difficulties neither short-term complications.
Most part of uniportal VATS procedures performed in paediatric surgery are minor procedures (26,27). Thoracic sympathectomy due to hyperhidrosis, pneumothorax, empyema decortication, biopsies and resection of lung nodes have been described in the literature.
Fernandez-Pineda et al.  reported the first experience with this technique in a 14-year-old oncological patient with an infectious pulmonary nodule caused by Histoplasma capsulatum and resected by uniportal approach (31). Several years later they described their experience with a review of 11 patients with satisfactory outcomes (34).
A standardized use of uniportal VATS in paediatric patients for complex thoracic surgeries like mayor pulmonary resections or neonatal surgery is difficult to achieve. Nevertheless, uniportal VATS is safe and feasible if is performed by surgeons with experience in minimally invasive surgery (35,36). Gonzalez-Rivas et al. reported in 2016 a case of a 10-year-old patient with an endobronchial tumour. A right upper sleeve lobectomy and a tracheoplasty, and associated mediastinal lymphadenectomy was performed (29). According to our knowledge this is the most complex surgery performed by means of uniportal VATS in a paediatric population.
Another great challenge for the paediatric thoracic surgeon is neonatal pathology. As we discussed, the reduced space in these patients and anatomical characteristics in this age make more difficult the development of minimally invasive techniques.
Thoracoscopy has been limited in low weight patients due to both the reduced space in thorax and the absence of specific material for this age (18,22). Because of these difficulties, Rothenburg et al. reported 26 lobectomies for benign diseases where he determined the need of specific instruments adapted to paediatric patients (23). By the other hand, a few authors have reported their experiences with uniportal VATS in newborn patients. Our group previously reported  the experience with a low weight premature who was treated with uniportal approach with satisfactory outcomes (33). A low birth weight neonate male of 1,040 grams born at 28 weeks with an esophageal atresia type C was presented. The patient underwent surgery by tracheo-esophagic fistula closure and esophagic anastomosis by uniportal VATS at 24 hours of life. Surgery developed without incidents and with excellent outcomes. Up to this point, four more cases with same pathology have been operated with the same technique by our group with better results than with conventional surgery.
Thoracic pathology in paediatric patient can be classified in three groups: infectious or acute pathology, congenital pathology and oncological pathology. Uniportal VATS seams a good alternative with multiples advantages to treat the most part of diseases of these three groups (Table 2). In adults, oncological indications are the most frequent for uniportal VATS surgery. By contrast, in paediatric patients oncological disease is less frequent because lung or pleural tumours are uncommon (29). Thoracic surgery is carried out in paediatric patients predominantly with benign indications. Infectious disease represents the most frequent cause of thoracic surgery in this age, followed by congenital pathology where neonatal pulmonary malformations are remarkable.
In the last years, several variations to improve the original technique have been reported both for adults and children surgeries (34,37-42). Fernandez-Pineda et al.  reported the approach by single port but with access through two intercostal spaces (camera trough upper intercostal space and instrumentation trough lower intercostal space) (34). With this approach, they conserved functional and aesthetic advantages of uniportal VATS, however camera mobility was not conditioned by instrumental mobility. Subxiphoid or infrasternal approach has also been reported by other authors as a new alternative to traditional uniportal VATS intercostal access (38,40-42). Through this incision thymectomies, lobectomies, even bipleural approaches have been reported. More and more paediatric patients can benefit from this advance.
Advantages of uniportal approach in pediatric thoracic surgery
Although there are few reports in literature about uniportal VATS in paediatric age, several studies have already demonstrated unquestionable improvements that uniportal surgery offers in adult population (44).
The single incision approach generates less pain postoperative than conventional thoracotomy or multiport access (47). This improve early mobilization and early respiratory rehabilitation. Chest tube can be removed earlier after surgery. In addition, the decrease of postoperative pain accelerates extubation in the paediatric patients allowing to introduce fast track protocols in thoracic paediatric surgery with reduced hospitalization time (48,49).
The main disadvantage of open thoracic surgery in the paediatric patient is morbidity associated with thoracotomy. The risk of developing deformities like scoliosis, scapular winging and muscle weakness after thoracic surgery is high, because of the development of musculoskeletal and nervous structures, that is achieved during childhood, especially during the first two years of life (50-53). However, no thoracic deformities after uniportal VATS have been reported. Any damage to the innervation of serratus anterior muscle and no need costal resection have been described (51). In addition, aesthetic advantages of a single 2.5–5 cm incision are obvious compared to open thoracotomy or multiportal approach.
One of the main disadvantages or thoracoscopy in paediatric surgery is the lack of space in thoracic cavity. This, together with the low volume of thoracic pathology at this age, generates a longer learning curve and reduces the application of this technique to highly complex surgical teams.
However, more and more authors defend that uniportal VATS as an effective and reproducible method in most of thoracic surgeries. This technique offers a similar vision to open surgery because of direct thoracic access unlike thoracoscopy that offers an angular vision (42,54). In addition, in uniportal VATS, all surgeons are looking at the same screen in front of them (Figure 2). This position improves the surgical posture and facilitates manual movements because hand-eye coordination improves (44,55,56). The direct vision makes manual movements similar to open surgery and learning curve is shorter that in multiportal approach (43,44,46,57).
The multiple advantages described for uniportal VATS have determined an increase of use in paediatric surgery in the last years. This approach allows a direct access to thoracic cavity with less morbidity than open surgery. In addition, its direct vision offers less technical difficulty than multiportal thoracoscopic surgery. Despite of this, the learning curve for the application of this technique in children is higher than in adults due to the lower incidence of thoracic pathology and the size of the thoracic cavity of the children. Consequently, only in high complex services of paediatric surgery this technique should be used.
One of the greatest challenges for paediatric surgeons has always been to adapt adult surgical techniques to paediatric and neonatal surgery. Due to the current advances in uniportal VATS, more and more paediatric pathologies are approached by this technique and more paediatric patients can benefit from its advantages.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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Cite this article as: Casal-Beloy I, Míguez Fortes L, Gómez Tellado MA, González-Rivas D. Thinking uniportal in pediatric thoracic surgery. Pediatr Med 2019;2:13.