Single port video-assisted thoracic surgery: advancing scope technology

We read with interest the article by Yang et al. [1] on the use of a flexible video endoscope for single-port video-assisted thoracic surgery (VATS) right upper lobectomy to improve space available for the operating surgeon and reduce fencing. The video endoscope their group described has great visual versatility, and can be utilized for multiple indications beyond those of thoracic surgery, for example as an aortic angioscope during aortic dissection surgery [2]. We have had the experience of using both the flexible video endoscope and another type of wide-angled rigid thoracoscope (Endocameleon, Karl Storz, Germany) for single-port VATS lung resections [3]. The wide-angled rigid thoracoscope allows vision between 0° and 120° through a rotating prism mechanism at the tip that provides variable views. One disadvantage of the flexible video-endoscope design is that the curved scope tip can occasionally interfere with the instruments in the operating field, which may inadvertently damage the soft scope tip. Furthermore, unlike conventional thoracoscopes, the handle design for angle adjustment is more akin to a bronchoscope, which may require a period of familiarization. The rigid 120° thoracoscope also has its shortcomings, being slightly wider than the flexible video endoscope for comparable visual resolution, hence occupying a larger proportion of the single incision. Although the choice of thoracoscope may play a role in facilitating single-port VATS lobectomy, to reduce instrument fencing and improve operating space during single-port VATS, the proper positioning of the instrument within the single incision and the maximal utilization of the 3D pleural cavity space with multiple angulated instruments may be more important [4]. Over the years, scopes have become narrower, and have more visual versatility and clarity to allow smaller surgical incisions and reduce interference with other instruments. The holy grail of scope design is a camera system that does not need to occupy the surgical incision, does not interfere with other instruments and provides multidirectional views. In the future, multiple small ‘remote’ wireless video cameras can be placed into the thoracic cavity, which are then held against the inner chest cavity by strong magnets, also known as magnetic anchoring and guidance systems (MAGS) camera, providing the ideal solution [5]. Although initially developed for single-incision laparoscopic surgery of the abdomen, ironically, MAGS may be more suited for surgery within the chest cavity because the rigidity of the chest wall provides more stability and less movement for magnetic anchorage when compared with the abdomen. We eagerly await further development and refinement of this technology.