An alternative chest tube placement after uniportal video-assisted thoracic surgery

The field of video-assisted thoracic surgery (VATS) is still in continuous development. The advent of uniportal technique has added a versatile tool for thoracic surgeons; currently, it is used for minor thoracic procedures including lung wedge resections up to complex thoracic operations (i.e., chest wall resection, pneumonectomy or bronchoplastic resection) demonstrating the versatile nature of this technique (1). The main potential advantage claimed by surgeons who support uniportal VATS is the lower post-operative pain if compared with multiport VATS as well as reduction of morbidity, faster recovery and shorter hospital stay. Nevertheless, a widespread adoption of uniportal VATS is hampered by some limitations due to a single thoracoscopic access, such as a lack of exposure and crowding of instrumentations making surgical manoeuvring more technically demanding (2). We tried and tested the uniportal approach and found it very convincing. We believe that the benefits to the patient are far in excess the challenges for the surgeon; however, these challenges become more affordable after an appropriate learning curve. In our opinion, what we consider a problem in se is the correct placement of the pleural drainage at the end of the procedure. The chest tube should be inserted to reach the thoracic apex in order to drain air. At the same time, it should prevent the collection of effusions in the pleural cavity (3). The uniportal technique contemplates placing the tube through the thoracotomy, using the same via, from skin to pleura (4). We are not confident with this approach for several reasons: firstly, the suboptimal angulation between the chest wall and the pleural cavity could create tube kinking, wrong positioning, loss of suction and residual idro-pneumothorax. Secondly, the passage of the chest tube directly through the mini-invasive access could impair the correct reconstruction of muscular plane and may compromise the subcutaneous and skin suturing with post-operative unaesthetic results. Finally, a patent passage between pleural cavity and subcutaneous tissue is a potential source of air/fluid collection and infection. We propose a feasible, safety and easy-performing technique for chest tube placement after uniportal VATS procedures that may prevent all potential drawbacks described above.