The most common approach for complex procedures such as bronchial, vascular and carinal resections is still the open surgery. The technical difficulties, the steep learning curve and the concerns about performing an oncologic and safe reconstruction in advanced cases, are the main reasons for the low adoption of VATS for sleeve resections.

The sleeve procedures offer benefits of parenchymal preservation and oncologic safety even for patients who can tolerate more extensive resections. However sleeve resections are technically more demanding than pneumonectomy and are more prone to particular complications.

Sleeve procedures are contraindicated when local extension of the tumor requires pneumonectomy as it occurs with involvement of interlobar fissure. The surgeon must identify and avoid reconstructive techniques with risk to develop a severe complication. If the bronchial reconstruction is likely to fail because of the excessive tension or poor anastomotic technique, the result should be carefully evaluated at the end of the procedure, leading to an extensive resection in case of doubt.

Thanks to the recent improvements in thoracoscopy, sleeve resections can be performed without performing thoracotomies. During the last years, experience gained through VATS techniques, design improvements of the surgical instruments and improvements of high definition cameras have greatly contributed to advances in VATS. Most of the authors use 3-4 incisions for thoracoscopic sleeve procedures. However these surgical techniques can be performed through a single 4 cm incision approach by skilled uniportal VATS surgeons. Because its approach is less invasive, the uniportal approach for VATS has emerged as a novel technique, applicable to all large spectrum of pulmonary resections including complex cases and broncho vascular reconstructive procedures.

We consider very important the proper placement of the incision, especially when it is performed by uniportal VATS. Performing the incision at the fourth or fifth intercostal space, more anterior (anterior axillary line), helps to use the needle holder parallel to the hilum, making suturing similar to an open anterior thoracotomy. Using a wound protector is helpful because fatty tissue could interfere with the suture threads.Our preferred method for the anastomosis is to use a running absorbable suture for membranous and cartilaginous portion (Polydioxanone, PDS 3/0) or by using only one prolene 3/0 suture with 2 needles. The running suture makes the thread movement easier, as well as the tying, specially when we use only one suture with 2 needles. We always test the anastomosis under saline water and we only place one chest tube at the end of the operation. For tracheal or carinal resections and reconstructions, the high frequency ventilation jet is our preferred method for ventilation to avoid interference with the anastomosis of the lateral portion of trachea and bronchus.

Our team has the largest experience in the world performing bronchovascular reconstructions by minimally invasive surgery to avoid pneumonectomy in case of central tumors suitable for this technique. We performed the first Uniportal VATS bronchial sleeve lobectomy in the world in 2012 (published in JTCVS), the first VATS double sleeve lobectomy in 2014 (published in ACTS), and first carinal sleeve resection in 2016 (published in JTD)

Our Bibliography for complex tumors and sleeve resections

-Gonzalez-Rivas D, Garcia A, Chen C, Yang Y, Jiang L, Sekhniaidze D et  al. Technical aspects of uniportal video-assisted thoracoscopic doublesleeve bronchovascular resections. Eur J Cardiothorac Surg 2020; doi:10.1093/ejcts/ezaa037.

-Gonzalez-Rivas D, Fernandez R, Fieira E, et al. Uniportal video-assisted thoracoscopic bronchial sleeve lobectomy: first report. J Thorac Cardiovasc Surg. 2013 Jun;145(6):1676-7.

-Gonzalez-Rivas D, Yang Y, Stupnik T, Sekhniaidze D, et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections. Eur J Cardiothorac Surg 2016;49:i6–i16.

-Gonzalez-Rivas et al. Technical aspects of Uniportal video-assisted thoracoscopic sleeve resections: Where are the limits? JTCVS techniques 2020. In press

-Gonzalez-Rivas D, Soultanis KM, Garcia A, Yang K, Qing Y, Yie L, Zhao G, Chen A, Huang Y, Li G, Jiang G. Uniportal video-assisted thoracoscopic lung sparing tracheo- bronchial and carinal sleeve resections. J Thorac Dis 2020. doi: 10.21037/jtd.2020.04.05

-Gonzalez-Rivas D, Delgado M, Fieira E, et al. Left lower sleeve lobectomy by uniportal video-assisted thoracoscopic approach.Interact Cardiovasc Thorac Surg. 2014 Feb;18(2):237-9

-Gonzalez-Rivas D, Yang Y, Sekhniaidze D, et al. Uniportal video-assisted thoracoscopic bronchoplastic and carinal sleeve procedures. J Thorac Dis 2016;8(Suppl 2):S210-S222.

-Guido-Guerrero W, Gonzalez- Rivas D. Uniportal video-assisted thoracoscopic surgery pneumonectomy: an update in the evolution of this minimally invasive approach. Shanghai Chest 2020;4:21.

-Soultanis KM, Gonzalez-Rivas D. Uniportal video-assisted sleeve resections: how to deal with specific challenges. J Thorac Dis 2019. doi: 10.21037/ jtd.2019.06.52

-Hengrui Liang, Diego Gonzalez-Rivas (cofirst Author), Yanran Zhou, Jun Liu , Xi Wu , Jianxing He, Shuben Li M.D Non-intubated Anesthesia for Tracheal/Carinal Resection and Reconstruction. Thorac Surg Clinics. Feb 2020. Vol 30, Issue 1, pg 83-90

-Soultanis KM, Chen Chao M, Chen J, Wu L, Yang C, Gonzalez-Rivas D et  al. Technique and outcomes of 79 consecutive uniportal video-assisted sleeve lobectomies. Eur J Cardiothorac Surg 2019; doi:10.1093/ejcts/ezz162.

-Guido-Guerrero W, Bolaños-Cubillo A, Gonzalez-Rivas D. Single-port video-assisted thoracic surgery (VATS)-advanced procedures & update. J Thoracic Dis 2018;10(Suppl 14):S1652-S1661
-Jiang L, Liu J, Gonzalez-Rivas D, Shargall Y, Kolb M, Shao W, Dong Q, Liang L, He J. Thoracoscopic Surgery for Tracheal and Carinal Resection and Reconstruction under Spontaneous Ventilation. J Thorac Cardiovasc Surg. 2018 Jun;155(6):2746-2754
-Complex uniportal video-assisted thoracoscopic sleeve lobectomy during live surgery broadcasting. Yang Yang · William Guido Guerrero · Iskander Algitmi · Diego Gonzalez-Rivas. Journal of Thoracic Disease 8(6):1345-1348

-Sekhniaidze D, Gonzalez-Rivas D. Uniportal video- assisted thoracoscopic sleeve resection. Ann Cardiothorac Surg 2016;5:145-6.

-Uniportal video-assisted thoracoscopic lobectomy with en bloc chest wall resection Gonzalez-Rivas D, Boxiong Xie, Yang Yang, Gening Jiang. The Journal of Visualized Surgery 2015 ,1:7

-Thoracoscopic double sleeve lobectomy in 13 patients: a series report from multi-centers. Huang J, Li J, Qiu Y, Xu X, Sekhniaidze D, Chen H, Gonzalez-Rivas D, He J.J Thorac Dis. 2015 May;7(5):834-42.

-Uniportal video-assisted thoracoscopic right upper sleeve lobectomy. Guido W, Gonzalez-Rivas D, Duang L, Yang Y, Lee W, Jiang G. J Vis Surg 2015; 1:10

-Uniportal video-assisted thoracoscopic bronchial sleeve lobectomy: First report. Gonzalez-Rivas D, Fernandez R, Fieira E, Rellan L. J Thorac Cardiovasc Surg. 2013 Jun;145(6):1676-7

Gonzalez-Rivas D, Fieira E, Delgado M, de la Torre M, Fernández L, Fernandez R. -Uniportal video-assisted thoracoscopic sleeve lobectomy and other complex resections.  J Thorac Dis 2014;6(S6):674-681

-Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer? Gonzalez-Rivas et al. J Thorac Dis 2014;6(6):641-648.

-Bronchovascular right upper lobe reconstruction by uniportal video-assisted thoracoscopic surgery. Gonzalez-Rivas et al. J Thorac Dis 2014;6(6):861-863

-Double sleeve uniportal video-assisted thoracoscopic lobectomy for non-small cell lung cancer. Gonzalez-Rivas D et al. Annals of cardiothoracic surgery. Masters of cardiothoracic surgery section. April 2014. doi: 10.3978/j.issn.2225-319X.2014.03.13

-Left lower lobe sleeve lobectomy by uniportal video-assisted thoracoscopic approach. Gonzalez-Rivas D, Delgado M, Fieira E, Pato O Interact Cardiovasc Thorac Surg. 2014 Feb;18(2):237-9

-Uniportal Video-assisted thoracoscopic pneumonectomy. Gonzalez-Rivas et al. J Thorac Dis. 2013 August; 5(Suppl 3): S246–S252. doi: 10.3978/j.issn.2072-1439.2013.07.44

-Single-port video-assisted thoracoscopic lobectomy with pulmonary artery reconstruction. Gonzalez-Rivas D, Delgado M, Fieira E, Mendez L. Interact Cardiovasc Thorac Surg. 2013 Aug 9. [Epub ahead of print]

-Single-incision thoracoscopic right upper lobectomy with chest wall resection by posterior approach. Gonzalez-Rivas D, Fernandez R, Fieira E, Mendez L. Innovations . 2013 Jan-Feb;8(1):70-2. doi: 10.1097/IMI.0b013e3182852005.

-Single-incision video-assisted thoracoscopic right pneumonectomy. Gonzalez-Rivas D, de la Torre M, Fernandez R, Garcia J. Surg Endosc. 2012;26(7):2078-9

-Video-Assisted Thoracoscopic Lobectomy Of An Upper Lobe Tumor With Vascular Involvement. Diego Gonzalez , Ricardo Fernandez, Eva Fieira, Mercedes De La Torre, Jose Garcia, Maria Delgado. Innovations Vol 6.Number 3. May/jun 2011.

-Video-Assisted Thoracoscopic Lobectomy Of A Superior Sulcus Tumor. Diego Gonzalez , Mercedes De La Torre, Ricardo Fernandez, Maria Delgado, Marina Paradela, Jose Garcia InnovationsVol 6.Number 3. May/jun 2011.