Efficacy and safety of single-, two-, and three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MIN Weirun ^1,2,3 , CAO Wei ¹ , LI Haochi ¹ , ZHANG Jinlong ¹ ,  DONG Xinchun ^2,3 , LUO Xindong ¹ , HE Shengliang ^2,3 ,  GOU Yunjiu ^2,3

1. Department of Cardiothoracic Surgery, Gansu Provincial Hospital of Traditional Chinese Medicine (The First Affiliated Hospital of Gansu University of Chinese Medicine), Lanzhou, 730050, P. R. China;
2. Gansu Provincial Thoracic Disease Clinical Medical Research Center, Lanzhou, 730000, P. R. China;
3. First Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, 730000, P. R. China;

Corresponding?author：

DONG Xinchun, Email: 3050319523@qq.com; GOU Yunjiu, Email: gouyunjiu@163.com

Keywords：

Pneumothorax; spontaneous pneumothorax; single-port thoracoscopic surgery; two-port video-assisted thoracoscopic surgery; three-port video-assisted thoracoscopic surgery; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202402034

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Objective To systematically evaluate the efficacy and safety of video-assisted thoracoscopic surgery (VATS) with different numbers of ports in the treatment of spontaneous pneumothorax. Methods We conducted a comprehensive search of CNKI, PubMed, The Cochrane Library, Web of Science, EMbase, Wanfang Data, and the Chinese Medical Journal Full-text Database for clinical controlled trials on VATS with different port numbers for spontaneous pneumothorax, from their inception to March 2023. Two researchers independently screened the literature and assessed its quality.The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of cohort and case-control studies, and the Cochrane risk-of-bias tool was used to evaluate randomized controlled trials (RCT). Meta-analysis was performed using RevMan 5.4.1 software. Results A total of 107 studies were included, comprising 35 RCT, 2 cohort studies, and 70 case-control studies. All cohort and case-control studies included in the analysis had NOS scores≥7. The meta-analysis revealed that compared to two-port VATS (2P-VATS) and three-port VATS (3P-VATS), single-port thoracoscopic surgery (SPTS) was associated with less intraoperative blood loss (SMD=–1.58, 95%CI: –1.93 to –1.22, P<0.001; and SMD=–1.59, 95%CI: –2.03 to –1.14, P<0.001, respectively), shorter postoperative hospital stay (SMD=–1.05, 95%CI: –1.29 to –0.82, P<0.001; and SMD=–1.08, 95%CI: –1.39 to –0.77, P<0.001), shorter duration of postoperative chest tube drainage (SMD=–0.75, 95%CI: –1.00 to –0.50, P<0.001; and SMD=–1.23, 95%CI: –1.72 to –0.75, P<0.001), fewer postoperative complications (OR=0.34, 95%CI: 0.26 to 0.45, P<0.001; and OR=0.47, 95%CI: 0.33 to 0.68, P<0.001), and lower pain scores at 24, 48, and 72 hours after surgery (P<0.05). The operative time for SPTS was shorter than that for 2P-VATS (SMD=–0.53, 95%CI: –0.90 to –0.16, P=0.005) but showed no significant difference compared to 3P-VATS (P=0.21). When comparing 2P-VATS with 3P-VATS, 2P-VATS demonstrated less intraoperative blood loss (SMD=–1.02, 95%CI: –1.81 to –0.22, P=0.01), shorter postoperative hospital stay (SMD=–0.59, 95%CI: –1.11 to –0.06, P=0.03), shorter duration of chest tube drainage (SMD=–0.46, 95%CI: –0.85 to –0.08, P=0.02), fewer postoperative complications (OR=0.36, 95%CI: 0.22 to 0.59, P<0.001), and lower pain scores at 24, 48, and 72 hours after surgery (P≤0.05). Conclusion Both SPTS and 2P-VATS are effective and safe surgical options for spontaneous pneumothorax, deserving further promotion and application in clinical practice. However, due to limitations in the quantity and quality of the included studies, more large-sample, high-quality research is needed to validate these findings.

Citation： MIN Weirun, CAO Wei, LI Haochi, ZHANG Jinlong, DONG Xinchun, LUO Xindong, HE Shengliang, GOU Yunjiu. Efficacy and safety of single-, two-, and three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: A systematic review and meta-analysis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(3): 461-467. doi: 10.7507/1007-4848.202402034 Copy

1.	Fiorelli A, Cascone R, Carlucci A, et al. Uniportal thoracoscopic surgical management using a suture traction for primary pneumothorax. Asian Cardiovasc Thorac Ann, 2021, 29(3): 195-202.
2.	喬貴賓, 陳剛. 自發性氣胸的處理: 廣東胸外科行業共識(2016年版). 中國胸心血管外科臨床雜志, 2017, 24(1): 6-15.Qiao GB, Chen G. Management of spontaneous pneumothorax: Guangdong thoracic surgery industry consensus (2016 edition). Chin J Thorac Cardiovasc Surg, 2017, 24(1): 6-15.
3.	Bintcliffe O, Maskell N. Spontaneous pneumothorax. BMJ, 2014, 348: g2928.
4.	Levi JF, Kleinmann P, Riquet M, et al. Percutaneous parietal pleurectomy for recurrent spontaneous pneumothorax. Lancet, 1990, 336(8730): 1577-1578.
5.	Fung S, Jaber K, Kivilis M, et al. Postoperative pain and clinical outcome following two- and three-port video-assisted thoracoscopic surgery for secondary spontaneous pneumothorax. J Clin Med, 2022, 11(5): 1404.
6.	王永平, 王輝, 鄭翔, 等. 自發性氣胸單孔胸腔鏡手術后肺部并發癥預測模型的構建. 腹腔鏡外科雜志, 2024, 29(5): 321-325.Wang YP, Wang H, Zheng X. Prediction model construction of pulmonary complicationsafter single port thoracoscopic spontaneous pneumothorax operation. J Laparosc Surg, 2024, 29(5): 321-325.
7.	Berlanga LA, Gigirey O. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single-incision laparoscopic surgery port: a feasible and safe procedure. Surg Endosc, 2011, 25(6): 2044-2047.
8.	Salati M, Brunelli A, Xiumè F, et al. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach. Interact Cardiovasc Thorac Surg, 2008, 7(1): 63-66.
9.	Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg, 2005, 28(1): 43-46.
10.	Migliore M. Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease. J Thorac Cardiovasc Surg, 2003, 126(5): 1618-1623.
11.	Wang P, Zhang L, Zheng H, et al. Comparison of single-port vs. two-port VATS technique for primary spontaneous pneumothorax. Minim Invasive Ther Allied Technol, 2022, 31(3): 462-467.
12.	Fung S, Ashmawy H, Safi S, et al. Two-port versus three-port video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: feasibility, postoperative outcome and long-term recurrence rates. BMC Surg, 2021, 21(1): 428.
13.	由兆磊, 李德生, 居來提·艾尼瓦爾, 等. 單孔胸腔鏡與傳統三孔腔鏡手術治療自發性氣胸療效比較的Meta分析. 中國循證醫學雜志, 2015, 15(8): 945-950.You ZL, Li DS, Julaiti A, et al. Single-incision video-assisted thoracic surgery versus conventional three-port surgery for primary spontaneous pneumothorax: a meta-analysis. Chin J Evid Based Med, 2015, 15(8): 945-950.
14.	李華偉, 張興博, 趙寧, 等. 胸腔鏡手術下治療原發性自發性氣胸的臨床療效及復發因素分析. 中國胸心血管外科臨床雜志, 2016, 23(7): 692-697.Li HW, Zhang XB, Zhao N, et al. Efficacy and risk factors of recurrence after video-assisted thoracoscopic surgery for primary spontaneous pneumothorax. Chin J Thorac Cardiovasc Surg, 2016, 23(7): 692-697.
15.	Porcel JM, Lee P. Thoracoscopy for spontaneous pneumothorax. J Clin Med, 2021, 10(17): 3835.
16.	Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
17.	Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med, 2009, 6(7): e1000097.
18.	張健. 單孔法、雙孔法及三孔法胸腔鏡手術治療青年人自發性氣胸的臨床療效對比. 心理月刊, 2020, 15(13): 148.Zhang J. Comparative clinical efficacy of single-port, double-port, and triple-port thoracoscopic surgery in treating spontaneous pneumothorax in young adults. Psychological Monthly, 2020, 15(13): 148.
19.	章少欽. 單孔與三孔電視胸腔鏡手術在自發性氣胸中的應用效果比較. 浙江創傷外科, 2020, 25(5): 834-836.Zhang SQ. Comparison of the application effect of single-port and three-port video-assisted thoracoscopic surgery in spontaneous pneumothorax. Zhejiang J Trauma Surg, 2020, 25(5): 834-836.
20.	Tsuboshima K, Wakahara T, Matoba Y, et al. Single-incision thoracoscopic surgery using a chest wall pulley for lung excision in patients with primary spontaneous pneumothorax. Surg Today, 2015, 45(5): 595-599.
21.	Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg, 2013, 8: 153.
22.	李金友, 孫振宇, 顧敏威. 單孔法、雙孔法及三孔法胸腔鏡手術治療青年人自發性氣胸的對比研究. 實用醫學雜志, 2017, 33(1): 99-101.Li JY, Sun ZY, Gu MW. A comparative study of three-port, double port and uniportal VATS for young people with spontaneous pneumothorax. J Pract Med, 2017, 33(1): 99-101.
23.	周小江, 徐剛. 單孔和雙孔胸腔鏡手術治療自發性氣胸的對比研究. 貴州醫藥, 2016, 40(4): 391-392.Zhou XJ, Xu G. A comparative study of single-port and two-port thoracoscopic surgery in the treatment of spontaneous pneumothorax. Guizhou Med J, 2016, 40(4): 391-392.
24.	Yang Y, Dong J, Huang Y. Single-incision versus conventional three-port video-assisted surgery in the treatment of pneumothorax: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg, 2016, 23(5): 722-728.
25.	Qin SL, Huang JB, Yang YL, et al. Uniportal versus three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: a meta-analysis. J Thorac Dis, 2015, 7(12): 2274-2287.
26.	Ocakcioglu I, Alpay L, Demir M, et al. Is single port enough in minimally surgery for pneumothorax? Surg Endosc, 2016, 30(1): 59-64.
27.	Song IH, Lee SY, Lee SJ. Can single-incision thoracoscopic surgery using a wound protector be used as a first-line approach for the surgical treatment of primary spontaneous pneumothorax? A comparison with three-port video-assisted thoracoscopic surgery. Gen Thorac Cardiovasc Surg, 2015, 63(5): 284-289.
28.	古衛權, 楊劼, 葉國麟, 等. 單操作孔電視胸腔鏡手術治療自發性氣胸. 中華胸心血管外科雜志, 2012, 28(3): 176.Gu WQ, Yang J, Ye GL, et al. Single-port video-assisted thoracoscopic surgery for spontaneous pneumothorax. Chin J Thorac Cardiovasc Surg, 2012, 28(3): 176.

1. Fiorelli A, Cascone R, Carlucci A, et al. Uniportal thoracoscopic surgical management using a suture traction for primary pneumothorax. Asian Cardiovasc Thorac Ann, 2021, 29(3): 195-202.
2. 喬貴賓, 陳剛. 自發性氣胸的處理: 廣東胸外科行業共識(2016年版). 中國胸心血管外科臨床雜志, 2017, 24(1): 6-15.Qiao GB, Chen G. Management of spontaneous pneumothorax: Guangdong thoracic surgery industry consensus (2016 edition). Chin J Thorac Cardiovasc Surg, 2017, 24(1): 6-15.
3. Bintcliffe O, Maskell N. Spontaneous pneumothorax. BMJ, 2014, 348: g2928.
4. Levi JF, Kleinmann P, Riquet M, et al. Percutaneous parietal pleurectomy for recurrent spontaneous pneumothorax. Lancet, 1990, 336(8730): 1577-1578.
5. Fung S, Jaber K, Kivilis M, et al. Postoperative pain and clinical outcome following two- and three-port video-assisted thoracoscopic surgery for secondary spontaneous pneumothorax. J Clin Med, 2022, 11(5): 1404.
6. 王永平, 王輝, 鄭翔, 等. 自發性氣胸單孔胸腔鏡手術后肺部并發癥預測模型的構建. 腹腔鏡外科雜志, 2024, 29(5): 321-325.Wang YP, Wang H, Zheng X. Prediction model construction of pulmonary complicationsafter single port thoracoscopic spontaneous pneumothorax operation. J Laparosc Surg, 2024, 29(5): 321-325.
7. Berlanga LA, Gigirey O. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single-incision laparoscopic surgery port: a feasible and safe procedure. Surg Endosc, 2011, 25(6): 2044-2047.
8. Salati M, Brunelli A, Xiumè F, et al. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach. Interact Cardiovasc Thorac Surg, 2008, 7(1): 63-66.
9. Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg, 2005, 28(1): 43-46.
10. Migliore M. Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease. J Thorac Cardiovasc Surg, 2003, 126(5): 1618-1623.
11. Wang P, Zhang L, Zheng H, et al. Comparison of single-port vs. two-port VATS technique for primary spontaneous pneumothorax. Minim Invasive Ther Allied Technol, 2022, 31(3): 462-467.
12. Fung S, Ashmawy H, Safi S, et al. Two-port versus three-port video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: feasibility, postoperative outcome and long-term recurrence rates. BMC Surg, 2021, 21(1): 428.
13. 由兆磊, 李德生, 居來提·艾尼瓦爾, 等. 單孔胸腔鏡與傳統三孔腔鏡手術治療自發性氣胸療效比較的Meta分析. 中國循證醫學雜志, 2015, 15(8): 945-950.You ZL, Li DS, Julaiti A, et al. Single-incision video-assisted thoracic surgery versus conventional three-port surgery for primary spontaneous pneumothorax: a meta-analysis. Chin J Evid Based Med, 2015, 15(8): 945-950.
14. 李華偉, 張興博, 趙寧, 等. 胸腔鏡手術下治療原發性自發性氣胸的臨床療效及復發因素分析. 中國胸心血管外科臨床雜志, 2016, 23(7): 692-697.Li HW, Zhang XB, Zhao N, et al. Efficacy and risk factors of recurrence after video-assisted thoracoscopic surgery for primary spontaneous pneumothorax. Chin J Thorac Cardiovasc Surg, 2016, 23(7): 692-697.
15. Porcel JM, Lee P. Thoracoscopy for spontaneous pneumothorax. J Clin Med, 2021, 10(17): 3835.
16. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
17. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med, 2009, 6(7): e1000097.
18. 張健. 單孔法、雙孔法及三孔法胸腔鏡手術治療青年人自發性氣胸的臨床療效對比. 心理月刊, 2020, 15(13): 148.Zhang J. Comparative clinical efficacy of single-port, double-port, and triple-port thoracoscopic surgery in treating spontaneous pneumothorax in young adults. Psychological Monthly, 2020, 15(13): 148.
19. 章少欽. 單孔與三孔電視胸腔鏡手術在自發性氣胸中的應用效果比較. 浙江創傷外科, 2020, 25(5): 834-836.Zhang SQ. Comparison of the application effect of single-port and three-port video-assisted thoracoscopic surgery in spontaneous pneumothorax. Zhejiang J Trauma Surg, 2020, 25(5): 834-836.
20. Tsuboshima K, Wakahara T, Matoba Y, et al. Single-incision thoracoscopic surgery using a chest wall pulley for lung excision in patients with primary spontaneous pneumothorax. Surg Today, 2015, 45(5): 595-599.
21. Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg, 2013, 8: 153.
22. 李金友, 孫振宇, 顧敏威. 單孔法、雙孔法及三孔法胸腔鏡手術治療青年人自發性氣胸的對比研究. 實用醫學雜志, 2017, 33(1): 99-101.Li JY, Sun ZY, Gu MW. A comparative study of three-port, double port and uniportal VATS for young people with spontaneous pneumothorax. J Pract Med, 2017, 33(1): 99-101.
23. 周小江, 徐剛. 單孔和雙孔胸腔鏡手術治療自發性氣胸的對比研究. 貴州醫藥, 2016, 40(4): 391-392.Zhou XJ, Xu G. A comparative study of single-port and two-port thoracoscopic surgery in the treatment of spontaneous pneumothorax. Guizhou Med J, 2016, 40(4): 391-392.
24. Yang Y, Dong J, Huang Y. Single-incision versus conventional three-port video-assisted surgery in the treatment of pneumothorax: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg, 2016, 23(5): 722-728.
25. Qin SL, Huang JB, Yang YL, et al. Uniportal versus three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: a meta-analysis. J Thorac Dis, 2015, 7(12): 2274-2287.
26. Ocakcioglu I, Alpay L, Demir M, et al. Is single port enough in minimally surgery for pneumothorax? Surg Endosc, 2016, 30(1): 59-64.
27. Song IH, Lee SY, Lee SJ. Can single-incision thoracoscopic surgery using a wound protector be used as a first-line approach for the surgical treatment of primary spontaneous pneumothorax? A comparison with three-port video-assisted thoracoscopic surgery. Gen Thorac Cardiovasc Surg, 2015, 63(5): 284-289.
28. 古衛權, 楊劼, 葉國麟, 等. 單操作孔電視胸腔鏡手術治療自發性氣胸. 中華胸心血管外科雜志, 2012, 28(3): 176.Gu WQ, Yang J, Ye GL, et al. Single-port video-assisted thoracoscopic surgery for spontaneous pneumothorax. Chin J Thorac Cardiovasc Surg, 2012, 28(3): 176.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Efficacy and safety of single-, two-, and three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: A systematic review and meta-analysis

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