Clinical outcomes of artificial pneumothorax-assisted three-port VATS versus conventional two-port and uniportal VATS in mediastinal tumor resection_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Xingchi , LIU Dazhi , TENG Hong , XU Wei , WU Qiong , ZHANG Xiaoxiao ,  XU Shiguang

Department of Thoracic Surgery, General Hospital of Northern Theater Command, Shenyang, 110011, P. R. China;

Corresponding?author：

XU Shiguang, Email: 13309884079@163.com

Keywords：

Artificial pneumothorax; three-port thoracoscopic surgery; two-port thoracoscopic surgery; uniportal thoracoscopic surgery; mediastinal tumors

DOI：

10.7507/1007-4848.202604033

Video：

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Objective To compare the differences in clinical outcomes of artificial pneumothorax-assisted three-port, two-port, and uniportal thoracoscopic surgeries for the treatment of mediastinal tumors. Methods A retrospective analysis was conducted on clinical data of patients who underwent mediastinal tumor surgery in the Department of Thoracic Surgery at the General Hospital of Northern Theater Command from September 2020 to November 2024. Patients were divided into three groups based on the surgical approach: an artificial pneumothorax-assisted three-port thoracoscopy group, a two-port thoracoscopy group, and a uniportal thoracoscopy group. Perioperative data including operation time, intraoperative blood loss, postoperative hospital stay, chest tube indwelling rate, postoperative drainage volume, chest tube duration, and postoperative pain visual analogue scale (VAS) scores were compared among the three groups. Results A total of 308 patients were included. The artificial pneumothorax-assisted three-port thoracoscopy group comprised 75 patients [29 males, 46 females; median age: 57 (IQR: 47, 62) years]. The two-port thoracoscopy group included 127 patients [49 males, 78 females; median age: 52 (IQR: 43, 60) years], and the uniportal thoracoscopy group included 106 patients [48 males, 58 females; median age: 52.5 (IQR: 42, 62) years]. The operation time in the artificial pneumothorax-assisted three-port thoracoscopy group [74 (62, 99) min] was significantly shorter than that in the two-port thoracoscopy group [91 (71, 118) min] and the uniportal thoracoscopy group [90 (68, 110) min] (P<0.05). Intraoperative blood loss [30 (20, 75) mL] was also significantly less than that in the two-port thoracoscopy group [55 (30, 105) mL] and the uniportal thoracoscopy group [55 (30, 100) mL] (P<0.05). Regarding postoperative recovery, the length of hospital stay in the artificial pneumothorax-assisted three-port thoracoscopy group [2 (2, 4) days] was shorter than that in the two-port thoracoscopy group [3 (2, 5) days] and the uniportal thoracoscopy group [3 (3, 6) days] (P<0.05). On postoperative day 1 (POD1), the VAS score in the artificial pneumothorax-assisted three-port thoracoscopy group [4 (3, 4) points] was lower than that in the two-port thoracoscopy group [4 (3, 5) points] and the uniportal thoracoscopy group [4 (3, 5) points] (P<0.05). The chest tube indwelling rate (52.0%) was significantly lower than that in the two-port thoracoscopy group (92.9%) and the uniportal thoracoscopy group (84.9%) (P<0.05). POD1 chest tube drainage volume [80 (0, 105) mL] and chest tube duration [1 (0, 2) days] were also significantly less or shorter than those in the two-port thoracoscopy group [110 (80, 150) mL, 2 (1, 2) days] and the uniportal thoracoscopy group [100 (50, 150) mL, 1 (1, 2) days], respectively (P<0.05). Conclusion All three different surgical approaches for mediastinal tumors are safe and effective. Artificial pneumothorax-assisted three-port thoracoscopic surgery demonstrates comprehensive advantages in terms of operation time, intraoperative blood loss, and postoperative recovery.

1.	王晨晗, 王鋒, 胡文滕, 等. 達芬奇機器人與胸腔鏡經劍突下入路治療前縱隔腫瘤臨床療效的回顧性隊列研究[J]. 中國胸心血管外科臨床雜志, 2024, 31(2): 236-242.Wang CH, Wang F, Hu WT, et al. Clinical efficacy of da Vinci robotic and thoracoscopic transxiphoid approach in the treatment of anterior mediastinal tumors: a retrospective cohort study[J]. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(2): 236-242.
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3.	Roviaro GC, Rebuffat C, Varoli F, et al. Videoendoscopic thoracic surgery[J]. Int Surg, 1993, 78(1): 4-9.
4.	De Giacomo T, Diso D, Anile M, et al. Thoracoscopic resection of mediastinal bronchogenic cysts in adults[J]. Eur J Cardiothorac Surg, 2009, 36(2): 357-359.
5.	Gonzalez-Rivas D, de la Torre M, Fernandez R, et al. Single-port video-assisted thoracoscopic left upper lobectomy[J]. Interact Cardiovasc Thorac Surg, 2011, 13(5): 539-541.
6.	Ke L, Liu J, Shuai Y, et al. Intercostal approach VATS is feasible for large-sized anterior mediastinal tumors[J]. Sci Rep, 2024, 14(1): 17227.
7.	Suzuki K, Oizumi H, Suzuki J, et al. Thoracoscopic lateral basal segmentectomy based on dissection along the intersegmental veins[J]. Ann Thorac Surg, 2023, 115(3): e83-e85.
8.	Hu CG, Zheng K, Liu GH, et al. Effectiveness and postoperative pain level of single-port versus two-port thoracoscopic lobectomy for lung cancer: a retrospective cohort study[J]. Gen Thorac Cardiovasc Surg, 2021, 69(2): 318-325.
9.	Kikunaga S, Fujimori S, Suzuki S, et al. The strategy and outcome of three-port thoracoscopic surgery for synchronous and metachronous multiple lung cancer[J]. Kyobu Geka, 2021, 74(1): 33-39.
10.	Li X, Guo S, Liang W, et al. Tubeless anesthesia improves postoperative recovery following VATS wedge resection: a prospective randomized controlled study[J]. BMC Surg, 2025, 26(1): 54.
11.	包明勝, 陳健, 謝厚寵, 等. 喉罩聯合支氣管封堵器單肺通氣在胸腔鏡下肺部分切除術中應用效果及對患者應激反應及蘇醒質量影響[J]. 臨床軍醫雜志, 2025, 53(3): 277-279.Bao MS, Chen J, Xie HC, et al. Application effect of laryngeal mask combined with bronchial blocker for one-lung ventilation in video-assisted thoracoscopic partial pulmonary resection and its influence on stress response and recovery quality[J]. Clin J Med Off, 2025, 53(3): 277-279.
12.	Hong Z, Sheng Y, Cui B, et al. A comparative study of robotic surgery and thoracoscopic surgery for mediastinal cysts[J]. BMC Surg, 2023, 23(1): 102.
13.	Zhang M, Wang H, Pan X, et al. Thoracoscopic resection of bulky thymoma assisted with artificial pneumothorax: a report of 19 consecutive cases[J]. Oncol Lett, 2016, 11(5): 3061-3063.
14.	Tanigawa Y, Nakamura K, Yamashita T, et al. Changes in respiratory mechanics of artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position[J]. Sci Rep, 2021, 11(1): 6978.
15.	Zhao L, Zhang X, Gao C, et al. A comparison of bronchial blocker under artificial pneumothorax and double-lumen endobronchial tube for lung isolation in thoracoscopic enucleation of oesophageal leiomyoma[J]. J Cardiothorac Surg, 2021, 16(1): 322.
16.	Xiao H, Zhang H, Pan J, et al. Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study[J]. BMC Pulm Med, 2024, 24(1): 165.
17.	Li L, Zhao L, He J, et al. Application of right bronchial occlusion under artificial pneumothorax in the thoracic phase of minimally invasive McKeown esophagectomy[J]. Ann Thorac Cardiovasc Surg, 2021, 27(6): 339-345.
18.	Choque-Velasquez J, Resendiz-Nieves JC, Rezai Jahromi B, et al. The microsurgical management of benign pineal cysts: Helsinki experience in 60 cases[J]. Surg Neurol Int, 2019, 10: 103.
19.	Li Z, Yang L, Yang H, et al. Comparison of superselective renal artery embolization versus retroperitoneal laparoscopic partial nephrectomy in ruptured hemorrhagic renal angiomyolipoma: a single-center study[J]. Diseases, 2024, 12(9): 218.
20.	李華艷, 李東澤, 周子涵, 等. 改良胸腔引流管理方案在胸腔鏡肺切除患者快速康復中的應用[J]. 中國微創外科雜志, 2025, 25(4): 222-226.Li HY, Li DZ, Zhou ZH, et al. Application of a modified chest drainage management protocol in rapid recovery of patients undergoing thoracoscopic pulmonary resection[J]. Chin J Minim Invas Surg, 2025, 25(4): 222-226.
21.	You D, Qin L, Li K, et al. A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty[J]. Korean J Pain, 2021, 34(3): 271-287.
22.	Zhao G, Jiang X, Wang F, et al. Lobectomy with high-position single-intercostal two-port video-assisted thoracoscope for non-small cell lung cancer is a safe and effective surgical procedure[J]. J Thorac Dis, 2020, 12(12): 7346-7354.
23.	Yan B, Yao X, Zhao Z, et al. Learning curve for double-port video-assisted thoracoscopic lung segmentectomy: a propensity score matching study[J]. J Cardiothorac Surg, 2024, 19(1): 681.
24.	Israfilov N, Y?ld?r?m Gü?lü ?, Karada? Erko? S, et al. Retrospective analysis of factors affecting chronic postoperative pain after thoracotomy: single center experience[J]. Turk J Anaesthesiol Reanim, 2023, 51(3): 235-242.
25.	Rivera-Ramos H, Larra?aga-Altuna L, García-Olivera M, et al. Incidence and risk factors of chronic post-thoracic surgery pain: a retrospective study[J]. Rev Esp Anestesiol Reanim (Engl Ed), 2025, 72(1): 101644.
26.	Geraci TC, Sorensen A, James L, et al. Use of a novel digital drainage system after pulmonary resection[J]. J Thorac Dis, 2022, 14(9): 3145-3153.
27.	Zhu Y, Tan J, Liu LK, et al. A novel nomogram for predicting non-infectious fever in patients following laparoscopic myomectomy[J]. Sci Rep, 2024, 14(1): 27810.

1. 王晨晗, 王鋒, 胡文滕, 等. 達芬奇機器人與胸腔鏡經劍突下入路治療前縱隔腫瘤臨床療效的回顧性隊列研究[J]. 中國胸心血管外科臨床雜志, 2024, 31(2): 236-242.Wang CH, Wang F, Hu WT, et al. Clinical efficacy of da Vinci robotic and thoracoscopic transxiphoid approach in the treatment of anterior mediastinal tumors: a retrospective cohort study[J]. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(2): 236-242.
2. 陳真, 時鴻娟, 夏道奎, 等. 經劍突下與經肋間切口胸腔鏡前縱隔病變切除臨床療效[J]. 實用醫學雜志, 2022, 38(24): 3129-3134.Chen Z, Shi HJ, Xia DK, et al. Thoracoscopic surgery for anterior mediastinal lesions: subxiphoid vs. intercostal approach[J]. J Pract Med, 2022, 38(24): 3129-3134.
3. Roviaro GC, Rebuffat C, Varoli F, et al. Videoendoscopic thoracic surgery[J]. Int Surg, 1993, 78(1): 4-9.
4. De Giacomo T, Diso D, Anile M, et al. Thoracoscopic resection of mediastinal bronchogenic cysts in adults[J]. Eur J Cardiothorac Surg, 2009, 36(2): 357-359.
5. Gonzalez-Rivas D, de la Torre M, Fernandez R, et al. Single-port video-assisted thoracoscopic left upper lobectomy[J]. Interact Cardiovasc Thorac Surg, 2011, 13(5): 539-541.
6. Ke L, Liu J, Shuai Y, et al. Intercostal approach VATS is feasible for large-sized anterior mediastinal tumors[J]. Sci Rep, 2024, 14(1): 17227.
7. Suzuki K, Oizumi H, Suzuki J, et al. Thoracoscopic lateral basal segmentectomy based on dissection along the intersegmental veins[J]. Ann Thorac Surg, 2023, 115(3): e83-e85.
8. Hu CG, Zheng K, Liu GH, et al. Effectiveness and postoperative pain level of single-port versus two-port thoracoscopic lobectomy for lung cancer: a retrospective cohort study[J]. Gen Thorac Cardiovasc Surg, 2021, 69(2): 318-325.
9. Kikunaga S, Fujimori S, Suzuki S, et al. The strategy and outcome of three-port thoracoscopic surgery for synchronous and metachronous multiple lung cancer[J]. Kyobu Geka, 2021, 74(1): 33-39.
10. Li X, Guo S, Liang W, et al. Tubeless anesthesia improves postoperative recovery following VATS wedge resection: a prospective randomized controlled study[J]. BMC Surg, 2025, 26(1): 54.
11. 包明勝, 陳健, 謝厚寵, 等. 喉罩聯合支氣管封堵器單肺通氣在胸腔鏡下肺部分切除術中應用效果及對患者應激反應及蘇醒質量影響[J]. 臨床軍醫雜志, 2025, 53(3): 277-279.Bao MS, Chen J, Xie HC, et al. Application effect of laryngeal mask combined with bronchial blocker for one-lung ventilation in video-assisted thoracoscopic partial pulmonary resection and its influence on stress response and recovery quality[J]. Clin J Med Off, 2025, 53(3): 277-279.
12. Hong Z, Sheng Y, Cui B, et al. A comparative study of robotic surgery and thoracoscopic surgery for mediastinal cysts[J]. BMC Surg, 2023, 23(1): 102.
13. Zhang M, Wang H, Pan X, et al. Thoracoscopic resection of bulky thymoma assisted with artificial pneumothorax: a report of 19 consecutive cases[J]. Oncol Lett, 2016, 11(5): 3061-3063.
14. Tanigawa Y, Nakamura K, Yamashita T, et al. Changes in respiratory mechanics of artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position[J]. Sci Rep, 2021, 11(1): 6978.
15. Zhao L, Zhang X, Gao C, et al. A comparison of bronchial blocker under artificial pneumothorax and double-lumen endobronchial tube for lung isolation in thoracoscopic enucleation of oesophageal leiomyoma[J]. J Cardiothorac Surg, 2021, 16(1): 322.
16. Xiao H, Zhang H, Pan J, et al. Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study[J]. BMC Pulm Med, 2024, 24(1): 165.
17. Li L, Zhao L, He J, et al. Application of right bronchial occlusion under artificial pneumothorax in the thoracic phase of minimally invasive McKeown esophagectomy[J]. Ann Thorac Cardiovasc Surg, 2021, 27(6): 339-345.
18. Choque-Velasquez J, Resendiz-Nieves JC, Rezai Jahromi B, et al. The microsurgical management of benign pineal cysts: Helsinki experience in 60 cases[J]. Surg Neurol Int, 2019, 10: 103.
19. Li Z, Yang L, Yang H, et al. Comparison of superselective renal artery embolization versus retroperitoneal laparoscopic partial nephrectomy in ruptured hemorrhagic renal angiomyolipoma: a single-center study[J]. Diseases, 2024, 12(9): 218.
20. 李華艷, 李東澤, 周子涵, 等. 改良胸腔引流管理方案在胸腔鏡肺切除患者快速康復中的應用[J]. 中國微創外科雜志, 2025, 25(4): 222-226.Li HY, Li DZ, Zhou ZH, et al. Application of a modified chest drainage management protocol in rapid recovery of patients undergoing thoracoscopic pulmonary resection[J]. Chin J Minim Invas Surg, 2025, 25(4): 222-226.
21. You D, Qin L, Li K, et al. A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty[J]. Korean J Pain, 2021, 34(3): 271-287.
22. Zhao G, Jiang X, Wang F, et al. Lobectomy with high-position single-intercostal two-port video-assisted thoracoscope for non-small cell lung cancer is a safe and effective surgical procedure[J]. J Thorac Dis, 2020, 12(12): 7346-7354.
23. Yan B, Yao X, Zhao Z, et al. Learning curve for double-port video-assisted thoracoscopic lung segmentectomy: a propensity score matching study[J]. J Cardiothorac Surg, 2024, 19(1): 681.
24. Israfilov N, Y?ld?r?m Gü?lü ?, Karada? Erko? S, et al. Retrospective analysis of factors affecting chronic postoperative pain after thoracotomy: single center experience[J]. Turk J Anaesthesiol Reanim, 2023, 51(3): 235-242.
25. Rivera-Ramos H, Larra?aga-Altuna L, García-Olivera M, et al. Incidence and risk factors of chronic post-thoracic surgery pain: a retrospective study[J]. Rev Esp Anestesiol Reanim (Engl Ed), 2025, 72(1): 101644.
26. Geraci TC, Sorensen A, James L, et al. Use of a novel digital drainage system after pulmonary resection[J]. J Thorac Dis, 2022, 14(9): 3145-3153.
27. Zhu Y, Tan J, Liu LK, et al. A novel nomogram for predicting non-infectious fever in patients following laparoscopic myomectomy[J]. Sci Rep, 2024, 14(1): 27810.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesClinical outcomes of artificial pneumothorax-assisted three-port VATS versus conventional two-port and uniportal VATS in mediastinal tumor resection

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