Surgery Today

https://doi.org/10.1007/s00595-021-02290-w

ORIGINAL ARTICLE

Modified 2‑cm super single port vs. the traditional 3‑cm single port
for video‑assisted thoracoscopic surgery lobectomy
Gaoli Liu1 · Ping Dong1 · Haifeng Hu1 · Shaowen Zhang1 · Zhangfan Mao1 

Received: 4 November 2020 / Accepted: 21 February 2021

© Springer Nature Singapore Pte Ltd. 2021

Abstract
Purposes  We introduce a novel 2-cm single port designed to minimize intercostal muscle and nerve damage in video-assisted
thoracoscopic surgery (VATS) lobectomy, and compared it with the 3-cm traditional single port.
Methods  We analyzed, retrospectively, the clinical data, safety, convenience, incision complications, and postoperative pain
and numbness in 81 patients who underwent either modified (n = 42) or traditional (n = 39) single-port VATS lobectomy.
Results  The preoperative variables were comparable between both single-port VATS lobectomy groups after matching. There
were no serious complications and there was no mortality in either group. There were no remarkable differences between
the groups in intraoperative blood loss, chest tube duration, lymph node dissection, or postoperative complications. The
modified single-port group had a longer operation time (p < 0.05), but the static and dynamic postoperative VAS scores and
incisional numbness were better in the modified single-port group (p < 0.05). The modified single-port group also had an
obvious advantage in incision seepage, healing, and appearance.
Conclusions  Our 2-cm modified single port for lobectomy is safe and effective, and results in less postoperative pain and
incisional numbness than the 3-cm traditional single port.

Keywords  Postoperative pain · 2-cm single port · Video-assisted thoracoscopic surgery · Super port · Uniportal

Introduction inevitable postoperative pain. Thus, we devised a 2-cm

According to the Cancer Statistics 2018 report published by
CA: A Cancer Journal for Clinicians, lung cancer accounted
for 11.6% of the total number of new cancer cases diagnosed
worldwide [1]. Surgery is the most important treatment for
middle- and early stage lung cancer; however, open and
minimally invasive thoracic operations are still associated
with postoperative pain [2], and 30–50% of these patients
continue to suffer chronic pain [3] [4] [5].
The traditional thoracoscopic single-port incision requires
the chest wall and intercostal muscles to be cut to access the
thoracic cavity effectively. The size of the traditional single-
port incision is usually 3–4 cm [6]. However, the intercostal
and epidermal nerves can be cut or injured, which causes
modified incision technique for thoracoscopic surgery, which
allows access to the thoracic cavity without needing to cut
the intercostal muscle with an electric knife, thereby greatly
reducing muscle and nerve injuries. We named this tech-
nique the “Super single port.”
We analyzed the clinical data of patients who underwent
our modified single port or traditional single-port thoraco-
scopic lobectomy in the Department of Thoracic Surgery
at the People’s Hospital of Wuhan University between
February, 2019 and October, 2019. Surgical safety, degree
of pain in the first 3 postoperative days (PODs), and inci-
sional numbness 3 months postoperatively were the main
observation indicators and we also explored the effect of the
modified incision on video-assisted thoracoscopic surgery
(VATS) lobectomy.

Gaoli Liu and Ping Dong contributed equally to the work.

* Zhangfan Mao
maozhangfan@whu.edu.cn
1
Department of Thoracic Surgery, Renmin Hospital of Wuhan
University, 238 Jiefang Road, Wuhan 430060, China

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Methods
Patients
We reviewed data of consecutive adult patients who under-
went either 2-cm modified single port or 3-cm traditional
single-port VATS lobectomy for pulmonary lesions between
February, 2019 and October, 2019 in our department. All
operations were performed by the same medical team.
Because each operation was either a 2- or 3-cm single-port
VATS lobectomy, there were inclusion and exclusion criteria
for this study.
The inclusion criteria were an age younger than 75 years
and older than 18 years; pulmonary lesions with a diameter
less than 1.5 cm; no obvious swollen lymph nodes in the
chest; and a preoperative clinical diagnosis of lung cancer
with TNM stage I or indeterminate lung nodules. The exclu-
sion criteria were a history of chronic pain or mental ill-
ness; alcohol abuse, drug abuse, or long-term use of pain
relief drugs, sedative hypnotics, antidepressants, antianxi-
ety drugs, or NSAID drugs; communication disorders; com-
plete pleural adhesion, intolerance to one-lung ventilation,
or severe thoracic deformities; and obesity or neoadjuvant
chemotherapy or radiotherapy.
Study and operative methods
Before surgery, each patient’s clinical history was collected
carefully. All patients underwent routine blood tests, liver
and kidney function tests, arterial blood gas analyses, pul-
monary function tests, electrocardiograms, echocardiogra-
phy tests, and other examinations. No severe lung or heart
Fig. 1  Intercostal muscles were bluntly separated with the vascular clamp
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Surgery Today
disease was found in any of the patients before surgery.
Head magnetic resonance imaging (MRI) or chest computed
tomography (CT), abdominal B-mode ultrasonography, and
body bone scans were also performed routinely, to exclude
distant metastasis. There were no contraindications to sur-
gery. Before and after the operation, nurses provided pam-
phlets and verbal education to the patients, and coughing
training was carried out routinely prior to the operation.
Surgery was performed under combined intravenous and
inhalation anesthesia with double-lumen tracheal intubation
and selective one-lung ventilation. Patients were placed in
the lateral decubitus position and given intercostal block
anesthesia with 0.75% ropivacaine injection before the skin
was incised. The procedure was decided according to the
specific conditions during the surgery. A thoracic drainage
tube was routinely retained intraoperatively. A chest X-ray
was taken at the bedside within 24 h to assess the pulmo-
nary lobe expansion and pleural effusion states. Patients
were encouraged to cough and start ambulating early after
the operation.
Both the modified and traditional single-port incisions
were made in the fourth or fifth intercostal spaces of the axil-
lary midline. The traditional single-port incision was made
as usual to a length of approximately 3 cm, and intercostal
muscle incisions of 4 cm were made by an electric knife
[6]. The final size of the traditional single-port wound was
about 4.5 × 2 cm for the operation after a wound protec-
tor (HK-60/70-60/100(B), Beijing Hangtian Kadi Technol-
ogy Development Institute) was placed. Conversely, for the
modified single port, a 2-cm skin incision was made, and
the subcutaneous tissue and chest wall muscles, including
the anterior serratus and intercostal muscles, were bluntly
separated at a single point, using the vascular clamp (Fig. 1).
Surgery Today
When the vascular clamp separated into the thoracic cavity
and expanded appropriately, a wound protector was placed.
Then, a single-port wound about 2.3 × 1.5 cm in size was
formed [7]. We named this the “super single-port” [7].
The traditional single-port lobectomy procedure was per-
formed as usual, but the modified single-port procedure was
improved. During the modified single-port lobectomy, we
prepared two sets of 10-mm and 5-mm thoracoscopic sys-
tems on standby. The 10-mm high-definition thoracoscope
was used during dissection for better vision, and the 5-mm
one was inserted when using the endo-stapler for better
space. In all procedures, we removed the lymph nodes in the
hilar and oblique fissure first, the order of treatment being
the vein, pulmonary fissure or artery, and then bronchus.
Dissection was performed with a 4-mm electrocautery hook
and 4-mm aspirator, while retracting the lobe with a 5-mm
double-joint clamp. We dissected the mediastinal pleura
first. For upper or middle lobectomy, we dissected the pul-
monary vein into the segmental branches. We ligated the
branches using 2–0 silk, because they were too close to the
port. In lower lobectomy, the inferior pulmonary vein was
ligated with an 8-mm endo-stapler. The pulmonary fissure
was dissected with a harmonic scalpel and a 12-mm endo-
stapler. The arteries were ligated with silk and a harmonic
scalpel or an 8-mm endo-stapler. Finally, the bronchus was
transected with a 12-mm endo-stapler. The endo-stapler was
used with the 5-mm thoracoscope instead of the 10-mm
thoracoscope. There were three instruments in the single
port: a 5-mm thoracoscope, a 5-mm double-joint clamp, and
an 8- or 12-mm endo-stapler with a total width of either
18 mm or 22 mm (Fig. 2). The pulmonary lobe was placed
in a bag and extracted carefully (Fig. 3). Finally, an Fr.22
thoracic drainage tube was placed (Fig. 4).
Fig. 2  a Instruments used in the super single-port technique were a
4-mm electrocautery hook, a 4-mm aspirator, and a 5-mm double-
joint clamp. b Four instruments were maneuvered in the super sin-
gle port simultaneously during dissection, including a 10-mm thora-
After the lobe was removed, the mediastinal lymph
nodes were dissected in groups 5, 6, and 7 for left lung
cancer and in groups 2, 4, and 7 for right lung cancer. The
lymph node dissection was more difficult via the super
single-port procedure because of its smaller size, but oth-
erwise, the procedures were similar. We sometimes turned
the operating table to maximize exposure, and inserted the
5-mm thoracoscopic lens for vision to allow more space
for other instruments in the super single port.
We collected the following observation indicators from
the medical records: operation time, intraoperative blood
loss, chest tube duration, postoperative complications,
hospitalization time, number of lymph nodes dissected,
postoperative pathology, incision seepage, and poor heal-
ing. The degree of pain, incisional numbness, and overall
satisfaction of the patients were evaluated by nurses at
9 am from the day of operation until postoperative day
(POD) 3 and then 3 months postoperatively. The degree
of pain was assessed by a visual analogue scale (VAS),
with a score of 0 indicating no pain and a score of 10 indi-
cating the most severe pain possible [8]. The higher the
VAS score, the more severe the pain. The VAS score was
divided into a static score and a dynamic score. The static
score required patients to rest for more than 30 min before
the assessment, whereas the dynamic score was recorded
after the patient coughed or moved from the bed. Inci-
sional numbness was defined as dull and reduced sensitiv-
ity around the skin incision after the operation.
The patients were followed up for 3–5 months. Each
patient was treated in accordance with the ethical princi-
ples outlined in the Declaration of Helsinki. We obtained
the consent of all patients to access their medical history.
Finally, the clinical data of 42 patients were collected,
coscopic lens, a 5-mm double-joint clamp, a 4-mm suction catheter,
and an electrocautery hook. c During the endo-stapler application,
there were three instruments in the port: a 5-mm thoracoscopic lens, a
5-mm double-joint clamp, and a 12-mm endo-stapler
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Fig. 3  Pulmonary lobe was pulled out in a bag
Fig. 4   Fr.22 thoracic drainage tube was placed
after the exclusion of 8 patients for whom data were
incomplete.
Statistical analysis
Continuous variables are expressed as means ± standard
deviation and categorized variables are expressed as percent-
ages. Either a t test or a non-parametric test was used to com-
pare the measurement data. The χ2 test, continuity correc-
tion, and Fisher’s exact test were used to test the categorical
data. Pearson’s or Spearman’s correlation test was used for
the correlation analysis, and SPSS 25.0 statistical software
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Surgery Today
(IBM Corp, Armonk, NY, USA) was used to analyze the
data; A p value of < 0.05 indicated a significant difference.
Results
In total, 81 patients who underwent successful lobectomy, 42
underwent our 2-cm modified single-port procedure (modi-
fied group), and 39 underwent the 3-cm traditional single-
port procedure (traditional group). There was no incidence
of conversion to thoracotomy, although two patients in the
2-cm modified group required conversion to a two-port pro-
cedure and one patient in the traditional group required con-
version to a two-port procedure with a high-glucose injec-
tion into the chest cavity to control continuous air leakage of
the drainage tube. This patient recovered and was discharged
2 weeks later. There were no serious complications or perio-
perative death in either group.
Table 1 summarizes the baseline characteristics of the
two groups, including sex, age, weight, height, BMI, history
of cigarette smoking, history of alcohol consumption, educa-
tion level, employment type, American Society of Anesthe-
siologists (ASA) score, and Eastern Cooperative Oncology
Group (EOCG) status. The baseline characteristics were not
significantly different between the groups (all p > 0.05). The
operation time in the modified group was longer than that in
the traditional group (p < 0.05). However, there were no sig-
nificant differences in intraoperative blood loss, pathological
results, number of lymph nodes dissected, chest tube dura-
tion, use of analgesics, or hospitalization time between the
two groups (all p > 0.05). There were three cases of incision
Surgery Today

Table 1  Baseline characteristics of the patients who underwent video-assisted thoracoscopic surgery via the modified 2-cm single-port incision
vs. the traditional 3-cm incision
Variables Modified incision (n = 42) Traditional incision (n = 39) P value Statistic

Sex
 Male 25 27 0.487 0.829
 Female 17 12
Age (median and range) 57 (19–75) 56 (19–24) 0.698 − 0.388
BMI (median and range) 21.63 (15.43–31.22) 21.71 (16.30–21.90) 0.296 − 1.045
Smoking history
 Yes 9 13 0.229 1.449
 No 33 26
Drinking history
 Yes 9 9 0.858 0.032
 No 33 30
Education level
 Low 21 22 0.564 0.334
 High 21 17
Employment type
 Manual labor 14 20 0.102 2.675
 Knowledge workc 28 19
ASA score (median and range) 1 (0–2) 1 (0–2) 0.441 − 0.770
ECOG status (median and range) 1 (0–2) 1 (0–2) 0.730 − 0.345
Sleep quality before surgery 1/1/18/22 2/2/18/17 0.728 1.364

seepage and three cases of incisional poor healing in the
traditional group, but none in the modified group (Table 2).
The static and dynamic VAS scores on the day of opera-
tion, the first 2 days postoperatively, and 3 months post-
operatively were better in the modified group than in the
traditional single-port group (all p < 0.05), but on POD 3, the
VAS scores were not different (all p > 0.05). The incisional
numbness 3 months postoperatively was significantly less in
the modified group than in the traditional group (p < 0.05).
The overall satisfaction of the patients 3 months postop-
eratively was also better in the modified group (p < 0.05)
(Table 3).
Discussion
Compared with traditional thoracoscopic surgery, single-
incision thoracoscopic surgery can improve postoperative
pain, sensory abnormalities, and patient satisfaction [9] [10]
[11] [12]. However, finding ways to reduce the size of the
wounds and postoperative pain has become the goal of many
surgeons. We conducted this retrospective study to analyze
the basic data of 81 patients who underwent thoracoscopic
pulmonary lobectomy and compare the effects of a modi-
fied incision vs. a traditional incision on postoperative pain
and numbness of the incision. We found that our modified
incision for thoracoscopic lobectomy was safe and effective
and that it could reduce wound seepage and pool healing,
alleviate early pain, and decrease the occurrence of numb-
ness around the incision postoperatively.
In 2013, a method of entering the thoracic cavity through
a subperiosteal approach adjacent to the ribs was adopted
[13]. This method involved using an electric knife to cut
the periosteum on the surface of the ribs and accessing the
thoracic cavity along the upper edge of the ribs under the
periosteum to avoid damaging the intercostal muscle fibers
and nerves. However, the thoracic muscles and periosteal
nerves were still injured. Our procedure used blunt separa-
tion of the chest wall and intercostal muscles, but did not use
an electric knife to enter the thoracic cavity. This is similar
to Yang’s method, but Yang’s incision was more than 3-cm
long [14]. In our experience, blunt separation in a 3-cm port
would tear muscles seriously, whereas single-point blunt
separation via a 2-cm port would minimize damage to the
muscles and nerves.
To avoid injuring the nerves, we performed blunt separa-
tion. Because the nerves are sensitive to thermal and elec-
trical damage, using electrocautery will increase the pos-
sibility of nerve injury. Moreover, we cannot predict how
much nerve injury will be caused by electrocautery and it is
difficult to reduce or prevent nerve injury by controlling the
use of electrocautery. This is similar to avoiding the use of
electrocautery when dissecting the right recurrent laryngeal
nerve lymph nodes in minimally invasive esophagectomy.

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 Surgery Today

Table 2  Perioperative indexes of the patients who underwent video-assisted thoracoscopic surgery via the modified 2-cm single-port incision vs.
the traditional 3-cm incision
Variables Modified incision Traditional incision P value Statistic
(n = 42) (n = 39)

Operation time (min) (median and range) 153 (80–279) 119 (63–157) 0.045 − 2.004
Intraoperation blood loss (ml) (median and range) 125 (90–450) 150 (100–350) 0.348 − 0.938
Extubation time (d) (median and range) 4 (2–13) 5 (2–14) 0.005 − 2.802
Postoperative hospital stay (d) (median and range) 7 (5–16) 7 (5–16) 0.244 − 1.165
Time of beginning get out of bed (d) (median and range) 2 (1–3) 2 (1–4) 0.005 − 2.809
Pathological results
 Benign 3 1 0.662 0.191
 Adenocarcinoma 35 32
 Non-adenocarcinoma 4 6
Pathological stage of malignant tumor
 Stage IA 36 35 1.000 0.825
 Stage IIB 3 3
 Stage IIIA 0 0
 Stage IB, IIA, IIIB, and IV 0 0
 Tumor size (cm) (median and range) 1.0 (0.9–1.5) 1.2 (0.6–1.5) 0.130 − 1.514
Tumor component
 pGGN 19 14
 mixGGN 15 16
 Solid 5 8
 Number of autosuture cartridges used (median and range) 5 (3–8) 5 (3–8) 0.622 − 0.493
 The number of dissected lymph nodes (median and range) 10 (8–17) 11 (8–16) 0.179 − 1.342
 Postoperative complications 2 4 0.342 0.902
 Prolonged air leak (> 5 days) (year) 1 2 0.948 0.004
 Postoperative atrial fibrillation (year) 1 2 0.948 0.004
 Incision seepage 0 4
 Incision poor healing 0 3
 Conversion to two-port 2 1 1.000 0.000

The incision size in our modified group was 2 cm, and
after placing the wound protector, the port was 2.3 cm on
average, although the final size varied slightly depending
on the patient’s body type. Because maneuvering operat-
ing instruments in and out of a 2.3-cm incision port during
the operation, we used the 10-mm thoracoscopic lens for
good vision and the 5-mm thoracoscopic lens for good
operating space. There were four instruments criss-cross-
ing the 2.3-cm operative port during dissection: a 10-mm
thoracoscopic lens for vision, a 5-mm double-joint clamp
for retraction, a 4-mm suction catheter, and an electro-
cautery hook for dissection. There were three instruments
in the port during endo-stapler application: a 5-mm thora-
coscopic lens for vision, a 5-mm double-joint clamp for
retraction, and an 8- or 12-mm endo-stapler for transec-
tion. If the operation was difficult, it could be converted
to a two-port procedure, as in the case of two patients
from the 2-cm modified group in this study. The reason
for this conversion to a two-port procedure was to control
bleeding that occurred while transecting the arteries with
the stapler, by ligating the arteries before using the stapler,
or with a Hem-o-lok®.
The lobectomy by a super single port is more difficult
than by a traditional port because of the smaller aperture,
as demonstrated by the longer operation time in our super
single-port group. However, for lobectomy and lymph node
dissection, the quality of surgery was not greatly affected,
as demonstrated by the similar postoperative complications,
number of lymph nodes, and hospital stay of the two groups.
We prepared two sets lens, because a 5-mm lens allowed
access to more space for the other instruments to operate.
The two cases of conversion to thoracotomy occurred when
the pulmonary artery was treated with the stapler. Some-
times, it was difficult to use the stapler to transect the vessels
because of the smaller port size, so we improved this before
using the stapler, by ligating the pulmonary artery or treat-
ing it directly with the Hem-o-lok®. Thereafter, there was
no conversion to thoracotomy.

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Surgery Today

Table 3  Postoperative pain and satisfaction of patients who underwent video-assisted thoracoscopic surgery via the modified 2-cm single-port
incision vs. the traditional 3-cm incision
Variables Modified incision (n = 42) Traditional incision (n = 39) P value Statistic

Use of analgesics
 Oral 2 4 0.403 2.182
 Intravenous 29 21
 Unused 11 14
Static VAS
 9 am on POD 1 2 (0–5) 3 (1–6) 0.000 – 4.009
 9 pm on POD 1 2 (0–5) 3 (1–6) 0.000 – 3.873
 9 am on POD 2 2 (0–4) 2 (0–5) 0.024 – 2.255
 9 pm on POD 2 1 (0–4) 2 (1–5) 0.000 – 3.618
 9 am on POD 3 2 (0–3) 2 (1–6) 0.748 – 0.321
 9 am on POD 3 1 (0–3) 2 (1–7)– 0.284 – 1.072
3-month post-operation 0 (0–1) 0 (0–1) 0.272 – 1.099
 Dynamic VAS
 9 am on POD 1 4 (2–8) 6 (2–8) 0.000 – 4.568
 9 pm on POD 1 4.5 (1–8) 6 (3–8) 0.000 – 3.967
 9 am on POD 2 4 (1–7) 5 (2–8) 0.001 – 3.189
 9 pm on POD 2 3 (1–5) 5 (2–8) 0.000 – 4.172
 9 am on POD 3 4 (1–6) 4 (1–8) 0.052 – 1.947
 9 pm on POD 3 3 (1–5) 4 (2–9) 0.039 – 2.061
Static VAS
 3-month post-operation 0 (0–1) 0 (0–1) 0.272 – 1.099
Dynamic VAS
 3-month post-operation 1 (0–3) 0 (0–3) 0.728 – 0.347
Incisional numbness 3-month post-operation (year) 4 15 0.005 7.889
Patient postoperative satisfaction (dissatisfied/neutral/ 1 (2.4%)/3 (7.2%)/16 2 (5.2%)/9 (23.1%)/18 0.036 7.820
satisfied/very satisfied) (38.1%)/22 (52.4%) (46.2%)/10 (25.6%)

POD postoperative day

It was also more difficult to remove the lobe through a
super single port, but prior to its inception, we had accumu-
lated much experience. When encountering cases of a crush-
ing bag and crushing tumor, we had extended the incision,
but in this series, we did not. Usually, we prefer to perform
local resection of the tumor first, so as to avoid tumor crush-
ing and facilitate subsequent lobe removal. When the lobe
is difficult to remove, it should be pulled carefully along the
edge of the lung. When the lobe does not moved out easily,
it can be returned to the bag and taken out again along the
edge.
Single-port blunt separation minimizes damage to mus-
cles and nerves, because it avoids the thermoelectric injury
caused by electrocautery and extensive muscle tears by
multipoint blunt separation. When the wound protector is
removed, the muscles retract elastically. In this study, there
was no incision seepage or poor healing observed in the
modified group, but there were four cases of incision seep-
age and three cases of incisional poor healing in the tradi-
tional group. There are many causes of postoperative pain,
including intercostal nerve injury. Our results showed that
improving the incision reduced the VAS scores and numb-
ness of the incision significantly in the early postoperative
period. In the present study, incisional numbness was evi-
dent 3 months postoperatively in 15 patients from the tradi-
tional group, but in only but 4 from the modified group. This
may be, because our data included all abnormal sensations
except pain in incisions, including dullness, reduced sensi-
tivity, abnormal sensations with a change in weather, and
so on. In this study, there were more patients administered
intravenous drugs in the modified group, but the difference
was not significant. The modified incisions were smaller,
resulting in better cosmesis, so the overall satisfaction of the
patients 3 months postoperatively was better.
Single-port video-assisted thoracoscopic surgery
(SPVATS) anatomical resection has been shown as a feasible
technique for lung cancer patients, but whether SPVATS has
equivalent or better oncological outcomes for lung cancer
patients remains controversial [15]. Wu and his colleagues’
preliminary results revealed that SPVATS anatomical

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resection achieves acceptable 2-year survival outcomes for
early stage lung cancer and is consistent with AJCC 8th
staging system 2-year survival data [16]. Kook et al. also
reported acceptable midterm survival and recurrence-free
survival after single-port thoracoscopic lobectomy compa-
rable to those after the two- and three-port approach [17]. In
this study, we focused on the safety and postoperative pain
of lobectomy performed with the two different single-port
incisions. The long-term prognosis of the modified single-
port group is under follow-up and further data are needed to
confirm its prognosis.
Conclusion
Our modified single port for lobectomy is safe and effective,
and associated with significantly less pain and a lower inci-
dence of incisional numbness than the traditional technique.
The cosmetic appearance of the modified single-port inci-
sion is also better. We believe that this surgical method is a
promising new option for small pulmonary nodules.
Funding None.
Data availability  The data that support the findings of this study are
available from the corresponding author upon reasonable request.
Declarations  2013;96(6):1982–6.
Conflict of interest  Gaoli Liu and the other co-authors have no conflict
of interest to declare.
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