Safety And Recovery Of Tubeless Strategy In Uniportal VATS Wedge Resection

Uniportal video-assisted thoracoscopic (VATS) wedge resection is widely used for the diagnosis and treatment of peripheral pulmonary nodules. Conventional postoperative chest tube drainage is routinely applied to prevent pneumothorax, but it is associated with increased postoperative pain, delayed mobilization, and prolonged hospital stay. In recent years, tubeless strategies have been introduced in carefully selected patients to enhance recovery; however, postoperative residual pneumothorax and pleural re-intervention remain major safety concerns.

Previous retrospective studies suggest that intraoperative aspiration may improve the feasibility of tubeless VATS, but single aspiration may not completely prevent re-entry of air into the pleural space. A modified strategy using double intraoperative aspiration performed entirely before chest closure may enhance lung re-expansion and reduce postoperative pleural complications. To date, no prospective randomized controlled trial has directly compared different intraoperative aspiration-based tubeless strategies.

This study is a single-center, prospective, three-arm randomized controlled trial conducted at Guangzhou Medical University First Affiliated Hospital. Adult patients undergoing uniportal VATS wedge resection who pass a standardized intraoperative water-seal air leak test will be randomized in a 1:1:1 ratio to one of the following groups:

conventional chest tube drainage,

single intraoperative aspiration tubeless, or

double intraoperative aspiration tubeless.

All aspiration procedures are completed intraoperatively, and no postoperative aspiration or intermittent drainage is permitted in tubeless groups. Perioperative management is standardized across all groups.

The primary outcome is the incidence of pleural re-intervention (thoracentesis or chest tube insertion) within 30 days after surgery. Secondary outcomes include postoperative recovery quality assessed by the QoR-15 questionnaire, postoperative pain assessed by visual analog scale (VAS), lung re-expansion on postoperative day 1 imaging, length of hospital stay, and postoperative pulmonary complications.

This trial aims to provide high-quality evidence to determine whether optimization of intraoperative pleural space management can improve the safety and reliability of tubeless uniportal VATS wedge resection while preserving enhanced recovery benefits.

Inclusion criteria

• Age 18 to 80 years
• Scheduled to undergo uniportal video-assisted thoracoscopic (VATS) wedge resection
• Able to tolerate general anesthesia and single-lung ventilation
• Passed a standardized intraoperative water-seal air leak test, confirming absence of persistent air leak before chest closure
• Able and willing to provide written informed consent
• Able to complete postoperative assessments and 30-day follow-up

Exclusion criteria

• Planned anatomical lung resection (segmentectomy or lobectomy) or combined complex thoracic procedures
• Extensive pleural adhesions, severe emphysema, bullous lung disease, or other conditions associated with high risk of air leak
• Positive intraoperative air leak test indicating persistent air leak
• Requirement for additional intraoperative procedures that may significantly affect pleural air leak or lung re-expansion
• Conversion to multiport VATS or thoracotomy before randomization
• Severe comorbidities or other conditions deemed by the investigators to make participation inappropriate
• Inability to complete follow-up or insufficient clinical data