Redefining thoracic access: subxiphoid uniportal VATS lung resection—recovery, opioid consumption and learning curve

Background Subxiphoid uniportal video-assisted thoracic surgery presents a more specialised approach to undertake lung resection, aiming to minimise postoperative pain. This approach has been controversial since its introduction attracting contradicting opinions from both sceptics and believers. The technique has progressed since its reported early experiences. Such controversy and progress of this technique mandates reporting the experience of one of its early adopters spanning one decade of subxiphoid VATS lung resections. Methods Single-centre retrospective cohort study including oncological lung resections undertaken between 2016 and 2025 using subxiphoid uniportal VATS by an early adopter of this technique. Operative and perioperative outcomes were examined, including postoperative pain and opioid use. Learning curve was evaluated using cumulative sum (CUSUM) analysis. Comparative analysis evaluated outcomes before and after CUSUM inflection point. Results 126 consecutive subxiphoid VATS lung resections were included. The predominant indication was lung cancer. Median surgery duration was 127 min (IQR: 95–171). Overall conversion rate was 3.2%, and conversion to thoracotomy was required only in one patient (0.8%). Median postoperative length of stay was 3 days (IQR: 2–5). Complete R0 resection was achieved in 93.8%. There was no thirty-day mortality. 73.3% of patients with documented assessments had no pain or mild pain on postoperative day 1. Median OME was 38 mg in the first 24 h, and 15 mg between 24 and 48 h. Learning curve analysis demonstrated a significant reduction in operative time, accompanied by improvement in outcomes following the initial programme phase. Conclusions This decade-long experience suggests that subxiphoid uniportal VATS can be performed for oncological lung resection with acceptable perioperative outcomes and low morbidity and mortality within an experienced specialist programme, with operative efficiency improving over the course of the programme. Comparative prospective studies remain necessary to establish any advantage over conventional approaches.