Surgical Techniques Development

Background/Objectives: Primary hyperparathyroidism (PHPT) is most commonly caused by a single cervical parathyroid adenoma; however, a minority of cases originate from ectopic glands, including intrathoracic localizations. Intrathoracic ectopic parathyroid glands (EPGs) are rare and pose significant diagnostic and therapeutic challenges due to their anatomical variability and overlap with other mediastinal pathologies. Methods: We retrospectively analyzed 13 consecutive patients with PHPT caused by intrathoracic EPGs, who underwent minimally invasive surgical resection between 2015 and 2024 at two Italian tertiary referral centers. Demographic characteristics, biochemical profiles, imaging findings, surgical approaches, intraoperative parathyroid hormone (ioPTH) kinetics, and postoperative outcomes were evaluated. Results: All patients underwent successful resection using video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). Ectopic glands were identified in thymic, mediastinal, retroesophageal, paratracheal, and aortopulmonary locations. Postoperative normalization of calcium, phosphate, and PTH levels confirmed biochemical cure in all patients. No intraoperative complications or 30-day mortality were observed. Higher preoperative PTH levels were associated with longer operative times only in an exploratory, non-significant manner. Conclusions: Intrathoracic EPGs should be suspected in patients with PHPT and negative cervical imaging. Minimally invasive thoracic surgery provides safe and effective treatment with excellent biochemical outcomes. Elevated preoperative PTH levels may reflect increased surgical complexity, a hypothesis that warrants validation in larger cohorts. Full article

Objectives: The incidence of distal gastric cancer has declined worldwide owing to successful Helicobacter pylori eradication and improvements in environmental and dietary factors. In contrast, adenocarcinoma of the esophagogastric junction (AEG) and proximal gastric cancer have become increasingly prevalent, creating a growing need for function-preserving surgical approaches. Proximal gastrectomy has emerged as an attractive alternative to total gastrectomy because of its potential advantages in nutritional preservation and postoperative quality of life. However, concerns regarding postoperative reflux esophagitis have historically limited its widespread adoption. This review aimed to summarize the evolution of reconstruction after proximal gastrectomy and evaluate the advantages, limitations, and clinical outcomes of contemporary reconstruction techniques. Methods: A narrative review of the current literature was performed, focusing on reconstruction strategies following proximal gastrectomy. Major contemporary techniques, including double-tract reconstruction (DTR), double-flap reconstruction (DFT; Kamikawa method), side-overlap fundoplication by Yamashita (SOFY), and Toupet-like fundoplication reconstruction, were reviewed. Comparative evidence regarding reflux control, nutritional outcomes, operative complexity, anastomotic complications, and postoperative quality of life was examined. Results: Substantial advances in reconstructive techniques have significantly improved functional outcomes after proximal gastrectomy. DTR provides reliable reflux prevention, reproducibility, and broad applicability in minimally invasive surgery. DFT achieves excellent anti-reflux efficacy while preserving physiological food passage through the remnant stomach. SOFY offers favorable functional outcomes with reduced technical complexity and is particularly suited to laparoscopic and robotic surgery. Toupet-like reconstruction represents a promising alternative with encouraging early clinical results. Comparative studies indicate that all contemporary anti-reflux reconstruction methods substantially reduce reflux esophagitis compared with conventional esophagogastrostomy. Although each technique demonstrates specific advantages and limitations, no single reconstruction method has consistently shown superiority across all clinically relevant outcomes, including reflux prevention, nutritional preservation, operative complexity, and quality of life. Conclusions: Modern reconstruction techniques have expanded the role of proximal gastrectomy as a function-preserving alternative to total gastrectomy for proximal gastric cancer and AEG. Current evidence suggests that DTR, DFT, SOFY, and Toupet-like reconstruction can all achieve satisfactory oncological and functional outcomes when appropriately applied. Rather than identifying a universally superior procedure, contemporary practice should emphasize individualized reconstruction based on patient characteristics, surgeon expertise, and institutional experience. Future advances in robotic surgery, perioperative care, and standardized outcome assessment are expected to further optimize long-term outcomes following proximal gastrectomy. Full article

The annual congress of the Italian Association of Plastic Aesthetic Surgery (AICPE), with more than 700 members, represents one of the most relevant conference meetings in Europe relating to Aesthetic Plastic Surgery due to the number of participants and due to the faculty of invited speakers chosen for their renowned scientific value. The 13th meeting was held in Rome (Italy) from 10 to 12 April 2026. Key focus areas of the scientific program concerned breast (reduction, lifting supported or not by mesh, implant surfaces, augmentation), face and neck (lifting, blepharoplasty, malar implants, feminization), body (abdominoplasty and torsoplasty, post-partum and ex-obesity surgery, body and limb contouring, complication treatments) and nose surgery combined with medical innovations in energy devices, threads and aesthetic medicine procedures. Special attention was also given to the theme of the therapeutic role of aesthetic surgery, which is increasingly becoming an integral part of a clinical pathway useful for restoring the patient’s psycho-physical balance. Presented here is a report of the abstracts accepted due to their innovative or cutting-edge content that were selected to be given as oral presentations during the congress sessions. The 2nd edition of the Saccomanno memorial award for the best abstract presented by a young surgeon has been organized with the endorsement of Surgical Techniques Development by MDPI. Full article

Background/Objectives: Septal deviation is a common cause of nasal obstruction, and achieving long-lasting septal straightening while preserving cartilage remains a surgical challenge. In this study, we describe and evaluate a simple suture technique designed to effectively straighten the nasal septum in both experimental and clinical settings. Methods: The technique combines cartilage scoring with the placement of a mattress suture to correct septal deformities. It was first tested in vitro using fifteen rabbit ear cartilage specimens and subsequently applied in vivo in a clinical series of forty-five patients presenting with septal deviation. The approach was assessed for ease of application, suitability in difficult anatomical regions (including severe caudal or dorsal deviations), cartilage preservation, and durability of correction. Clinical outcomes were followed for up to twelve months. Results: The combined scoring and mattress suture technique successfully straightened cartilage in both experimental and clinical applications. The method proved technically straightforward and applicable even in challenging septal areas. It allowed for conservative management with increased cartilage preservation. In the patient cohort, initial favorable outcomes were maintained throughout follow-up period. Conclusions: This simple suture technique represents an effective and conservative method for septal straightening. It is easy to perform, preserves cartilage, and seems to provide stable short- to mid-term results. The method may be particularly useful in cases of severe caudal or dorsal septal deviation. Full article

Objective: Osteosynthesis in the case of a sternal wound infection is challenging. It requires osteosynthesis systems that go beyond the usual wire techniques. In principle, there are three different systems, namely plates with locking screws, clips, and distance systems, which are the original methods used in chest wall reconstruction. The aim of this study is to assign these systems to the corresponding sternal pathologies. Patients and methods: This is a retrospective single-center analysis. Bone pathology is divided into three grades: grade I (good substance/no fractures), grade II (good substance/few transverse fractures), grade III (poor substance/substance defects/multiple transverse fractures). The individual osteosynthesis systems are assigned to the different grades accordingly. The suitability of the individual systems is analyzed in the short term and long term. Results: A total of 130 patients were included. Stable osteosynthesis was achieved in all patients. For grade I defects, 75 plates and 24 clips were used. For grade II defects, mainly plates (255) but also clips (16) were used. A distance system was used 24 times for grade III defects. One plate fractured. No other implant-related complications occurred. Discussion: If the different osteosynthesis systems are used according to the bone pathology, a stable chest wall can be restored in all patients. The individual systems have their own specific characteristics, which must be taken into account with regard to the suitability and invasiveness of the procedure. No single system is suitable for treating all sternal pathologies. Full article

Background/Objectives: Epidermolysis bullosa (EB) comprises a heterogeneous group of rare inherited skin-fragility disorders in which even minimal trauma can cause blistering, chronic wounds, scarring, and functional impairment. After surgical release of EB hand deformities, wound coverage is challenging because autologous split-thickness skin grafting creates an additional donor-site wound in already fragile tissue. This preliminary case series reports our single-center pediatric experience using intact fish skin grafting (iFSG) as an adjunct after EB hand surgery. Methods: We conducted an observational case series of five pediatric patients with dystrophic EB, including eight operated hands, treated between December 2022 and December 2025. iFSG was applied after the release of contractures and/or pseudosyndactyly. Primary outcomes were time to complete re-epithelialization, need for re-application, need for autologous grafting, and early complications. Secondary outcomes included dressing-related pain assessed with an age-appropriate visual analog scale during awake dressing care, dressing burden, and early recurrence signals. Results: The iFSG application was feasible in all cases. One localized second application was required, and no patient required autologous split-thickness skin grafting. Mean dressing-related pain was 1.6 on the visual analog scale, and mean time to complete re-epithelialization was 47.6 days. No allergic reactions occurred. Healing was slower in the two most severe bilateral mitten-hand cases, and one patient developed limited dorsal disepithelialization attributed to prolonged dressing contact on extremely fragile skin. One partial recurrence of pseudosyndactyly was observed during follow-up without the need for revision surgery. Conclusions: iFSG was feasible in this small preliminary pediatric dystrophic EB hand surgery series and may provide a biologically active scaffold that supports secondary closure while avoiding autologous donor-site creation. Because of the rarity of the disease, the limited sample size, the absence of a comparator group, and the limited follow-up, these findings should be interpreted cautiously. Larger multicenter studies with standardized functional, pain, recurrence, and caregiver-reported outcomes are needed to define the role of iFSG in EB hand reconstruction. ABILHAND-Kids was also administered to patients/caregivers and suggested encouraging perceived improvement in postoperative hand use and independence in daily activities. Full article

The annual congress of the Italian Association of Plastic Aesthetic Surgery (AICPE) is one of the most relevant conference meetings in Europe concerning aesthetic plastic surgery as there are a number of participants, over 400, and an international team of invited speakers chosen for their renowned scientific value. The 12th meeting was held in Rimini (Italy) from 6 to 8 June 2025. The scientific issues concerned new advancements in aesthetic surgery. This book of abstracts contains research related to facial surgery, body contouring, breast surgery, and rhinoplasty, also including aesthetic medicine, AI’s impact on the medical profession, and forensic medicine. For the first time, the AICPE established an award in memory of Flavio Saccomanno for the best paper presented by a young surgeon with the endorsement of Surgical Techniques Development by MDPI. Full article

Background: Laparoscopic partial splenectomy (LPS) is a technically demanding procedure. The main difficulty when considering LPS is the bleeding risk. With advancements in technology and a deeper understanding of spleen vascular distribution, LPS has emerged as a feasible and safe procedure. Methods: There are many techniques used in order to prevent bleeding; in our case, we performed LPS using transient main splenic artery clamping. Our case represents a 65-year-old man who was diagnosed with a space-occupying lesion in the lower pole of the spleen and underwent LPS by temporary non-selective occlusion of the splenic artery. Results: The LPS was successfully performed. The surgery length was about 105 min, and it took about 48 min from placement of the bulldog on the splenic artery (warm ischemia), transecting the splenic parenchyma and release of the bulldog. The estimated blood loss was less than 50 mL. The recovery was smooth and uneventful, and the patient was discharged on the third postoperative day. Conclusions: LPS with temporary occlusion of the main trunk of splenic artery is shown to be an effective, practicable and reliable method that is associated with minor operative blood loss. Full article

Background: Total knee arthroplasty in patients with hemophilia remains the most effective surgical intervention for end-stage hemophilic arthropathy, yet it poses unique surgical and perioperative challenges that are rarely encountered in standard osteoarthritis cases. This article synthesizes technical, anatomical, and perioperative considerations specific to hemophilic patients and integrates prospective clinical data derived exclusively from the hemophilic cohort of our long-term study (twenty patients, twenty knees; 2015–2024). Emphasis is placed on deformity correction, bone loss management, implant selection, hemostatic strategies, transfusion patterns, and perioperative pitfalls. The objective is to provide a comprehensive narrative reference for surgeons managing complex hemophilic knees, consolidating both evidence-based recommendations and practical perioperative “tips and tricks” accumulated across more than a decade of clinical experience. Methods: This prospective observational study evaluated twenty consecutive male patients with hemophilia who underwent primary total knee arthroplasty for advanced hemophilic arthropathy between 2015 and 2024 at our institution. The following variables were collected: operative time measured from skin incision to skin closure, postoperative transfusion requirement, length of hospitalization measured in days, early postoperative complications, and functional recovery as assessed by the Knee Society Score. Early complications included postoperative bleeding or hematoma, superficial or deep infection, and stiffness requiring intensive physiotherapy or manipulation under anesthesia. Results: The mean age at the time of surgery was 44.8 years with a standard deviation of 7.2 years, ranging from 31 to 59 years. The mean operative time in the hemophilic cohort was 154.54 min with a standard deviation of 18.36 min. The range of operative time was from 120 to 180 min. Nine of the twenty patients, representing 45 percent, required postoperative blood transfusion. The mean length of hospital stay in the hemophilic cohort was 12.3 days with a standard deviation of 2.38 days, ranging from 9 to 17 days. The mean Knee Society Score improved from 38 points preoperatively to 82 points at final follow-up, representing a mean increase of 44 points. Conclusions: Total knee arthroplasty in hemophilic patients is safe and effective when specialized surgical techniques, comprehensive synovectomy, precise deformity correction, optimized hemostasis, and structured postoperative coagulation factor replacement are implemented. Functional outcomes and prosthetic survival are excellent in experienced centers. Full article

Background/Objectives: Tonsillectomy remains one of the most frequently performed procedures in pediatric otolaryngology. This study compared the clinical efficacy and postoperative morbidity of coblation tonsillectomy (Group A) versus traditional cold dissection (Group B), focusing on postoperative pain, recovery time, and hemorrhagic complications. Methods: A prospective, randomized, single-blinded study was conducted involving 100 pediatric patients (n = 50 per group) aged 3 to 17 years. Patients were monitored for 10 days postoperatively. The primary outcome was pain intensity, measured twice daily using the Wong–Baker FACES Pain Rating Scale. Secondary outcomes included operative time, analgesic consumption, time to return to a normal diet, and secondary hemorrhage rates. Results: The mean operative time for Group A was significantly shorter (18.5 ± 4.2 min) compared to Group B (24.1 ± 5.6 min; p < 0.05). Pain assessment showed significantly lower mean pain scores for the Coblation group during the critical first week. For instance, on Post-op Day 1, the mean pain score was 3.2 for Group A vs. 5.8 for Group B (p < 0.001). Patients in Group A returned to a normal solid diet significantly earlier (mean day 5.2 ± 1.1) than those in Group B (mean day 7.4 ± 1.5; p < 0.01). Secondary hemorrhage occurred in 1 case (2%) in Group A and 1 case (2%) in Group B (p = 1.00). Conclusions: Coblation tonsillectomy significantly reduces postoperative pain and accelerates recovery without compromising the safety profile. The clinical benefits, despite the higher procedural cost, justify its preference in modern pediatric surgical practice due to improved quality of life for the patient. Full article

Introduction: Plantar fasciitis is a common cause of heel pain in adults, with a significant impact on quality of life and athletic performance. While conservative treatments are effective in most cases, a subset of patients remains symptomatic and may require surgical intervention. Minimally invasive techniques, such as bipolar radiofrequency (RF) coblation using the TOPAZ system, have emerged as promising alternatives to traditional open or endoscopic procedures. Methods: This retrospective study evaluated the clinical outcomes of 49 consecutive patients (20 males and 29 females; mean age 54.3 ± 11.4 years; mean BMI 25.3 ± 3.2, range 21.5–34.7) with chronic plantar fasciitis unresponsive to at least six months of conservative treatment. The affected side was left in 24 patients and right in 25, and 35 patients were regularly engaged in sports prior to symptom onset. All patients underwent percutaneous bipolar RF coblation using the TOPAZ device between July 2019 and November 2024. Patient-reported outcome measures—including the Visual Analog Scale (VAS), AOFAS Ankle–Hindfoot Score, SF-36, and Tegner Activity Scale—were collected at the final follow-up (mean 41.7 ± 18.3 months, range 6–71). Results: Statistically significant improvements were observed in pain and function: mean VAS decreased from 8.5 to 3.1 (p < 0.001), and American Orthopaedic Foot and Ankle Society (AOFAS) pain and function scores improved from 2.5 and 12.75 to 28.75 and 38.75, respectively (p < 0.001). The mean Tegner score increased from 1.3 to 4.1 (p < 0.001), with 100% of previously active patients returning to sport. No major complications or reoperations were reported. Conclusions: Percutaneous bipolar RF coblation appears to be a safe and effective treatment for recalcitrant plantar fasciitis, offering significant pain relief, functional improvement, and a high return-to-sport rate with minimal morbidity. This technique may represent a valuable intermediate option between conservative care and open surgery. Full article

Background/Objectives: Chronic otitis media with effusion (OME) is the primary cause of conductive hearing loss in children. High recurrence rates following conventional surgery are often linked to incomplete nasopharyngeal clearance or persistent adenotonsillar biofilms. This study evaluates the long-term impact of endoscopic coblation adenotonsillotomy on middle ear clearance and disease recurrence compared to conventional curettage adenoidectomy. Methods: We conducted a prospective comparative study on 142 pediatric patients with persistent OME. Participants were allocated into Group A (Endoscopic Coblation Adenotonsillotomy, n = 72) and Group B (Conventional Curettage Adenoidectomy, n = 70). Groups were homogeneous regarding age, gender, and baseline audiological parameters (p > 0.05), all presenting with moderate conductive hearing loss and Type B/C tympanograms. Primary outcomes included tympanometric normalization (Type A conversion), auditory gain (Air–Bone Gap closure), and the rate of secondary ventilation tube (VT) insertion, monitored at 1, 3, 6, and 12 months. Results: At the 1-month follow-up, Group A showed a higher normalization rate than Group B (75.0% vs. 60.0%), though this was near the threshold of statistical significance (p = 0.058). However, at 3, 6, and 12 months, the coblation group demonstrated significantly higher recovery rates (p < 0.05). By 12 months, 94.4% of Group A maintained a Type A tympanogram compared to 78.5% in Group B. Group A achieved a significantly lower mean ABG at 12 months (8.2 ± 3.1 dB vs. 12.6 ± 5.4 dB, p < 0.001), reflecting a superior auditory gain (20.2 dB vs. 15.3 dB). Furthermore, the recurrence rate was significantly lower in Group A (4.1% vs. 15.7%, p = 0.021), resulting in a substantially lower requirement for secondary VT insertion compared to the conventional group (2.7% vs. 12.8%, p = 0.018). Conclusions: Endoscopic coblation adenotonsillotomy provides significant long-term clinical advantages over conventional curettage. By ensuring precise, atraumatic clearance of the Fossa of Rosenmüller and addressing the tonsillar biofilm reservoir, this technique achieves more stable middle ear aeration and superior auditory recovery, significantly reducing the necessity for secondary surgical interventions at one year. Full article

Background/Objectives: This study aims to develop and validate a reproducible training model, built using common hospital items, for laparoscopic inguinal hernia repair with an intracorporeal suturing approach, specifically focusing on iliopubic tract redress in pediatric patients. Methods: Pediatric surgery residents and consultants were instructed on model building and engaged in training sessions. They practiced for four weeks with the handcrafted model and completed a post-simulation survey. The time taken to conclude the training task and the modified Objective Structured Assessment of Technical Skills score were compared between the initial and last sessions at the end of the training period. Additionally, the time required by consultants to perform the laparoscopic procedure in vivo, intraoperative complications, and recurrence rates were analyzed from the time they started the training. Results: A feasible model was created using a colostomy dressing support, Penrose drains, Foley catheters, feeding tubes, and surgical gloves to simulate. The sample involved a total of twelve residents and five consultants with an average age of 33 years old. All participants successfully completed the task during the session. Since the consultants started their training on the model, the operative results for laparoscopic inguinal hernia repair in the theater have improved. Conclusions: Training experience on this model led to improve laparoscopic skills such as cutting and dissection and intracorporeal tying and knotting. This study confirms that training outside clinical practice can significantly benefit laparoscopic proficiency and safety in vivo. Full article

Background/Objectives: Superior cluneal nerve entrapment syndrome (SCNES) is an underrecognized cause of chronic low back pain, particularly in adolescents where published experience is limited. This article describes a reproducible open surgical technique for superior cluneal nerve (SCN) decompression. Methods: We outline indications and relative contraindications, required instrumentation, key surface landmarks, and a stepwise operative approach. The nerve is identified where SCN branches traverse the thoracolumbar fascia and fibro-osseous tunnel near the posterior iliac crest. Decompression is performed via limited fasciotomy and release of surrounding soft tissues, with attention given to identifying additional branches requiring release. Results: The technique provides consistent exposure and decompression of the SCN branches using an approximately 5 cm oblique incision centered over the expected crossing point (about 7 cm lateral to the midline and roughly 4 cm lateral to the PSIS). Pearls and pitfalls are provided to reduce peri-incisional numbness and avoid thermal injury to the nerve. Conclusions: Open SCN decompression is a focused procedure that can be considered after confirmation of SCNES by clinical criteria and response to diagnostic block. Standardizing technique and postoperative care may facilitate broader adoption and future outcome studies in pediatric populations. Full article

Background: Cemented fixation remains the standard for total knee arthroplasty (TKA), with Palacos^® R considered the gold standard bone cement. However, more cost-efficient alternatives, like Biomet Bone Cement^® (BBC), require evaluation to confirm comparable outcomes. This retrospective 5-year study compares the clinical safety, performance, and radiographic outcomes of BBC versus Palacos-R in primary TKA, highlighting BBC’s potential as a comparable, cost-effective option amid the increasing cost of outpatient surgeries. Methods: This is a single-center, retrospective study of 128 consecutive patients undergoing primary TKA, evaluated over 5 years. The first 64 patients received Palacos-R, and the subsequent 64 patients received BBC. Radiographic outcomes, including cement gaps, radiolucency, periprosthetic osteolysis, and subsidence, were assessed using the Knee Society Radiographic scheme at immediate post-operative, 6-month, 1-year, 3-year, and 5-year intervals. Clinical outcomes were measured using the Knee Society Score (KSS) and the University of California Los Angeles Activity (UCLA) score. Statistical analyses included chi-square, Fisher’s exact tests, and t-tests (p < 0.05). Results: Cement gaps were significantly higher in the Palacos-R cohort at immediate postop (p = 0.0002) and 1-year (p = 0.0003), with no significant difference at 3 and 5 years. Radiolucency was non-progressive (<2 mm) in both cohorts. KSS was significantly higher in the Palacos-R group at 6 months, 1 year, and 3 years (p < 0.001), but equivalent at 5 years (p = 0.42). UCLA scores showed no differences. No revisions were required in either cohort. Conclusions: While BBC demonstrated comparable radiographic stability and clinical outcomes to Palacos at 5 years with no revisions in either cohort, the absence of preoperative KSS and UCLA scores is a major limitation that prevents adjustment for baseline function and limits interpretation of the early postoperative KSS differences. Full article

Background: Unicompartmental knee arthroplasty (UKA) is an effective treatment for isolated compartment knee osteoarthritis, but it is associated with a higher risk of revisions. UKA-to-TKA conversions remain surgically challenging. In particular, the restoration of correct femoral rotation is difficult, mainly because of bone loss and altered anatomical landmarks. We describe a novel imageless robotic-assisted technique for UKA-to-TKA conversion using the ROSA™ robotic system and report a representative clinical case. Methods: After a standard medial parapatellar approach and joint exposure, the landmarks are registered with the UKA in situ, followed by the standard workflow for a robotic-assisted primary TKA according to the “inverse functional alignment” philosophy (virtual planning, tibial cut, planning adjustment, distal femoral cut and planning adjustment). At last, the femoral component rotation is defined using the FuZion^® tensioner, with the UKA femoral component being left in situ to compensate for the lateral posterior condyle bone loss. Results: A 72-year-old female patient underwent robotic-assisted lateral UKA-to-TKA conversion due to aseptic loosening of the tibial component. Accurate bone resection, restoration of alignment, and soft tissue balancing were achieved, avoiding the use of augments. Postoperative recovery was uneventful, with satisfactory clinical and functional outcomes at 3-month follow-up. Conclusions: Imageless robotic-assisted UKA-to-TKA conversion using the ROSA™ system seems a valuable aid in these complex scenarios. To our knowledge, this is the second report describing this procedure using the ROSA™ robot and the first presenting a distinct surgical technique. Further studies on larger cohorts are needed to confirm this technique efficacy and possible limitations. Full article

Objectives: To evaluate the short-term safety (30-day and in-hospital morbidity and mortality) and technical feasibility of uniportal video-assisted thoracic surgery (U-VATS) for anatomical lung resection in octogenarians (≥80 years) compared with younger patients (<80 years) at a single center. Methods: Ninety consecutive patients undergoing U-VATS anatomical lung resections between January 2020 and January 2024 were retrospectively analyzed. Patients were stratified by age: 60 patients < 80 years and 30 octogenarians ≥ 80 years. Propensity score matching (nearest-neighbor, 1:2 ratio, caliper 0.2 SD) yielded a matched cohort of 60 patients (40 younger, 20 octogenarians) for comparative analysis. Results: After matching, standardized mean differences (SMD) were <0.25 for most covariates, indicating good balance. Octogenarians demonstrated lower FEV1 (75.2 ± 15.3% vs. 87.5 ± 18.2%, p = 0.012) and DLCO (68.4 ± 12.1% vs. 78.5 ± 14.3%, p = 0.009), consistent with age-related pulmonary changes. Charlson Comorbidity Index was higher (5.3 ± 1.2 vs. 3.8 ± 1.4, p = 0.001). Surgical parameters were comparable: operative time (143.80 ± 42.3 vs. 136.55 ± 38.7 min, p = 0.524), blood loss (median 80 [IQR 50–120] vs. 95 [IQR 60–130] mL, p = 0.742). Zero conversions occurred. Major complications (Clavien–Dindo ≥ 3) occurred in 10% vs. 0% (absolute risk difference 10%, 95% CI: −3.2% to 23.2%). No 30-day mortality. 90-day mortality: 5% vs. 0% (p = 0.333); one-year: 15% vs. 0% (p = 0.035). Conclusions: U-VATS is technically feasible in carefully selected octogenarians with comparable intraoperative parameters to younger patients. Postoperative recovery differed meaningfully, with higher delirium rates, longer hospitalization, and greater rehabilitation needs. One-year mortality was higher in octogenarians, reflecting competing comorbid risk rather than surgical harm. Residual imbalance in comorbidity burden and pulmonary reserve after matching limits causal inference. These hypothesis-generating findings support U-VATS in selected octogenarians when comprehensive geriatric assessment and structured delirium prevention guide perioperative management; validation in larger multicenter prospective studies is required. Full article