A Pulley-Assisted Ligature Technique for Safe and Versatile Vascular Division During Uniportal Video-Assisted Thoracic Surgery

Uniportal video-assisted thoracoscopic surgery (uVATS) provides excellent postoperative outcomes but limits instrument triangulation, making vascular stapling particularly challenging. We developed a simple "pulley technique" using a loop ligature device to create gentle, multidirectional, and dynamically adjustable traction during pulmonary vessel division. This technique involves passing a vessel tape around the target vessel through a loop ligature device and externalizing the tape to allow controlled retraction. The system stabilizes the vessel, improves the angle for stapler insertion, and minimizes the risk of overstretching. Compared with conventional traction methods, the pulley mechanism reduces instrument collision and provides more predictable tension distribution. The technique was successfully applied in multiple lobectomies and segmentectomies without vascular injury or conversion. Its simplicity, reproducibility, and low cost make it a valuable adjunct for improving safety and efficiency in uVATS.