Routine conventional leak test is not required for robotic major pulmonary resections.

Objective: We retrospectively evaluated whether or not conventional air leak testing is necessary in robotic major pulmonary resections.

Methods: After excluding patients who received 2 or more days of postoperative drainage for chylothorax or excessive pleural effusion, 578 patients who underwent major pulmonary resection using minimally invasive approaches between February 2019 and November 2023 at our institution were included in this study. All patients were divided into two groups including thoracoscopic (n = 471) and robotic (n = 107) approaches.

A robotic fissureless right upper lobectomy using a posterior approach.

The fissureless technique in a lobectomy is considered useful to avoid postoperative prolonged air leak when a fissure is fused because it is not dissected. In particular, this technique has been used most frequently in right upper lobectomies because the dense fissure was most frequently found between the right upper and middle lobes. We believe that the surgical steps in this technique should be modified depending on the surgical approach, although the concept that the hilar structures, including the pulmonary vessels and bronchi, are each transected prior to division of a dense fissure is the same.

A robotic left S6 and S1/2c segmentectomy using the lung-inverted approach.

In pulmonary segmentectomy, the dominant pulmonary arteries are traditionally divided at the fissure. However, this approach sometimes leads to inadvertent injury to the pulmonary artery and prolonged air leak when the fissure is fused. To overcome these problems, by taking advantage of the good visualization provided by robotic surgery, we have adopted the lung-inverted approach without fissure dissection for segmentectomy.

Feasibility and Safety of Uniportal Thoracoscopic Segmentectomy Using a Unidirectional Dissection Approach without Dissecting a Fissure.

: Few original articles describe the perioperative outcomes of uniportal thoracoscopic segmentectomy using a unidirectional dissection approach. In this retrospective study, we evaluated the feasibility and safety of this procedure. : This study included 119 patients who underwent uniportal thoracoscopic segmentectomy in our department between February 2019 and December 2022.

Uniportal thoracoscopic mediastinal lymphadenectomy using appropriate surgical steps.

Background: Although lymphadenectomies play an important role in the surgical treatment of patients with non-small cell lung cancer (NSCLC), the quality of lymphadenectomies via a uniportal approach has only been evaluated in a few studies. We describe the surgical steps for a mediastinal lymphadenectomy via uniportal video-assisted thoracoscopic surgery (uVATS) and compare the quality of mediastinal lymphadenectomies using uVATS versus multiportal video-assisted thoracoscopic surgery (mVATS).

Methods: Between April 2017 and January 2023, we analyzed data from 304 patients with NSCLC who underwent (bi-)lobectomy with nodal dissection (ND)2a-1 or greater lymphadenectomy via uVATS or mVATS.

Robotic upper division segmentectomy of the left upper lobe without turning the lung.

The fissureless technique in lobectomy or the unidirectional dissection technique in segmentectomy is considered useful to avoid a postoperative prolonged air leak if a fissure is fused because it is not dissected. Another advantage of this technique is that it does not require repeated rotation of the lung to obtain a good surgical view, which may result in a shorter operating time. We believe that this technique is suitable for a robotic approach because we sometimes find it difficult to rotate the lung parenchyma in the limited rigid thoracic cavity when using the robotic approach.

Two cases of lower lobe segmentectomy (left and right) using the lung-inverted approach in a robotic operation.

In pulmonary segmentectomy, the dominant pulmonary arteries are conventionally divided at the fissure. However, this approach sometimes leads to accidental injury of the pulmonary artery and prolonged air leaks when the fissure is fused. To overcome these problems, we have adopted the lung-inverted approach without dissection of a fissure for segmentectomy, taking advantage of the good view provided by robotic surgery.

Comparison of the Learning Curve between Uniportal and Robotic Thoracoscopic Approaches in Pulmonary Segmentectomy during the Implementation Period Using Cumulative Sum Analysis.

Background: The aim of this retrospective study was to compare the learning curve and perioperative outcomes between the two approaches uVATS and RATS during their implementation periods.

Methods: The uVATS group included 77 consecutive uVATS segmentectomies performed by HI between February 2019 and June 2022, while the RATS group included 30 between July 2022 and September 2023. The patient characteristics, perioperative outcomes, and learning curves were compared between the two groups.

A robotic left S1+2c subsegmentectomy using preoperative simulation.

Although there are reports describing segmentectomy by a robotic approach, reports describing robotic subsegmentectomy are rare because this procedure requires more precise anatomical knowledge and exposure of subsegmental pulmonary vessels and bronchi. However, the robotic approach has several advantages, including a high-definition 3-dimensional surgical view and precise motion without tremor, which may allow us to perform the subsegmentectomy more easily. Considering these advantages of the robotic approach, we successfully performed a robotic left S1+2c segmentectomy with a short console time and a good postoperative course.

A robotic anterior (S3) segmentectomy of the left upper lobe.

A robotic approach might be more suitable for pulmonary segmentectomy than the conventional thoracoscopic approach, because the high-definition 3-dimensional surgical view and precise motion without tremor allow us to dissect pulmonary vessels and bronchi to the periphery. However, among several types of segmentectomies, the anterior segmentectomy (S3) of the left upper lobe may be one of the most difficult to achieve in the robotic approach because the dissected hilar region tends to be obstructed by the lung parenchyma in the "looking-up" view. We offer two technical tips to achieve robotic left S3 segmentectomy.

A robotic fissureless left lower lobectomy.

The fissureless technique is considered one of several useful techniques for patients with a fused fissure to avoid postoperative prolonged air leak. When performing the fissureless technique for a lower lobectomy, we consider two important points necessary to perform this technique safely and appropriately. The first is not to injure the pulmonary artery behind the lower bronchus when encircling or dividing it.

Learning curve for uniportal thoracoscopic pulmonary segmentectomy: how many procedures are required to acquire expertise?

Background: Minimally invasive surgeries are increasingly being performed. However, few studies have evaluated the learning curve for uniportal thoracoscopic segmentectomies. Therefore, we investigated the learning curve for uniportal thoracoscopic segmentectomy in our department.

Early chest drain removal on the day of uniportal thoracoscopic segmentectomy.

Objective: Although early removal of postoperative chest drains can facilitate recovery, it can be difficult to achieve in segmentectomy due to the management of air leakage in intersegmental planes. This study prospectively examined the feasibility of drain removal on the same day of uniportal thoracoscopic segmentectomy.

Methods: Twenty patients who underwent uniportal thoracoscopic segmentectomy between July 2021 and May 2022 were enrolled in this prospective study.

Anterior unidirectional approach in a uniportal thoracoscopic anterior segmentectomy (S3) of the right upper lobe for a dense fissure.

Most types of segmentectomies require dissection of a fissure to expose the pulmonary arteries, which is considered a conventional technique. Therefore, it is necessary to deal with a dense fissure in a pulmonary segmentectomy as well as in a lobectomy. Nevertheless, only a few reports describe the operative technique for managing a dense fissure in a pulmonary segmentectomy.

A uniportal thoracoscopic fissureless lingual segmentectomy for a patient with a dense fissure.

Postoperative prolonged air leak is one of the most common morbidities in general thoracic surgery, and a dense fissure is considered to be one of the main causes of prolonged air leak. In a patient with a dense fissure, the fissureless technique is considered one of the most useful options to avoid prolonged air leak, which has been reported in several previous articles after a lobectomy. However, there are few reports describing the operative technique to treat a dense fissure via a pulmonary segmentectomy, although the management of a dense fissure is necessary in a pulmonary segmentectomy as well as in a lobectomy.

Right basal bronchial fistula due to amebic infection: a case report.

Background: Pleuropulmonary amebiasis is the second most common form of extraintestinal invasive amebiasis, but cases that include bronchopleural fistula are rare.

Case Presentation: A 43-year-old male was referred to our hospital for liver abscess, right pleural effusion, and body weight loss. He was diagnosed with a bronchopleural fistula caused by invasive pleuropulmonary amebiasis and human immunodeficiency virus (HIV) infection.

Primary pulmonary pleomorphic liposarcoma found with a massive hemothorax.

Background: Pleomorphic liposarcoma (PLPS) is a rare and aggressive subtype of liposarcoma. Here we report the case of a 45-year-old man with PLPS in the lung, which was accompanied by a massive hemothorax.

Case Presentation: The patient presented to hospital with chest pain.

Standardization of intra- and peri-operative management to reduce postoperative drainage time after major thoracoscopic pulmonary resections.

Background: It is important to reduce the postoperative drainage time after thoracic surgery to relieve postoperative pain and facilitate patient mobilization. We standardized intra- and peri-operative management of major, thoracoscopic pulmonary resections in February 2019. In this study, we investigated whether this standardization reduced the postoperative drainage time.

Supervision by an experienced surgeon can reduce the learning curve of uniportal thoracoscopic lobectomy.

Background: This retrospective study was performed to investigate the learning curve of uniportal thoracoscopic lobectomy with ND2a-1 or greater lymphadenectomy for two senior surgeons, and to evaluate how supervision affected the learning curve.

Methods: Between February 2019 and January 2022, 140 patients with primary lung cancer underwent uniportal thoracoscopic lobectomy with ND2a-1 or greater lymphadenectomy in our department. Two senior surgeons (HI and NM) performed most of the operations, with junior surgeons performing the rest.

[Gefitinib Monotherapy Afforded Long-Term Survival of an Octogenarian Patient with a Postoperative Recurrence of a Pulmonary Adenocarcinoma-A Case Report].

An 83-year-old(at the time of postoperative recurrence)female clinically diagnosed with primary lung cancer underwent right upper lobectomy and lymph node dissection(ND2a-2). Postoperative pathological staging revealed a Stage ⅠB (pT2aN0M0)adenocarcinoma that was EGFR mutation-positive(exon 21: L858R). Fifty-one months after surgery, the patient developed a mediastinal lymph node metastasis, and radiotherapy was delivered.

A dense fissure is not a contra-indication for uniportal thoracoscopic lobectomy.

Background: A dense fissure is a main cause of a postoperative prolonged air leak (PAL). Such a fissure, if exposed, sometimes incidentally injures the pulmonary artery. We investigated whether uniportal thoracoscopic lobectomy which is considered technically more difficult than the conventional multiportal approach was appropriate for patients with dense fissures.

[Multidisciplinary Treatment for Postoperative Recurrent Patients-Report of a Long-Term Survivor].

We present a long-term survivor who received multidisciplinary treatment for a postoperative recurrence. A 52-year-old female who had been clinically diagnosed with primary lung cancer underwent a right lower lobectomy, middle lobe wedge resection, and lymph node dissection(ND2a-1), and was pathologically diagnosed with primary pulmonary papillary adenocarcinoma( pT3N0M0, Stage ⅡB)positive for a sensitizing EGFR mutation(L858R). The patient was given UFT as postoperative adjuvant chemotherapy for 2 years.

Infrared thoracoscopic extended lobectomy (right upper lobe and S6) with intravenous indocyanine green administration using preoperative simulation to ensure safe surgical margin.

Although it is crucial to ensure a sufficient surgical margin for a malignant neoplasm, we sometimes struggle to achieve this goal using a minimally invasive approach because it is difficult to palpate the tumor adequately via the small skin incision. To overcome this issue, we adopted a preoperative simulation method for a patient undergoing a right upper lobe and a posterior segmentectomy of the lower lobe (extended lobectomy) and obtained successful results. The discrepancy between the virtual and the actual surgical margins was 5 mm.