須田 隆

We report the surgical technique for subxiphoid robotic thymectomy with combined superior vena cava (SVC) resection. A blood-drainage cannula was inserted into the left internal jugular vein as a blood-drainage route. A blood infusion cannula was inserted into the left femoral vein. During SVC clamping, an assistant pumped blood through the circuit to prevent clotting. The tumour, SVC, thymus, part of the pericardium and part of the right lung were excised en bloc through a subxiphoid incision. We limited reconstruction to the right brachiocephalic-SVC anastomosis. Robotic-assisted thymectomy via the subxiphoid approach enables SVC replacement, which was previously feasible only with open surgery.

BACKGROUND: Uniportal thoracoscopic surgery has gained popularity as a minimally invasive approach for anatomical lung resection. While outcomes from high-volume centers have been reported, evidence describing nationwide real-world practice across institutions with varying experience is scarce. This study aimed to evaluate the current status and perioperative outcomes of uniportal thoracoscopic anatomical pulmonary resections in Japan. METHODS: We conducted a multicenter retrospective study under the Japanese Uniportal Video-assisted Thoracoscopic Surgery Interest Group. Patients with primary lung cancer who underwent uniportal thoracoscopic lobectomy or segmentectomy in Japan between April 2018 and March 2023 were included. Clinical information was collected from participating institutions, and patient characteristics, operative variables, and perioperative outcomes were evaluated. The primary outcome was the incidence of procedure-related complications, with secondary outcomes including operative time and other perioperative parameters. RESULTS: A total of 3,546 patients were analyzed, comprising 2,780 lobectomies and 766 segmentectomies. The proportion of segmentectomies gradually increased during the study period. In the lobectomy group, the median operative time was 170 min, with prolonged air leak in 7.6% and significant vessel injury in 3.4%. In the segmentectomy group, the median operative time was 154 min, with prolonged air leak in 4.6% and significant vessel injury in 3.5%. Thirty-day mortality was 0.3% in both groups, and conversion to multiport or thoracotomy occurred in 1.8-3.6% of cases. CONCLUSIONS: This nationwide analysis indicates that uniportal thoracoscopic anatomical pulmonary resection is performed safely in Japan, with perioperative outcomes comparable to those reported internationally. Although operative times were slightly longer than those in single-institution series, complication rates remained low, indicating that uniportal thoracoscopic anatomical pulmonary resection is being conducted with acceptable perioperative outcomes in real-world practice.

Uniportal video-assisted thoracoscopic surgery (VATS) is considered the optimal access method for pneumothorax surgery. Currently, uniportal VATS is used worldwide because it requires an incision in only one intercostal space, which simplifies postoperative pain control, due to reduced acute pain, and the incidence of chronic pain is also potentially lower. It is essential to tailor the surgical technique to each individual case, ensure reliable closure of air leaks, and minimize the risk of recurrence. This article introduces the practical aspects of uniportal VATS for pneumothorax, focusing on the pitfalls. Moreover, detailed methodologies for the lateral intercostal approach for uniportal lung wedge resection, and subxiphoid uniportal bilateral lung resection are provided. During lung resection (bullectomy) for primary spontaneous pneumothorax, the reinforcement-equipped cartridge is used to prevent recurrence, and an oxidized regenerated cellulose sheet is applied as a covering material. In the case of secondary spontaneous pneumothorax, in addition to the oxidized regenerated cellulose sheet, the most appropriate reinforcement material is applied after the surgical procedure. During lung resection, the planned resection line should be marked as needed to clearly define the resection area and ensure no residual lesions are left behind. When partial lung resection is challenging, or in cases of air leakage from a pedunculated bulla, suture closure or ligation may be required. The most common approaches include direct suturing of the damaged pleura or ligating the base of the bulla. Given the condition of the underlying lung, reinforcement with covering materials is essential in all cases. This article includes numerous visual materials, including figures and videos, to illustrate the uniportal VATS technique for pneumothorax. Irrespective of the technique used, it is necessary for clinicians to undergo training, refine their skills, and select the appropriate instruments.

OBJECTIVE: Thymomas sometimes are located in the cervical region, and strategies are needed to safely remove these tumors. The purpose of this study was to evaluate the feasibility and safety of subxiphoid robotic thymectomy (SRT) for anterior mediastinal tumors located in cervical region. METHODS: This was a retrospective database review of patients who underwent SRT from January 2011 to April 2024. Of the 81 patients who underwent SRT for anterior mediastinal tumors, 79 patients were included, excluding 2 patients who underwent reconstruction using artificial blood vessels. RESULTS: In total, 41 patients in whom part of the tumor was located above or in contact with the innominate vein were classified as group A, and 38 patients in which the tumor was located caudal to the innominate vein were classified as group B. The patients in group A were significantly younger (median, 54 years vs 63 years; P = .035). There were no differences in perioperative data between the 2 groups: operative time (median, 192 vs 188 minutes; P = .961), intraoperative blood loss (median: 5 vs 5 g; P = .235), combined resection rate (17.1% vs 21.1%; P = .776), duration of thoracic drain insertion (median: 1 vs 1 day; P = .221), postoperative hospital stay (median: 4 vs 4 day; P = .694), and postoperative complications (9.8% vs 5.3%; P = .677). Conversion to other approaches and perioperative mortality were not observed in either group. CONCLUSIONS: SRT, which enables full visualization of the innominate vein from the midline view, may offer increased safety for complicated thymectomies, including those requiring combined resection of the innominate vein, and may demonstrate safety comparable with that of procedures performed for cases caudal to the innominate vein.

BACKGROUND: Postoperative pneumonia is a serious lung cancer surgery complication. Perioperative oral management can help prevent its development. OBJECTIVES: This study aimed to determine the characteristics of patients who developed postoperative pneumonia despite perioperative oral management. METHODS: This study included 396 consecutive patients who underwent lung cancer surgery under general anesthesia at Fujita Health University Okazaki Medical Center from April 2020, the opening of the hospital, to the end of December 2023. Patient data, including age, gender, body mass index, underlying disease, smoking index, spirogram, operative time, amount of blood loss during operation, and operative procedure, were obtained from medical records. Oral examinations were conducted to determine the number of remaining teeth and whether dental caries are present and to examine tooth mobility and probing pocket depths > 4 mm. Furthermore, the patients were asked whether they had regular dental checkups. The patients were divided into the pneumonia and no-pneumonia groups following lung surgery, and the factors involved in postoperative pneumonia were investigated. RESULTS: A total of 390 patients were analyzed (six were excluded), of whom 33 developed postoperative pneumonia. Among them, 17 were excluded from the analysis due to preoperative interstitial pneumonia. Consequently, the incidence of postoperative pneumonia was 16 of 373 patients (4.3%). Significant differences were observed between the groups in terms of age, sex, chronic obstructive pulmonary disease, smoking index, operative time, number of remaining teeth, and regular dental checkups. Logistic regression analysis using these significant items revealed that fewer than 20 remaining teeth were significantly associated with the development of postoperative pneumonia (p = 0.043). CONCLUSIONS: The results of this study indicated that the incidence of postoperative pneumonia following perioperative oral function management was maintained as low as that reported previously. The importance of dental intervention in the perioperative period was also elucidated. A high number of patients who developed postoperative pneumonia despite these interventions had fewer than 20 remaining teeth, suggesting that more attention should be paid to perioperative oral management, including the prevention of aspiration pneumonia.