TAKAHIRO NEGI

We report subxiphoid uniportal robotic thymectomy without intercostal access using the da Vinci Xi multi-port robot system. A 4-cm vertical incision was made 1 cm caudal to the xiphoid process. The AIRSEAL ROBOTIC SOLUTION, an air seal system compatible with the da Vinci port was used to insufflate CO2 at 8 mmHg. During port insertion, the left and right hands were crossed into the wound, with the camera, left hand, and right hand inserted in the order from the anterior chest to the dorsal side. To reduce the interference between the ports at the head, a key technique is to pull the camera port forward to prevent it from colliding with the other ports. Subxiphoid uniportal robotic thymectomy using the da Vinci Xi is a technique that combines excellent surgical visibility from the subxiphoid process, minimal invasiveness and enhanced operability provided by the robotic system.

We performed the first case of major lung resection using the hinotori™ surgical robot system, which is a new surgical support robot system developed in Japan. A left lower lobectomy and subcarinal lymph node dissection were performed. The operation time was 3 h and 5 min, the cockpit time (console time) was 2 h and 5 min, and the blood loss was 40 g. Although the hinotori™ surgical robot system requires further improvements to be used for lung cancer surgery, even in its current state, there is no difference in operability compared to the da Vinci robot, and it is possible to perform the same surgery. Further evaluation with additional cases is required in future.

BACKGROUND: We previously reported on subxiphoid uniportal thymectomy (SUT) and subxiphoid robotic thymectomy (SRT). This descriptive study aimed to evaluate the feasibility and safety of both SUT and SRT techniques. METHODS: Between March 2011 and December 2022, 268 patients underwent subxiphoid thymectomy. In cases demonstrating no evidence of invasion into other organs, SUT was selected due to its minimal invasiveness. In cases where the tumor was in contact with the innominate vein or those with suspected invasion into other organs, SRT with additional intercostal ports was selected due to the enhanced operability provided by the robotic system. The patients' backgrounds and the perioperative outcomes of each technique were evaluated. RESULTS: SUT was performed in 207 patients, while SRT was performed in 61 patients. In the SUT group, 15 patients required an additional intercostal port, and 2 patients required a median sternotomy; the SUT completion rate was 91.78%. The median operative time was 117.00 [interquartile range (IQR), 88.00-148.50] min, with a median blood loss of 5.00 (IQR, 1.00-5.00) mL. Combined resection was performed in 11 (5.31%) patients, and postoperative complications were observed in 4 patients (1.93%). None of the patients in the SRT group required median sternotomy. The median operative time was 203.00 (IQR, 158.00-278.00) min, with a median blood loss of 5.00 (IQR, 5.00-22.00) mL. Combined resection was performed in 14 patients (22.95%), and postoperative complications were observed in 5 patients (8.20%). No mortalities occurred in either group. CONCLUSIONS: Subxiphoid thymectomy is a safe and feasible technique for both early and advanced stages of the disease requiring complex surgical procedures.

The potential advantages of video-assisted thoracoscopic surgery (VATS) for children include better cosmetic outcomes and reduced risk of postoperative musculoskeletal deformities. The uniportal approach is expected to promote minimally invasive surgery and help reduce the incidence of postoperative musculoskeletal deformities. Uniportal VATS was performed safely in three children (mean age of 23.3 months) with congenital pulmonary airway malformation or extralobar pulmonary sequestration. Our findings suggest that minimally invasive lobectomy may be achieved through uniportal VATS in children.

BACKGROUND: Lung cancer frequently occurs in lungs with background idiopathic interstitial pneumonias (IIPs). Limited resection is often selected to treat lung cancer in patients with IIPs in whom respiratory function is already compromised. However, accurate surgical margins are essential for curative resection; underestimating these margins is a risk for residual lung cancer after surgery. We aimed to investigate the findings of lung fields adjacent to cancer segments affect the estimation of tumor size on computed tomography compared with the pathological specimen. METHODS: This analytical observational study retrospectively investigated 896 patients with lung cancer operated on at Fujita Health University from January 2015 to June 2020. The definition of underestimation was a ≥10 mm difference between the radiological and pathological maximum sizes of the tumor. RESULTS: The lung tumors were in 15 honeycomb, 30 reticulated, 207 emphysematous, and 628 normal lungs. The ratio of underestimation in honeycomb lungs was 33.3% compared to 7.4% without honeycombing (P=0.004). Multivariate analysis showed that honeycombing was a significant risk factor for tumor size underestimation. A Bland-Altman plot represented wide 95% limits of agreement, -40.8 to 70.2 mm, between the pathological and radiological maximum tumor sizes in honeycomb lungs.

We report a lateral approach using the grasping technique for uniportal major lung resection. Grasping dissected tissue with grasping forceps enables the dissected surface to be three-dimensionally dissected from important organs, such as blood vessels, which, therefore, makes the procedure safe. Furthermore, there is an incision wound on the middle axillary line at the 6th intercostal space, and therefore, either the anterior or posterior side of the hilum can be easily observed, and a stapler can pass through all structures of the hilum easily.

INTRODUCTION: Thoracoscopic lobectomy for primary lung cancer is performed at many institutions. However, few reports are available on postoperative prognosis for progressive stages. In 2004, we adopted lobectomy by video-assisted thoracoscopic surgery (VATS), which would be applicable to the clinical stages up to stage IIIA. This study reports long-term outcomes of surgery for primary lung cancer at several stages, including IIIA. METHODS: We compared the long-term outcomes of 315 VATS cases with those of 159 open thoracotomy cases. RESULTS: The overall 5-year survival rate was 78.1% for the VATS group and 61.9% for the open thoracotomy group. A statistically significant difference between the survival curves of the two groups was observed (P = .001). When analyzing the survival curves for both groups by pathological (p) stage, significant differences were observed for p-stages IB and IIIA, with the VATS group producing better results than the open thoracotomy group. CONCLUSION: The long-term outcomes of patients with primary lung cancer at our institution were more favorable in the group undergoing VATS lobectomy than in the group undergoing open thoracotomy.

OBJECTIVES: The aim of the present study was to examine some initial results and learning curves concerning subxiphoid single-port thymectomy (SSPT), thereby clarifying the safety of this surgical approach and describing the precautions for adopting it. METHODS: From March 2011 to August 2019, a total of 203 patients underwent thymectomy for either anterior mediastinal tumours or myasthenia gravis at Fujita Health University Hospital. Of these 203 patients, 147 patients who had undergone SSPT were selected as participants for the present study. RESULTS: Of the 147 cases, transition to a different approach was required in three (2.0%) cases: two (1.3%) cases transitioned to median sternotomy, whereas one (0.7%) case transitioned to the side chest trans-intercostal approach. The two cases that transitioned to median sternotomy were the second cases for different operators after they began performing this technique. There were six (4.0%) cases with complications and no deaths. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 38th case. In the 83 cases handled by one surgeon, the learning curves descended from the 31st case. CONCLUSIONS: SSPT is a safe modality with few complications and no associated cases of mortality reported. Operators are required to experience 31-38 cases until the operation time for SSPT was stabilized. Special care should be exercised to prevent vascular damage in the vicinity of the innominate veins during the early stages after SSPT introduction.

Subxiphoid uniportal bilateral lung wedge resection, in which all manipulations are performed via a 3-cm wound positioned below the xiphoid process, can be performed in the supine position without the patient having to change positions. It also enables one-stage bilateral lung resection. We report the surgical procedure and initial results of subxiphoid uniportal bilateral lung wedge resection. A 3-cm transverse incision was made 1 cm caudally below the xiphoid process. A port for uniportal surgery was inserted. After CO2 insufflation at 8 mmHg, the lung was grasped and lifted with bent grasping forceps, and by bending the tip of a stapler, the surgeon resected the affected portion of the bilateral lungs. In this approach, there is one incision, no intercostal nerve damage and bilateral surgery can be performed in the same procedure; therefore, the technique may have the benefit of lesser invasiveness for the patient. Furthermore, a detailed comparison of subxiphoid uniportal bilateral lung wedge resection with the one-stage lateral intercostal approach with a larger subject sample is needed.

OBJECTIVE: We compared post-thoracotomy pain syndrome (PTPS) incidence in patients who underwent uniportal or multiportal video-assisted thoracoscopic surgery (VATS). METHODS: We included 223 patients who underwent either uniportal or multiportal VATS between January 2017 and October 2018 (pulmonary lobectomies and pulmonary segmentectomies-uniportal: n=19, multiportal: n=133; wedge lung resections-uniportal: n=16, multiportal: n=55). We retrospectively studied incidences of PTPS in all subgroups. RESULTS: Incidences of PTPS were significantly less for uniportal procedures for both the pulmonary lobectomy/segmentectomy group (P=0.024) and the wedge lung resection group (P=0.0315) than for multiportal procedures. CONCLUSION: Patients who underwent uniportal VATS procedures had lower incidences of PTPS than the multiportal VATS group. The uniportal VATS approach is therefore beneficial for patients.

OBJECTIVE: Precise prediction of postoperative pulmonary function is extremely important for accurately evaluating the risk of perioperative morbidity and mortality after major surgery for lung cancer. This study aimed to compare the accuracy of a single-photon emission computed tomography/computed tomography (SPECT/CT) method that we recently developed for predicting postoperative pulmonary function versus the accuracy of both the conventional simplified calculating (SC) method and the method using planar images of lung perfusion scintigraphy. METHODS: The relationship between the postoperative observed % values of the forced expiratory volume in 1 second (FEV1) or diffusing capacity for carbon monoxide (DLCO or DLCO') and the % predicted postoperative (%ppo) values of FEV1, DLCO, or DLCO' calculated by the three methods were analyzed in 30 consecutive patients with lung cancer undergoing lobectomy. RESULTS: The relationship between the postoperative observed % values and %ppo values calculated by the three methods exhibited a strong correlation (Pearson r>0.8, two-tailed p<0.0001). The limits of agreement between the postoperative % values and %ppo values did not differ among the three methods. The absolute values of the differences between the postoperative % values and %ppo values for FEV1 and DLCO' were comparable among the three methods, whereas those for DLCO of SPECT/CT were significantly higher than those of the planar method. Conversely, in patients with preoperative %DLCO' of <80% predicted, the absolute values of the differences between the postoperative %DLCO' and %ppoDLCO' of SPECT/CT tended to be smaller than those of the SC and planar methods. CONCLUSION: The accuracy of SPECT/CT for predicting postoperative pulmonary function is comparable with that of conventional methods in most cases, other than in some patients with diffusion impairment.

Background: This study aimed to investigate the initial results of an endoscopic surgical approach for the treatment of intramediastinal ectopic parathyroid adenoma and to evaluate the effectiveness of a single-incision resection using the subxiphoid approach. Methods: Five cases of patients (1.89%) were diagnosed with ectopic mediastinal parathyroid tumor and underwent resection from 2008 to 2017 in Fujita Health University Hospital. They were retrospectively analyzed. Results: Four patients underwent single-port mediastinal tumor resection using the subxiphoid approach and 1 patient underwent multi-port mediastinal tumor resection using the lateral thoracic approach. The operation time was 134±83.52 min, and the amount of blood loss was 81.8±173.41 mL. The rate of conversion to thoracotomy was 0%, and no intraoperative or postoperative complications were observed. The amount of postoperative oral analgesics was 112.83±209.12 tablets, and their administration period was 561.6±1,229.5 days. The length of hospital stay was 4±2.35 days, and the duration of chest tube drainage was 1.33±1.95 days. The patient who underwent multi-port mediastinal tumor resection using the lateral thoracic approach reported postoperative pain. Serum calcium levels decreased from 10.56±1.52 mg/dL preoperatively to 8.96±0.5 mg/dL postoperatively, and serum phosphorous levels increased from 2.84±0.42 mg/dL preoperatively to 3.6±0.51 mg/dL postoperatively. Intact-PTH hormone levels decreased from 221±169.84 pg/dL preoperatively to 70.2±44.28 pg/dL postoperatively. No recurrence of hyperparathyroidism has been observed in any patient. Conclusions: The single-incision mediastinal tumor resection via the subxiphoid approach, without going through the intercostal space, is considered as a useful endoscopic surgical approach for the treatment of mediastinal ectopic parathyroid adenomas due to the limited occurrence of post-thoracotomy pain syndrome and the superior esthetic outcomes associated with the procedure as compared to thoracotomy and median sternotomy.