PRP was a valid preoperative strategy to improve physical performance in patients with both NSCLC and COPD and this advantage was also maintained after surgery.

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Objective: Erector spine plane block (ESPB) is a newly defined regional anesthesia technique performed by injection of local anesthetic beneath the erector spine muscle. We tested ESPB as a regional rescue analgesia bedside technique to be performed in the thoracic surgical ward, reporting a 7-patient case series. Methods: We report our experience in rescue analgesia after thoracic surgery. During the postoperative stay, numeric rating scale (NRS) score >3 and inability to perform physiotherapy or effective cough due to postoperative pain represented the criteria for proposing rescue analgesia with ESPB. NRS at rest and during movements was recorded; blood gas analysis and spirometry were performed to evaluate PaO2/FiO2 (P/F), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) before ESPB execution. After performing the ESPB, static and dynamic NRS, P/F, and FVC and FEV1 were recorded at 40 minutes and 80 minutes. Results: NRS had a reduction at rest and in dynamic assessment. The P/F did not improve but spirometric measures improved. FVC had a relevant improvement only after 80 minutes; FEV1 was increased after 40 minutes. Conclusion: The use of ESPB as postoperative rescue analgesia can offer several advantages due to effective rescue analgesia and safety that makes it easy to perform in the thoracic surgical ward or in an outpatient clinic setting.

Morgagni hernia is a relatively uncommon congenital diaphragmatic hernia in which abdominal contents protrude into the chest through the foramen of Morgagni. It usually occurs on the right side of the chest but may occur on the left side or in the midline. In adults, it commonly presents with non-specific symptoms such as dyspnea, cough, gastroesophageal reflux disease and other. Surgical repair should be always performed to prevent the risk of hernia incarceration. Transthoracic approach has been proposed especially in cases with indeterminate, anterior pericardial masses. We believe that in adult obese patients with Morgagni hernia and voluminous hernial sac containing only omentum, the transthoracic approach can represent a valid alternative to transabdominal approach. The use of hybrid robotic thoracic surgery can be strongly recommended because it allows, through robotic instruments, to perform delicate surgical maneuvers in difficult to reach anatomical areas and, with the final extension of a port-site incision, to remove voluminous specimens from the thoracic cavity, avoiding the chest wall discomfort that follow the thoracotomy access.

Between April 2016 and October 2017, we retrospectively reviewed all patients undergoing excision of large mediastinal masses using a hybrid robotic thoracic approach at the Unit of Thoracic Surgery of Monaldi Hospital in Naples. The inclusion criteria for this approach were: evident unilateral predominance of the mass; absence of invasion to surrounding structures. Planned conversion to sternotomy was necessary in one patient for tenacious adhesions between the mediastinal goiter and the left innominate vein. In all cases the postoperative course was uneventful. The hybrid robotic approach, adopted in our Unit, consists of a thoracic procedure performed completely with articulated surgical instruments under three-dimensional vision and followed by final extension of a port-site incision to retrieve the voluminous specimen. This approach uses all the advantages of robotic technology that enables to perform a fine dissection in the small space of the anterior mediastinum and at the same time, through the simple extension of a minimally invasive access, avoids the painful sequelae of thoracotomy. In selected cases, with increased experience in robotic surgery, it can be proposed for excision of large mediastinal masses, although a longer follow-up period is necessary to validate our findings.

In this article we report two cases of left lower lobe lung cancer undergoing a surgical procedure that allowed the preservation of lung parenchyma and avoided pneumonectomy. The first case concerned a left lower lobe non‐small cell lung cancer with extracapsular spread in a metastatic interlobar lymph node and the second a left lower lobe lung cancer with invasion of the pulmonary artery at the origin of lobar branches to the lower lobe. In both cases, a lung‐sparing surgical treatment was preferred and a left lower lobectomy was performed with division of lingular arteries and the interlobar artery, preserving the remaining arterial branches to the upper lobe.

A knowledge of pulmonary vein anatomy variants allows an appropriate preoperative radiological assessment and safe surgical management of vascular anomalies in patients undergoing major lung resections. In our case, multiple pulmonary vein variations were identified pre‐ and intraoperatively in a patient undergoing thoracoscopic right lower lobectomy and included superior and common basal veins from the right lower lobe draining separately into the left atrium, middle lobe veins joining the superior segment right lower lobe vein and additional superior segment right lower lobe vein draining directly into the left atrium. The recognition of these anatomical abnormalities in pulmonary veins may help thoracic surgeons avoid surgical complications in patients undergoing anatomical lung resections.