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Background: Prolonged air leakage after a lobectomy remains a frequent complication in patients with dense fissures. To avoid postoperative air leakage, we used the "thoracoscopic fissureless technique" for patients with dense fissures. A thoracoscopic approach is useful for the fissureless technique because it gives a good operative view from various angles without dividing the fissure. In this study, we compared the perior intraoperative results of thoracoscopic fissureless lobectomies to traditional lobectomies with fissure dissection for pulmonary artery (PA) exposure in order to identify the efficacy of thoracoscopic fissureless lobectomy.Methods: Between April 2012 and November 2015, 175 patients underwent a thoracoscopic lobectomy with three or four ports, of whom 14 underwent a fissureless lobectomy because of dense fissures. We compared the characteristics and perioperative outcomes of the patients who underwent the fissureless technique (fissureless technique group, n=14) and the traditional fissure dissection technique for PA exposure (traditional technique group, n=161). In our department, fissureless lobectomy is indicated for patients with a fused fissure (fissural grade III or IV as proposed by Craig in 1997) or inflammation makes it difficult to expose the PA, while the traditional technique is used for other patients.Results: Although the fissureless technique group had longer operation time than the traditional technique group (P=0.0045), there was no significant inter-group difference about blood loss (P=0.85), occurrence rate of intraoperative massive bleeding (P=0.6) or conversion rate to thoracotomy (P=0.31). According to postoperative results, there was no significant inter-group difference in duration of chest tube drainage (P=0.56), length of postoperative hospital stay (P=0.14), or morbidity rate (P=0.16). No mortality occurred in either group.Conclusions: A thoracoscopic fissureless lobectomy is feasible and safe, and useful to avoid postoperative air-leakage in patients with dense fissures.

Background: Correlations between volume doubling time (VDT) of primary lung cancer (PLC), histology, and ground glass opacity (GGO) components remain unclear. The purpose of this study was to evaluate and compare VDT of PLC in terms of histology and presence or absence of GGO components. Methods: A total of 371 surgically resected PLCs from 2003 to 2015 in our institute were retrospectively reviewed. The VDT was calculated both from the diameters of the entire tumor and of consolidation by using the approximation formula of Schwartz. Results: The median VDTs of adenocarcinoma, squamous cell carcinoma, and others (large cell neuroendocrine carcinomas, small cell lung carcinomas, pulmonary pleomorphic carcinomas, and large cell carcinomas combined) were 261, 70, and 70 days, respectively; these differ significantly (P<0.001). All PLCs with GGO were adenocarcinomas. The VDT of adenocarcinomas with GGO was significantly longer than that of those without GGO (median VDT: 725 and 177 days, respectively), squamous cell carcinomas, and others. When the VDT calculated from the maximum diameter of consolidation component was compared, adenocarcinomas with GGO also showed significantly slower growth than those without GGO (median VDT: 248 versus 177 days, respectively, P=0.040). Conclusions: The VDT of PLCs is longest for adenocarcinomas. VDT was significantly longer in adenocarcinomas with GGO components than in those without such components, irrespective of VDT calculated on the basis of either the entire tumor diameter or consolidation diameter.

The appropriate lateral and posterior basal (S9 + 10) segmentectomy requires exposure and recognition of common basal pulmonary vein branches located deeply in the lung parenchyma. Therefore, we applied the intersegmental tunnelling method in S9 + 10 segmentectomy to recognize the dominant veins to the S9 + 10 segment accurately. Between April 2014 and December 2015, five patients underwent thoracoscopic S9 + 10 segmentectomy using intersegmental tunnelling. By using this technique, we can recognize the branches of the pulmonary vein to the affected S9 + 10 segment accurately. This technique can let us perform appropriate S9 + 10 segmentectomy.

Purpose: The objective of this study was to assess the perioperative results of a single-incision approach using multi-DOF forceps for spontaneous pneumothorax, in comparison with the traditional 3-port approach. Methods: Between May 2012 and June 2013, 44 patients with spontaneous pneumothorax underwent SITS, and their clinical characteristics and perioperative results were evaluated. We then compared those who had undergone SITS (SITS group) with those who had undergone traditional 3-port surgery before the study period (3-port group). Results: The two groups were similar in terms of mean patient age and pneumothorax laterality (p = 0.81, 0.38), but the proportion of male patients was higher in the 3-port group than in the SITS group (p = 0.0026). Operation time in the SITS group (52.4 min) was longer than in the 3-port group (35.9 min, p <0.0001). The duration of postoperative drainage and hospital stay did not differ significantly between the groups (p = 0.19, 0.075). Although 14 of the 56 SITS patients (25%) showed mild adhesion in the pleural cavity, none required conversion to a 3-port approach. The bullous region in two or three lobes was resected in 23 patients (41%). Conclusions: SITS using multi-DOF forceps is a useful approach for treatment of spontaneous pneumothorax in selected patients.

Surgical treatment under general anesthesia for SSP is effective for arresting persistent air leaks or avoiding pneumothorax relapse, compared with drainage or pleurodesis, and is feasible if the appropriate perioperative management is performed.

Introduction: The objective of this study was to evaluate intraoperative vessel injury and assess troubleshooting during thoracoscopic anatomic pulmonary resection. Methods: Between April 2012 and March 2016, 240 patients underwent thoracoscopic anatomic lung resection, 26 of whom were identified as having massive bleeding intraoperatively. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with (n ¼ 26) and without (n ¼ 214) vessel injury. In addition, we compared perioperative results based on the period when surgery was performed: early period: April 2012 to March 2014 (n ¼ 93) or late period: April 2014 to March 2016 (n ¼ 146). Results: The surgical procedures included 20 lobectomies and 6 segmentectomies. One of the 26 patients had vessel injury at 2 points, giving a total of 27 points of injury. Hemostasis was mostly achieved by application of thrombostatic sealant (63.0%). There were no significant differences in the length postoperative hospitalization (p ¼ 0.67) or morbidity rate (p ¼ 0.43) between the vessel injury and the no-vessel injury groups. There were no significant differences in the incidence of significant intraoperative bleeding (p ¼ 0.13) and total blood loss (p ¼ 0.13) between the early and late periods. Conclusions: Application of thrombostatic sealant is one of the useful methods to achieve hemostasis during thoracoscopic anatomic pulmonary resection. Vascular hazards are inherent to a thoracoscopic approach. Therefore, thoracic surgeons should always be concerned about significant intraoperative bleeding and treat it appropriately.

Background To standardize the technical strategy for right upper lobe (RUL) segmentectomy, we previously developed simplified 3-dimensional (3D) anatomic models that classify the RUL anatomy into 14 patterns according to the branching pattern of bronchi and veins. We aimed to study the surgical outcome of RUL segmentectomy guided by these simplified anatomic models. Methods Patients were classified into the anatomic models, and the approach to the intersegmental veins was selected accordingly. The intersegmental vein and corresponding intersegmental plane were as follows: V 1 b (the apicoanterior plane), V 2 a (the apicoposterior plane), and V 2 c (the posteroanterior plane). Clinicopathologic characteristics and short- and long-term outcomes were analyzed retrospectively. Results Thirty-four consecutive patients who underwent thoracoscopic RUL segmentectomy guided by simplified anatomic models between January 2016 and December 2019 at Gunma University were analyzed. All the patients were classified into a model: anterior + central Iab type (47%), anterior + central Ib type (41%), anterior II type (12%), or central III type (0%). The standard approaches to intersegmental veins were an anterior approach for V 1 b, a posterobronchial approach for V 2 a, and an interlobar approach for V 2 c. The approach to intersegmental or intrasegmental veins was modified according to the anatomic model in 4 cases (12%). The median operative time, blood loss, and hospital stay were 222 minutes, 19 grams, and 7 days, respectively. Prolonged air leakage was observed in 1 patient. Conclusions Segmentectomy guided by simplified anatomic models promotes anatomic classification, development of a standardized approach for segmental vein identification, and acceptable outcomes, which can facilitate the implementation of RUL segmentectomy.