Kyobu geka. The Japanese journal of thoracic surgery最新文献

Thoracic endovascular aortic repair (TEVAR) has been widely applied to not only true aortic aneurysms but also dissecting aortic aneurysms (DAA). However, persistent false lumen perfusion from distal re-entry remains a major concern, potentially leading to aneurysmal expansion or rupture. We report a case of ruptured Stanford type B DAA successfully treated with TEVAR combined with the candy-plug( CP) technique. A 53-year-old man with a history of Stanford type B acute aortic dissection presented with acute chest pain. Contrast-enhanced computed tomography (CT) revealed rupture of the false lumen in the descending thoracic aorta with left hemothorax. Emergency TEVAR was performed to close the primary entry, followed by CP deployment to occlude false lumen. Postoperative imaging demonstrated complete false lumen thrombosis and aortic diameter reduction without complications. Combined TEVAR with the CP technique may be a feasible and effective option for ruptured Stanford type B DAA, although careful long-term follow-up is required.

Robot-assisted thoracic surgery( RATS) has become widely adopted as a standard minimally invasive approach for lung cancer surgery. While bronchoplasty has traditionally been performed via thoracotomy or video-assisted thoracic surgery( VATS), its application under robotic assistance remains limited, and practical experience has yet to be fully established. Our institution introduced RATS in 2018 and has accumulated substantial experience with standardized surgical procedures. After sufficient experience was obtained, bronchoplasty using the da Vinci system was introduced in a planned manner for carefully selected cases in which pneumonectomy could be avoided. To date, four cases of planned robotic bronchoplasty have been performed. Simple bronchial stump closure and unintentional bronchial injury repair were excluded from this series. Bronchial anastomosis was performed using either 4-0 Prolene or 4-0 PDS Stratafix, selected according to anatomical conditions. The high-definition three-dimensional visualization and articulated instruments provided by the robotic system allowed precise needle control and uniform suture placement. Continuous suturing was primarily employed, with careful attention to tension control and accurate mucosal alignment. Stable operative fields were achieved through a cooperative team-based approach, in which the assistant consistently managed exposure, suction, hemostasis, and stapling procedures. All procedures were completed robotically without conversion to thoracotomy. No intraoperative complications or bronchial anastomosis-related postoperative complications, including leakage or stenosis, were observed. Postoperative courses were uneventful in all cases. Although our experience is limited, these findings suggest that robotic bronchoplasty can be safely performed when appropriate patient selection, standardized techniques, and close collaboration between the console surgeon and assistant are ensured. Further accumulation of cases is necessary to clarify the role of robotic bronchoplasty in lung cancer surgery.

Background: Robot-assisted thoracic surgery (RATS) provides a stable magnified three-dimensional view and precise instrument control, and its application to complex procedures such as bronchial reconstruction has expanded worldwide. Dual-portal RATS, as a reduced-port approach, offers advantages in minimal invasiveness but presents specific challenges, including limited assistant working space and robotic arm interference.

Case presentation: A 77-year-old man with suspected primary lung cancer underwent right upper lobectomy using dual-portal RATS. Intraoperatively, severe adhesion of hilar lymph nodes to the upper lobe bronchus suggested extranodal invasion, requiring bronchial sleeve resection. Bronchial reconstruction was successfully completed using continuous suturing with barbed sutures under robotic assistance.

Results: The postoperative course was uneventful, and the patient was discharged on postoperative day 4. While robotic assistance enabled precise bronchial suturing, technical difficulties related to assistant maneuverability and arm interference were encountered, particularly during bronchial anastomosis.

Conclusions: Based on early experience with reduced-port RATS, we established practical principles to minimize arm interference and emphasize team-based training, including simulation. With appropriate technical refinement and education, dual-portal RATS may represent a feasible and safe approach for complex bronchial reconstruction.

We have performed more than 100 bronchial plasties and 60 pulmonary artery plasties to date. Robot-assisted thoracic surgery was initiated at our institution in October 2018, and the da Vinci Xi system was introduced in October 2024. We recently performed a robot-assisted procedure using the da Vinci Xi system that involved left main pulmonary artery clamping and pulmonary artery plasty in a patient with pulmonary artery invasion by left hilar lymph nodes. The patient was a man in his 70s with a medical history of atrial fibrillation and prior treatment for intrahepatic cholangiocarcinoma. During follow-up, a 15-mm tumor arising from the wall of a left upper lobe cyst was identified, along with enlarged hilar lymph nodes infiltrating the A3 branch. The patient was diagnosed with cT1bN1M0, cStageⅡA non-small cell lung cancer and underwent left upper lobectomy with systematic lymph node dissection. Dissection of the hilar lymph nodes from the A3 root was technically challenging due to severe adhesion and vascular involvement. After exposing the superior pulmonary vein, the main pulmonary artery and interlobar pulmonary arteries were encircled and clamped. Following partial resection of the pulmonary artery, vascular reconstruction was performed using continuous suturing with 5-0 prolene. We plan to expand the indications for this robot-assisted technique to include bronchial reconstruction and locally invasive lung cancer, while maintaining strict safety measures.

Robot-assisted thoracic surgery has enabled safe and precise surgical procedures by providing a high-definition three-dimensional visual field and highly dexterous instrument manipulation. At our institution, we have actively performed robot-assisted thoracic surgery, including complex segmentectomy, with a continuous emphasis on establishing safe and reliable surgical techniques. In recent years, with the widespread adoption of neoadjuvant immunotherapy, the number of surgical resections for advanced lung cancer has increased, and reports of robot-assisted high-complexity reconstructions, such as bronchoplasty and vascular reconstruction, have also become more frequent. Building on the reconstructive techniques established through conventional open thoracotomy, we are planning to introduce robot-assisted reconstructive surgery at our institution. During this process, we aim to faithfully reproduce the principles of open surgical techniques within the robotic setting while achieving an optimal balance between safety and minimal invasiveness. In this article, we provide an overview of our approach to this endeavor.

Robot-assisted surgery is rapidly expanding in the field of thoracic surgery, including procedures for lung cancer. However, robot-assisted airway reconstruction-particularly sleeve bronchoplasty-remains a highly challenging surgical procedure. Approximately two decades ago, robot-assisted airway reconstruction was investigated as my doctoral research topic, providing an early foundation for the development of this technique. This article summarizes the evolution of robot-assisted airway reconstruction techniques, from procedures initially developed through animal experimentation to those currently applied in clinical practice. Key technical considerations, as well as current limitations and unresolved challenges, are also discussed. Although these techniques are still evolving, they allow for the effective utilization of the advantages inherent to robotic surgery. Furthermore, continued advancements in surgical instrumentation are expected to facilitate further refinement and expansion of their clinical applications.

Thoracotomy is still frequently selected for vascular and bronchial reconstruction. However, if these procedures can be safely performed using a minimally invasive approach, patients may benefit greatly through accelerated postoperative recovery. In this study, we reviewed the perioperative outcomes of robotic vascular and bronchial reconstruction performed at our department( March 2024 to July 2025:one case of vascular and bronchial reconstruction and seven cases of bronchoplasty) and compared them with those of thoracotomy cases( November 2012 to July 2025, 53 cases) to evaluate the feasibility and advantages of the robotic approach. Furthermore, based on our experience, we discuss key technical strategies and considerations essential for completing these procedures safely and efficiently.

In Japan, sleeve lobectomy with bronchial reconstruction accounts for only a small proportion of all lobectomies, making it difficult to acquire sufficient technical proficiency through clinical experience alone. Therefore, structured off the job training is considered important. We have developed a training method for sleeve resection using a high-fidelity, life-sized three-dimensional (3D) airway model reconstructed from computed tomography (CT) data. Recently, robotic-assisted sleeve lobectomy has been increasingly reported. Although robotic systems provide enhanced instrument dexterity, bronchial reconstruction under robotic assistance presents specific challenges, including the lack of tactile feedback, a restricted operative field inherent to minimally invasive surgery, and the need for careful management of suture length, tension, and anastomotic technique. Even experienced surgeons may encounter approach-specific pitfalls, underscoring the importance of adequate preoperative preparation. To address these issues, the 3D model was further refined by incorporating a chest wall module that reproduces the minimally invasive surgical environment, enabling realistic robotic-assisted training. Various continuous suturing techniques, including those using short double-armed needles or absorbable barbed sutures, can be practiced in a dry-laboratory setting. This training system allows repeated practice with easy access, independent of time and location, and may contribute to improved technical skills and procedural safety in robotic-assisted sleeve lobectomy.

Robot-assisted thoracic surgery( RATS) is increasingly used in difficult surgeries because of its excellent operability with three-dimensional stereoscopic visual fields and multiple joints. RATS is useful for suture procedures, but not for ligation procedures due to lack of sense of touch, which is needed for precise power adjustment. In this report, we describe bronchoplasty with RATS in a case of right upper lobe resection. A large needle driver and Cadiere forceps were used with the right and left hands, respectively, as instruments for bronchorrhaphy. Barbed suture( V-Loc 180 closure device, 3-0, 15 cm)with a looped thread end was used to minimize the number of ligations for bronchorrhaphy. The 3-0 suture was selected to avoid the risk of cutting a thread. Continuous suture was performed using each of two threads for the semiperimeter of the bronchus clockwise and counterclockwise from the deepest part, and the two threads were ligated where they met. The bronchus was tightened slowly at each stitch, and the last three stitches were made with the bronchus opened. Finally, the threads were carefully pulled to tighten the bronchus. This case indicates that robot-assisted bronchoplasty with continuous suture can be performed safely with no stress.

Robot-assisted thoracoscopic surgery (RATS) has reached approximately 10,000 cases annually in Japan and has been established as one of the minimally invasive approaches. In the coming years, as institutions accumulate more experience, the indications are expected to expand to more complex cases. Among these, suturing techniques required for bronchial and pulmonary vessel reconstruction are particularly valuable in RATS due to the multi-articulated instruments;however, their frequency remains limited since resection procedures constitute the mainstay of thoracic surgery. Moreover, the typical candidates are technically and oncologically challenging cases, such as central lung cancer and locally advanced lung cancer with hilar lymph node involvement. Therefore, it is essential to share and systematically accumulate technical refinements and insights based on experience, including the use of barbed sutures in bronchial anastomosis and clamp management during pulmonary artery reconstruction. Mastery and practice of these technical skills by a greater number of thoracic surgeons will form the foundation for ensuring the safety and further effective development of RATS in Japan.