Intraoperative robotic surgical system-related problems in robot-assisted thoracoscopic surgery.

BACKGROUND: Malfunctions of robotic instruments during robotic surgery are well known to occur; however, detailed reports on the inherent problems associated with robotic instruments and robotic surgical systems are scarce. The objective of this study was to retrospectively investigate the intraoperative problems associated with robotic surgical systems and robotic instruments. MATERIALS AND METHODS: This was a single-center retrospective study. Between April 2012 and December 2022, 544 patients with consecutive lung malignancies and/or mediastinal tumors underwent robot-assisted thoracoscopic surgery. Among these, 15 cases had intraoperative problems associated with the robotic surgical system. Human error was defined as a problem caused by the incorrect operation of the robotic surgical system and human factors as problems in which the robotic surgical system stopped owing to damage to the instruments of the robotic surgical system or the self-diagnosis of the robotic surgical system. We retrospectively investigated the causes of intraoperative problems in these cases. RESULTS: There were 4 cases (0.7%) with problems related to the robotic surgical system, 2 of which were human errors, and 11 (2.0%) with problems related to robotic surgical instruments, 6 of these were related to instruments and 5 were related to robotic staplers. Five of these were related to human factors. CONCLUSION: Teams performing robot-assisted thoracoscopic surgery should be familiar with the features of robotic surgical systems and various robotic devices, be aware of reported problems during robot-assisted thoracoscopic surgery, and be prepared for emergencies.

[Improved Surgical Technique for Closing the Tracheocutaneous Fistula].

The tracheocutaneous fistula is a late complication after tracheotomy decannulation, which decreases the quality of life. Though several procedures to close tracheocutaneous fistula were reported, postoperative wound dehiscence was frequently noted. We developed new surgical technique to prevent this complication and report a case in which the technique was successfully applied. This surgical technique is useful simple method to be effective, and safe.

Comparison of different approaches in complete thoracoscopic segmentectomy of lung lower lobe.

Background: Safe and oncologically acceptable segmentectomy outcomes were reported for early-stage lung cancer. The high-resolution computed tomography allowed us to find detailed structures inside the lungs, such as the pulmonary ligaments (PLs). Hence, we have presented the relatively anatomically challenging thoracoscopic segmentectomy, for the resection of the lateral basal segment, the posterior basal segment, and both segments through the PL as a PL approach. This study aimed to retrospectively examine the lung lower lobe segmentectomy, excluding the superior and basal segments (from S7 to S10), using the PL approach as an option to treat the lower lobe tumors of the lung. We then compared the efficacy of the PL approach in terms of safety with the interlobar fissure (IF) approach. The characteristics of the patients, intra- and postoperative complications, and surgical outcomes were analyzed. Methods: Of the 510 patients who underwent segmentectomy for malignant lung tumors from February 2009 to December 2020, 85 were included in this study. Among them, 41 underwent a complete lung lower lobe thoracoscopic segmentectomy, excluding S6 and basal segments (from S7 to S10), using the PL approach, and the remaining 44 used the IF approach. Results: The median age in 41 patients in the PL group was 64.0 years (range, 22-82), and that in 44 patients in the IF group was 66.5 years (range, 44-88), with significant differences in gender between these groups. Video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery were performed on 37 and 4 patients in the PL group and 43 and 1 patient in the IF group, respectively. Postoperative complication frequency was not significantly different between these groups. The most common complications were the air leaks that persisted for over 7 days in 1 and 5 patients in the PL and IF groups, respectively. Conclusions: Complete thoracoscopic segmentectomy of the lower lobe, excluding S6 and basal segments, using the PL approach is a reasonable option for lung lower lobe tumors compared with the IF approach.

Complete thoracoscopic S9 and/or S10 segmentectomy through a pulmonary ligament approach: a retrospective study.

BACKGROUND: The high resolution of computed tomography has found the pulmonary ligaments that consists of a double serous layer of visceral pleura, forms the intersegmental septum, and enters the lung parenchyma. This study aimed to investigate the clinical feasibility of thoracoscopic segmentectomy (TS) of the lateral basal segment (S9), posterior basal segment (S10), and both through the pulmonary ligament (PL). METHODS: Between February 2009 and November 2021, 542 patients underwent segmentectomy for malignant lung tumors at Tokyo Women's Medical University Hospital (Tokyo, Japan). This study included 51 patients. Among them, 40 underwent a complete TS of the S9, S10, or both by the PL approach (PL group), and the remaining 11 by the interlobar fissure approach (IF group). RESULTS: Patients' characteristics did not significantly differ between the two groups. In the PL group, 34 underwent video-assisted thoracoscopic surgery (VATS), and 6 underwent robot-assisted thoracoscopic surgery. In the IF group, all 11 underwent VATS. Operation duration, estimated blood loss, and postoperative complication frequency were not significantly different between these groups, but the maximum tumor diameter showed a significant difference. CONCLUSIONS: Complete TS of the S9, S10, and both through the PL is a reasonable option for tumors located in such segments. This approach is a feasible option for performing TS.

[Outcomes of Surgical Cases of Solitary Rib Metastases in Renal Cell Carcinoma].

BACKGROUND: Aggressive surgical treatment for renal cell carcinoma (RCC) bone metastasis has shown good results. METHODS: Since January 1995, four patients underwent surgery at our institution for rib metastasis of operated RCCs. Of these patients, three were male and one was female. The patients had a mean age of 67.5 years. Except one patient who presented with rib metastasis at the time of diagnosis of RCC, the average period of metastasis to the ribs after RCC surgery was 24.3 months. All patients underwent resection of metastasized tumors involving the ribs, with or without chest wall involvement. The clinical features of the surgical treatment for RCC bone metastasis were retrospectively analyzed. RESULTS: The mean time to tumor recurrence was 22.3 months postmetastasectomy. All patients developed other bone metastases and underwent multidisciplinary therapy. After metastasectomy, the four patients survived for 19~93 months. CONCLUSION: Surgical treatment for patients with rib metastases of RCC may contribute in prolonging survival.

[Surgical Cases of Solitary Lesion after Surgery for Primary Lung Cancer].

Lung nodules during postoperative follow-up of lung cancer are generally suspected to be its recurrence, but some cases are diagnosed as non-malignant disease. From January 2001 to November 2018, we experienced 5( 4.5%) new non-malignant lesions in 112 lung cancer patients who underwent a lung resection. The average period from first to second lung surgery was 36.2 months (range:3-64), and computed tomography findings before the second surgery were solid nodules in four cases and groundglass opacity in one case. The average maximum standardized uptake value of the lesions on fluorodeoxyglucose positron emission tomography was 4.29 (range:0-10.85). The diagnosis after the second surgery was pulmonary cryptococcosis in 2 cases, nontuberculous mycobacteriosis in 1 case, inflammatory mass in 1 case, and pneumonia in 1 case. The differential diagnosis between these diseases and lung cancer recurrence is discussed in the present study.

Robot-assisted thoracoscopic surgery using a narrow-profile vascular stapler through an 8-mm robotic port.

The number of robot-assisted thoracoscopic surgery (RATS) procedures performed for thoracic disease has been increasing. Recently, a narrow-profile vascular stapler (Signia small-diameter reload, Covidien Japan, Tokyo, Japan) has been developed to provide superior access and precise staple placement in video-assisted thoracoscopic surgery (VATS) procedures. A 70-year-old man who was an exsmoker visited our hospital with a complaint of coughing. Chest computed tomography revealed a tumor with a cavity, ~55 mm in diameter, in the right-middle lobe. A 4-arm RATS right-middle lobectomy was performed with a 4-cm utility thoracotomy with da Vinci Xi (Intuitive Surgical, Sunnyvale, CA, USA). The pulmonary vessels were divided using a narrow-profile vascular stapler through an 8-mm port. No complications occurred in the postoperative course. With a narrow-profile vascular stapler, portal RATS can be performed after VATS lung biopsy using 8-mm ports.

A pulmonary ligament approach for portal robotic segmentectomy of the lateral and posterior basal segments: a case report.

BACKGROUND: Thoracoscopic segmentectomy of the lateral and posterior basal segments is extremely technically challenging. Appropriate segmentectomy requires exposure and recognition of the branches of the bronchi and pulmonary vessels deep in the lung parenchyma. Although various approaches for these segmentectomies have been reported, the use of a pulmonary ligament approach is rational because it does not require any interlobar separation. Here, we report a successful case of portal robotic segmentectomy of the lateral and posterior basal segments through the pulmonary ligament approach. CASE PRESENTATION: A 60-year-old Japanese man with a history of low anterior resection for rectal cancer was referred to our department because of a lung nodule. His chest computed tomography revealed a 15-mm tumor in the left posterior basal bronchus. Robotic left S9-10 segmentectomy through the pulmonary ligament was performed with five-port incisions. CONCLUSIONS: An extremely technically challenging thoracoscopic segmentectomy of the lateral and posterior basal segments was performed through the pulmonary ligament using a robotic surgical system.

Effects of robot- and video-assisted thoracoscopic lobectomy experiences on the learning curve of lobectomy.

BACKGROUND: This study aims to investigate the effects of robot- and videoassisted thoracoscopic lobectomy on the learning curve of lobectomy. METHODS: Between September 2013 and February 2020, the first 68 consecutive patients (28 males, 40 females; median age: 71 years; range, 33 to 86 years) who were operated for lung malignancies and scheduled for robot-assisted thoracoscopic lobectomy were retrospectively analyzed. The characteristics of the patients and operative data were analyzed, and the operation times of the first 51 cases of video-assisted thoracoscopic lobectomy were compared with those of robot-assisted thoracoscopic lobectomy performed by a single surgeon. RESULTS: Of the patients, 62 had primary lung cancer and six had metastatic lung tumors. The majority of primary lung cancer patients (87.1%) had an adenocarcinoma. The most common clinical stage was IA1 (30.9%). There was no emergent conversion to thoracotomy in any of the patients. The median operation time was 223.5 min, and console time was 151 min. The most common complication was an air leak. All patients were alive. Compared to video-assisted thoracoscopic lobectomy, the median operation time was significantly longer in the robot-assisted thoracoscopic lobectomy group (p=0.0002). Similar to the operation time learning curve of the video-assisted thoracoscopic surgery group, the operation time learning curve of the robotassisted thoracoscopic surgery group increased from the first to ninth case (Phase 1), plateaued from the 10th t o 14th c ase ( Phase 2 ), and decreased from the 15th case (Phase 3). There was a statistically significant decrease in the operation time between Phase 1 and Phase 3 (p=0.0063). CONCLUSION: The results of robot-assisted thoracoscopic lobectomy by a single surgeon show that this surgery has a longer operation time, but the perioperative outcomes are satisfactory. The learning curve of this surgery may be gradual for experienced video-assisted thoracoscopic surgeons.

Manipulation of long-shaft stapler in robotic-assisted thoracoscopic surgery lung resection.

The number of robotic surgical procedures for thoracic disease is increasing. The automatic linear stapler has become a necessary device in endoscopic surgery. A 67-year-old man with a history of smoking was referred to our hospital for an abnormal finding on chest x-ray. Computer tomography of the chest revealed a ground glass nodule in the right middle lobe. We performed right middle wedge resection through the assistant port using a long-shaft stapler (LSS). Because the nodule was diagnosed as an adenocarcinoma on the intraoperative frozen section, the patient underwent robotic-assisted thoracoscopic surgery (RATS) right middle lobectomy using the da Vinci® Xi system. The pulmonary arteries, veins, right middle bronchus and minor fissure were divided using the LSS through the utility thoracotomy or assistant port. The postoperative course was uncomplicated. This case suggests that the LSS can be used in RATS lung resection for cancer.

[Usefulness of Long Shaft Stapler in Robot-assisted Thoracic Surgery Lung Resection].

Since national health insurance began to cover robot-assisted thoracoscopic surgery (RATS) for malignant lung tumors, malignant mediastinal tumors, and benign mediastinal tumors in Japan starting in 2018, the number of RATS performed domestically has increased rapidly. In the case of undiagnosed lung tumor, it is necessary to perform a thoracoscopic lung biopsy in the port arrangement for RATS lung resection in the case of undiagnosed lung tumor. The 2 ports are placed in the same 8th intercostal space and a 3 cm utility thoracotomy is added to the 4th or 5th intercostal space for the thoracoscopic lung biopsy. Because the assistant uses the stapler from the port, the distance to the target area increases. When it is converted to RATS for malignant lung diseases, the utility thoracotomy is often hidden by the robot arm and all ports placed in the 8th intercostal space are far from the target area. Furthermore, the assistant working space outside the patient's body is limited by the robot arms. The Signia stapling system has an adapter to extend the shaft. By attaching the adapter, the shaft can be extended by 10 cm. This permits easy handling of the stapler during both thoracoscopic biopsy and RATS lung resection.

Thoracoscopic surgical case of an ectopic mediastinal parathyroid adenoma detected by chance: a case report.

BACKGROUND: Ectopic mediastinal parathyroid tumor (EMPT) is a rare cause of primary hyperparathyroidism (PHPT); it is difficult to resect using the cervical approach. We describe a case of using video-assisted thoracic surgery (VATS) for EMPT resection. CASE PRESENTATION: A 67-year-old woman with a history of postoperative thyroid cancer had no symptoms. She was diagnosed with PHPT and underwent thyroid cancer surgery. She had serum calcium and intact parathyroid hormone (PTH) levels of 11.1 mg/dL and 206 pg/mL, respectively. Chest computed tomography showed a 10-mm nodule in the anterior mediastinum. Technetium-99 m methoxyisobutyl isonitrile scintigraphy showed an abnormal uptake lesion in the anterior mediastinum. She was diagnosed with PHPT caused by EMPT and underwent VATS. The pathological examination confirmed parathyroid adenoma. Her serum calcium and intact PTH levels were normal from 15 min after tumor resection. She has had no recurrence of EMPT. CONCLUSIONS: The VATS approach was effective for the resection of EMPT.

[Peripheral pulmonary artery aneurysm treated with embolization].

Althogh peripheral pulmonary aneurysm is a rare entity, the majority of cases become fatal if left untreated, due to sudden rupture and exsanguination. This emphasizes the need for treatment whenever a diagnosis made. A 81-year-old woman was found to have a coin lesion in the left middle field. Enhanced computed tomography (CT) showed strong staining and pulmonary angiography revealed a saccular dilation of the left A3b branch of the pulmonary artery. Successful embolization of the branch of the pulmonary artery was performed.

Pull-through technique with pincer tactics for stent placement in severe superior vena cava syndrome.

The pull-through technique is an interventional radiological procedure used when an occluded lesion cannot be traversed from one direction. To pass the lesion, a long guidewire is traversed from the opposite side and pulled through the ipsilateral sheath using a snare wire. The present report describes a case of severe superior vena cava syndrome treated by stent placement using a pull-through technique with pincer tactics. We successfully placed a stent in the occluded right internal jugular vein to the superior vena cava using a bilateral approach by snaring a guidewire in the right subclavian vein.