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Objective: This study aimed to report the initial experiences of 115 patients who underwent robotic thoracic surgery using the da Vinci single-port robotic surgical system (Intuitive Surgical)., Methods: Robotic thoracic surgery using the da Vinci single-port robotic surgical system was performed on 115 patients between November 2020 and June 2023. Patient characteristics, intraoperative outcomes, and postoperative outcomes were analyzed retrospectively., Results: The type of surgeries included thymectomy, mediastinal mass excision, anatomical pulmonary resection (including lobectomy and segmentectomy), esophagectomy, and enucleation of esophageal submucosal tumors in 41, 13, 54, 5, and 2 patients, respectively. The mean total operative time and chest tube duration for different procedures were as follows: thymectomy, 152.9. ± 6.7 minutes and 1.2 ± 0.5 days; mediastinal mass excision, 93.3 ± 26.5 minutes and 1.0 ± 0 days; anatomical pulmonary resection, 187.2 ± 55.8 minutes and 2.5 ± 1.5 days; esophagectomy, 485 ± 111.9 minutes and 12 ± 4.6 days; and enucleation of esophageal submucosal tumors, 170 ± 30 minutes and 5.5 ± 0.5 days, respectively. Conversion to a thoracotomy or sternotomy was not required. Conversion to video-assisted thoracic surgery occurred in 1 patient, and an additional port was applied in 2 patients. Two patients experienced postoperative complications greater than grade IIIa., Conclusions: Robotic thoracic surgery using the da Vinci single-port robotic surgical system is feasible and safe in various fields of thoracic surgery, including complex procedures such as anatomical pulmonary resection and esophagectomy. More complex thoracic surgeries can be performed with the continuous advancement and innovation of instruments in robotic systems., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether surgeon selection of instrumentation and other supplies during video-assisted thoracoscopic lobectomy (VATSL) can safely reduce intraoperative costs., Methods: In this retrospective, cost-focused review of all video-assisted thoracoscopic surgery anatomic lung resections performed by 2 surgeons at a single institution between 2010 and 2014, we compared VATSL hospital costs and perioperative outcomes between the surgeons, as well as costs of VATSL compared with thoracotomy lobectomy (THORL)., Results: A total of 100 VATSLs were performed by surgeon A, and 70 were performed by surgeon B. The preoperative risk factors did not differ significantly between the 2 groups of surgeries. Mean VATSL total hospital costs per case were 24% percent greater for surgeon A compared with surgeon B (P = .0026). Intraoperative supply costs accounted for most of this cost difference and were 85% greater for surgeon A compared with surgeon B (P < .0001). The use of nonstapler supplies, including energy devices, sealants, and disposables, drove intraoperative costs, accounting for 55% of the difference in intraoperative supply costs between the surgeons. Operative time was 25% longer for surgeon A compared with surgeon B (P < .0001), but this accounted for only 11% of the difference in total cost. Surgeon A's overall VATSL costs per case were similar to those of THORLs (n = 100) performed over the same time period, whereas surgeon B's VATSL costs per case were 24% less than those of THORLs. On adjusted analysis, there was no difference in VATSL perioperative outcomes between the 2 surgeons., Conclusions: The costs of VATSL differ substantially among surgeons and are heavily influenced by the use of disposable equipment/devices. Surgeons can substantially reduce the costs of VATSL to far lower than those of THORL without compromising surgical outcomes through prudent use of costly instruments and technologies., (Copyright © 2017 The American Association for Thoracic Surgery. All rights reserved.)

Objectives: Energy-based tissue fusion technology is being increasingly used for vascular division in numerous intra-abdominal applications. Very few data, however, are available regarding the application of this technology in the chest during anatomic lung resection. In the present review, we evaluated the use of energy-based fusion and lung sealants during anatomic lung resection., Methods: We performed a review of case series and published studies to evaluate the use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection. We then used energy-based coagulative fusion technology during anatomic lung resection (segmentectomy or lobectomy) in 316 cases from 2008 to 2011. Two energy applications were applied to the arterial and venous branches before vessel division., Results: In the first 12 cases, we used a device with a small curved jaw (range, 3.3-4.7 mm). Two partial venous dehiscences were noted and controlled intraoperatively. For the remaining cases, we used a larger jaw (6 mm × 22 mm) with no arterial or venous dehiscence occurring (vessels ranged from 0.4 to 1.2 cm). Autologous or synthetic tissue sealants applied to the parenchymal staple lines might reduce the severity and duration of perioperative air leaks. Suture line buttressing with pericardial or absorbable biosynthetic polyester strips might reduce the severity of air leaks in patients with severe emphysema undergoing anatomic lung resection or lung volume reduction surgery., Conclusions: The bipolar tissue fusion system provides a safe and effective technique for the division of the pulmonary arterial and venous branches during anatomic lung resection. Surgical sealants and buttressing adjuncts might reduce perioperative air leak potential., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Recently, linear staplers have been used frequently in thoracic surgery; however, air leakage from the staple line is still unresolved. Various buttress materials have been developed to prevent air leakage, but performance is still not satisfactory. We are therefore developing a new material, consisting of calcium alginate nonwoven fabric covered with sodium alginate sponge., Methods: Thirty-three beagle dogs were divided into 7 groups, and each underwent thoracotomy. Right middle lobe incision was performed with a linear stapler and 1 of the following buttress methods: group A, no buttress; group B, polyglycolic acid nonwoven fabric; group C, fibrin glue alone; group D, polyglycolic acid nonwoven fabric with fibrin glue; group E, polyglycomer sheet; group F, new alginate material; and group G, polyglycolic acid nonwoven fabric plus new alginate material. Burst pressures were measured under mechanical ventilation management., Results: Burst pressures were 12.0 ± 6.8 cm H(2)O in group A, 31.3 ± 6.6 cm H(2)O in group B, 13.9 ± 3.8 cm H(2)O in group C, 26.9 ± 2.8 cm H(2)O in group D, 24.8 ± 1.8 cm H(2)O in group E, 48.5 ± 4.9 cm H(2)O in group F, and 54.2 ± 12.4 cm H(2)O in group G. F and G group pressures reached the target of 40 to 50 cm H(2)O and were significantly higher than those of the 5 conventional groups (P < .0005), Conclusions: This alginate buttress should be effective for preventing air leakage during operations because it has both sealant and bolster effects working in conjunction., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Current video-assisted thoracoscopic surgery training models rely on animals or mannequins to teach procedural skills. These approaches lack inherent teaching/testing capability and are limited by cost, anatomic variations, and single use. In response, we hypothesized that video-assisted thoracoscopic surgery right upper lobe resection could be simulated in a virtual reality environment with commercial software., Methods: An anatomy explorer (Maya [Autodesk Inc, San Rafael, Calif] models of the chest and hilar structures) and simulation engine were adapted. Design goals included freedom of port placement, incorporation of well-known anatomic variants, teaching and testing modes, haptic feedback for the dissection, ability to perform the anatomic divisions, and a portable platform., Results: Preexisting commercial models did not provide sufficient surgical detail, and extensive modeling modifications were required. Video-assisted thoracoscopic surgery right upper lobe resection simulation is initiated with a random vein and artery variation. The trainee proceeds in a teaching or testing mode. A knowledge database currently includes 13 anatomic identifications and 20 high-yield lung cancer learning points. The "patient" is presented in the left lateral decubitus position. After initial camera port placement, the endoscopic view is displayed and the thoracoscope is manipulated via the haptic device. The thoracoscope port can be relocated; additional ports are placed using an external "operating room" view. Unrestricted endoscopic exploration of the thorax is allowed. An endo-dissector tool allows for hilar dissection, and a virtual stapling device divides structures. The trainee's performance is reported., Conclusions: A virtual reality cognitive task simulation can overcome the deficiencies of existing training models. Performance scoring is being validated as we assess this simulator for cognitive and technical surgical education., (Copyright © 2011. Published by Mosby, Inc.)

Objectives: Mechanical stapling devices have been established as the mainstay of therapy in the selective isolation and division of bronchial and vascular structures during anatomic lung resection. Few data are available regarding the application of energy-based tissue fusion technology during anatomic lung resection. In the present study, we evaluated the use of energy-based instruments for the division of the pulmonary arterial and venous branches during anatomic lung resection., Methods: Anatomic lung resection (segmentectomy or lobectomy) was performed using energy-based coagulative fusion technology. A low-profile jaw can be used to facilitate dissection in both open and video-assisted thoracic surgery cases, applying a seal 6 mm wide by 22 mm in length. Two energy applications were applied to the arterial and venous branches before vessel division., Results: The bipolar tissue fusion system was used in 211 patients between 2008 and 2010 (104 lobectomies and 107 anatomic segmentectomies). Initially, we used a device with a smaller, curved jaw (n = 12), producing a 3.3- to 4.7-cm seal. No arterial dehiscences and 2 partial venous dehiscences that were recognized and controlled intraoperatively occurred. For the remaining cases, we used a new device with a larger jaw that applied a seal 6 mm wide by 22 mm in length. No arterial or venous dehiscences (vessel size range, 0.4-1.2 cm) occurred., Conclusions: The bipolar tissue fusion system provided safe and reliable control of pulmonary arterial and venous branches during anatomic lung resection. The use of energy-based tissue fusion technology represents a reasonable alternative to mechanical stapling devices during anatomic lung resection., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Our objective was to attempt a clinical trial of segmentectomy using the infrared thoracoscopy system after intravenous injection of indocyanine green., Patients and Methods: A total of 8 patients with lung lesions were investigated (5 with primary lung cancer, 2 with metastatic lung tumor, and 1 with inflammatory change). All were scheduled to undergo segmentectomy and had been confirmed to have no allergy to iodine or indocyanine green. Informed consent was obtained from all patients. We identified the dominant pulmonary artery supplying the target segment using reconstructed computed tomography images. The dominant pulmonary artery of the target segment was ligated, and after we had observed the lung using the infrared thoracoscopy system after intravenous injection of indocyanine green (3.0 mg/kg), and marked the white-to-blue transitional zone by electrocautery, we performed segmentectomy., Results: Average operation time was 150 ± 62.1 minutes, and bleeding volume was 68.8 ± 30.5 mL. Under infrared thoracoscopy, the area with a normal blood supply became stained blue 13 seconds after injection of indocyanine green. Maximum staining intensity was attained 28 seconds after dye injection, and the observation duration was 3.5 minutes. A well-defined color zonation was observed in all patients. We had enough time to mark it. No complications attributable to infrared thoracoscopy after intravenous injection of indocyanine green were encountered., Conclusions: Infrared thoracoscopy with indocyanine green makes it possible to identify the target lung segment easily and quickly without the need for inflation. This method will be especially useful for cases associated with severe emphysema or when surgery offers a limited view, as is the case with video-assisted thoracic surgery., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: We investigated the feasibility and safety of four-arm robotic lung lobectomy in patients with lung cancer and described the robotic lobectomy technique with mediastinal lymph node dissection., Methods: Over 21 months, 54 patients underwent robotic lobectomy for early-stage lung cancer at our institute. We used a da Vinci Robotic System (Intuitive Surgical, Inc, Mountain View, Calif) with three ports plus one utility incision to isolate hilum elements and perform vascular and bronchial resection using standard endoscopic staplers. Standard mediastinal lymph node dissection was performed subsequently. Surgical outcomes were compared with those in 54 patients who underwent open surgery over the same period and were matched to the robotic group using propensity scores for a series of preoperative variables., Results: Conversion to open surgery was necessary in 7 (13%) cases. Postoperative complications (11/54, 20%, in each group) and median number of lymph nodes removed (17.5 robotic vs 17 open) were similar in the 2 groups. Median robotic operating time decreased by 43 minutes (P = .02) from first tertile (18 patients) to the second-plus-third tertile (36 patients). Median postoperative hospitalization was significantly shorter after robotic (excluding first tertile) than after open operations (4.5 days vs 6 days; P = .002)., Conclusions: Robotic lobectomy with lymph node dissection is practicable, safe, and associated with shorter postoperative hospitalization than open surgery. From the number of lymph nodes removed it also appears oncologically acceptable for early lung cancer. Benefits in terms of postoperative pain, respiratory function, and quality of life still require evaluation. We expect that technologic developments will further simplify the robotic procedure., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: This study was undertaken to determine the recurrence rate after limited resection of small lung carcinoma and to evaluate intraoperative frozen-section examination accuracy for Noguchi classification., Methods: Enrollment requirements were as follows: pulmonary nodule 2 cm or smaller, diagnosed or suspected clinical T1 N0 M0 carcinoma in the lung periphery, and ground-glass opacity findings and lack of evident pleural indentations or vascular convergence on high-resolution computed tomographic scan. A wedge or segmental resection specimen, removed with custom stapler cartridges, was immediately reinflated and examined by frozen-section with hematoxylin-eosin and Victoria blue-van Gieson stains. If the tumor was confirmed as Noguchi type A or B with resection margins greater than 1 cm, the patient was closed and followed up on an outpatient basis. End points were 5-year disease-free survival and intraoperative classification accuracy., Results: From August 1998 through October 2002, a total of 50 patients were enrolled (20 men and 30 women, ages 30-77 years). Tumor sizes ranged from 2 to 21 mm (11 mm average). There were 2 Noguchi type A tumors, 23 Noguchi type B tumors, 15 Noguchi type C tumors, 5 atypical adenomatous hyperplasias, 4 fibroses, and 1 granuloma. Frozen-section accuracy was approximately 98% (39/40). One intraoperative type B diagnosis was revised to type C after postoperative pathologic study. No morbidity, mortality, or recurrence has been seen with a median follow-up of 50 months., Conclusion: Noguchi type A and B tumors may well be in situ carcinomas, and frozen-section examination was highly accurate. Neither local recurrence nor distant metastases have been found to date. Limited resection initial results appear promising.

Background: We determined the feasibility, safety, and short-term efficacy of bronchoscopic placement of a one-way endobronchial valve in selected bronchopulmonary segments as an alternative to surgical lung volume reduction., Methods: A total of 21 patients with incapacitating emphysema who underwent this procedure were studied. All patients had placement of the endobronchial valves into the most emphysematous lung segments. We recorded any major complications or deaths attributed to the procedure and analyzed (1) improvements in the spirometric and functional parameters and quality of life and (2) the radiologic changes compared with the baseline data at 30 and 90 days., Results: A total of 20 patients had complete follow-up data. There was no mortality in the group studied. The forced expiratory volume at 1 second, forced expiratory volume at 1 second (percentage of predicted), forced vital capacity, and forced vital capacity (percentage of predicted) all improved significantly at 90 days (0.73 +/- 0.26 L vs 0.92 +/- 0.34 L [P =.009]; 33.3% +/- 11.9% vs 42.2% +/- 15.0% [P =.006]; 1.94 +/- 0.62 L vs 2.25 +/- 0.61 L [P =.015]; and 63.3% +/- 17.6% vs 73.9% +/- 17.1% [P =.012], respectively). The 6-minute walking distance improved at 30 and 90 days (251.6 +/- 100.2 m vs 306.3 +/- 112.3 m and 322.3 +/- 129.7 m; P =.012 and P =.003). The results of the 36-Item Short-Form Health Survey and the St George Respiratory Questionnaire showed significant improvements at 90 days. The Medical Research Council dyspnea grade also improved significantly at 30 and at 90 days (P =.006 and P =.003, respectively)., Conclusions: Endobronchial valve placement is a safe procedure, with significant short-term improvements in functional status, quality of life, and relief of dyspnea in selected patients with emphysema. A larger study with long-term follow-up is therefore warranted.

To determine the clinicopathologic characteristics of peripheral non-small-cell carcinomas, the cases of 337 patients undergoing major pulmonary resection with complete lymphadenectomy were retrospectively reviewed with regard to lymph node involvement, recurrence, and prognosis. All of the tumors were 3.0 cm or less in diameter and were categorized as T1 (318 patients) or T2 (19). Eighty-eight patients (26.1%) had lymph node involvement: 32 (9.5%) at N1 nodes, 55 (16.3%) at N2 nodes, and 1 (0.3%) at N3 nodes. Although the prevalence of lymph node involvement did not differ significantly with tumor histologic type, it was quite low in squamous cell carcinomas 2.0 cm or less in diameter. Of the 56 N2/3 metastases, 14 (25%) occurred in a "skipping" manner, and all but one had a nonsquamous histologic makeup. Of the 213 patients with a follow-up period of 5 years or more, 59 patients (27.7%) showed cancer recurrence. This occurred at a distant site in 67.8% of the cases. Five-year survival rates based on nodal status were 91.9% (NO), 61.8% (N1), 44.5% (N2), and 0% (N3). Because of the relatively high prevalence of lymph node involvement, complete hilar/mediastinal lymphadenectomy should be routinely done regardless of tumor histologic type and size, as long as patients are at good risk. However, in squamous cell histologic types, mediastinal lymphadenectomy might be dispensable if the tumor is less than 2.0 cm in diameter, or if the hilar node is proved to be tumor-free on pathologic examination of the frozen section during operation. Although video-assisted major pulmonary resection currently has limited application, this new technique may represent a surgical option in resection without complete lymphadenectomy.

Forty patients with malignant pulmonary disease underwent evaluation, staging, and a biopsy or resection by means of video-assisted thoracic surgery. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three a lobectomy for primary carcinoma, six exploration of the thorax, five biopsy of the aortopulmonary window, and eighteen a sublobar resection for primary carcinoma of the lung. There was no mortality. Three patients had air leaks that lasted an average of 8 days. Video-assisted thoracic surgery seems to be useful for more precise staging of carcinoma of the lung, and, in some patients, resectional operations can be performed.