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Robot-assisted lobectomy has been used to treat non-small cell lung cancer and usually uses 3 or 4 ports and 3 or 4 robotic arms. We recently developed a two-port approach for robotic lobectomy using three robotic arms and performed a propensity score-matched analysis to compare the feasibility of the two-port and three-port techniques.Data on robotic lobectomy for non-small cell lung cancer were retrospectively reviewed. Patients were matched using propensity score based on age, sex, smoking, diabetes, hypertension, forced expiratory volume per 1 s, neoadjuvant chemotherapy, clinical stage, lobe involved, tumor size, and cell types. Overall, 53 and 89 patients who underwent the two-port and three-port approaches, respectively, were matched (1:1 ratio; caliper distance, 0.2). We analyzed the perioperative outcomes and postoperative pain to evaluate the feasibility and safety.The matched group included 37 patients each who underwent two-port and three-port robotic lobectomy. The operation time was shorter in the two-port group (P = .01). The number of lymph nodes resected (P = .70), conversion to multiport or thoracotomy (P .99), morbidity and mortality (P = .31), drain indwelling time (P = .32), and hospital stay (P = .11) were not significantly different between the groups. The postoperative pain was less at 0-3 postoperative days (P .01) in the two-port group. The total medical cost was not markedly increased after transitioning to the two-port technique.Two-port approach in robotic lobectomy is a safe and feasible alternative approach for treating non-small cell lung cancer.

The extracellular vesicle (EV) concentration is known to be higher in cancer patients than in healthy individuals. Herein, we report that EV levels differ in the tumor-draining pulmonary vein blood and the peripheral blood of animal models and human subjects at different pathological stages of lung cancer. Ten rabbits and 40 humans formed the study cohorts. Blood was collected from the peripheral vein of members of all groups. Pulmonary blood was collected intraoperatively from all groups except for the healthy human controls. Quantitative analysis of EV levels was performed using a nanoparticle tracking assay, a CD63 enzyme-linked immunosorbent assay, and western blotting. The EV levels in the peripheral blood of animals and patients with lung cancer were higher than those in the peripheral blood of healthy controls (p

OBJECTIVES The technique of simultaneously visualizing pulmonary nodules and the intersegmental plane using fluorescent images was developed to measure the distance between them intraoperatively. METHODS Patients who underwent pulmonary segmentectomy were consecutively included in this study between March 2016 and July 2019. Computed tomography or electromagnetic bronchoscopy-guided localization with indocyanine green–lipiodol emulsion was performed on the day of surgery. In the middle of the surgery, after dividing the segmental artery, vein and bronchus to a targeted segment, 0.3–0.5 mg/kg of indocyanine green was injected intravenously. RESULTS In total, 31 patients (17 men and 14 women with a mean age of 63.2 ± 9.8 years) were included in this study. The mean size and depth of the nodules were 1.2 ± 0.5 (range 0.3–2.5) cm and 16.4 ± 9.9 (range 1.0–42.0) mm, respectively. Pulmonary nodules and intersegmental plane of all the patients were visualized using a fluorescent thoracoscope. The resection margins were more than the size of the tumour or were 2 (mean 2.4 ± 1.2) cm in size in all patients except one. The resection margin of this patient looked sufficient on the intraoperative view. However, adenocarcinoma in situ at the resection margin was identified based on the pathological report. The mean duration of the operation was 168.7 ± 53.3 min, and the chest tube was removed on an average of 4.7 ± 1.8 days after surgery in all patients. CONCLUSIONS The dual visualization technique using indocyanine green could facilitate an easier measurement of the distance between pulmonary nodules and the intersegmental plane during pulmonary segmentectomy.

Indocyanine green (ICG) has been used to detect several types of tumors; however, its ability to detect metastatic lymph nodes (LNs) remains unclear. Our goal was to determine the feasibility of ICG in detecting metastatic LNs. We established a mouse model and evaluated the potential of ICG. The feasibility of detecting metastatic LNs was also evaluated in patients with lung or esophageal cancer, detected with computed tomography (CT) or positron-emission tomography (PET)/CT, and scheduled to undergo surgical resection. Tumors and metastatic LNs were successfully detected in the mice. In the clinical study, the efficacy of ICG was evaluated in 15 tumors and fifty-four LNs with suspected metastasis or anatomically key regional LNs. All 15 tumors were successfully detected. Among the fifty-four LNs, eleven were pathologically confirmed to have metastasis; all eleven were detected in ICG fluorescence imaging, with five in CT and seven in PET/CT. Furthermore, thirty-four LNs with no signals were pathologically confirmed as nonmetastatic. Intravenous injection of ICG may be a useful tool to detect metastatic LNs and tumors. However, ICG is not a targeting agent, and its relatively low fluorescence makes it difficult to use to detect tumors in vivo. Therefore, further studies are needed to develop contrast agents and devices that produce increased fluorescence signals.

BACKGROUND: With advances in surgical technology, thoracic surgeons have widely adopted minimally invasive limited-resection techniques to preserve normal tissues. However, it remains difficult to achieve in situ localization of invisible pulmonary nodules during surgery. Therefore, we proposed an in situ ultra-low-dose X-ray imaging device for intraoperative pulmonary nodule localization during minimally invasive surgeries. METHODS: The proposed device features a hand-held type and consists of a carbon nanotube-based X-ray source and an intraoral dental sensor. In a preclinical study, we created pseudo pulmonary nodules using ex vivo pig lungs. Subsequently, its clinical feasibility was evaluated using ex vivo lung cancer specimens from patients with cancer who had undergone minimally invasive surgery. RESULTS: Using the proposed device, we successfully differentiated normal and abnormal tissues from X-ray images of resected lung specimens. In addition, our proposed device only yielded an average radiation dose of 90.9 nGy for a single acquisition of X-ray images and demonstrated excellent temperature stability under consecutive X-ray irradiations. The radiation exposure of our proposed device (0.1±0.0006 µSv/h) was significantly lower than that of conventional C-arm fluoroscopy (41.5±51.8 µSv/h). In both preclinical and clinical studies, the margin of nodule shadows was clearly visualized using the proposed device. CONCLUSIONS: The proposed device substantially reduced radiation exposure to staff and patients and may allow in situ localization of pulmonary nodules. Our proposed device clearly revealed the margins of lung nodules with radiocontrast injection and showed the potential to identify solid nodules without the use of radiocontrast agents.

BACKGROUND: We aimed to assess the possibility of detecting esophageal cancer after intravenous injection of indocyanine green (ICG) in preclinical and clinical models. METHODS: Forty-five rabbits were surgically implanted with VX2 tumors into the esophageal muscular layer 2 weeks before esophagectomy. The rabbits received intravenous injection of ICG at doses of 1, 2, or 5 mg/kg at 3, 6, 12, 24, or 48 h before surgical removal of esophagus. Twelve patients scheduled to undergo esophagectomy were also enrolled, and all received 2 mg/kg of ICG intravenously at 3, 6, 12, or 24 h before surgical removal of esophagus. The fluorescence intensity was measured in all resected specimens from the rabbits and patients using a near-infrared (NIR) fluorescence imaging system after surgery. RESULTS: Esophageal tumors were successfully established in all rabbits, and fluorescent signals were detected in all animal and patient specimens. Tumor-to-normal ratio (TNR) analysis showed that higher doses resulted in a greater TNR. Injection of at least 2 mg/kg of ICG was required for clear visualization of the tumor, and the TNR was highest at 12 h after injection. The TNR in patients was also highest at 12 h (P=0.0004), with 2 mg/kg of ICG. None of the patients had major complications following ICG injection. CONCLUSIONS: NIR fluorescence imaging can be used to visualize esophageal cancer after systemic injection of ICG. ICG at 2 mg/kg at 12 h is optimal for tumor detection. However, since the clinical trials were conducted in a small number of patients, further studies are needed in larger populations.

MINI: Recent developments in near-infrared fluorescent imaging have revealed the usefulness of indocyanine green (ICG) for preoperative pulmonary nodule localization. However, it is difficult to determine the resection margins of deep-seated nodules using this technique, given the limited depth penetration and diffusion of ICG through the lung tissue without pooling around the lesion. The optimal fluorescent iodized emulsion, a mixture of ICG solution and Lipiodol (ethiodized oil), can overcome these limitations and may allow the accurate localization and resection of pulmonary nodules. Objective This study was conducted to develop a fluorescent iodized emulsion comprising indocyanine green (ICG) solution and lipiodol (ethiodized oil) and evaluate its feasibility for use in a clinical setting. Background ICG use for the preoperative localization of pulmonary nodules is limited in terms of penetration depth and diffusion. Methods First, fluorescent microscopy was used to investigate the distribution of ICG-lipiodol emulsions prepared using different methods. The emulsions were injected in 15 lung lobes of 3 rabbits under computed tomography fluoroscopy guidance; evaluation with imaging and radiography was conducted after thoracotomy. Subsequently, the emulsions were used to preoperatively localize 29 pulmonary nodules in 24 human subjects, and wedge resections were performed using fluorescent imaging and C-arm fluoroscopy. Results The optimal emulsion of 10% ICG and 90% lipiodol mixed through 90 passages had even distribution and the highest signal intensity under fluorescent microscopy; it also had the best consistency in the rabbit lungs, which persisted for 24 hours at the injection site. In human subjects, the mean diameter of pulmonary nodules was 0.9 ± 0.4 cm, and depth from the pleura was 1.2 ± 0.8 cm. All emulsion types injected were well localized around the target nodules without any side effects or procedure-related complications. Wedge resection with minimally invasive approach was successful in all pulmonary nodules with a free resection margin. Conclusions A fluorescent iodized emulsion prepared by mixing ICG with lipiodol enabled accurate localization and resection of pulmonary nodules.

Indocyanine green (ICG) fluorescence imaging has been used to detect many types of tumors during surgery; however, there are few studies on thymic masses and the dose and time of ICG injection have not been optimized.We aimed to evaluate the optimal ICG injection dose and timing for detecting thymic masses during surgery.Forty-nine consecutive patients diagnosed with thymic masses on preoperative computed tomography (CT) and scheduled to undergo thymic cystectomy or thymectomy were included. Patients were administered 1, 2, or 5 mg/kg of ICG at different times. Thymic masses were observed during and after surgery using a near-infrared fluorescence imaging system, and the fluorescence signal tumor-to-normal ratio (TNR) was analyzed.Among the 49 patients, 14 patients with thymic cysts showed negative fluorescence signals, 33 patients with thymoma or thymic carcinoma showed positive fluorescence signals, and 2 patients showed insufficient fluorescence signals. The diagnosis of thymic masses based on CT was correct in 32 (65%) of 49 cases; however, the differential diagnosis of thymic masses based on NIR signals was correct in 47 of 49 cases (96%), including 14 cases of thymic cysts (100%) and 33 cases of thymomas or thymic carcinomas (94%). In addition, TNR was not affected by the time or dose of ICG injection, histological type, stage, or tumor size.Low-dose intravenous injection of ICG at flexible time can detect thymic tumors. In addition, thymic cysts can be distinguished from thymomas or thymic carcinomas during surgery by the absence of ICG fluorescence signals.

IMPORTANCE: Identification of the tumor margin during surgery is important for precise minimal resection of lung tumors. Intravenous injection of indocyanine green (ICG) has several limitations when used for intraoperative visualization of lung cancer. OBJECTIVES: To describe a technique for intraoperative visualization of lung tumor margin using ICG inhalation and evaluate the clinical applicability of the technique in mouse and rabbit lung tumor models as well as lung specimens of patients with lung tumors. DESIGN, SETTING, AND PARTICIPANTS: In lung tumor models of both mice and rabbits, the distribution of inhaled ICG in the lung tumor margin was investigated in vivo and ex vivo using a near-infrared imaging system. Lung tumor margin detection via inhalation of ICG was evaluated by comparing the results obtained with those of the intravenous injection method (n = 32, each time point for 4 mice). Based on preclinical data, use of ICG inhalation to help detect the tumor margin in patients with lung cancer was also evaluated (n = 6). This diagnostic study was conducted from May 31, 2017, to March 30, 2019. MAIN OUTCOMES AND MEASURES: The use of tumor margin detection by inhaled ICG was evaluated by comparing the inhaled formulation with intravenous administration of ICG. RESULTS: From 10 minutes after inhalation of ICG to 24 hours, the distribution of ICG in the lungs was significantly higher than that in other organs (signal to noise ratio in the lungs: 39 486.4; interquartile range [IQR], 36 983.74-43 592.5). Ex vivo and histologic analysis showed that, in both lung tumor models, inhaled ICG was observed throughout the healthy lung tissue but was rarely found in tumor tissue. The difference in the fluorescent signal between healthy and tumor lung tissues was associated with the mechanical airway obstruction caused by the tumor and with alveolar macrophage uptake of the inhaled ICG in healthy tissues. Inhalation at a 20-fold lower dose of ICG had a 2-fold higher efficiency for tumor margin detection than did the intravenous injection (2.9; IQR, 2.7-3.2; P

Background: The optimal chemical agent for additional pleurodesis during video-assisted thoracoscopic surgery (VATS) bleb resection in primary spontaneous pneumothorax (PSP) remains controversial. We compared the efficacy and safety of iodopovidone with those of minocycline for additional chemical pleurodesis during VATS bleb resection. Methods: Of 332 patients who underwent VATS bleb resection, 299 patients diagnosed with PSP were enrolled in this study. The patients were divided into two groups according to the chemical agents used for additional pleurodesis (iodopovidone versus minocycline). Propensity score matching was performed on the basis of the preoperative clinical parameters. Postoperative complications, chest tube indwelling time, postoperative hospital stay, and recurrence rate were compared between the two groups. Results: The median duration of follow-up was 14 months (range, 1–94 months). After propensity score matching, 94 patients from the iodopovidone group and 94 patients from the minocycline group were matched. The perioperative outcomes, including fever, prolonged air-leak, prolonged-effusion, postoperative bed-side pleurodesis, and rehospitalization because of complications, were not significantly different between the two groups. However, the amount of drainage during the first two postoperative days, duration of chest tube indwelling, and duration of hospitalization were significantly shorter in the minocycline group (P Conclusions: This study confirmed the safety of both minocycline and iodopovidone for additional pleurodesis. However, we carefully recommend minocycline over iodopovidone for pleurodesis because of faster postoperative recovery.

Background: CO 2 insufflation could provide a better surgical field during single-incision thoracoscopic surgery (SITS) with small tidal two-lung ventilation (ST-TLV). Here we compared the surgical field and physiological effects of ST-TLV with and without CO 2 during SITS. Methods: Patients underwent scheduled SITS bullectomy. Surgery under ST-TLV general anesthesia performed without CO 2 (group NC) or with CO 2 insufflation (group C). The surgical field was graded at thoracoscope introduction and at bulla resection as follows: good (more than half of the 1st rib visible; bleb easily grasped with the stapler), fair (less than half of the 1st rib visible; some manipulation needed to grasp the bleb with the stapler), or poor (1st rib non-visible; bleb ungraspable). Vital signs, arterial blood gas analysis (ABGA), and mechanical ventilation parameters, postoperative chest tube indwelling duration, length of hospital stays, and complications were recorded. Results: A total of 80 patients were ultimately included. The surgical field at thoracoscope introduction was better in group C (P=0.022). However, at bleb resection, the surgical fields did not differ (P=0.172). The operation time was significantly longer in group C (P=0.019) and anesthesia recovery time was not different (P=0.369). During the CO 2 insufflation, the airway pressure was higher in group C (P=0.009). Mean PaCO 2 was significantly higher (P=0.012) and mean PaO 2 was significantly lower (P=0.024) in group C, but both values were within the physiologically normal range. Postoperative chest tube indwelling duration and length of hospital stays were not statistically different (P=0.234 and 0.085 respectively). Postoperative complication frequencies were similar (12.5% for group NC, 10.0% for group C, P=0.723). Conclusions: SITS with CO 2 insufflation during ST-TLV did not produce a superior surgical field except at the beginning of surgery. CO 2 insufflation required more time and resulted in higher mean PaCO 2 and peak airway pressure.

In this paper, we described our clinical experiences with respect to image-guided thoracic surgery, including procedures involving percutaneous injection of fluorescent dye, radiotracers, and hook wires, guided by preoperative computed tomography (CT); and transbronchial injection of fluorescent dye by using electromagnetic navigational bronchoscope technology. Our recent experience with the intravenous systemic injection of fluorescent dye for the intraoperative detection of pulmonary lesions and intersegmental planes are also described in this review.

This article addresses technical details of uniportal VATS segmentectomy by lung segments, suggesting available techniques for lesion localization and identification of the intersegmental plane. Long-term results and superiority have not yet been characterized in standard VATS for lung malignancy. Indications include almost all thoracic procedures currently performed by conventional multiport VATS. We review our experience and published literature on the feasibility of uniportal VATS segmentectomy.

In this article, we present 2 cases with successful reduction of herniated organs and repair of a ruptured diaphragm through a single-port video-assisted thoracoscopic surgery (VATS) approach using CO2 gas insufflation in haemodynamically stable patients. A CO2 insufflation was useful to push the diaphragm down and aided in reducing the size of the herniated organ. This approach did not cause damage to the herniated organs and no additional instrument or assistant was required. Thus, CO2 insufflation makes the single-port VATS procedure easier even in haemodynamically stable trauma patients.

This is the first study to evaluate the feasibility of mediastinal lymph node dissection (MLND) based on sentinel lymph node (SLN) status during pulmonary metastasectomy. A total of 22 patients (16 men, 6 women; age 63.3 ± 7.01 years) who were candidates for metastasectomy through segmentectomy or lobectomy with MLND owing to cancers metastatic to the lung were enrolled in this study. Radiotracer was administered at the peritumoral region before surgery or soon after initiating surgery. During the operation, the radioactivity of the lymph nodes (ex vivo) was counted with a handheld gamma probe after MLND. Lobectomy was performed in 17 patients, and segmentectomy, in 5 patients. The number of dissected lymph nodes per patient was 14.4 ± 8.69 (range, 5–36). In all patients, the SLN could be detected, and the number of SLNs identified was 2.0 ± 1.15 (range, 1–5) per patient. Lymph node metastasis was identified in 3 of the 22 patients (13.6%), and none of the 3 patients with N1 or N2 disease had false-negative SLNs. SLN identification might be an indicator of whether or not MLND should be performed during pulmonary metastasectomy. However, further large-volume and multi-institutional studies are needed.

The development of single-port thoracoscopic surgery and two-lung ventilation reduced the invasiveness of minor thoracic surgery. This study aimed to evaluate the feasibility and safety of single-port thoracoscopic bleb resection for primary spontaneous pneumothorax using two-lung ventilation with carbon dioxide insufflation.Between February 2009 and May 2014, 130 patients underwent single-port thoracoscopic bleb resection under two-lung ventilation with carbon dioxide insufflation. Access was gained using a commercial multiple-access single port through a 2.5-cm incision; carbon dioxide gas was insufflated through a port channel. A 5-mm thoracoscope, articulating endoscopic devices, and flexible endoscopic staplers were introduced through a multiple-access single port for bulla resection.The mean time from endotracheal intubation to incision was 29.2±7.8 minutes, the mean operative time was 30.9±8.2 minutes, and the mean total anesthetic time was 75.5±14.4 minutes. There were no anesthesia-related complications or wound problems. The chest drain was removed after a mean of 3.7±1.4 days and patients were discharged without complications 4.8±1.5 days from the operative day. During a mean 7.5±10.1 months of follow-up, there were five recurrences (3.8%) in operated thorax.The anesthetic strategy of single-lumen intubation with carbon dioxide gas insufflation can be a safe and feasible option for single-port thoracoscopic bulla resection as it represents the least invasive surgical option with the potential advantages of reducing operative time and one-lung ventilation-related complications without diminishing surgical outcomes.

e15558 Background: Exosome concentration is known to be higher in cancer patients than in healthy individuals. In this study, we observed that the levels of exosomes differ in tumor-draining pulmonary blood and in peripheral blood in animal models and human subjects at different pathological stages of lung cancer. Methods: Ten rabbits and 40 humans formed the study cohorts. Blood was collected from a peripheral vein in all groups, and pulmonary blood was collected intraoperatively from all groups, except the healthy human controls. Quantitative analysis of exosomes was performed by nanoparticle tracking assay, CD63 enzyme-linked immunosorbent assay, and western blotting. Results: The peripheral blood of lung cancer-bearing animals and patients with lung cancer carried higher amounts of exosome than that from healthy controls ( p < 0.01 and p < 0.001, respectively). Moreover, pulmonary blood from lung cancer-bearing animals and patients had significantly higher exosome levels, compared to preoperative peripheral blood ( p < 0.01 and p < 0.0001, respectively). In patients, pulmonary exosome levels showed higher correlation with pathological stages of lung cancer than the peripheral exosome levels. Conclusions: Exosome levels increased with increasing grade of lung cancer, and this trend was more prominent in the pulmonary than in the peripheral blood.

e15550 Background: Exosomes are endosome-derived nano size (30-150 nm) extracellular microvesicles released from many cell types including cancer cells and encapsulated by cell membrane play a key role for cell to cell communication. Use of exosomes as a biomarkers in lung cancer is a rising nanotechnology in a liquid biopsy. We explored a role of an exosome specific marker and the relationship between pathological stage of lung cancer patients who underwent surgery and lung cancer specific exosome markers. Methods: Conditioned medium from non-small cell lung cancer (NSCLC) cells and human pulmonary alveolar endothelial cell (HPAEpiC) was collected and exosomes were isolated by size exclusion chromatography. Proteomics analysis was performed to investigate lung cancer specific proteins. Written informed consent was obtained from all human subjects (17 controls and 54 patients), approved by the Korea University Guro Hospital Institutional Review Bored. Plasma exosomes were isolated using dual size exclusion chromatography. We validated proteomics results with lung cancer exosome-specific protein 1 (LESP-1) ELISA assay and western blot assay in lung cancer patients with healthy control. Cancer cell lines with pCMV-CD63-GFP were transduced by lentiviral vectors containing LESP-1 shRNA. The distribution of GFP+ exosomes and cell migration were examined by immunocytochemistry (ICC) and cell migration assay. Results: We identified LESP1 by the proteomics analysis of exosomes from NSCLC cell lines, but not in HPAEpiC cell. Level of LESP1 was dramatically increased in exosomes from NSCLC cell lines and from NSCLC patients. LESP-1 concentration increased in lung cancer patients than healthy controls ( p < 0.0001) and increased according to the grade of lung cancer stage in peripheral blood ( p < 0.0001). Western blot results confirmed the presence of the LESP1 with higher intensity band at each grade of lung cancer stage than healthy controls. Interestingly, we found that the number of GFP+ exosomes was decreased and cell migration was inhibited when the LESP1 was suppressed in NSCLC cells. Conclusions: The LESP-1 in exosomes was highly expressed in blood plasma of lung cancer patients, and the exosome release and cancer cell migration was inhibited by the LESP-1, which suggest that LESP-1 could be a feasible factor for diagnosis and treatment of non-small cell lung cancer.

Lobectomy with systemic lymph node dissection remains the mainstay of surgical treatment of non-small cell lung cancer. The emerging technique of uniportal video-assisted thoracic surgery (VATS) major lung resection may be a promising candidate for a VATS technique with less intercostal pain, a better postoperative course, and comparable oncologic outcomes to conventional VATS lobectomy. This chapter presents the technical details of uniportal VATS resection, specific for lower lobe lesions. Various individual approaches will be determined by the surgeon’s experience.

COPatients underwent scheduled SITS bullectomy. Surgery under ST-TLV general anesthesia performed without COA total of 80 patients were ultimately included. The surgical field at thoracoscope introduction was better in group C (P=0.022). However, at bleb resection, the surgical fields did not differ (P=0.172). The operation time was significantly longer in group C (P=0.019) and anesthesia recovery time was not different (P=0.369). During the COSITS with CO

Background: Three-dimensional (3D) video systems offer better depth perception and are associated with improved performance during endoscopic or robotic surgery. We compared the impact of a 3D video system with a two-dimensional (2D) video system on a simulation program for uniportal thoracoscopic surgery. Methods: We launched an endoscopic simulation program for uniportal surgery using a 3D high-definition video system for training surgeons and medical students. This program included three basic surgical skills: (I) peg transfer, (II) passing a needle through a 3-mm hole, and (III) suturing on a tailor-made skin model. We evaluated the impact of 3D vision during simulation for uniportal surgery in each task. Overall, 113 trainees (85 surgeons in training and 28 medical students) who had not experienced a 3D video system were registered in the program. The three surgical simulation skills were evaluated under 2D and 3D video systems. Results: The 3D video system allowed for shorter procedural times [92 participants (80.0%) in task 1, 102 (86.4%) in task 2, and 88 (74.6%) in task 3] and improved performance. Moreover, 65 s in task 1, 145 s in task 2, and 32 s in task 3 were shortened using the 3D video system. Post-simulation survey revealed improved depth perception (n=71, 60.2%) and handling of instruments on the uniportal surgical module (n=39, 33.1%) as advantages of the 3D video system during simulation. Sixty (50.8%) trainees were not negatively affected by the use of the 3D glasses; however, 53 (44.9%) felt eye discomfort during simulation. Conclusions: We concluded that the 3D video system has potential advantages, such as improved procedure time and handling of instruments, during basic simulation of uniportal surgery for surgical trainees.

Background The da Vinci Single-Site platform (Intuitive Surgical, Mountain View, CA) has been applied in many fields of surgery, but use of this single-site platform in thoracic surgery has not been reported. This study reported our experiences and surgical outcomes with robotic single-site surgery in the field of thoracic surgery. Methods We retrospectively reviewed 14 patients who underwent robotic single-site thoracic surgery at 2 different institutions. Results All 14 cases were successfully completed, without conversion to conventional multiport robotic surgery. The most frequent diagnoses were thymic cyst (n = 4) and pericardial cyst (n = 3). The median largest mass size was 4.1 cm (range, 2.0 to 6.5 cm). The median operation time was 105 minutes (range, 27 to 185 minutes). After the operation, pleural effusion occurred in 1 patient (case 7) on the side on which the operation was performed but was managed with conservative treatment. The median duration of chest tube stay was 2 days (range, 1 to 3 days), and hospital stay was 4 days (range, 3 to 11 days). The median peak pain score after the operation was 3 (range, 1 to 7). Compared with thoracoscopic single-port surgery, robotic single-site thoracic surgery showed a longer operative time and higher cost. Conclusions This study demonstrated that robotic single-site thoracic surgery for mediastinal masses is a safe and feasible procedure. Although this study reports the initial series and the cases were relatively simple, more advanced and complex procedures could be done with the advent of new technology in the near future.

Recently, some groups have reported the utilization of electromagnetic navigational bronchoscopy (ENB) for localization of pulmonary lesion. Its application for intraoperative visual localization with dyes to determine the target area has been increasing. In this paper, we reviewed the feasibility of ENB utilization for video-assisted thoracoscopic surgery (VATS) or robotic sublobar resection as a localization tool, and its future application in minimally invasive thoracic surgery.

PURPOSE This study assessed physical development of patients with pectus excavatum and evaluated the effect of the Nuss procedure on physical development. METHODS A total of 146 patients underwent the Nuss procedure; of these, at the time of the study, the bar had been removed from 123 patients (84.9%; male 93, female 30) who were eligible for participation in this study. Heights and body weights of patients were measured prior to surgery and immediately before bar removal. Chest computed tomography (CT) was performed preoperatively and immediately before bar removal. The associations between physical development and chest CT indices were evaluated. RESULTS The height standard deviation score (SDS) was - 0.66 ± 2.23 preoperatively and 0.04 ± 1.34 immediately before bar removal (p

BACKGROUND: This study was conducted to measure the serial changes in pulmonary function over 12 months after lobectomy in subjects with lung cancer and to evaluate the actual recovery of pulmonary function in comparison with the predicted postoperative values. METHODS: Subjects who underwent lobectomy for primary lung cancer were included in this study. In the statistical analysis, we included data from 76 subjects (52 men and 24 women; mean age, 63.4 y) who completed perfusion scintigraphy 1 week before surgery and FEV1 and diffusion capacity of the lung for carbon monoxide (DLCO) assessments preoperatively and at 1, 6, and 12 months postoperatively. RESULTS: The actual percent-of-predicted FEV1 1 month postoperatively was 77.9% of the preoperative value, which was almost equal to the predicted postoperative value, and significantly increased to 84.3% by 6 months and 84.2% at 12 months. The actual percent-of-predicted DLCO 1 month postoperatively was 81.8% of the preoperative value, which was similar to the predicted postoperative value, and also significantly increased to 91.3% at 6 months and 96.5% at 12 months. However, the actual pulmonary function test results at 1 y in subjects with COPD or in those who underwent thoracotomy or received adjuvant chemotherapy were not different from the predicted postoperative values. CONCLUSIONS: Actual pulmonary function compared with predicted postoperative values improved over time over 1 y after lobectomy. However, this improvement was not observed in subjects with COPD or in those who underwent thoracotomy or received postoperative adjuvant chemotherapy.

Objectives There are few reports on optimal surgical approaches to bilateral pulmonary metastasis and the sequences used in the operation. The aim of this study was to evaluate the feasibility of the thoracoscopic bilateral approach to pulmonary metastasis. Methods From June 2006 to February 2013, 61 patients underwent a planned bilateral pulmonary metastasectomy with one- (n = 52) or two-stage (n = 9) thoracoscopic surgery. We retrospectively analysed the outcomes of this group of patients to define the role and limitation of thoracoscopic surgery in bilateral disease. Results In 17 patients with bilateral single lesions on the computed tomography (CT) scans, we were able to resect more nodules than initially imaged in 7 patients (41.2%), and there were 2 patients (11.8%) who had more true metastatic lesions than expected. Among 44 patients who showed more than two bilateral multiple lesions on the CT scan, we were able to resect more than 10 nodules in 2 patients (4.5%). The overall accuracy rate for resected malignant nodules was 76.6%, and 9 patients (14.8%) actually had the disease confined to the unilateral thorax, with solitary (n = 8) and multiple (n = 1) metastases after bilateral exploration. The prognostic factors for unilateral disease were unilateral lesion on the positron emission tomography (PET) scan (P = 0.024). The values of FVC and FEV1 were, respectively, 14.4 and 15.4% reduction at 6 months postoperatively in patients who had three or more nodules resected. Sarcomatous histology (P = 0.039), a diameter larger than 3 cm (P = 0.042) and bilateral lesion on PET (P = 0.035) were the prognostic factors for intrathoracic recurrences. Conclusions Bilateral pulmonary metastasectomy was performed safely with thoracoscopy in patients with bilateral oligo-metastatic sub-pleural lesions and the one-stage approach was a feasible option in bilateral single lesions. Preoperative PET scan could help predict intrathoracic recurrence after thoracoscopic metastasectomy.

This study evaluated long-term outcomes of pulmonary metastasectomy for solitary lung metastases to clarify the role of video-assisted thoracoscopic surgery in the selected population. We retrospectively investigated oncologic results after the resection of solitary lung metastases guided by thin-section chest computed tomography scans in 105 patients. Pulmonary metastasectomy for solitary lung metastases was approached by thoracotomy (n = 43) and by thoracoscopy (n = 62). Compared to the thoracotomy group, the thoracoscopy group had a shorter hospital stay (p

Preclinical studies of lung cancer require suitable large-animal models to allow evaluation and development of surgical and interventional techniques. We assessed the feasibility and safety of a novel rabbit lung cancer model of solitary tumors, in which real-time computed tomography fluoroscopy is used to guide inoculation of VX2 carcinoma single-cell suspensions. Thirty-eight rabbits were divided into four groups according to the volume of the VX2 tissue or cell suspension, the volume of lipiodol, the volume of Matrigel, and the injection needle size. The mixtures were percutaneously injected into rabbit lungs under real-time computed tomography fluoroscopy guidance. Two weeks later, VX2 lung carcinomas were confirmed via positron emission tomography/computed tomography, necropsy, and histology. Real-time computed tomography fluoroscopy allowed the precise inoculation of the tumor cell suspensions containing lipiodol, while the use of Matrigel and a small needle prevented leakage of the suspensions into the lung parenchyma. Solitary lung tumors were successfully established in rabbits (n = 22) inoculated with single-cell suspensions (150 mu L), lipiodol (150 mu L), and Matrigel (150 mu L) using a 26-gauge needle. This combination was determined to be optimal. Pneumothorax was observed in only two of the 38 rabbits (5.3%), both of which survived to the end of the study without any intervention. Real-time computed tomography fluoroscopy-guided inoculation of VX2 single-cell suspensions with lipiodol and Matrigel using a small needle is an easy and safe method to establish solitary lung tumors in rabbits.

Clinical vignette A 75-year-old male presented with abnormalities upon chest computed tomography (CT) scanning at a routine check. He had a 1.7-cm sized ground glass opacity (GGO) on the posterior segment of the right upper lung (RUL) and a 1.2-cmsized semisolid lung nodule on the left upper lung (LUL). To differentiate synchronous metastasis, sequential CT-guided core biopsy was performed for the GGO lesion on the posterior segment of the RUL and the posterior segment of the LUL. Both lesions were suspected to be adenomatous hyperplasia or non-small cell lung cancer. Adenocarcinoma was detected in situ upon pathologic examination. A positron emission tomography (PET) scan showed no lymph node metastasis or extrathoracic distant metastasis. The LUL semisolid lesion showed mild hypermetabolism, while the RUL pure GGO lesion showed no definite uptake on PET scan. Pulmonary function was as follows: forced vital capacity (FVC), 3.07 L (75%); forced expiratory volume in 1 second (FEV1), 2.34 L (88%); carbon monoxide lung diffusion capacity (DLCO), 20.7 mL/mmHg/min (116%). The patient was referred for surgical resection of bilateral synchronous lung lesions. In this case, by employment of the dual localization technique (hook-wire and lipiodol), we performed bilateral uniportal video-assisted thoracoscopic surgery (VATS) resection. Wedge resection was carried out for the GGO lesion on the posterior segment of the RUL and left upper divisional segmentectomy was carried out for the semisolid lesion on

This study was to evaluate the feasibility of near infrared (NIR) fluorescent images as a tool for evaluating the perfusion of the gastric tube after esophagectomy. In addition, we investigated the time required to acquire enough signal to confirm the presence of ischemia in gastric tube after injection of indocyanine green (ICG) through peripheral versus and central venous route. 4 porcine underwent esophagogastrostomy and their right gastric arteries were ligated to mimic ischemic condition of gastric tube. ICG (0.6mg/kg) was intravenously injected and the fluorescence signal-to-background ratios (SBR) were measured by using the custom-built intraoperative color and fluorescence imaging system (ICFIS). We evaluated perfusion of gastric tubes by comparing their SBR with esophageal SBR. In ischemic models, SBR of esophagus was higher than that of gastric tube (2.8±0.54 vs. 1.7±0.37, p

Single-port thoracoscopic segmentectomy is a challenging option in the early stages of lung cancer. The purpose of this study was to determine the feasibility of single-port video-assisted thoracoscopic surgery (VATS) segmentectomy compared to conventional multi-port VATS.A total of 45 patients underwent pulmonary segmentectomy by video-assisted thoracoscopic surgery between March 2006 and October 2015. We analyzed the operative outcomes of segmentectomy by surgical approach (34 single-port versus 11 multi-port).Twenty-three primary lung cancers (51.1%), 16 benign lung diseases (35.6%), and 6 secondary lung cancers (13.3%) were diagnosed and included in our study. In 29 malignancy cases (64.4%), the mean tumor size was 1.8±0.7 (range, 1-3.5) cm. Twenty patients (44.4%) underwent preoperative localization with hook-wire and radiocontrast. The most frequent operated segment was the left upper divisional segment (n=9, 30%). There was no significant difference in operation time (P=0.073), the number of dissected lymph nodes (P=0.310), intraoperative events (P=0.412), and the development of prolonged air leak (5 days) (P=0.610) between the single-port and multi-port VATS segmentectomy groups. There was a reduction in postoperative morbidity (P0.001) and hospital stay (P=0.029) in the single-port VATS group.Single-port VATS segmentectomy for early lung cancer and benign lung disease, is a safe and feasible option for patients undergoing pulmonary segmentectomy.

Esophageal leiomyoma is the most common benign tumor of the esophagus. Although enucleation via thoracotomy has been considered standard treatment, minimally invasive surgery is increasingly used for the treatment of this disease. We analyzed our surgical outcomes by comparing thoracotomy and the thoracoscopic approach. A retrospective review was performed of patients who underwent surgical resection of esophageal leiomyomas at the Seoul National University Hospital. Between 1982 and 2005, 63 patients were identified (male, n= 39; female, n= 24) at a mean age of 44.5 years. Thirty-two patients (51%) were symptomatic. Forty-five patients underwent thoracotomy, and 18 patients were resected using thoracoscopy. There was no mortality. The mean length of hospital stay was 10.3 days in the open group and 8.0 days in thoracoscopy group. Intraoperative mucosal repair was required in eight patients. Preoperative endoscopic mucosal biopsy within 1 month was identified as a risk factor for mucosal injury. Among the 11 patients with tumors less than 1.5 cm in size, thoracoscopic resection was attempted on four patients, and three out of the four cases required conversions to thoracotomy. Minimally invasive surgery for esophageal leiomyoma can be performed with good results. Our results suggest that the thoracoscopic approach should be considered as a standard surgical method for the treatment of esophageal leiomyoma. However, in cases of small tumors less than 1.5 cm in size, localization of the tumor may be difficult, and if asymptomatic, a regular monitoring should be considered as an alternative approach in such small tumors.

Introduction The lung is one of the most important organs affected by metastasis of hepatocellular carcinoma. However, pulmonary metastasectomy for hepatocellular carcinoma has not been well documented. The aim of this study was to evaluate long-term outcome after pulmonary metastasectomy due to metastasis of hepatocellular carcinoma. Methods Between January 1998 and December 2008, 41 patients underwent pulmonary metastasectomy. Retrospective reviews of medical records and telephone surveys were conducted to identify risk factors of long-term survival. Results Median time between a complete remission of hepatocellular carcinoma and pulmonary metastasectomy was 11 (4–105) months. During median 25-month follow-up time after metastasectomy, hepatocellular carcinoma recurred in 33 patients. Overall survival rate was 66.9 ± 10% in all 41 patients and disease free survival was 24.5 ± 10% in 24 patients who had no viable hepatocellular carcinoma in the liver preoperatively. An analysis of recurrence revealed that survival was better in patients whose recurrence was limited to either in the liver or lungs compared to that in patients whose recurrence took place in the distant organ other than the liver or lungs (extrahepatic/extrapulmonary metastasis) ( p = 0.004, log-rank). Conclusions Pulmonary metastasectomy for hepatocellular carcinoma can be performed safely without major morbidity. Recurrence at organs other than the liver or lung was found to result in poor survival, which suggests that a careful search for distant metastasis at other locations is mandatory for patient selection. This study demonstrated that pulmonary metastasectomy can play an important role in selected patients with pulmonary metastasis of hepatocellular carcinoma.

Robotic-assisted thoracic surgery has gained widespread acceptance for various thoracic diseases owing to its surgical accuracy. With recent advances in robotic-surgery devices, the single-site approach has become possible in robotic surgery. Herein, we report the case of single-site robotic surgery for mediastinal tumors by the thoracic approach. We performed robotic surgery with single-site instruments in a 50-year-old male with a mediastinal tumor in the anterior mediastinum. The instruments used were an 8.5-mm endoscope, 5-mm curved non-wristed instruments, and an accessory tracer on the 3-cm-diameter single-port device for the single-site robotic system. The potential benefits of this approach to thoracic surgery are better surgical accuracy and the enhanced operative field of robotic surgery, as well as the potential benefits of single-port thoracoscopic surgery.

Background: The benefit of superior vena cava (SVC) resection in thoracic malignancies remains controversial. We analyzed the results of extended resection in patients with thoracic malignancy involving the SVC. Material and Method: From March 2000 to March 2009, we performed surgical resection and reconstruction in 18 thoracic malignancies involving the SVC. Ten male and 8 female enrolled and their mean age was 56 years. Result: SVC reconstruction was performed in 9 patients with polytetrafluoroethylene (PTFE) graft. Primary closure was possible in 6 patients by partially clamping the SVC. Patch angioplasty was performed in 3 patients with PTFE or autologous pericardial patch. Three-year survival was 58.0% and median survival time was 24.5 months. Disease specific survival and recurrence free survival were not significantly different between lung cancer and mediastinal malignancy. Obstruction of graft was detected in 4 patients during follow-up; SVC graft obstruction in 1 patient, and accessory graft between the innominate vein and right atrium in 3 patients. Conclusion: Extended resection of thoracic malignancies involving the SVC was a feasible method in selected patients. Although the morbidity rate was relatively high, mid-term survival was acceptable when complete resection was possible.