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OBJECTIVES Extended reality (XR), encompassing both virtual reality (VR) and augmented reality, allows the user to interact with a computer-generated environment based on reality. In essence, the immersive nature of VR and augmented reality technology has been warmly welcomed in all aspects of medicine, gradually becoming increasingly feasible to incorporate into everyday practice. In recent years, XR has become increasingly adopted in thoracic surgery, although the extent of its applications is unclear. Here, we aim to review the current applications of XR in thoracic surgery. METHODS A systematic database search was conducted of original articles that explored the use of VR and/or augmented reality in thoracic surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to December 2020. RESULTS Our search yielded 1494 citations, of which 21 studies published from 2007 to 2019 were included in this review. Three main areas were identified: (i) the application of XR in thoracic surgery training; (ii) preoperative planning of thoracic procedures; and (iii) intraoperative assistance. Overall, XR could produce progression along the learning curve, enabling trainees to reach acceptable standards before performing in the operating theatre. Preoperatively, through the generation of 3D-renderings of the thoracic cavity and lung anatomy, VR increases procedural accuracy and surgical confidence through familiarization of the patient’s anatomy. XR-assisted surgery may have therapeutic use particularly for complex cases, where conventional methods would yield inadequate outcomes due to inferior accuracy. CONCLUSION XR represents a salient step towards improving thoracic surgical training, as well as enhancing preoperative planning and intraoperative guidance., Extended reality (XR), encompassing both virtual (VR) and augmented reality (AR), allows the user to interact with a computer-generated environment based on reality.

Surgical approach for resection of tumours involving the thoracic inlet has largely been developed in the context of lung cancer of the superior sulcus. Therefore, initial anterior approaches included a thoracotomy associated with a longitudinal cervicotomy. Here, we describe a variation of the previously described anterior surgical approaches of the thoracic inlet that we performed for the resection of a primary mesenchymal tumour of the left middle scalenus muscle secreting fibroblast growth factor-23 responsible for tumour-induced osteomalacia. This approach allowed a safe control of the great vessels phrenic nerve and brachial plexus as well as a comfortable access to the middle scalenus muscle through an L-shaped incision with a cervico-manubriotomy without thoracotomy. The tumour was resected entirely with the middle scalenus. After 3 months of follow-up, the symptoms resolved entirely.

OBJECTIVES The cervicothoracic junction is a special section that connects the neck, thoracic cavity, mediastinum and axilla. Tumours in the region often invade or compress surrounding tissues and organs, which makes the surgical treatment difficult. METHODS A retrospective analysis involving 69 patients with tumours at the cervicothoracic junction. Clinical data with regard to manifestation, surgical approach, resection degree, outcome and pathological types were collected. RESULTS A total of 48 cases of asymptomatic patients and 21 cases of patients with ≥1 clinical manifestation were enrolled in the study. Twenty-seven patients received radical resection with video-assisted thoracoscopic surgery. Anterior approach was the predominant treatment method in open surgery (25 cases, 36.2%), while the anterolateral approach was used in 8 cases (6 cases of hemiclamshell incisions and 2 cases of trap-door incisions). In addition, we observed 1 case of posterior approach, 2 cases of posterolateral approach and 1 case of supraclavicular approach combined with posterolateral approach. Pathological examination results revealed 67 cases of radical resection and 2 cases of microscopic residual. Neurilemmoma was the most widespread pathological type (30 cases, 43.5%), followed by tumour originating from fibrous tissues (5 cases, 7.2%). A 3-year overall survival rate of the 69 patients was 89.9%, while a 5-year overall survival rate was 85.5%. CONCLUSIONS Tumours associated with the cervicothoracic junction are characterized by their unique location, complex anatomy and various histopathological subtypes. An individualized approach during surgery enhances safety and standardized of treatments for patients with tumours located at the cervicothoracic junction.

A 24-year-old man presented with a dumbbell-shaped right posterior mediastinal mass. The patient was placed in the prone position following general anaesthesia and intubation. After laminectomy and dissection of the dorsal part of the tumour using a posterior approach were performed, the tumour was completely resected using a robotic approach in the thoracic cavity without repositioning. This is the first report of robotic resection for posterior mediastinal tumour in the prone position as well as a novel combined posterior approach and robotic resection for dumbbell tumours.

Objectives We previously reported that cell sheet transplantation combined with an omentopexy (OP) procedure is more effective for repairing heart damage when compared with cell sheet transplantation alone. However, a simultaneous (conventional) laparotomy as part of the OP may adversely affect the general condition of critically ill heart failure patients who would otherwise benefit from cell sheet transplantation, which is a paradox to be reconciled before this treatment can be applied in a clinical setting. We devised a novel endoscopic approach termed 'transphrenic peritoneoscopy' (TPP) for minimal access to abdominal organs from the thoracic cavity. Herein, we evaluated the feasibility and safety of TPP with an OP in a porcine myocardial infarction model. Methods Myocardial infarction was induced in 4 mini pigs by placing an ameroid constrictor around the left anterior descending artery. One month later, a left thoracotomy was performed in 2 randomly selected mini pigs, and a laparoscopic port was placed on the left diaphragm to gain access into the abdominal cavity. Using a low-pressure pneumoperitoneum, a flexible gastrointestinal endoscope was advanced, then the omentum was partially grasped with endoscopic forceps and brought back into the thoracic cavity via the diaphragm. Skeletal myoblast cell sheets were then implanted over the impaired myocardium, followed by placing the omentum over the sheets. Results TPP-assisted OP was accomplished in 2 post-myocardial infarction mini pigs with severe heart failure with an intra-abdominal pressure ≤8 mmHg within 30 min (22 and 27 min, respectively). Necropsy findings revealed a viable omentum flap and pedicle in both animals, with no evidence of procedure-related complications. Angiographic and histological analyses confirmed vessel communication between the omentum and the left ventricle. Conclusions Our TPP approach was shown to be feasible and safe with a low-pressure pneumoperitoneum, while the omentum flap was durable. This successful combination of techniques may provide less-invasive endoscopic intervention and regenerative therapy.

OBJECTIVES Video-assisted thoracic surgery (VATS) is a complex technique requiring dedicated surgical training. Platforms for such training are scarce and often rely on the use of live animals, which raises ethical concerns. The objective of this study was to develop a box trainer that is dedicated for VATS training and able to reproduce bleeding scenarios. METHODS The developed Tuebingen Thorax Trainer comprises 5 components that are mounted on a human anatomy-like thoracic cavity containing a porcine organ complex. Any standard thoracoscopic instrument can be used. The organ complex is attached to a perfusion module. We assessed the applicability of the system in four 1-day VATS training courses at the Tuebingen Surgical Training Center. Assessment was performed using a questionnaire handed out to all participants. RESULTS Forty participants have been trained with the Tuebingen Thorax Trainer at our institution since November 2016. Thirty-five (87.5%) participants stated that the Tuebingen Thorax Trainer is an adequate model for VATS training. The ex vivo organ complex was reported to be realistic with regards to the level of detail and scale (76%). A large proportion of participants (27.5%) were experienced with VATS and reported having performed >50 procedures before taking the training course. CONCLUSIONS This new training device allows realistic training for VATS procedures. ‘Stagnant hydrostatic perfusion’ permits simulation of reproducible bleeding scenarios. The device is low in production costs and offers a strong resemblance to the clinical scenario. It reduces the use of animal models and contributes to the efforts in making surgical skills training for VATS more accessible.

Objectives Thoracic reintervention is a common treatment; however, preventing adhesion of the lung to the thoracic cavity wall remains a problem. This study aimed to investigate the effect on pleural adhesion of covering the postoperative pleural injury site with cross-linked gelatin glue (gelatin plus glutaraldehyde, hereafter 'gelatin glue') and to evaluate the proliferation of healing cells on gelatin glue. Methods We created a rat incisional lung-wound model and compared the effects of sealing the wound with gelatin glue (group A, n = 5), fibrin glue (group B, n = 5) or fibrin glue with a polyglycolic acid sheet (group C, n = 5). Adhesions were assessed 28 days postoperatively and compared among the groups using the Karacam's scoring method. Lung-wound healing was studied histologically at day 7 postoperatively. Mesothelial cell proliferation was investigated on gelatin and fibrin glues in vitro. Results There were no or few adhesions of the chest wall in group A. The adhesion scores (mean ± standard deviation) were 1.2 ± 0.4, 2.6 ± 1.4 and 3.2 ± 1.2 in groups A, B and C, respectively (A vs C, P = 0.0496). During the healing process, the gelatin glue surface was covered by mesothelial-like cells. Proliferation of cultured mesothelial cells was promoted on the gelatin glue compared with the fibrin glue. Conclusions Covering lung wounds with the gelatin glue reduced adhesions and promoted the growth of healing cells compared with the fibrin glue. These findings suggest that the gelatin glue may help prevent adhesions and thus be a therapeutically effective biomaterial in lung surgery.

A right-sided descending aorta with a left aortic arch is a rare congenital anomaly in which the aortic arch crosses the midline from the left side of the trachea coursing to the descending aorta in the right thoracic cavity. The surgical repair of an interrupted aortic arch with a right-sided descending aorta carries great risks of bronchial and oesophageal obstruction. Herein, we describe a case of successful surgical repair of an interrupted aortic arch with a right-sided descending aorta using the swing-back and trap-door techniques.

We evaluated the viability of free fat grafts in the thoracic cavity using 3-month old male swine (n = 2). After left caudal lobectomy, 1-3 g of subcutaneous fat tissue harvested via the thoracotomy site was implanted in the chest cavity. At re-thoracotomy 6 weeks after implantation, all of the implanted fat grafts (n = 15) were found to have closely adhered to the parietal pleura and visceral pleura. There was a significant decrease by ∼30% in the weight of the fat grafts after implantation. Regardless of the weight loss, the implanted fat graft showed normal structuring without scar formation in the central area. Our results may suggest that free fat pads, which weighed up to 3 g, were successfully cultured in the thoracic cavity until the implanted tissues integrated into the surrounding tissues. Therefore, the free fat pad can be used as a biomaterial for some purposes in thoracic surgery.

OBJECTIVES: Although there is no consensus on the management of bronchogenic cyst, most surgeons advocate early removal, even in asymptomatic patients. To evaluate the feasibility and safety of video-assisted thoracic surgery (VATS) in the management of bronchogenic cysts and long-term follow-up, a retrospective analysis was performed. METHODS: From January 1995 to April 2013, we retrospectively reviewed the charts of 113 patients who underwent VATS resection of bronchogenic cysts in our institution. Resection of the bronchogenic cysts by VATS was initially performed in patients who had a cyst in the thoracic cavity and no evidence of severely dense adhesion to other organs or tissues on a CT scan. Also, patients with a history of previous thoracic surgeries, in addition to those with concomitant diseases requiring surgical treatment, were enrolled in our series. Operations were carried out using the conventional three-port technique and histological examinations confirmed the diagnosis of benign bronchogenic cyst containing a ciliated columnar epithelial lining. RESULTS: The median size of the cysts was 3.7 cm in their greatest diameter (range, 1–10 cm). One hundred and nine patients with bronchogenic cyst were resected completely by VATS. In 4 cases, VATS was converted to open thoracotomy or median sternotomy: major adhesion to the bronchus in 2, left innominate venous injury in 1 and repair of bronchial tear by surgery in 1. We identified 5 intraoperative complications of tracheobronchial tear, vascular injury and oesophageal laceration. The median operation time was 96.8 min (range, 15– 320 min). There were no operative mortalities or major postoperative complications. Patients with VATS excision were discharged after a median of 3.7 days postoperatively. The long-term follow-up ranged from 1 to 11 years, with a median follow-up of 4.2 years. There were no late complications or recurrences. CONCLUSIONS: Considering the low conversion and complication rate, VATS was safe and effective in the resection of the bronchogenic cysts. The size and the location of cysts were not important considerations in selecting the surgical method. VATS excision should be considered the primary therapeutic option in the management of patients with bronchogenic cysts.

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has evolved dramatically into a sophisticated technique capable of performing some of the most complex thoracic procedures. The idea of operating through fewer surgical incisions and, therefore, with potentially better cosmesis, less postoperative pain and paraesthesia, has led to uniportal VATS increasing in popularity worldwide. The uniportal approach demands instrument design to be better suited for operating with multiple instruments through a single small incision. Furthermore, the drive by surgeons and industry to develop novel, smaller, more specialized procedure-specific instruments for uniportal VATS to further allow reduction in incision size is relentless. Refinement of uniportal VATS instruments, angulated and narrower endostaplers, and improvements in video-camera systems, including 3D systems, and 120° articulating lens will make uniportal VATS major lung resection easier to perform and learn. In the future, we could see the development of subcostal or e-NOTES access, endorobotic arms that open and operate within the chest cavity, and cross-discipline imaging assistance for uniportal VATS procedures.

OBJECTIVES: Mediastinoscopy remains the gold standard for surgical exploration of the mediastinum. The use of this approach to access the left thoracic cavity could be complicated by vascular or neurological lesion. The aim of this experimental work was to describe a new approach to the left thoracic cavity through a cervical incision and retrosternal space using a flexible endoscope as a unique instrument. METHODS: We conducted an experimental work on 12 refrigerated and non-embalmed cadavers. Through a cervical incision, we dissected the retrosternal space to the level of Louis angle and then opened the left mediastinal pleura. We introduced the flexible endoscope through this pleural window into the left thoracic cavity. We defined three distances between the borders of the endoscope entry point, the phrenic nerve and the mammary artery: Distance 1: between the medial edge of the endoscope entrance point and the medial edge of the left mammary artery, Distance 2: between the top of the endoscope entrance point and the penetration of phrenic nerve in the left thoracic cavity and Distance 3: between the lateral edge of the entrance point of the endoscope and the medial edge of the phrenic nerve. To measure these distances, we performed a left postero-lateral thoracotomy. RESULTS: Procedure was successfully executed in 10 of the 12 studied subjects. The mean distances 1, 2 and 3 were 17.1 (range 2–40), 39.5 (17–80) and 19.1 mm (10–40), respectively. The minimal Distance 1 was in two subjects 0.2 and 0.5 mm. CONCLUSIONS: This approach avoids the para-aortic and supra-aortic zone; this access could be less dangerous than already described access techniques. Despite the limits of our work on cadavers, and the two failures in the application of the access, the mean distances we calculated show the potential safety of our approach concerning the phrenic nerve and the mammary artery. An experimental protocol on living animals is currently underway with the aim of confirming the safety of our approach.

OBJECTIVES: Sample extraction from the thoracic cavity through an intercostal space during video-assisted thoracoscopic surgery can result in cancer cell contamination by tumour crushing and tumour cell extravasation, and may have adverse effects on the surgical outcome. Lavage cytology of the sample extraction bag was investigated to clarify the risk of cancer cell spillage and identify the clinicopathological features associated with susceptibility to cancer cell spillage during extraction. METHODS: Lavage cytology of the sample extraction bag was investigated in 464 patients with negative pleural lavage cytology who underwent lung resection for primary lung cancer via video-assisted thoracoscopic surgery between January 2010 and December 2012. The surgical procedures, pathological findings and clinical course were evaluated by hospital record review. RESULTS: The incidence of positive bag lavage cytology (BLC) was 13.6%. Statistically significant factors associated with susceptibility to BLC positivity were tumour size, standardized uptake value of positron emission tomography, pathological features such as pathological N score, pleural invasion, vascular invasion and papillary-predominant adenocarcinoma. Among patients with Stage I lung cancer, the survival rate was significantly lower in the BLC-positive group than in the BLC-negative group. CONCLUSIONS: BLC positivity can be related to oncological characteristics such as tumour invasiveness and adhesiveness as opposed to tumour size and surgical margin, and may help to determine the prognosis of Stage I lung cancer. The sample extraction bag must be carefully manoeuvred through the intercostal space to prevent cancer cell dissemination to the chest wall or thoracic cavity.

OBJECTIVES: Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. Current methods are associated with risks of chronic neuropathic pain and a visible chest scar. We developed a novel surgical technique for the performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery with a flexible endoscope in a porcine model. METHODS: Transumbilical flexible endoscopic thoracic sympathectomies were performed in seven farm pigs (three acute and four 4-week survivals). Under general anaesthesia, animals were intubated and mechanically ventilated with a dual lumen endotracheal tube through tracheostomy. A newly developed long transabdominal trocar was placed through the umbilicus. After insertion of a gastroscope through this trocar, a small incision was created on both sides of the diaphragm by a needle-knife. Then the gastroscope was inserted into the thoracic cavity, and the sympathetic chain was identified at the desired thoracic level and ablated. Operation time, safety and feasibility were recorded in all animals. RESULTS: The transumbilical thoracic sympathectomies were successfully completed in all pigs with a mean operation time of 66.7 ± 9.4 min. Intraoperative bleeding occurred in one pig during the electrosurgical incision of diaphragm tissue, which was successfully controlled by hot biopsy forceps. No other acute intraoperative complications were observed in any cases. In the acute group, the length of the diaphragm incision ranged from 4 to 5 mm in three pigs. In the survival group, the animals recovered promptly from surgery. In three pigs, a small pneumothorax was found in the postoperative chest X-ray, but all of them were completely resolved with conservative treatment. Autopsy showed all bilateral T3 sympathetic chains were successfully ablated and no evidence of vital structure injury or diaphragmatic hernia. CONCLUSIONS: Transumbilical flexible endoscopic thoracic sympathectomy is technically feasible, simple and safe in a porcine model. This technique can be used as a novel experimental platform for studies of natural orifice transluminal endoscopic surgery (NOTES) for intrathoracic surgery.

Thoracic surgeons frequently encounter early lung cancer showing a pure ground-glass nodule. Although thoracoscopic wedge resection is used extensively, it cannot be easily located for surgical procedures. Thoracoscopic ultrasonography is a real-time and less invasive technique for small lung lesion localization during thoracoscopic surgery. However, this technique has not been widely adopted because residual air in the lung results in poor ultrasound images. A 64-year-old woman was found to have pure ground-glass nodule. For intraoperative localization, we performed thoracoscopic ultrasonography. To deflate the lung, we insufflated carbon dioxide into the thoracic cavity and maintained an intrathoracic pressure of 10 mmHg for 5 min. We easily achieved complete lung collapse without any complications; pure ground-glass nodule clearly showed as a hyperechoic lesion. We performed thoracoscopic wedge resection with a pathological diagnosis of adenocarcinoma in situ. Carbon dioxide insufflation into the thoracic cavity may be effective for complete lung deflation, which is useful to detect small lung nodules.

Pneumothorax associated with treatment for pulmonary malignancy (PATPM) is a rare complication. Its clinicopathological features have not yet been clearly defined. Forty-one patients with PATPM from September 2002 to March 2009 were included. We evaluated the clinicopathological findings and treatment outcome of these patients. Of the 41 patients, 21 had primary lung cancer and 20 had metastatic lung tumours. Twenty-four patients (58.5%) required chest tube drainage for more than six days. Ten patients (24%) finally, received surgical treatment. Regarding the surgical procedure, conversion to open thoracotomy was required in seven (70%) of these 10 patients because of dense adhesions or anatomical changes in the thoracic cavity caused by treatment or the progression of the tumours. Two patients had severe complications after surgery. One of these two patients and another patient died of primary disease within 30 days after surgery. The median survival time in the 10 patients with surgery was 223 days (range 22-1059 days). PATPM tends to require chest tube drainage for a long period, and sometimes needs surgical treatment, which may be difficult. We should carefully identify patients who would derive considerable benefit from surgical treatment.

Deep sternal infections secondary to bony instability and malunion, can result in mediastinitis. Previous authors have described the use of prophylactic rigid plate fixation in high-risk patients. The purpose of our study is to review the use of prophylactic sternal platting with pectoralis advancement flaps in high-risk patients with a history of chest irradiation. Fourteen patients (July 2003-September 2008) with a history of chest irradiation who underwent a median sternotomy followed by prophylactic rigid plate fixation of the sternum were reviewed. Breast cancer was the most common etiology of chest irradiation (n=11, 78%). The average EuroSCORE was 24.06% with 72% of patients having a preoperative New York Heart Association (NYHA) class≥III. There were no episodes of sternal non-union, mediastinitis or death. Follow-up was 100% with a 0% 30-day and a 7.1% one-year mortality rate (non-cardiac). A comparison between mean preoperative left ventricular ejection fraction (LVEF) (49.6%) and postoperative LVEF (59.7%) was statistically significant (P

Cervical incision thoracic surgery has recently been described. Currently, there is a move to increase the role of flexible endoscopy in surgery. The use of a flexible endoscope through a natural orifice into the thoracic cavity still remains ethically doubtful. The authors present a surgical experimental study using a flexible endoscope through a cervical incision for the exploration of both the mediastinum and the thoracic cavity in a cadaver. An experimental work on 10 refrigerated and non-embalmed cadavers was initiated. We used a unique device - a standard double-channel flexible video gastroscope. Through a small cervical incision, we performed simultaneous exploration of the mediastinum and both pleural cavities. Identification and biopsies of mediastinal lymph nodes at levels 2R, 4R, 7 and 4L were easy to perform in all subjects. In eight cadavers, we performed an assessment of bilateral pleural cavities and multiple pleural biopsies as well as bilateral thoracic sympathectomy. A chest tube was placed in the thoracic cavity at the end of all pleural procedures. The potential advantages of this approach are simultaneous exploration of the mediastinum and pleura and the performance of several thoracic interventions through a small cervical incision. The flexible endoscope could become a surgical tool for thoracic surgery.

The surgery of the cervico-thoracic inlet is a challenge for the thoracic surgeon. Several authors have described different approaches - with different degrees of invasiveness - to this anatomical area. We used the transmanubrial osteomuscular sparing approach described by Grünenwald and Spaggiari for six patients with five different indications: 1) left anterior Pancoast tumor; 2) glomus tumor originating from the inferior trunk (C8-T1 roots) of the right brachial plexus; 3) T1 vertebral tumor; 4) right internal jugular chain, Pirogoff confluence and subclavian artery metastatic lymph nodes from thyroid carcinoma; 5) chondrosarcoma of the first left rib. The results have been satisfactory from a surgical point of view, considering that the approach gave a good exposure of the operative field (especially at the cervical level), without cosmetic problems or functional limitations. In our experience, the transmanubrial osteomuscular sparing approach is a valid technique for the treatment of several kinds of tumors of the cervico-thoracic inlet, giving a good exposure of the operative field. In the case of anterior Pancoast tumors, the upper lobectomy may necessitate a further axillary thoracotomy, when fissural adherences are present.

Less than 25 cases of azygous vein lacerations secondary to blunt trauma have been published in the medical literature, most of these injuries were resulting from motor vehicle accidents, but have been described due to falls or assaults. These lesions should be considered as thoracic great vessels injuries and if not recognized promptly carry a high morbidity and mortality. We report a case of a young male involved in a high-speed car collision, admitted to the emergency room in an unstable condition secondary to hypovolemic shock due to azygous vein injury. The patient underwent emergent right antero-lateral thoracotomy followed by sternotomy for surgical control of the vascular injury and resuscitation. Laparotomy and splenectomy were also required, the abdomen was closed. The thoracic cavity was left packed and closure was delayed for 48 h. The patient survived and was transferred to another hospital seven days later.

Plombage, a variant of collapse therapy for patients with pulmonary tuberculosis that uses a variety of foreign materials, was undertaken until the 1950s before the invention of effective antimicrobial therapy. Complications related to previous plombage procedures are not uncommon. Management of these complications can be challenging. We report a patient presenting with extrusion of plombage 59 years later and managed successfully with removal of the plomb and pectoral muscle flap transposition.

OBJECTIVES: Ivor Lewis minimally invasive oesophagectomy (ILMIE) is a complex surgery aiming to remove an oesophageal tumour and to create a new gastric tube in the abdomen. The objective was to assess the technical and early outcomes of ILMIE for gastric tube construction in the thoracic cavity. METHODS: A retrospective analysis was conducted in 25 middle or lower oesophageal cancer patients treated with ILMIE between August and December 2012. A gastric tube was constructed in the thoracic cavity in all patients. The gastric tube and the oesophagus were anastomosed using a circular stapler. Clinical data (age, gender, pathological pattern and TNM stage), surgical data (operation time, intraoperative blood loss and intraoperative complications) and follow-up data (postoperative complications, length of stay, thoracic tube drainage time and time before eating) were assessed. RESULTS: The mean age was 61 ± 8 years. Sixteen patients were male and 9 were female. Oesophageal cancer was located in the middle oesophagus in 5 cases and in the lower oesophagus in 20. No conversion to open surgery was performed. The mean operative time and intraoperative blood loss were 320 ± 63 min and 137 ± 95 ml, respectively. A mean of 2.4 ± 0.5 linear stapler cartridges was used per patient. A mean of 14.6 ± 5.4 lymph nodes was dissected per patient. Postoperative hospital stay was 13.2 ± 2.4 days. Intraoperative and postoperative complications occurred in 12% (3 of 25) and 20% (5 of 25) of patients, respectively, including 1 case of anastomotic fistula. The patients were followed up for a mean of 3.5 ± 1.2 months, and there was no relapse or death. CONCLUSIONS: The construction of a gastric tube through the thoracic cavity using ILMIE is feasible and safe in patients with middle or lower oesophageal cancer. However, longer follow-up and larger sample sizes are needed to evaluate the oncological efficacy.

The most common indication for reoperation after Ross operation is degeneration of the pulmonic conduit. Pulmonary autograft (aortic root) dilatation and insufficiency is another potential problem during follow-up. This report describes double (aortic and pulmonary) root re-replacement 5 years after Ross-Konno operation in a patient with straight back syndrome. The causes of reoperation were pulmonary conduit degeneration, moderate aortic insufficiency, aortic root dilatation compressing left atrium, left main bronchus and left pulmonary artery. Clamshell technique provided safe and effective approach for this patient with very narrow thoracic cavity.

Objectives Empyema is a well-known complication following lung resection. In particular, empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) is difficult to treat. Here, we present our experience of MRSA empyema treated with local irrigation using arbekacin. Methods Six patients consisted of 4 males and 2 females with an average age of 65.7 years. They developed MRSA empyema following lung resection and were treated at our institution between 2007 and 2011. Cases comprised four primary and one metastatic lung cancer, and 1 patient was a living lung transplantation donor. The surgical procedure consisted of four lobectomies, one segmentectomy and one wedge resection. After diagnosis of MRSA empyema, anti-MRSA drugs were administered intravenously in all cases. In addition, arbekacin irrigation at a dose of 100 mg dissolved in saline was performed after irrigation with saline only. Results The average number of postoperative days for the diagnosis of MRSA empyema was 13 (range 4-19). The period of irrigation ranged from 6 to 46 days. Arbekacin irrigation did not induce nephrotoxicity or other complications, and no bacteria resistant to arbekacin was detected in the thoracic cavity. We re-operated on 1 case because he had pulmonary fistula and severe wound infection. At the time of removing the thoracic catheter, MRSA in the pleural effusion disappeared completely in 3 patients. The period until MRSA concentration in the pleural effusion became negative after starting arbekacin irrigation ranged from 4 to 9 days. In the remaining cases, in which MRSA did not disappear, the catheter was removed because of no inflammatory reaction after stopping irrigation and clamping the catheters. All patients were discharged from our institution without thoracic catheterization and no patients had relapsed during the follow-up period ranging from 6 to 44 months. Conclusions Irrigation of the thoracic cavity with arbekacin proved to be an effective, safe and readily available method for treating MRSA empyema following lung resection.

The use of video-assisted thoracoscopic surgery (VATS) in dealing with thoracic trauma has been well established. VATS avoids a thoracotomy and offers excellent visualization of the entire pleural cavity. The removal of bullets from the pleural cavity using VATS has also been reported, but, to our knowledge, this is the first time a bullet has been removed from the pericardial cavity using VATS.

This study was performed to evaluate the efficacy of a novel chest drainage system. This system employs guide wire-based active chest tube clearance to improve drainage and maintain patency. A 32 Fr chest tube was inserted into pleural cavities of five pigs. On the left, a tube was connected to the chest canister, and on the right, the new system was inserted between the chest tube and chest canister. Acute bleeding was mimicked by periodic infusion of blood. The amount of blood drained from each chest cavity was recorded every 15 min for 2 h. After completion of the procedure, all residual blood and clots in each chest cavity were assessed. The new system remained widely patent, and the amount of drainage achieved with this system (670+/-105 ml) was significantly (P=0.01) higher than that with the standard tube (239+/-131 ml). The amount of retained pleural blood and clots with this system (150+/-107 ml) was significantly (P=0.04) lower than that with the standard tube (571+/-248 ml). In conclusion, a novel chest drainage system with active tube clearance significantly improved drainage without tube manipulations.

Objectives A term female with the diagnosis pentalogy of Cantrell associated with hypoplastic left heart syndrome was born without complication. A significant portion of the sternal body was hypoplastic. The right ventricle was found to be herniated into the abdominal cavity. Method The patient underwent an uncomplicated repair of an omphalocele. The infant then underwent an uncomplicated modified Norwood procedure. The right ventricular mass was reduced into the thoracic cavity prior to the Norwood. Results Because of inability to close the anterior chest wall, a skin allograft was employed to cover the heart. The child died of fungal sepsis at 3 months of life. Conclusions Repair of these complex constellation of defects, although successful technically, should take into account long-term morbidity that precludes a positive outcome.

We report a case of a 21-year old male with an asymptomatic solitary costal exostosis incidentally detected on a chest X-ray. The exostosis originated from the costochondral junction of the left fourth rib and protruded into the thoracic cavity. Exploratory thoracoscopy showed that the exostosis had scratched the adjacent pericardium and visceral pleura. A 5.5-cm long rib segment including the exostosis was excised. This report describes that the thoracoscopic findings of an asymptomatic costal exostosis originate from the costochondral junction, demonstrating that this condition may cause more extensive thoracic organ injury than expected.

We herein present an extremely rare case of a perforation of the ascending aorta with a hematoma extending into the left-side upper extrapleural cavity. A 62-year-old male with a sudden onset of severe chest pain was referred to our institution because of an abnormal shadow in the left-side upper lung field. Computed tomography revealed a small fusiform aortic arch aneurysm and a hematoma extending to the left-side upper extrapleural cavity. We diagnosed the patient to have acute aortic syndrome and urgent surgery was thus performed. Major bleeding which might be caused by a progression of the perforation was seen during a dissection of the aorta. The aortic arch was transected and a total arch replacement was performed with a 26 mm Dacron graft. No findings of a rupture of the aortic arch aneurysm or dissection were observed. The histopathology of the aorta revealed a severe atheromatous lesion with calcification and thinning disarrayed elastic fibers. The postoperative course was essentially good except for the development of pericardial effusion which required drainage.

The transition to totally endoscopic arterial bypass grafting (TECAB) by computer enhanced instrumentation systems brings the loss of an assisting hand for grasping the pedicle of the internal thoracic artery (ITA) and holding the threads, since only two robotic arms are positioned in the thoracic cavity. That is why exact planning of every step during surgery is mandatory. Especially the positioning of the IMA pedicle during beating heart procedures is imperative for friction-free workflow during the anastomosis. Stay sutures may partially overcome this problem. However, the pedicle hanging on stay sutures still tends to sway around, repositioning is limited. To aid in better workflow, we developed an easy-to-use and cheap holder for the IMA pedicle without the need of any additional port. By inserting a steel wire through the stabilizing system, the pedicle can be easily fixed onto it thus positioned and repositioned wherever it is needed during sewing the anastomosis.