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Percutaneous or transbronchial markings are performed to localize pulmonary nodules preoperatively. We present a novel intraoperative procedure that utilizes virtual thoracoscopic imaging-assisted pleural marking. In this procedure, a virtual thoracoscopic image is created preoperatively, and the coordinates of the pleural point above the tumor are determined. The pleural marker is intraoperatively placed on the coordinates, and dye is transferred to the visceral pleura with two lung ventilations. We present the specific procedures and countermeasures for cases when nodules are not palpable. Additionally, we present a comparison between the various methods of preoperative marking and this method.

Introduction: The decrease in the postoperative recurrence rate after thoracoscopic bullectomy for spontaneous pneumothorax is an issue that should be tackled even at this moment. We presently make sure to do the reinforcement of the visceral pleura around between the staple line on bullectomy and the common sites of the new-born bullae such as apex, top site of S6, interlobar fissure to prevent postoperative recurrence., Purpose: We evaluated the latest efficacy of preventing postoperative recurrence by widely covering the staple line and the common sites of the new-born bullae with a polyglycolic acid( PGA) sheet after bullectomy., Methods: Retrospective analyses were performed for 1,097 patients with spontaneous pneumothorax who received thoracoscopic bullectomy at our hospital between January 2011 and December 2020. The 1-year, 3-years, 5-years postoperative recurrence rates of 229 patients with spontaneous pneumothorax were respectively calculated with the Kaplan-Meier method., Results: The 1-year, 3-years, 5-years postoperative recurrence rates of spontaneous pneumothorax were 0.9%, 3.6%, 4.0%, respectively., Conclusions: Combination treatment with bullectomy and wide coverage of the staple line and the common sites of the new-born bullae with the PGA sheet reduced satisfyingly postoperative recurrence rates of spontaneous pneumothorax.

Purposes: Here, we present the tips and pitfalls of video-assisted thoracoscopic( VATS) total pleural adhesiolysis( TPA), determined on an empirical basis., Patients and Methods: From 2012 to 2020, VATS-TPA was performed in 33 patients undergoing pulmonary anatomic lung resection at our institute. The basic procedure was as follows:after peeling off the area of pleural adhesion surrounding the surgical ports using the fingers, the thoracoscope was inserted into the thorax and the adhesions in other areas were peeled off under thoracoscopic guidance., Results: The adhesiolysis group had a longer operating time, greater blood loss, and higher rate of conversion to thoracotomy compared to the non-adhesiolysis group. However, the results were acceptable considering the extra manipulation for adhesiolysis., Conclusions: VATS-TPA is a necessary component of the standard surgical procedure for general thoracic surgeons in cases of total pleural adhesion.

The adhesion between the visceral and parietal pleura makes video-assisted thoracoscopic surgery (VATS) difficult or impossible. When performing VATS without conversion to thoracotomy due to pleural adhesion, it is important to( ⅰ) evaluate the presence and extent of the adhesion preoperatively, (ⅱ) carefully perform detachment, and( ⅲ) adequately repair the injured visceral pleura. We evaluate visceral sliding with the help of chest ultrasonography and plan the best approach to make utility inci-sions, camera port, and third-port incisions. Considering the difficulty in repairing the injured visceral pleura under VATS, we perform extra-pleural detachment of adhesions around the injured visceral pleura, which can facilitate the repair of the pleural injury. For repairing pleural injury, we use free mediastinal fat tissue as biological pledgets to support suturing. In this report, we present the approaches and techniques we follow to perform VATS for patients with pleural adhesion.

Malignant pleural mesothelioma (MPM) is a rare tumor and associated with very poor prognosis. The median survival time( MST) was 8.9 months for those treated by palliative care only. For a radical treatment, total removal of the tumor is the main therapy as well as other solid tumors, but these diffuse and infiltrate growth pattern of tumor make it difficult. The MST was 13 months for patients treated by surgery only. On the other hand, MST using pemetrexed/cisplatin was 12.1 months. There are negative opinions for invasive surgical treatment such as extrapleural pneumonectomy (EPP). Currently surgical treatment of mesothelioma is conducted as part of the multidisciplinary treatment combined with chemotherapy and radiation therapy.

A 45-year-old man experienced dyspnea on effort and was hospitalized due to severe mitral valve regurgitation and atrial fibrillation. He also had alcoholic cirrhosis. After he was stabilized, mitral valve plasty and Maze procedure were performed. The postoperative clinical course was satisfactory. During the follow-up period, he began to suffer from persistent left pleural effusion, which amounted to about 2,500 to 3,000 ml, and required intercostal tube drainage weekly. Therefore a pleuro-peritoneal shunt was implanted. The pleural effusion decreased, and he obtained significant relief from dyspnea. After one year, we confirmed that pleural effusion had not reoccurred, and removed the pleuro-peritoneal shunt.

A 75-year-old woman who had been treated for pulmonary Mycobacterium intracellulare infection was admitted to a nearby hospital because of hemoptysis, right pneumothorax, and empyema. She had been treated by thoracic drainage and pleural lavage, but was reffered to our hospital because of refractory empyema. Her chest radiograph and chest computed tomography( CT) showed right chronic empyema of which pleural aspirate was smear positive for acid-fast bacilli and positive for the polymerase chain reaction method(PCR)-Mycobacterium intracellulare. Serum levels of white blood cell and C-reactive protein(CRP) were found to be slightly elevated. She was treated with combined use of ethambutol, rifampicin, clarithromycin, and kanamycin and with pleural curettage by thoracoscopic surgery. After surgery additional treatment was done using urokinase which was administered into the thoracic cavity via an thoracic tube. Chronic empyema gradually improved with the treatment and the pleural effusion became bacterial free, enabling the patient to discharge from hospital without thoracic drainage.

Secondary spontaneous pneumothorax (SSP) such as lymphangioleiomyomatosis (LAM), bronchiolitis obliterans (BO) is intractable or repeated the recurrence of pneumothorax. The most effective chemical pleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reduction in the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleural interventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation. We must be considered for new approaches to these intractable secondary pneumothoraces which replaced traditional conservative and surgical approaches. We had proposed new 2 approaches of total pleural covering (TPC) and awake surgical intervention (ASI) for intractable pneumothorax. We applied the TPC modified with coverage of air leak points with polyglycolic acid (PGA) sheet to 5 patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemical pleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrence has been observed. TPC is reliable procedure for management intractable bilateral SSP. For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgical intervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1 case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothorax can be applicable to selected patients with deteriorated general condition.

Because extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) suffers from unsatisfiable risk/benefit ratio, very careful consideration on its indication should be required. EPP is a complicated, multi-step surgery that includes pleural dissection, division of hilum, resection of a block of pleura, lung, diaphragm and pericardium, and reconstruction of diaphragm and pericardium. Therefore establishment of surgical images of whole procedures before starting surgery is essential. Dissection of parietal pleura is a particularly important procedure of EPP, because it determinates operating time, surgical blood loss, surgical morbidity/mortality and curability. Technical difficulty of pleural dissection strikingly differs according to the degree of pleural thickening, pleural adhesion and the severity of pleural invasion of the tumor. Although good surgical view is essential for safety, excessive thoracotomy may lead to postoperative pain and respiratory disorder. Underestimation of clinical stage is rather common in MPM even after vigorous preoperative assessment. Surgeons sometimes encounter T4 (i.e., unresectable) MPM such as diffuse chest wall invasion, vascular invasion, peritoneal invasion, and positive pericardial effusion that have not been detected preoperatively. Therefore, potentially-T4 site should be 1st processed for possible discontinuance of operation.

The recent development of thoracic surgery has depended on the progressive advances of surgical materials. For the reconstruction of the pleura, the chest wall, the diaphragm, the pericardium and other cardiac structures, materials of high quality are indispensable, and their appropriate use is also important.

Reinforcement of the visceral pleura along the stapled line and prevention of lung-chest wall adhesion is supposed to decrease the recurrence rate of video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. Covering over the stapled line with an absorbable mesh; polyglycolic acid and regenerative oxidized cellulose mesh, and a fibrin glue is recognized useful for that, although, it tends to be troublesome in VATS procedure. In this article, we present the knack of the covering method: (1) installation of the absorbable mesh on the visceral pleura; a folded absorbable mesh is hold with the endoscopic autosuture or grasping foreceps and placed on the pleura without curling up; (2) installation of a fibrin glue over the pleura and the mesh using a rubbing device (U-rod); each of the fibrinogen solution and the thrombin solution are applied and rubbed on the pleura and the mesh. Surgeons can perform them without any complicated technique.

Based on a hypothesis that the most effective target area for controlling malignant pleural effusion is the parietal pleura, the author has selectively carried out the multimodality treatment with limited operations combined with parietal pleurectomy (PL) followed by paclitaxel administered by 24-hour intrathoracic infusion and systemic chemotherapy. Seven patients with carcinomatous pleuritis were enrolled in the study. During a median follow-up period of 22 months, malignant effusion was controlled successfully in all patients. Although the imbalance on assessment and small sample size render the results inconclusive, the interim results presented here suggest that the tactic of targeting PL warrants further study in a less-invasive manner.

A 67-year-old man with a history of surgical resection of the superior lobe of the left lung and thoracoplasty due to pulmonary tuberculosis occurring approximately 40 years previously, was admitted to the hospital due to recurrent hemoptysis. X-ray films and computed tomography (CT) scans of the chest showed the left thoracic cavity to be filled with empyema, compressing the inferior lobe downward. Since three unsuccessful attempts were made at bronchial artery embolization for hemostasis, yielding hemoptysis of approximately 1,000 ml, emergency surgery was performed. To prevent massive intra-operative hemoptysis, the left pulmonary artery was blocked by median sternotomy. A transverse incision was then made, and thus pleuropneumonectomy could be safely performed. Since it allows early blocking of blood vessels surrounding the hilum of the lung and the main bronchus, anterior approach is useful in treating hemorrhagic empyema and wet pleurisy with internal fistula.

Between 1987 and March 2000, we have operated on eight patients for malignant mesothelioma which consisted of four of localized type and four of diffuse type. We have aggressively resected mesothelioma combined with chemotherapy whether the tumor was primary or recurrent, and concluded the following. 1) In localized malignant mesothelioma, en-bloc primary tumor resection was possible and additional resection for recurrence was effective and useful for long time survival. 2) In diffuse malignant mesothelioma, complete tumor resection was impossible to even perform pleuropneumonectomy accompanied with partial resection of pericardium and diaphragm and, therefore, the prognosis was poor in four patients and all died around one year. 3) Because recurrent pattern for localized type was diffuse type, diagnosis and surgical treatment in early stage was essential for long time survival.

A 58-year-old man was admitted to our hospital because of chest pain and dyspnea on July 15, 1999. A chest X-ray showed left pleural effusion, and a chest CT revealed left pleural effusion and diffuse pleural thickening. Because pleural fluid cytology and percutaneous needle pleural biopsy were negative for malignancy, thoracoscopic biopsy was performed on July 28. The biopsied specimen revealed malignant pleural mesothelioma (epithelial type). An operation was performed on August 16. First, mediastinal lymph node dissection was performed and we identified that there was no lymph node metastasis by frozen section diagnosis. Then panpleuropneumonectomy with combined resection of the diaphragm and pericardium was performed.

A 73-year-old male was admitted with dyspnea and cough. The chest X-ray showed left massive pleural effusion and diffuse pleural tumor in the left thorax. It was diagnosed as epithelial-cell type mesothelioma by pleural needle biopsy. After conforming the regression of the tumor from conducting two courses of combined treatment with cisplatin and doxorubicin, panpleuropneumonectomy was performed. He died from sepsis on the thirty second day after operation due to complication of postoperative diaphragmatic hernia and gastric perforation. When conducting a panpleuropneumonectomy to diffuse pleural mesothelioma, the most appropriate approach must be taken to the combined with resection and reconstruction of the diaphragma.

Transverse sternotomy was performed in a 39-year-old man having bilateral lung metastatic lesions of yolk sac tumor. This approach provided an excellent operative field. Bilateral partial lobes including parietal pleura and diaphragma were readily resected. As described in this paper, transverse sternotomy is one of the beneficial method in the thorough surgical treatment for metastatic bilateral lung lesion.

A felt-like bioabsorbable prosthesis (Polyglycolic Acid (PGA) pledget and sheet; Medifit feft) was used for pulmonary fistula in a total of 10 patients. "Fibrin glue A" was absorbed into the PGA prosthesis previously. And next, the part of pulmonary fistula was coated with "Fibrin glue B", and then covered with the fibrin-absorbed PGA prosthesis. The prosthesis adhered to the diseased part of pulmonary pleura immediately, and therefore, in all these 10 patients, the post-operative air-leakage was stopped up to 4 days and neither side effect nor complication was observed.

We studied the influence of pleurotomy during harvesting IMA for CABG on postoperative pulmonary function. Ninety nine cases underwent CABG surgery from January 1991 to July 1992, were divided into three subgroups, 45 patients (subgroup AY 2) having bilateral IMAs graft with pleurotomy, 45 patients (subgroup AY 1) having unilateral IMA graft with pleurotomy, 9 patients (subgroup AN) having unilateral IMA graft or vein grafts without pleurotomy. Frequencies of chest X-rays abnormality such as elevation of diaphragm and accumulation of pleural effusion before discharge around 2 weeks after surgery, were not significantly different among three subgroups. 58 cases without chest X-rays abnormalities were divided into three subgroups in the same way. There was no case with late extubation or with postoperative pulmonary complication. At first we compared pre-with postoperative pulmonary function in each subgroups. Pulmonary function (VC, FEV1.0, peak flow, MMF, V50, V25) was significantly deteriorated in the patients with pleurotomy, while VC, FEV1.0, peak flow significantly decreased, and MMF, V50 and V25 tended to decrease in the patients without pleurotomy. Moreover, magnitude of change of pulmonary function from pre- to postoperative period were not different significantly among three subgroups. In conclusions pleurotomy itself didn't appear to influence postoperative morbidity.

A 71-year-old female was seen with a complaint of chest pain and cough, and a history of tuberculous pleurisy and artificial pneumothorax 40 years ago. The diagnosis of empyema with carcinoma was made by chest X-ray and CT scans. The examination of lung function showed a restrictive disorder. The value of the predicted postoperative FEV1 0.75 l encouraged to perform operation. A left pleuropneumonectomy and combined resections of the invasive portion of the pericardium and left atrium was performed. Histological examination revealed large cell carcinoma of lung (pT 4 N 1 M 0). The literatures are reviewed concerning the thoracic malignant tumor arising in chronic empyema cavity on Japanese cases.

We reported a successful pleuro-venous shunt operation (Pl-V shunt) for a patient of liver cirrhosis with secondary hydrothorax. A 78-year-old female was admitted to our hospital because of severe dyspnea and palpitation. Chest x-ray film revealed right sided massive pleural effusion. Over several weeks the chest tube drainaged about 1,500 ml of transudative fluid per day. We performed Pl-V shunting and pleural effusion subsequently decreased in amount and dyspnea disappeared. This Pl-V shunting is thought to be useful for such a patient with massive pleural effusion which failed to respond to medical therapy.

Among surgically resected 192 lung cancer cases, eleven with a interlobar pleural involvement (p 3) were studied to clarify their characters. The five year survival rate of interlobar p 3 was 12.5% (15.6% in case of excluding death of other diseases), which was better than that of the other parietal p 3. Result of surgical treatment of lobectomy + partial resection for interlobar p 3 had better tendency compared with that of bilobectomy or pneumonectomy. But, unfortunately it was necessary for interlobar p 3 to care the local recurrence in the future. We hope that the general rule of the treatment for interlobar p 3 was carefully discussed furthermore, including the safety margin in the partial resection or the classification on T factor.

A 63-year-old female was admitted to our hospital with chief complaint of exertional dyspnea. Right massive pleural effusion was found. After chest drainage was performed, chest CT scan and MRI showed several masses in the anterior mediastinum and on the diaphragma. Mesothelioma was suspected for needle biopsy. Pleuropneumonectomy with combined resection of diaphragma, superior vena cava and pericardium was performed. Histologically, the Tumor was mixed thymoma. She is well and alive for three years after operation. Pleuropneumonectomy may be a choice of effective treatments for invasive thymoma with pleural dissemination.

Three cases of catamenial pneumothorax were presented. A 42-year-old woman with intrapelvic endometriosis had recurrent right-sided pneumothorax with menstruation more than six times. At the operation only a bleb was noted at the apex of the right lung. In a 16-year-old woman who already had been operated on for recurrent right-sided pneumothorax one year ago, left-sided pneumothorax occurred on the day of the beginning of each menstruation four times. A small bleb was noted at the apex. A 29-year-old woman with cesarean section at the age of 25 had recurrent right-sided pneumothorax occurring on the day before the beginning of menstruation three times. Though the operation was performed during her menstrual period, neither air leakage nor any lesions were found. In all cases each lesion was resected and did not prove endometriosis, and partial parietal pleurectomy was performed for pleurodesis. No pneumothorax has recurred.