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Background: The aim of this study was to document the physical stress experienced by a surgeon during thoracoscopic pulmonary lobectomy and mediastinal lymph node dissection for lung cancer by measuring the intraoperative electromyography (EMG). Methods: Surface EMG was recorded during 12 cases of thoracoscopic lobectomy. During the operation, 16 channels of a wireless EMG were used to measure muscle activity and fatigue from the bilateral muscles of the splenius capitis (SC), upper trapezius (UT), middle deltoid (MD), flexor carpi radialis (FCR), extensor carpi radialis (ECR), lumbar erector spinae (LES), rectus femoralis (RF), and tibialis anterior (TA). The EMG signals were processed to collect the values of the root mean square for muscle activity and median frequency (MF) for muscle fatigue. Results: All operations were completed without adverse events. The mean operating time was 99.16±35.15 minutes. During the operation, the mean muscle activity of all muscles was 21.91±12.85 mV. High muscle activity was observed in the bilateral FCR and ECR, whereas low muscle activity was observed in the bilateral SC and LES. The final MFs in the bilateral SC and LES were found to be decreased from the initial status, which implied increased muscle fatigue. The muscles of the right and left LES were significantly fatigued by up to 29% and 37% compared to their initial status (P=0.021 and P=0.007, respectively). The MFs of the bilateral LES decreased with time (an average decreases of 0.008/5 minutes, P=0.002 in right LES and 0.004/5 minutes, P=0.018 in left LES). Conclusions: During thoracoscopic lobectomy, muscle fatigue was observed in muscles related to a static posture, such as the bilateral SC, UT, and ES. Further studies are required to investigate the ergonomic adjustments needed to reduce muscle fatigue in these static muscles.

Patients with smaller body surface area (BSA) have smaller pleural cavities, which limit visualization and instrument mobility during video-assisted thoracoscopic surgery (VATS). We investigated the effects of BSA on outcomes with robotic-assisted VATS lobectomy.We analyzed 208 consecutive patients who underwent robotic-assisted lobectomy over 34 months. Patients were separated into group A (BSA ≤1.65 m(2)) and group B (BSA1.65 m(2)). Operative times, estimated blood loss (EBL), conversions to thoracotomy, complications, hospital length of stay (LOS), and in-hospital mortality were compared.Group A had 40 patients (BSA 1.25-1.65 m(2)), and group B had 168 patients (BSA 1.66-2.86 m(2)). Median skin-to-skin operative times [± standard error of the mean (SEM)] were 169±16 min for group A and 176±6 min for group B (P=0.34). Group A had median EBL of 150±96 mL compared to 200±24 mL for group B (P=0.37). Overall conversion rate to thoracotomy was 8/40 (20.0%) in group A versus 12/168 (7.1%) in group B (P=0.03); while emergent conversion for bleeding was 2/40 (5.0%) in group A versus 5/168 (3.0%) in group B (P=0.62). Postoperative complications occurred in 12/40 (30.0%) in group A, compared to 66/168 (39.3%) in group B (P=0.28). Patients from both groups had median hospital LOS of 5 days (P=0.68) and had similar in-hospital mortality.Patients with BSA ≤1.65 m(2) have similar perioperative outcomes and complication risks as patients with larger BSA. Patients with BSA ≤1.65 m(2) have a higher overall conversion rate to thoracotomy, but similar conversion rate for bleeding as patients with larger BSA. Robotic-assisted pulmonary lobectomy is feasible and safe in patients with small body habitus.

Background There are several anatomical variations of the pulmonary vein which can cause serious complications in pulmonary lobectomy. Case presentation We inadvertently divided the left superior pulmonary vein during thoracoscopic left lower lobectomy in a lung cancer patient. Retrospective review of the preoperative computed tomography showed extra-pericardial common trunk of the left pulmonary venous system. Left superior pulmonary vein was reimplanted into stump of divided common trunk via thoracotomy. Conclusions Awareness of vascular anomalies will help thoracic surgeons to prevent potential morbidity and mortality from complications.

Treatment of bronchial fistula (BF) after pulmonary lobectomy is a challenge. Often, patients require long hospital stay, have recurrent empyema and pneumonia, are susceptible to sepsis, often need broad-spectrum antibiotics, as well as various surgical approaches. With the advent and growing evidence of the benefits of negative pressure therapy (NPT), its use in some patients with BF has been reported with encouraging results concerning its feasibility and cost-effectiveness. The aim of this study was to demonstrate the application of NPT as a resource for BF treatment and comparatively analyze the overall cost of treatment. RESUMO O tratamento de fistula bronquica (FB) apos lobectomia pulmonar e um desafio. Muitas vezes, o paciente demanda longo tempo de internacao, apresenta recidivas de empiema e pneumonia, pode evoluir para sepse, frequentemente necessita de antibioticoterapia de amplo espectro, bem como de varias abordagens cirurgicas. Com o advento e acumulo de evidencias dos beneficios da terapia por pressao negativa (TPN), seu uso em alguns pacientes com FB tem sido relatado com resultados animadores relativos a sua viabilidade e ao seu custo-efetividade. O objetivo deste estudo foi demonstrar a aplicacao de TPN como recurso para tratamento da FB e analisar comparativamente o custo global do seu tratamento.

Diffuse tracheobronchial calcification is a physiological condition associated with advanced age, especially in women. A calcified bronchus can be fractured during major lung resections (lobectomy, bilobectomy, and pneumonectomy), exposing patients to intraoperative air leakage and broncho-pleural fistula (BPF) occurrence. We retrospectively evaluated the use of Progel® application on the suture line of bronchial stump after pulmonary lobectomy analysing the intraoperative air leak and BPF occurrence. Between January 2014 and December 2014, Progel® was applied in 11 patients who presented intraoperative bronchial fractures after suture resection by mechanical staplers and air leak from bronchial stump, in order to treat air leakage. Patients were 7 men and 4 women, aged between 56 and 81 years (mean age 71.2 ± 12.1 years). Surgical procedures included 6 upper lobectomies (4 right, 2 left), 1 bilobectomy and 4 lower lobectomies (3 right, 1 left). Mean hospital stay was 4.5 ± 2.6 days (2-8 days). None of the patients had postoperative air leakage. No Progel® application-related complications occurred. No other major complications occurred. No mortality occurred. Progel® proved to be useful in treating intraoperative air leakage during major lung resections, particularly those occurring as a result of fracture of the bronchus from a mechanical stapler.

OBJECTIVES: The most recent evolution of patient management after thoracic surgery implies the concept of fast-tracking. Since 2008, our unit has implemented a programme based on clinical protocols and standardized pathways of care aimed to reduce the postoperative stay after major lung resection. The objective of this study was to verify the safety of this policy by monitoring the patient readmission rate. METHODS: This is a prospective observational study on 914 consecutive pulmonary lobectomies performed at our institution from January 2000 to October 2010. Since we started the fast-tracking program in January 2008, we divided the patients into two groups: early period (678 patients, 2000–2007) and recent period (236 patients, 2008–October 2010). Several baseline and operative factors were used to build a propensity score that was applied to match the recent group patients with their early group counterparts. These two matched groups were then compared in terms of early outcomes and readmission rate. Readmission was defined as a re-hospitalization for any cause related to the operation within 30 days after discharge. We excluded from the analysis those patients with in-hospital mortality. RESULTS: Propensity score yielded 232 well-matched pairs operated on in the early (non-fast-tracked patients) and most recent period (fast-tracked patients). The fast-tracking management resulted in a postoperative stay reduction of 2.8 days (P< 0.0001), with a 3-fold higher proportion of patients discharged before the sixth postoperative day (P< 0.0001). Nevertheless, we did not observe any differences in terms of readmission rate between the two periods. CONCLUSIONS: In our experience, the implementation of a fast-tracking program after pulmonary lobectomy was very effective and safe. It led to a postoperative reduction of hospital stay without an increase in the readmission rate.

As part of the Second Catania Symposium on Thoracic Oncology, as we started the experience with video-assisted thoracic surgery (VATS) lobectomy for lung malignancies, we reviewed our data and argued some comments in a more general discussion. Operated patients with non-small-cell lung cancer were divided in two groups and compared: VATS (collected in a prospective database) and open (historical group). Out of 74 patients, 31 in group A and 44 in group B. The majority of patients in group A were stage I–II. Mean operative time was shorter in group A. Postoperative hospital stay was shorter in group A. There was no mortality. VATS is effective and safe to perform pulmonary lobectomy in our unit, and it represents our preferred approach for early-stage lung cancer.

Most thoracic surgeons have experienced difficulty dissecting the pulmonary hilus because of scarring. In such potentially dangerous situations, we advocate a method of clamping and severing the pulmonary lobar root structure en masse.

A 68-year-old male patient was admitted directly to the Coronary Catheterization Laboratory after electrocardiogram transmission that revealed ST-segment elevation in the inferior wall leads accompanying acute chest pain. Coronary arteriography revealed an opaque metallic object located in the proximal segment of the right coronary artery. The foreign body (FB) could …

BACKGROUND: Recently, minimally invasive approaches for pulmonary lobectomy have gained increasing interest and acceptance. Besides, the "conventional" video-assisted thoracoscopic (VATS) approach, the robotic technique with the da Vinci™ surgical system has been evaluated by different groups. METHODS: An appraisal of both approaches is given based on profound personal experiences and with reflexion of the current literature. RESULTS: Both techniques have been proven to be feasible and safe. Operating times and costs are higher with the robotic approach, without proven advantages over conventional VATS. Long-term follow-up data support the oncologic accuracy of the VATS approach but are still lacking for the robotic approach. CONCLUSIONS: The robotic approach provides no proven benefits over the conventional thoracoscopic approach and is thus not recommended for pulmonary lobectomy.

Much controversy exists regarding the management of chest tubes following pulmonary lobectomy. The objective of this study was to analyse the effect of a new chest tube management protocol on clinical features, such as postoperative air leak, drain characteristics, 30-day postoperative complications and length of hospital stay. We retrospectively analysed 133 patients who underwent pulmonary lobectomy, from January 2005 to December 2008. A new chest tube protocol was introduced on 1 January 2007 and included placement of a single chest tube and early conversion to water seal. The chest tube was removed when air leak had resolved and (non-chylous) fluid drainage was

Several authors have reported major complications during thoracoscopic pulmonary lobectomy but a few papers have been published concerning minor adverse events. This definition in our report takes into account no life-threatening intraoperative complications managed with minimal invasive approach and with no need for conversion to thoracotomy. We retrospectively reviewed 644 patients who underwent thoracoscopic anatomic pulmonary lobectomy between April 2011 and May 2018: among these, 25 patients suffered minor intraoperative complications such as bronchial injury, stapler failure during parenchymal resection, injury to bronchial artery, oozing from vascular stump, etc. Our findings suggest that these complications don’t adversely affect the early postoperative outcomes but they still need proper management to avoid major intraoperative complications and an eventful postoperative course. The report shows that minor adverse events may occur for device malfunction but, in some instances, human errors or inadequate knowledge of technological instruments may be implicated.

Acute massive pulmonary artery embolism after pulmonary resection is very rare, but has a high mortality rate. This is one of the most severe complications after pulmonary resection. Acute pulmonary artery embolism developed suddenly in a patient who underwent lobectomy and was recovering without complications. Because the patient’s condition was aggravated after conservative treatment, we did emergency open embolectomy which was successful. Hence, we report this case with a literature review.

Background: Video assisted pulmonary lobectomy is 25 years old. Despite the recent advancement of minimally invasive surgery, this procedure is still related to a considerable amount of post-operative pain. We describe the results with ‘Microlobectomy’: an innovative technique which eliminated the utility port. Methods: Microlobectomy has been offered at James Cook University Hospital, UK, for the last 4 years. This manuscript represents a single centre, single surgeon consecutive series of cases from January 2014 until December 2016. The technique was recently described in a multi-center study. Its key principles are: no intercostal incisions larger than 5 mm, no utility incision, a 12 mm subxiphoid port (used for specimen retrieval and chest drainage), CO2 insufflation of the surgical field throughout the procedure, 5 mm diameter instruments and 5 mm optic are adopted. We offered this procedure to all the patients awaiting pulmonary lobectomy for different conditions, while relative contraindications were severe obesity and left ventricular hypertrophy for left sided procedure. Results: Data from 82 cases where recorded. Mean age was 66 years (range, 27–82 years). Sixty-nine operations (84.1%) were performed for pulmonary malignancy (stages from Ia to IIIb). Fifty-three patients underwent a right sided procedure and 29 a left sided, namely the procedures were: 30 right upper lobectomies, 9 right middle, 13 right lower, 15 left upper, 7 left lower, 4 trisegmentectomy, 2 lingulectomy, 1 right and 1 left pneumonectomy. Conversion rate was 3.7% (3 patients). The mean operative time was 189 minutes (range, 126–315 minutes). The 30 days mortality was 1.2% (1 patient deceased of sepsis). Morbidity was post-operative infection in 12 individuals (14.6%), atrial fibrillation in 3 (3.7%) and prolonged air leakage, over 5 days, in 9 (11%). Seventeen patients (20.7%) went home on the day after surgery, 31 (37.8%) went home on post-operative day 2. Sixty-three patients (76.8%) went home within the first week from the procedure. The median length of stay was 3 days (range, 1–34 days). Conclusions: We are enthusiast about these preliminary results and we will continue to offer this procedure in order to report on a wider cohort and also to have long term oncological follow up data.

Pulmonary lobectomy remains the gold standard therapy for early-stage lung cancer. With the spread of video-assisted thoracic surgery (VATS), surgeons began using this approach also to perform lobectomies, becoming progressively widespread worldwide. However some early-stage lung cancer patients are of questionable eligibility for open lobectomy being considered at high-risk to develop postoperative complications due to compromised pulmonary function or cardiopulmonary reserve. Herein we evaluate pathophysiology of VATS, focusing on: the correlation between the traditional predictors of outcome and overall complications, the current status of different VATS approaches and the role of VATS segmentectomy in high-risk patients, unable to tolerate lobectomy for their compromised cardiopulmonary reserve.

OBJECTIVE To explore the application of blocking the unilateral main pulmonary artery (MPA) in pulmonary lobectomy (PL) for patients with stage II and III lung cancer, and to retrospectively analyze the methods of surgery for blocking the unilateral main pulmonary artery, perioperative indications, intraoperative concerns and postoperative cardio-pulmonary complications. METHODS During a period from January 2006 to January 2008, intra-pericardial, or extra-pericardial separation and blockade of the le t or right MPA followed by completion of various PLs were conducted for 30 lung cancer patients in stage-II to III with ill-defi ned anatomic structure of the pulmonary hilum and difficult pulmonary angiodiastasis. RESULTS In the 30 patients, 5 were diagnosed as stage-IIb, 11 stage-IIIa, and 14 stage-IIIb. During the surgery, giant tumors at the superior pulmonary lobe, with a diameter of over 10 cm, were seen in 13 cases, in which tumor invasion in the extra pericardiac pulmonary artery was found in 5 cases. Hilar lymphadenectasis with severe tumor adhesion to pulmonary blood vessel could be seen in 20 cases and partial tumorous invasion in the pericardium in 7. In most of the cases, adhesions existed around the tumor, aorta, superior vena, and azygous vein. Invasion of the laryngeal and vagus nerves on the left side was found in 3 cases. Of the 30 patients, simple PL was conducted in 12, and sleeve lobectomy combined with a pulmonary arterioplasty in 18 cases. With a blockade of unilateral MPA, no intraoperative hemorrhea of pulmonary blood vessels occurred during surgery, when there was a clear surgical field of vision. Both PL and lymphadenectomy were smoothly completed in the 30 patients. The healthy pulmonary lobes with normal function were kept and total pneumonectomy was avoided. The time of blocking the pulmonary artery ranged from 10 to 30 min, and intraoperative blood loss was from 200 to 300 ml. Postoperative complicated acute pulmonary edema occurred in 5 patients and tachycardia in 7 cases. Nevertheless, all patients recovered and let the hospital after treatment. No severe cardiopulmonary complications were found in all patients of the group. CONCLUSION Blocking the unilateral MPA is effective to decrease the risk of intraoperative hemorrhea in the PL. It can shorten the time of surgery, improve the excision rate of lung cancer, and cut down on the rate of total pneumonectomy.

Purpose of review Air leak after pulmonary lobectomy is a relatively common problem, which when persistent can be a cause of other postoperative morbidity as well as contributing to extended hospitalization. A number of methods have been proposed to prevent and treat air leakage, but none have proved incontrovertibly effective. This article reviews the practice of using autologous blood as an effective technique to treat postoperative air leaks after lobectomy. Recent findings Five reports have looked specifically at the technique. In all cases, the procedure was safe and efficacious, with proven advantages over other methods of managing persistent air leaks. It allows earlier removal of chest drains and shortens hospitalization times. Summary Instillation of autologous blood into the pleural drain in the early postoperative period can lead to immediate sealing of the air leak and allow for earlier drain removal and timely patient discharge. It is a safe bed-side procedure and can be done with relative ease and at minimal cost.

Several states use certificate of need regulations (CON) to control the growth of acute-care services, but the possible association between these restrictions and the provision of cancer surgery has not been assessed. This study examines the association between acute-care CON, the availability of cancer surgery hospitals, and provision of six cancer operations. Medicare data were collected for beneficiaries treated with one of six cancer resections and an associated cancer diagnosis from 1989 to 2002. Hospital, procedure, and incidence rates for each cancer diagnosis were stratified by state and year. The number of hospitals performing each operation per cancer incident, the number of procedures performed per cancer incident, and hospital volume were compared between states with and without CON, and those that discontinued CON during the sample period were noted. The number of hospitals per cancer incident was lower in CON states versus non-CON states for colectomy (P = .022), rectal resection (P = .026), and pulmonary lobectomy (P = .032). Hospital volume was significantly higher in CON states versus non-CON states for colectomy (P = .006) and pulmonary lobectomy (P = .043). There were no differences between states with and without CON in the number of procedures per cancer incident. Although use of cancer procedures was similar in CON and non-CON states, those with acute-care CON had fewer facilities performing oncologic resections per cancer patient. Correspondingly, average hospital procedure volume tended to be higher in CON states. These differences may have important implications for patient outcomes and costs.

Background: VATS lobectomy– is a routine surgical procedure for pulmonary tuberculosis (TB) and lung cancer (LC) patients, today. Nevertheless, VATS lobectomy is associated with a longer learning curve because of its inherent basic limitations. The robotic surgical system developed essentially to overcome these limitations. The aim of this study is to compares perioperative outcome of RATS pulmonary lobectomy for LC and TB in a learning curve setting. Methods: Prospective clinical trial from May 2013 to January 2015. 47 consecutive patients were selected for RATS lobectomy. Two groups of patients: 1) with localized forms of cavitary pulmonary TB; 2) with LC. Results: 31 patients with cavitary pulmonary TB and 16 patients with LC were underwent RATS lobectomy. Total/console mean operative time was 204/137 min. and 252/200 min. in 1 st and 2 nd group, respectively. Intraoperative blood loss was less in TB-cases (135 vs 259 ml). Learning curve of RATS lobectomy showed progressive decline of operation time in lung cancer patients and irregular shape of thelearning curve in TB-cases due to higher frequency of pleural adhesions. There was less rate of postoperative morbidity and prevalence of non-threatening complications of life after the 20 th operation. Rate of perioperative morbidity was 17% and 12% in 1 st and 2 nd group, respectively. Conclusion: RATS lobectomy for cavitary pulmonary TB is effective and safety as well as for LC. Main key parameter that affects learning curve of robotic lobectomy in TB-cases is preoperative evaluation of pleural adhesions, in LC-patients – is the volume of lymphadenectomy. Postoperative morbidity is reduced to a minimum after 20 th operations.

Our objective was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process).After meetings with our anesthesiologists, we standardized our "in the operating room-to-skin incision protocols" before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated.One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p ≤ 0.001 for all). A protocol for the insertion of double-lumen endotracheal tubes was established and times decreased (mean, 14 minutes to 1 minute; p = 0.001). After all changes were made, the time between operating room entry and incision decreased from a mean of 64 minutes to 37 minutes (p0.001). Outcomes improved, mortality decreased from 3.2% to 0.26% (p = 0.015), and major morbidity decreased from 15.2% to 5.3% (p = 0.042).Lean and value stream mapping can be safely applied to the clinical algorithms of high-risk patient care. We demonstrate that elimination of non-value-added steps can safely decrease preincision time without increasing patient risk in patients who undergo pulmonary lobectomy. Selected centers may be able to adopt some of these lean-driven protocols.

Diffuse alveolar hemorrhage (DAH) from systemic lupus erythematosus (SLE) is a rare but potentially life-threatening condition. We report the case of a 14-year-old female with SLE who developed hypoxia and shock secondary to severe alveolar hemorrhage. She was successfully managed by placement on extracorporeal membrane oxygenation (ECMO) followed by emergent pulmonary lobectomy and medical treatment including high-dose methylprednisolone, cyclophosphamide, intravenous immunoglobulin, and plasmapheresis.

Objective: The aim was to evaluate the feasibility and safety of early chest tube removal after complete video-assisted thoracic lobectomy (CVATL). Methods: Retrospective analysis was performed on effects of chest tube removal on patients with lung cancer after pulmonary lobectomy between November 2013 and October 2014. 154 eligible patients included 97 cases for CVATL and 57 cases for open thoracic lobectomy. Patients with CVATL were divided randomly into experimental group (EG) and control group (CG), in which 51 patients in EG had chest tube removal on the 2 nd day after operation; 46 patients in CG had the tube removal when the drainage volume

Purpose: Although metastases to the lung from other organs are usually removed with limited lung resections (e.g., wedge resections or segmentectomies), pulmonary lobectomies are often required to remove whole pulmonary tumors. This study investigated the clinical applicability of pulmonary lobectomies to treat metastatic lung tumors. Methods: We retrospectively reviewed clinical records of 143 consecutive patients with metastatic tumors in the lung who underwent surgery in our department, including data sets for 100 patients treated for their first metastatic lung tumors. Results: Of the 100 patients, 23 received pulmonary lobectomies, 69 received wedge resections and eight received segmentectomies. Patients in the lobectomy group were more likely to be younger, have larger and/or multiple tumors, and to have tumors of musculoskeletal origin (sarcomas) than those who underwent segmentectomies or wedge resections (the limited resection group). The two groups did not significantly differ in survival (3-year survival rate; lobectomy vs limited resection: 75.2% vs 80.4%, P = 0.15), or post-operative morbidity, although the only post-operative morbidity was associated with post-operative prognosis in the lobectomy group. Conclusions: Pulmonary lobectomy is a safe and applicable surgical procedure for metastatic lung tumors when long survival is expected after the tumor resection.

We report the first case of pulmonary sequestration which was not detected in the preoperative evaluation, resulting in a life-threatening hemorrhagic shock rapidly during the procedure of thoracoscopic pulmonary lobectomy. The anesthesiologists could not figure out the reason for the hemorrhagic shock in the surgery until an emergent laparotomy was performed. The aim of presenting this clinical case is to highlight the vigilance for undiagnosed pulmonary sequestration which lacks any specific clinical feature but has the potential to become an anesthetic disaster.

Background Readmission rates after major procedures are used to benchmark quality of care. We sought to identify readmission diagnoses and factors associated with readmission in patients undergoing pulmonary lobectomy. Methods Analyzing the State Inpatient Databases (Healthcare Cost and Utilization Project), we reviewed all lobectomies performed from 2009 to 2011 in California, Florida, and New York. The group was subdivided into open (OL) versus minimally invasive lobectomy (MIL; thoracoscopic/robotic). We used unique identifiers to determine 30- and 90-day readmission rates and diagnoses and performed regression analysis to determine factors associated with readmission. Results A total of 22,647 lobectomies were identified (58.8% OL vs 41.2% MIL; median age, 68 years; median length of stay, 6 days). Most patients (59.8%) had routine discharge home (home health care, 29.4%; transfer to other facility, 8.8%; mortality, 1.9%). The 30-day readmission rate was 11.5% (OL 12.0% vs MIL 10.8%, p = 0.01), while the 90-day readmission rate was 19.8% (OL 21.1% vs MIL 17.9%, p 0.001). The most common readmission diagnoses were pulmonary (24.1%), cardiovascular (16.3%), and complications related to surgical/medical procedures (15.1%). Preoperative factors associated with readmission included male gender (odds ratio, 1.19), Medicaid payer (odds ratio, 1.29), and several individual comorbidities. Surgical approach and postoperative complications were not independently associated with readmission. Conclusions Readmission is a frequent event after pulmonary lobectomy and is strongly associated with preoperative demographic factors and comorbidities. Resources and services should be directed to patients at risk for readmission and multicomponent care pathways developed that may circumvent the need for repeat hospitalization.

Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions.Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions.We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P.05), total complications (40 [37%] vs 64 [50%]; P.05), urinary tract infections (3 [3%] vs 15 [12%]; P.05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P.05), with no difference in readmissions (7 [7%] vs 6 [5%]; P.05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P.05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P.05).Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.

Robotic assistance has been increasingly utilized for pulmonary lobectomy. Although the technical aspects of the operation require special training, robotic lobectomy possesses subjective advantages for the surgeon including better visualization of structures, the ability to control the camera rather than relying on an assistant to do so, increased range of motion of instruments, and improved ergonomics. Perioperative outcomes and overall survival following robotic lobectomy have been shown to be similar to VATS lobectomy.

A new robotic telesurgical device (TELELAP/ALFX) is used for the first time to execute an anatomical pulmonary resection (lobectomy) plus mediastinal lymph node dissection in the ovine model. This integrated operative system has 2 innovative peculiarities: ( a) tactile perception (engineered to give the operator a tactile feedback similar to that experienced when handling thoracoscopy instruments) and ( b) eye-tracking (immediate synchronization of the surgeon’s eyes movements with that of the robotic camera). Herein, we report a lower right pulmonary lobectomy under complete robotic assistance (TELELAP/ALFX). Standard endoscopic staplers were used in all the major maneuvers (bronchial as well as vascular resections and fissural completion) introduced through a utility 4-cm-sized incision. The specimen was placed in an endoscopic retrieval bag and removed through a service minithoracotomy. With the limitations because of interspecies differences in anatomical landmarks, a mediastinal lymph nodal dissection was also completed. The operative time was acceptable (~180 minutes) with blood loss of 100 mL. In conclusion, according to this first all experimental experience we may deem the TELELAP/ALFX system completely apt to perform major anatomic pulmonary resections and the regulatory process to run trials in humans are under way.

Subcutaneous emphysema frequently occurs after pulmonary resection, but is usually mild and self-limiting. Patients can, however, develop severe symptomatic subcutaneous emphysema despite adequate thoracic drainage. There is a paucity of efficacious treatments for subcutaneous emphysema that does not respond to chest tube drainage. Previous reports have suggested that thoracoscopy may be an efficacious treatment, but is unfavourable due to the risks associated with reoperation. We present a case of a patient who developed severe subcutaneous emphysema after pulmonary lobectomy that was quickly and effectively treated using a commercially available negative pressure wound therapy dressing.

Aim: To report a case of fused fissure between the right upper and middle lobes that we treated using a surgical stapler rather than a Ligasure device for the benefit of creating a better division between the right upper and middle lobes and to effectively seal the lung parenchyma. Case: A 2-year-old girl with congenital cystic adenomatoid malformation of the right middle lobe (RML) was referred to our institution for further management after a series of infections. The vein of the RML, which drains into the superior pulmonary vein, was isolated and divided using endoclips. The bronchus was then exposed and divided using endo-clips. The arteries of the RML could be identified and ligated, allowing a line demarcating the major fissure to be identified and dissected. A stapler device was then used to seal the lung parenchyma and create a division between the right upper and middle lobes. She is currently well after follow-up of 16 months, with no episodes of respiratory distress or recurrence of symptoms. Conclusion: Our technique for dividing the pulmonary vein, then the bronchus, then the pulmonary artery and finally the fused fissure is safe and could be applied whenever fused fissures are encountered during thoracoscopic pulmonary lobectomy.

We present the case of a 51 years old female who experienced foreign body aspiration 3 years before. The foreign body, which should be removed by bronchoscopy before, was lodged at the bifurcation of the right inferior bronchus and could only be removed via right lower lobectomy. The patient experienced a swift recovery and was well at follow-up 8 months later.

During thoracoscopic pulmonary lobectomy (TPL) in larger children (15 kg), an endoscopic stapler (ES) and endoscopic clipper (EC) are used during dissection and division of the pulmonary vessels (PVs) and bronchus. However, in smaller children (15 kg), ES/EC cannot be used because of limited space. We report our technique for thoracoscopic dissection and division of the PVs and bronchus in smaller children.Fifteen cases of sequestration/congenital cystic adenomatoid malformation weighing less than 15 kg (range, 8-15 kg; mean, 11 kg) were the subjects for this review. With the patient under single-lung ventilation in the lateral decubitus position, four ports ranging from 5 to 12 mm were placed. After the PVs and bronchus were exposed, thick silk was used to encircle them as a traction suture. By applying traction, the PVs and bronchus could be exposed, and ES/EC were used safely by applying countertraction.All cases had uneventful TPL (upper in 3 patients, middle in 3 patients, and lower in 9 patients). ES/EC were easy to use. Mean operative time was 220 minutes.Our technique allows the PVs and bronchus in children weighing less than 15 kg to be divided safely using ES/EC. We strongly recommend our technique, although simple, be used during TPL in smaller children.

本例は61歳の男性で, 56歳時に胸腺癌のため胸骨正中切開, 左前側方開胸下に胸腺全摘出, 左肺上葉および弓部大動脈部分切除を他科で実施された.術後のCTで大動脈解離を発症していた.背部圧迫感を主訴とする遠位弓部仮性大動脈瘤の増大のために紹介された.慢性大動脈解離で真腔が狭小化しカテーテル治療は危険であった.左胸腔頂に仮性動脈瘤を形成し肺切除も受けていたため左開胸によるアプローチも困難であった.大動脈の僅かな剥離と横切開のみで行える胸骨正中切開からのステントグラフト挿入術を選択した.ステントグラフトは壁薄ダクロン人工血管にZ一ステントを縫着した後, 特注の弱湾22Frシースに充填し, 脳分離体外循環下に下行大動脈内まで安全に挿入し放出した.人工血管中枢側は大動脈内腔に縫合した.本例は従来型の手術では不可能な症例で, 胸骨正中切開からのステントグラフト挿入術のよい適応であった.術後2年8ヶ月の現在, 再発なく元気に社会復帰している.

We describe a simple technique of controlling air leakage from the lung parenchyma using BiClamp(®). The device creates appropriate protein coagulation at an air leakage point of the lung parenchyma. The leakage point and adjacent area are grasped with BiClamp(®) forceps and coagulated without tissue carbonization. After the procedure, no air leakage was recognized under airway pressure test of 15-20 cmH(2)O. This method is easy to handle, especially in video-assisted thoracic surgery lobectomy with an economical advantage as "Ecosurgery".