Robotic surgeries have developed in the general thoracic field over the past decade, and publications on robotic surgery outcomes have accumulated. However, controversy remains about the application of robotic surgery, with a lack of well-established evidence. Robotic surgery has several advantages such as natural movement of the surgeon’s hands when manipulating the robotic arms and instruments controlled by computer-assisted systems. Most studies have reported the feasibility and safety of robotic surgery based on acceptable morbidity and mortality compared to open or video-assisted thoracic surgery (VATS). Furthermore, there are accumulated data to indicate longer operation times and shorter hospital stay in robotic surgery. However, randomized controlled trials between robotic and open or VATS procedures are needed to clarify the advantage of robotic surgery. In this review, we focused the literature about robotic surgery used to treat lung cancer and mediastinal tumor.

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Purpose: As chemotherapy has improved, the survival of patients with metastatic colorectal carcinoma has reached up to 2.5 years. Many of these patients experience pulmonary metastases; however, the prognosis after pulmonary metastasectomy is not satisfying. In this study, we analyzed the prognostic factors for survival in patients who underwent pulmonary metastasectomy.Methods: Eighty-seven patients with colorectal carcinoma received pulmonary metastasectomy. The pathological status of the primary tumor, outcome of the pulmonary metastasectomy, disease-free interval, perioperative carcinoembryonic antigen (CEA) level and history of liver metastases were assessed.Results: The five-year survival was 42.5% after pulmonary metastasectomy. A univariate analyses revealed that the CEA level (p = 0.043) and the number of pulmonary metastases (p = 0.047) were prognostic factors for survival. The CEA level was an independent prognostic factor in a multivariate analysis (relative risk = 2.01, p = 0.037). Among cases with elevated preoperative CEA levels, those whose CEA level normalized after metastasectomy had a better prognosis compared with those whose CEA level decreased but was still high, or whose level increased after metastasectomy (median survival time of 41.8 months compared with 28.1 or 15.7 months, respectively p = 0.021).Conclusion: The CEA level can be a predictive marker for the prognosis in patients with pulmonary metastases from colorectal carcinoma.

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Objective: Natural orifice transluminal endoscopic surgery (NOTES) has recently become a hot spot in the field of minimally invasive surgery. But, most of the procedures are still in the early stages of development and limited to animal experiments. Transareolar endoscopic surgery could work as a viable intermediate step before thoracic NOTES. Under intravenous anesthesia without endotracheal intubation, transareolar endoscopic thoracic sympathectomy (ETS) with a flexible endoscope has rarely been attempted. The objective of this study is to evaluate the feasibility and safety of this novel minimally invasive technique in managing primary palmar hyperhidrosis (PPH).Methods: From June 2012 to July 2014, a total of 58 male patients with severe PPH underwent transareolar ETS by use of a flexible endoscope. Under intravenous anesthesia without endotracheal intubation, a flexible endoscope was introduced through the incision on the edge of the areola into the thoracic cavity. The thoracic sympathetic chain was ablated at the level of the fourth rib.Results: All procedures were successfully performed with a mean operating time of 33.6 ± 8.3 min. All patients regained consciousness rapidly and none of them complained about sore throat after surgery. There were no operative mortality and conversion to open procedure. The symptoms of all patients disappeared as soon as the sympathetic chain was cut off. Fifty six patients (96.6%) were discharged from the hospital on the first postoperative day. The postoperative complications were minor, and no patients developed Horner’s syndrome. At 3 months postoperatively, there was no obvious surgical scar on the chest wall, and none of the patients complained about postoperative pain. Compensatory hyperhidrosis (CH) appeared in 19 patients. No recurrent symptoms were observed in our study. One year follow-up revealed an excellent cosmetic result and degree of satisfaction.Conclusion: Nonintubated transareolar ETS with a flexible endoscope is a safe, effective and minimally invasive therapeutic procedure, which has the possible advantages of thoracic NOTES and can be performed in routine clinical practice for male PPH patients.

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Purpose: Malignant pleural effusion (MPE) is common in patients with advanced cancer. Chemical pleurodesis can be considered for MPE that do not respond to chemotherapy, radiotherapy, or therapeutic thoracentesis. However, it is not yet clear which agent is more effective and safer in chemical pleurodesis.Methods: This study was designed as a single arm, multicenter, and open-label phase III clinical trial to evaluate efficacy and safety of chemical pleurodesis using mistletoe extraction (ABNOVAviscum^® Injection). References of other agents in chemical pleurodesis were investigated to compare efficacy and safety. Efficacy was evaluated by followed up chest X-ray and changes of clinical symptoms and Karnofsky performance scale. Safety was evaluated by serious adverse event (SAE) and changes of laboratory findings. A follow-up period was 4 weeks after last pleurodesis.Results: Of 62 patients, 49 (79.0%) had complete response, 11 (17.7%) had partial response, and two had no response. Mean response rate was significantly different in this study comparing with reference response rate which was 64% (p <0.0001). There were two SAEs, but all were recovered without sequelas.Conclusion: The results of this study suggest that mistletoe extraction (ABNOVAviscum^® Injection) could be an effective and safe agent of chemical pleurodesis in patients with MPE.

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Background: Long-term patency is required during treatment for benign airway stenosis. This study investigated the effectiveness of surgical airway plasty for benign airway stenosis.Methods: Clinical courses of 20 patients, who were treated with surgical plasty for their benign airway stenosis, were retrospectively investigated.Results: Causes of stenosis were tracheobronchial tuberculosis in 12 patients, post-intubation stenosis in five patients, malacia in two patients, and others in one patient. 28 interventional pulmonology procedures and 20 surgical plasty were performed. Five patients with post-intubation stenosis and four patients with tuberculous stenosis were treated with tracheoplasty. Eight patients with tuberculous stenosis were treated with bronchoplasty, and two patients with malacia were treated with stabilization of the membranous portion. Anastomotic stenosis was observed in four patients, and one to four additional treatments were required. Performance status, Hugh–Jones classification, and ventilatory functions were improved after surgical plasty. Outcomes were fair in patients with tuberculous stenosis and malacia. However, efficacy of surgical plasty for post-intubation stenosis was not observed.Conclusion: Surgical airway plasty may be an acceptable treatment for tuberculous stenosis. Patients with malacia recover well after surgical plasty. There may be untreated patients with malacia who have the potential to benefit from surgical plasty.

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Objective: We compared the midterm results of mitral valve repair with and without leaflet resection, and revealed the effectiveness of this technique, even for in the posterior leaflet alone.Patients: From August 2002 to March 2014, a total of 306 mitral valve repairs were carried out at our hospital. Of these patients, 50 cases did not undergo leaflet resection (Artificial Chordae; Group A) and 56 cases underwent leaflet resection (Resectional; Group R). There were no significant differences in the preoperative profiles.Results: The follow up rate was 98% and 100% respectively. The mean cardiopulmonary bypass time and aortic cross clamp time were not significantly different. The average ring size was significantly larger (p <0.01) in Group A. All cause mortality at 3 years and 8 years was both 97.8% in Group A and was both 98.1% in Group R. Freedom from moderate mitral regurgitation at 3 years was 97.1% and at 8 years was 91.7% in Group A and 97.4% and 94.6% in Group R respectively. There were no cases of mortality, re-operation for recurrent mitral regurgitation, hemolytic anemia and infectious endocarditis.Conclusion: We demonstrated good midterm results in mitral valve repair without leaflet resection. However, further follow-up was needed.

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Purpose: To compensate for the lack of haptic feedback by surgical robots, limitation of exerted forces could be implemented. The limits should be based on the observed relationship between tissue load and induced damage. This study examines whether age-related changes influence this relationship.Methods: Descending thoracic aortas of male C57BL/6J mice of 10, 25 and 40 weeks were clamped in vivo (no clamp, 0.5N or 2.0N) for 2 min. Functional integrity was tested in vitro by studying endothelium-dependent and -independent vasoreactivity.Results: Endothelium-dependent relaxation deteriorated with increased clamping force at all ages. Clamping did not influence endothelium-independent vasodilation. Age (10, 25 and 40 weeks) did not significantly impact on the effect of clamping on endothelium-dependent and independent vasoreactivity.Conclusions: Within the tested conditions, mechanical clamping induces damage to the vascular endothelium, but not to the smooth muscle cells. Age has no effect on the obtained results in mice from 10 to 40 weeks old.

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Background: Use of a minimally invasive approach for isolated aortic valve surgery is increasing. However, management of the root and/or ascending aorta through a mini-invasive incision is not so frequent. The aim of this study is to report our initial experience with surgery of the ascending aorta through a ministernotomy approach.Methods: We retrospectively analyzed 102 patients treated for ascending aorta disease through a ministernotomy. Several types of surgeries were performed, including isolated or combined surgical procedures. Pre-operative and operative parameters and in-hospital clinical outcomes were retrospectively analyzed.Results: Patient mean age was 63.9 ± 13.6 years (range 29–85). There were 33 (32.4%) female and 69 (67.6%) male patients. Preoperative logistic EuroSCORE I was 7.4% ± 2.1%. Mean cardiopulmonary bypass and aortic cross-clamp time were 123.7 ± 36.9 and 100.8 ± 27.5 min, respectively. In-hospital mortality was 0%.Conclusions: Our experience shows that surgery of the ascending aorta with or without combined procedures can be safely performed through an upper ministernotomy, without compromising surgical results. Although our series is not large, we believe that the experience gained on the isolated aortic valve through a ministernotomy can be safely reproduced in ascending aorta surgery as a routine practice.

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A 62-yr-old man was transferred to our institution with blunt chest trauma after being pinched between a car and a wall. Chest computed tomography revealed left-sided rib fractures, bilateral pneumothorax, and pneumopericardium, but no displacement of the heart. The pneumopericardium caused us to suspect a tear in the pericardium. Since the left pneumothorax was slightly more marked than the right, we planned a left-sided thoracoscopic exploration. As a result, a right-sided pericardial rupture was found and repaired under thoracotomy. It was difficult to judge the injured side of the pericardial tear. We learned a valuable lesson from this case: The extent of pleural air may be, but is not always, reliable for identification of the injured side of a pericardial rupture. Direct observation of the pleural space using a thoracoscope is necessary for definitive diagnosis.

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Stereotactic radiotherapy (SRT) is a useful treatment for malignant ling tumors. However, SRT is associated with complications such as high local recurrence rate and radiation-induced lung injury. Herein, we report a case of combined aortic resection for after SRT. An 82-year-old man underwent SRT for the metastatic lung carcinoma of rectal cancer at left lower lobe. Three years later, chest computed tomography showed local recurrence at the site of radiotherapy, with suspected invasion of the descending aorta. Thoracotomy was performed after metastatic lung carcinoma interpolation of a stent graft in the descending aorta. Because the tumor firmly adhered to the aorta, left lower lung lobe and aortic wall resection was performed. Pathological findings revealed fibrous hypertrophy and adhesion between the visceral pleura and aorta. As shown in our case, combined aortic resection and stent graft insertion is an effective minimally invasive and safe treatment for SRT-induced tissue damage.

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A 31 year old female with known history of coronary artery disease and percutaneous coronary intervention presented with acute coronary syndrome. Unknown that patient was pregnant she had inadvertent radiation exposure to the fetus during cardiac catheterization which showed triple vessel disease and severe left ventricular dysfunction. Patient subsequently underwent multivessel off pump coronary artery bypass surgery with intraaortic balloon pump support after declining the recommendation for abortion. Postoperative course was uneventful and patient subsequently delivered a full term healthy baby several months later.Off pump revascularization with its ability to maintain pulsatile perfusion to the fetus should be considered if technically feasible for severe coronary artery disease requiring surgery during pregnancy.

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