癒着・分葉不全に対する胸腔鏡下肺手術の工夫

Contrivance for Video-assisted Thoracic Surgery Lung Operation Especially Lobectomy with Adhesive and Fissureless Complications

癒着や分葉不全は呼吸器外科手術，特に胸腔鏡下手術において，手術手技，手術時間，出血量や気漏（air leakage）などの術中・術後問題発生要因の一つとなっている．本稿では，胸腔鏡下手術における癒着・分葉不全例の術前検査・手技的対処方法・合併症と，その対策について検討した．

There were 74 cases （29.5％） with adhesive and fissureless complications in comparison with all 251 cases who had undergone video-assisted thoracic surgery （VATS） lung operations in author’s hospital. On lobectomy and segmentectomy adhesive and fissureless effective factors were old age （p＝0.012）, the difference between ％DLco to ％DLco/VA （p＜0.05）, Brinkman index （p＝0.043） compared with non-adhesive cases, therefore operation times of fissureless group prolonged （p＝0.009）. The point at issue was in what manner we should perform appropriate division of the bronchus, the pulmonary arteries and the veins on the fissureless lobectomy.

Especially it is very important which the apicoposterior artery （rA2b：Asc） on right upper lobectomy and the lingular segmental artery （lA4＋5） on left upper lobectomy branch from the major fissure or not. For that purpose the management procedure had been done pulmonary artery （primary upper division：A1＋2＋A3）→pulmonary vein→bronchus→residual pulmonary artery （rA2b or lA4＋5）. On the very severe fissureless cases the management procedure had been done pulmonary vein→bronchus→pulmonary artery. Mobilization of “fissure first, hilum last” and/or “hilum first, fissure last” techniques should be performed for VATS fissureless lobectomy.