低侵襲・縮小手術としての単孔式胸腔鏡下肺切除術における工夫

Ingenuity for the Uniportal Video-assisted Thoracic Surgery as a Minimally Invasive Procedure

肺癌手術の低侵襲・創縮小手術アプローチの選択肢として多孔式胸腔鏡下手術（video-assisted thoracic surgery：VATS）に単孔式VATSが加わった．単孔式VATSは4 cm以下の創1ヵ所から胸腔鏡，手術器具を挿入し手術を施行する手技である1）．2004年にRoccoらがはじめて肺の楔状切除への適応を報告し2），その後2011年にGonzalezらが解剖学的肺切除に関する報告を行った3）．使用する肋間が1ヵ所のみであるため肋間神経痛を軽減できる可能性があり，アジアや欧州を中心に低侵襲手術の術式として盛んに施行され，近年本邦でも急激に普及し始めている．

Uniportal video-assisted thoracic surgery （VATS） is a minimally invasive, wound-reducing approach performed mainly in Europe and Asia. This approach is rapidly gaining popularity in Japan. We performed a technique with layer awareness, grasping and dissection of tissue membrane even in uniport VATS as for open thoracotomy or multiport VATS. Interference is a problem with uniport VATS because surgical instruments are inserted and removed through a small incision of 4 cm or less；therefore, instrument selection is critical. The use of curved forceps ensures more working space and reduced interference. The incision should be placed between the 4th or 5th intercostal space and should be 3.5 cm in size at our institution. For vascular manipulation, ligation and transection can be used when it is difficult to divide vessels with a stapler. During mediastinal lymph node dissection, a precise view can be achieved with the use of a custom-made spatula. Uniport VATS was performed in 51 cases from January 2019 to June 2022. Although recurrence was observed in two cases, no serious perioperative complications were observed, and the procedures were performed safely.