小型肺癌に対する単孔式胸腔鏡下区域切除での工夫

Ingenuities of Segmentectomy for Small Lung Cancer in Uniportal Video-assisted Thoracic Surgery

単孔式胸腔鏡下肺葉切除術は2011年にGonzalez-Rivasらにより報告され1），低侵襲手術として日本でも広まりつつある．当科でも2019年4月に肺葉切除術を開始し，2020年1月から区域切除術を開始した．悪性腫瘍に対する単孔式区域切除術（uniportal segmentectomy：UPS）の適応は多孔式と同様で，転移性肺癌，T1a以下の小型原発性肺癌，肺葉切除が困難な症例としている．区域面と腫瘍径との距離は，腫瘍径以上の距離を担保できる症例とし，断端細胞診で陰性を確認する2）．UPSでは触診で腫瘍を確認することがより困難であることから，術前に3D-CTで区域面との距離を確認すること，術中に区域間を同定することが重要であると考える．本稿では定型的区域切除の開始時から今までの成績と工夫について検証する．

Our department has been performing uniportal thoracoscopic lobectomy since April 2019 and now also performs segmentectomy for small malignant tumors. A skin incision of approximately 4 cm is created between the anterior fifth intercostal space on the left and right sides. Based on our experience, uniportal segmentectomy does not follow the learning curve unique to segmentectomy. For dissection of segmental surface, an automatic suture is used to prevent pulmonary fistulas. If the cutting line between the segments is straight, dissection can be performed easily even in uniportal surgery, in which the automatic suturing device is inserted from one direction. For inter-area identification, we use an air-containing collapsed line with normal ventilation, after which thoracoscopic indocyanine green （ICG） imaging is introduced. However, there have been cases in which a difference in inter-area identification occurred between ICG identification and the air-containing collapsed line. As such, it is better to utilize both methods in cases with masses close to the inter-areas.