鏡視下手術における癒着症例の対処法

Dealing with Pleural Adhesion in Video-assisted Thoracoscopic Surgery

近年の呼吸器外科手術では，胸腔鏡を用いた鏡視下手術が標準となった．鏡視下手術が開胸手術に比べて低侵襲であることは論をまたないところであるが，胸腔内の癒着は鏡視下手術完遂における課題の一つである．鏡視下手術は，ポート位置，切開のサイズ，胸腔鏡の仕様などが施設によりさまざまであり，癒着剝離においてもそれぞれの施設における工夫がなされているものと思われる．本稿では，当科における鏡視下手術での癒着症例の対処法について紹介する．

The adhesion between the visceral and parietal pleura makes video-assisted thoracoscopic surgery （VATS） difficult or impossible. When performing VATS without conversion to thoracotomy due to pleural adhesion, it is important to （ⅰ） evaluate the presence and extent of the adhesion preoperatively, （ⅱ） carefully perform detachment, and （ⅲ） adequately repair the injured visceral pleura. We evaluate visceral sliding with the help of chest ultrasonography and plan the best approach to make utility incisions, camera port, and third-port incisions. Considering the difficulty in repairing the injured visceral pleura under VATS, we perform extra-pleural detachment of adhesions around the injured visceral pleura, which can facilitate the repair of the pleural injury. For repairing pleural injury, we use free mediastinal fat tissue as biological pledgets to support suturing. In this report, we present the approaches and techniques we follow to perform VATS for patients with pleural adhesion.