ロボット支援下手術での有棘縫合糸を用いた二層縫合による気管支断端閉鎖の工夫

Dual Suturing Technique Without Tying for Closure of the Bronchial Stump in Robotic Surgery

気管支断端瘻（BPF）は肺癌手術におけるもっとも重篤な合併症の一つであり，気管支断端閉鎖や気管支吻合を確実に行うことが重要である．肺癌手術では気管支断端の閉鎖に縫合を要する場合があり，たとえば気管支中枢への浸潤が疑われる症例において，迅速病理検査で気管支断端の診断を確実にするため，鋭的切離と縫合閉鎖を行う1）．近年増加傾向にあるロボット支援下手術（RATS）は，多関節により運針の自由度が高いため，開胸や胸腔鏡補助下手術（VATS）よりも縫合が容易であるが，触覚がないため結紮はやや困難である．われわれは当院倫理委員会の承認（倫理承認番号：2022-45）を得て，結紮を必要としないSTRATAFIX（Ethicon社）［図1a］やV-Loc（Covidien社）などの有棘縫合糸，および固定強化のためのLAPRA-TY（Ethicon社）［図1b］を用いたRATS気管支断端閉鎖法を実施しているので報告する（図2a）．

In lung cancer surgery, when tumors are present in the branches of the bronchus, it may be appropriate to perform suture closure by sharply separating the bronchus, rather than using an autosuture device to ensure adequate margins. While robot-assisted thoracic surgery （RATS） simplifies needle handling compared to video-assisted thoracic surgery （VATS）, ligation remains challenging due to the lack of tactile feedback. To ensure closure of the bronchial segment by ligation in robotic surgery, we started a preliminary study to use dual barbed sutures that do not require ligation and clips for ligature fixation after the approval from the Ethics Committee of Mie University Hospital. We performed this procedure in five patients from January 2024 to present. Postoperative bronchoscopy, performed in four of the five patients, confirmed the bronchial stump was well closed in all cases, with no evidence of bronchopleural fistula （BPF）. However, two patients experienced prolonged hospitalization due to midlobar torsion and prolonged air leakage requiring pleurodesis, respectively. The preliminary results suggest that this novel technique provides reliable bronchial stump closure in RATS. We plan to conduct a larger cohort study with long-term follow-up to further confirm the safety and long-term BPF rate.