Respiratory Sugery

Lung cancer (also called primary lung cancer) is cancer that begins in the lungs. In our department, almost all cases undergo thoracoscopic surgery for these diseases. In addition, under the cooperation system of other departments such as Respiratory Medicine, Cardiology, and intensive care department, for patients who have difficulty undergoing surgery at other hospitals due to interstitial pneumonia, emphysema, heart bypass surgery, dialysis, etc. We are also considering indications after considering curability and preservation of respiratory function, and performing surgery.

Lung structure and lung cancer

The lungs are located in a box (thoracic cavity) bounded by the ribs and diaphragm and are divided into three chambers on the right and two chambers on the left. The room is called the lung lobe, and it looks like a mandarin orange in the figure. Breathing is performed by air moving through passages called trachea and bronchi, and taking in oxygen and expelling carbon dioxide in small sac structures called alveoli at the end. Lung cancer is cancerous cells anywhere from the bronchi to the alveoli. Lung cancer surgery is based on lung lobectomy, which removes each lung lobe (room) where the cancer is located. In advanced cases, bilobectomy or total pneumonectomy may be required, and combined resection of the cancer-infiltrated surrounding organs (chest wall, diaphragm, superior vena cava, pericardium, left atrium, etc.) is also performed. On the other hand, we also perform reduction surgery (wedge resection, segmental resection) that emphasizes preservation of lung function.

Thoracoscopic surgery for lung cancer

In our department, we place the utmost importance on the cure rate and safety of surgery for lung cancer, and actively perform thoracoscopic surgery.
In addition to conventional thoracoscope surgery, we also use single-port thoracoscope surgery and robot-assisted thoracoscope surgery.
We decide on the appropriate surgical method in consultation with the patient, taking into consideration the state of the disease and its curability.

Our department's custom-made medicine for lung cancer treatment

In our department, we examine and propose treatments that suit individual patients. Specifically, we propose reduction surgery that emphasizes the preservation of lung function, and stereotactic radiation irradiation and surgery at the time of recurrence (recurrence) if surgery is not desired after consultation.

Surgery for lung cancer can be divided into the following four types in descending order of resection range. (Figure below "Surgery for cancer")

1. Wedge resection (partial resection) to remove part of the lung
2. Unilateral pneumonectomy, in which one entire lung is removed
3. Lobectomy to remove lung lobes
4. Segmentectomy to remove lung segments

The standard surgical procedure for lung cancer is lobectomy, but in our department, we perform segmental resection and wedge resection as reduction surgery, taking into consideration the size of the lesion, presence or absence of lymph node metastasis, and respiratory function. In addition, we perform extended surgery and unilateral pneumonectomy for advanced lung cancer.

A pneumothorax is a lung disease that causes a hole in the lung, causing air to leak and the lung to collapse. Most of them occur when thin-walled balloon-like areas called lung cysts (bulla) rupture. It is common in young, tall, thin men, and symptoms such as chest pain, coughing, and shortness of breath occur.

Pneumothorax and lung cyst

In rare cases, an air leak called tension pneumothorax can get worse and worse, putting pressure on the lungs and heart. Recommended.

test

Most of them can be diagnosed by X-ray, but CT can be used to find out the cause in more detail. Also, even if the cause of the bulla is not found on CT, a small bulla that cannot be detected by other examinations can be found by actually looking inside the chest with a camera called an exploratory thoracoscope under general anesthesia. .

treatment

There are conservative treatment (treatment without surgery) and surgical treatment. Mild pneumothorax may be monitored, but moderate or severe pneumothorax may be treated by inserting a tube into the chest and sucking out the leaking air. It can be cured by itself, but there is a problem that it is easy to relapse. It is said that 30-50% of cases will recur if only conservative treatment is performed, and the number will drop to 3-7% if surgery is performed. At our hospital, surgery is performed using a thoracoscopic technique, which allows surgery to be performed with small wounds, and postoperative recovery is very good.

giant lung cyst

A disease in which large pulmonary cysts form in the thoracic cavity. Normal lung tissue is compressed and respiratory function is reduced. Surgery to remove the giant pulmonary cyst can expand the compressed lungs and improve respiratory function. A thoracoscopic surgery is also possible.

A mediastinal tumor is a tumor that occurs in the space (called the mediastinum) in the thorax that separates the left and right lungs by the pleura. It can be benign or malignant (thymoma, thymic carcinoma, neurogenic tumor, germ cell tumor, malignant lymphoma, etc.). It is often found incidentally during screening and is often asymptomatic.

mediastinal tumor

The mediastinum is the space in the thorax that separates the left and right lungs by the pleura, and tumors occur in the mediastinum. It can be benign or malignant (thymoma, thymic carcinoma, neurogenic tumor, germ cell tumor, malignant lymphoma, etc.). It is often found incidentally during screening and is often asymptomatic.

Thymoma is the most common mediastinal tumor and originates from an organ called the thymus located within the mediastinum. Although the degree of malignancy is low, if left untreated, infiltration and metastasis to multiple organs will occur, so resection is generally recommended.

myasthenia gravis

It is an autoimmune disease in which the autoantibody, anti-acetylcholine receptor antibody, binds to the neuromuscular junction of skeletal muscles, causing muscle weakness. Symptoms include muscle weakness, fatigue (especially worse in the evening), ptosis, and diplopia (seeing double). The thymus and surrounding fat tissue are thought to be involved in the production of autoantibodies, and are removed en bloc.

Traditionally, surgery for mediastinal tumors and myasthenia gravis has been performed via median sternotomy (a vertical incision in the sternum, used in cardiac surgery), but our department has adopted robot-assisted thoracic surgery and is actively performing surgery using a thoracoscope.

There are two types of surgical methods: median sternotomy and thoracoscopic tumor removal. In our department, we treat these diseases using a thoracoscope whenever possible, as this leaves a small incision, but we consult with the patient to determine the appropriate treatment method, taking into account the condition of the tumor and its curability.

Palmar hyperhidrosis is a condition in which excessive sweating of the hands interferes with daily activities. In addition to diseases such as thyroid disease and pheochromocytoma, this is thought to be caused by individual differences such as the relatively strong movement of the sympathetic nerve, which is one of the autonomic nerves. There are various treatment methods, but in many cases, methods other than surgery are ineffective for those who want a fundamental treatment or those who are severely ill.

Symptoms of palmar hyperhidrosis and typical treatments

People with palmar hyperhidrosis who visit our department have troubles due to sweat on their hands every day. Wrinkled important documents, not being able to shake hands, etc.

Treatment includes external application of antiperspirants (aluminum chloride, etc.), psychotherapy (counseling, autonomic nerve training, etc.), pain clinic (sympathetic ganglion block, etc.), oral treatment (herbal medicine, Pro-Vansin®: autonomic ganglion blockade). There is also an operation (sympathetic ganglionectomy) as a radical treatment.

Treatment of palmar hyperhidrosis in our department

In our department, we perform thoracoscopic bilateral sympathetic ganglionectomy using a thoracoscopic system for those who want radical treatment or those with severe disease. Surgery is usually performed on the day of admission, and if all goes well, you can leave the hospital the next day.

Two 5 mm skin incisions are made under the armpit, instruments such as a camera are inserted through them, the target sympathetic nerves are found, and the target sympathetic nerves are cut using an ultrasonic coagulator.

At our facility, we cut nerves with pinpoint accuracy and evaluate the effects during surgery. With this kind of ingenuity, only the sympathetic nerve that is the cause can be reliably cut, and the nerve is not cut more than necessary, so the therapeutic effect is maximized and complications are kept to a minimum.

Typical complications associated with surgery

For those who are planning to undergo surgery, even if the risk of various complications has already been factored in, we ask them to fully consider whether they want to improve their palmar hyperhidrosis for their current symptoms and future. increase.

compensatory sweating

There is a difference in the degree, but it almost occurs in those who have undergone surgery. Instead of sweating from the palms, the sweating of the back, abdomen, and lower extremities increases. Some people develop compensatory sweating to the point that it interferes with their daily activities.

Horner syndrome

Very rarely, mild cases can occur where nerves are naturally uncommon. Symptoms include decreased facial sweating and anisocoria, but most of them are temporary and improve.

effects on the heart

Since the sympathetic nerve is cut, the heart rate decreases by about 10%, but it does not affect daily life.
*Compared to normal Respiratory Sugery surgery, there are no dangerous procedures, so safety is very high.

Patients with multiple injuries due to traffic accidents, falls, etc., are transported to our hospital by ambulance. Chest trauma varies in severity, from those in serious condition requiring surgery to those requiring only conservative treatment. increase.

Typical chest injuries treated in our department

rib or sternum fracture

Rib or sternum fractures are basically injuries that often require only conservative treatment. However, if there are multiple fractures, and if the fractures damage organs such as the lungs, diaphragm, heart, thymus, liver, and spleen, or if there is a risk of damage, surgical treatment is required. .

Depending on the severity of the fracture, respiratory failure may occur and may require management in an intensive care unit.

In addition, fractures are a painful disease, making it difficult to expectorate phlegm, and may be accompanied by respiratory complications such as pneumonia and atelectasis (a condition in which air cannot enter the lungs). Various analgesia such as intravenous drip, oral medicine, or epidural anesthesia are performed as necessary.

lung contusion

It is caused by partial rupture of alveoli and capillaries associated with chest trauma. Respiratory failure may occur in extensive and severe cases. If bleeding into the lungs becomes severe, surgery may be performed.

Hemothorax or pneumothorax due to trauma

Any damage to the intrathoracic organs, such as the lungs or diaphragm, causes blood to accumulate in the pleural space, a condition called hemothorax. Leakage of air outside the lungs is called a pneumothorax. Respiratory failure can occur because the blood and air compress the lungs and interfere with normal breathing.

In many cases, relief can be obtained by draining or exhausting fluid with a tube called a chest drain, but if the underlying cause is a rib fracture or lung injury, surgical treatment is required.

Features of our surgery for chest trauma

In our department, we actively perform surgical treatment using thoracoscopic surgery. Depending on the situation, a thoracotomy (conventional surgery with a large skin incision) may be performed, but by performing less invasive surgery, we are striving to help those who have undergone surgery return to society earlier. . Most patients will be able to eat from the day after surgery, and depending on the severity of the injury, they will be asked to perform walking training with a physical therapist.

After surgery, there are many tubes necessary for treatment, such as a drip infusion, an oxygen mask, and a chest drain.

In addition, as a clinical study, our department is conducting a prospective study on respiratory system mechanics in patients with high-energy thoracic trauma. We ask for your cooperation.

Introduction - What does "Respiratory Sugery" do? ~

Internal medicine, surgery, emergency department... Thank you for entering the page of "Respiratory Sugery" among various departments.

"Respiratory surgery...is lung cancer and pneumothorax? In textbooks...is this the only page?" It's an important department.

What is the scope of Respiratory Sugery? …The answer is everything in the chest except for the heart/great vessels, esophagus, mammary glands, spine/clavicle.

In other words, the lungs, trachea, sternum/ribs, mediastinum, pleura/thoracic cavity, skin and soft tissue of the thorax, etc. There is no limit to the number of diseases that can be covered in detail. Because it is "too specialized".

As professionals in this field, we work day and night to help as many patients as possible. If you are interested, how about taking a look at the site once? You may see things that you have never seen before.

Features of our hospital

① One of the largest number of cases in Japan

Typical surgical cases include primary lung cancer, metastatic lung tumor, mediastinal tumor (thymoma, etc.), pneumothorax, empyema, chest trauma (rib fracture, etc.), and palmar hyperhidrosis. We have around 400 cases of general anesthesia annually, which is one of the largest in Japan. We have also received many referrals from other hospitals for difficult-to-operate cases. In addition, taking advantage of our strengths as a general hospital, we actively perform surgeries for patients with surgical risks such as heart and respiratory diseases and diabetes, while considering their indications.

② Minimally invasive surgery

In Japan and overseas, the theme of recent surgery is "minimally invasive surgery". Our department is particularly focused on minimally invasive surgery, and has actively adopted Video Assisted Thoracoscopic Surgery (VATS). We are performing Uni-Port Surgery (or 2 Port) to complete the surgery. Minimally invasive surgery reduces the postoperative burden on patients, and patients who are scheduled to be hospitalized are doing well after surgery and are discharged in 3 to 4 days.

Recently, we are also focusing on incorporating Robot Assisted Thoracoscopic Surgery (RATS).

③Trauma/emergency surgery

The most famous department in our hospital is the emergency department. In 2022, we were selected as No. 1 in the “National Emergency and Critical Care Center Evaluation” announced by ministry of Health, Labor and Welfare notation, Labor and Welfare, and have been honored for the ninth consecutive year. With this background, our department accepts a large number of emergencies centered on trauma. If deemed suitable, surgery is performed immediately.

For those who are considering training as a Senior Resident

The most worrisome question for Senior Resident is, "How much experience will I be able to accumulate?"

Our hospital is one of the most unique hospitals in the city. In that kind of place, I don't think I'll be able to get around to cutting myself. You may think, but I'm going to go around from the beginning of the Senior Resident. Of course, the staff will help you while you are unfamiliar. All of our staff members are highly experienced, and the atmosphere within the department is conducive to consultation.

Senior Resident are mainly in charge of emergency diseases, and the ability as an attending doctor is cultivated.

The most important thing in ward management is cooperation with other departments, but cooperation with any department, including Respiratory Medicine, is open and easy to consult. The ward and medical staff are all enthusiastic, and it can be said that it is a very comfortable environment to work in.

Academic activities are thriving throughout the hospital, and the environment is conducive to papers, presentations at academic conferences, and clinical research.

In this way, it is undoubtedly a top-level environment for a city hospital, and you will be able to receive satisfactory training.

Recommended rotation (for Junior Resident)

When it comes to surgical training, you just follow the senior and Senior Resident in the hospital ward, and although you've become clean during surgery, your gloves are clean and you just stand and stare at the screen. ?

Although we cannot perform too advanced procedures or manage them, we can proactively take charge of basic procedures such as chest tube insertion, drain removal, and thoracentesis if desired (of course, staff will provide guidance and backup). In surgery, if you have the opportunity, you can hold a camera and close the wound. It is said that seeing is believing, but "one try" is better than "seeing", so take advantage of this opportunity.

Reading chest X-rays is a necessary skill for any clinical department, but since pulmonary Respiratory Sugery interpret not only standing, but also sitting and recumbent photographs, they have the same skills as those in the intra-call and radiology departments. I'm here. It seems difficult to manage a thoracic drain, but when you observe the thoracic cavity during surgery, you get closer to understanding the essentials of how the thoracic cavity works. Observation of the thoracic cavity is also useful for interpreting chest X-rays and CT.

If you wish to have such a fruitful surgical training, let's rotate Respiratory Sugery.

Even if you are not applying for surgery, if you are applying for a department that may require the insertion of a chest tube, such as Respiratory Medicine or emergency medicine, this is a good opportunity to directly observe and study the anatomy of the thoracic cavity, so please rotate this course. I promise that it will be the sustenance for the future. Naturally, aspiring Respiratory Sugery are very welcome!

Attractiveness of Respiratory Sugery

We can completely cure primary lung cancer and metastatic lung cancer, treat pneumothorax and empyema with surgery for which medical management is limited, and provide an appropriate treatment policy by making a diagnosis with a lung biopsy. The greatest attraction is that the hands can greatly advance the treatment of patients.

Recently, many new drugs have appeared, especially in the field of lung cancer, and we are now able to operate on patients who were not candidates for surgery until now. Treatment is advancing day by day, and there is no end to what to study.

Certainly not all things go well. However, when I see the patients I am in charge of recovering well and being discharged from the hospital, or proceeding to the next treatment, I feel that I am glad that I became a Respiratory Sugery. You can get it.

Would you like to work with us as a "trump card" in respiratory medicine?

*This content is intended for doctor and is intended to deepen the understanding of this medical institution, and is not intended for publicity or advertising for the general public.

Nice to meet you, my name is Yutaka Takahashi Takahashi Respiratory Sugery Kobe City Medical Center General Hospital.
In our department, about 95% of surgeries are performed thoracoscopically in order to minimize the burden on patients after surgery. Last year's lung cancer surgery was reduced to 133 cases and corona, but all cases were thoracoscopic surgery. This time, we would like to introduce a single-incision thoracoscopic lung cancer surgery that pursues minimal invasiveness.
In addition, taking advantage of our strengths as a general hospital, we also treat patients for whom surgery is difficult at other hospitals, taking into account curability and preservation of respiratory function. I would appreciate it.

Yutaka Takahashi
Vice President
Respiratory Sugery Director

About lung cancer surgery

As you know, lung cancer is a cancer with a poor prognosis that is the third most common cancer in terms of incidence and the highest number of deaths.
In addition to surgery, chemotherapy and radiotherapy are available as treatments, and progress in the latter two has been particularly remarkable, but surgery is still the most radical cure. The basic surgery for lung cancer is lung lobectomy, not partial resection that removes only the tumor. This is the same for open chest, thoracoscopic, and robot-assisted surgery. For advanced lung cancer, thoracotomy is still sometimes performed, but thoracoscopy is used in combination, leaving only a 5 to 10 cm wound.
Robot-assisted surgery is also a type of thoracoscopic surgery.

Normal thoracoscopic surgery is mainly performed with three 2-3 cm incisions (ports), and the operation is performed by inserting instruments such as a thoracoscope and an automatic suture device through each port. Robot-assisted surgery has a number of advantages, such as magnified stereoscopic vision, a range of motion that is impossible for humans, and surgery using equipment with camera shake correction. However, with the current equipment, at least five surgical wounds (ports) are required, and the biggest drawback is that there are more wounds than normal thoracoscopic surgery.

The single-incision method introduced here is a method of performing surgery with one or two wounds, and is performed by inserting a thoracoscope and instruments through one or two ports. Therefore, it is a minimally invasive surgical method that can reduce the burden on the patient with only one surgical wound of 3 cm in size or an additional 1 cm incision. On the other hand, since this is an operation that uses fewer ports, it requires a high level of skill to operate thoracoscopes and other instruments with a smaller diameter than usual, and harmonious cooperation between the surgeon and assistant is required. At our hospital, we started lung cancer surgery with two surgical incisions two years ago, and we select cases and carry out with only one surgical incision.

In single-incision surgery, surgery is performed by inserting a thoracoscope and surgical instruments through a single incision.
It is a less invasive surgery

Postoperative pain in Respiratory Sugery surgery is caused by damage to the intercostal nerve that occurs during surgery, and no matter how small the wound is, if multiple intercostal portholes are created, the pain becomes severe. In our department, even if there are two wounds, they are placed between the same ribs, so the pain is reduced. Therefore, it is possible to eat and walk from the day after the operation, and since the surgical wound is sutured with an absorbable suture, there is no need to remove the suture. The earliest patients were discharged from the hospital within a few days after surgery, and the average postoperative hospital stay last year was 4.0 days.

Schematic diagram of conventional thoracoscopic surgery, robot-assisted surgery, and single-incision surgery

In the single-hole method, surgery is performed on a 3cm-sized wound under the armpit.

Lung cancer treatment at our hospital ~ Tailor-made treatment options ~

At our hospital, treatment policies for lung cancer are discussed at a joint conference by the departments of Respiratory Medicine, surgery, and Radiation Oncology, and the three departments work together to provide treatment. Treatment of advanced lung cancer is rarely completed by surgery alone, and we are working on custom-made treatments such as administration of anticancer drugs and radiation therapy before and after surgery to improve treatment results. For example:

Lung cancer treatment results from 2011 to 2020 (5-year survival rate)

Our department's clinical results - cooperating with other departments to deal with complications -

We are also able to treat patients who are considered difficult to operate on at other hospitals due to complications of serious respiratory or circulatory diseases or after cardiac surgery, etc., by utilizing our strength as a general hospital and cooperating with other departments such as Respiratory Medicine and Cardiology to treat lung cancer and other respiratory diseases using surgical techniques that are curative and preserve respiratory function.

Out of 319 total surgeries in 2020, 300 were thoracoscopic surgery

Since 2011, the number of surgeries has been on the rise, but last year the total number of surgeries decreased due to the spread of the new coronavirus infection. As mentioned above, in order to minimize the burden on patients after surgery, our department performs thoracoscopic surgery in 300 cases, which is about 95% of all surgeries, and handles all kinds of diseases.

Partial resection is the first choice for metastatic lung tumors and benign tumors, but if partial resection is difficult due to size or location, lobectomy or segmental resection is performed.
Although thoracoscopic lung lobectomy and segmental resection is a highly difficult surgical procedure, it is actively performed at our hospital, and accounts for about half of all thoracoscopic surgeries.

Minimally Invasive Surgery for All Respiratory Diseases

We have introduced mainly lung cancer, but we also provide minimally invasive surgery promptly for the following diseases.

·pneumothorax
There is an image that many people are young, but it is precisely because they are young that early social reintegration is desired. Since it is possible to leave the hospital in 1 to 2 days after surgery, it is important to shorten the period until surgery. With the cooperation of the Anesthesiology and operating room, pneumothorax is operated on a semi-urgent basis, and early discharge is planned. In addition, we have received many referrals for intractable pneumothorax, which is difficult to operate.

・empyema
Medical treatments such as antibiotics and drainage take a long time to heal, and a complete cure cannot be expected. Early thoracoscopic surgery to remove pus, place a drain in an effective position for irrigation, and irrigate after surgery can significantly shorten the treatment period and achieve sufficient re-expansion of the lungs. Timing is particularly important in this surgery, so it is performed more urgently than pneumothorax.

・Lung metastasis of other organ cancer
Unlike primary lung cancer, partial resection is the first choice. However, when this is difficult, lung lobectomy is required, but we are working on thoracoscopic segmental resection in order to preserve lung function as much as possible even in such cases.
・Mediastinal tumor ・Myasthenia gravis
We are actively performing thoracoscopic surgery, and we have introduced robot-assisted surgery for these diseases because it has great advantages.

- palmar hyperhidrosis
We have received many cases from Dermatology and have performed thoracoscopic sympathectomy. Because it requires general anesthesia, it requires hospitalization for one night and two days, but it is appreciated by young patients who suffer from palmar hyperhidrosis.

Nearly 400 surgeries are performed annually by three staff members and three trainees.

About our hospital's corona countermeasures and medical treatment status

There is a misunderstanding among some people that our clinic is refraining from general medical examinations, probably because we are treating patients with severe coronavirus. Corona patients are treated in a newly built annex, and there is no connection with general patients. In addition, all patients admitted to the main building, including emergency admissions, will undergo a PCR test at the time of admission, and patients undergoing scheduled surgery and tests that generate aerosols (lung function, bronchoscopy, etc.) will also include a symptom diary two weeks prior. I am getting it. We prevent the introduction of viruses through thorough infection control, so you can receive treatment at our hospital for all diseases, not just lung cancer, with peace of mind.

message to teachers

A definitive diagnosis of lung cancer can be obtained by collecting tumor tissue and examining it pathologically, so at the stage of introduction, only imaging diagnosis is used in most cases. In addition, since the condition for surgery is that there is no distant metastasis, there are many cases where it is difficult to determine whether surgery is possible. In such a case, please feel free to introduce us to our clinic. Respiratory Sugery and internal medicine work in close cooperation, so even when it is difficult for our department to deal with the problem, our department will consult with the Respiratory Medicine department.

Even after surgery for lung cancer, patients who do not require additional treatment after surgery and are only undergoing follow-up observation are examined together with local doctors. In our department, we only check recurrence by CT/PET etc. once every six months to a year. For the regional collaboration path, please refer to the "Hyogo Prefecture Cancer Community Collaboration Path" (http://www.hyogo-ganshinryo.jp/critical_path/index.html) on the website of the "Hyogo Prefecture Cancer Treatment Collaboration Council". Please refer to It is a pass that can be used even by doctors who do not specialize in respiratory medicine.
I have mainly talked about lung cancer, but I would like to introduce other diseases as well.