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Page 16 of 18 Ninomiya et al. Mini-invasive Surg 2022;6:33 https://dx.doi.org/10.20517/2574-1225.2022.12

The most serious situation necessitating emergent thoracotomy include aorta and trachea-bronchial injury.
We experienced one case of aortic bleeding by esophageal branch pull out during dissection around the
aorta. This case was successfully managed without thoracotomy by direct suturing using 5-0 Prolene
(Ethicon, Somerville, NJ, USA) with Cardiovascular Pledgets (Medtronic, Minneapolis, MN, USA). Only
one additional port was inserted for the temporal hemostasis by compression with a cherry dissector. The
robotic platform, with a three-dimensional view, articulation of instruments with seven degrees of freedom,
tremor filtering, and hand control with a 3:1 motion scale, enabled direct suturing of the aorta and ligation
with fine thread. Furthermore, the insertion of surgeon’s right hand from caudal direction was
ergonomically ideal for direct suturing of the aorta. It is noteworthy that the surgeon can choose any
EndWrist usage by manual hand control assignment in the case of repairing aorta and/or trachea-bronchial
injury in robotic surgery.

Many surgeons prefer PP to LDP when performing thoracoscopic esophagectomy and RATE because an
adequate surgical view can be easily obtained without the assistant’s effort. The limitation of RATE in LDP
is the compressing of the lung and rotation of the trachea by an assistant using trachea retractor. Artificial
pneumothorax by AirSeal insufflation system (ConMed) is useful in obtaining a good view without
compressing the lung and diminishing the assistant’s efforts. However, trachea retraction by the assistant is
mandatory to retrieve left RLN lymph nodes situated left side of the trachea. Two-lung ventilation in PP
using artificial pneumothorax may be ideal to expose lymph nodes around the trachea because trachea
rotation can be easily performed with a soft single lumen tube, unlike the hard double-lumen tube used for
[30]
single-lung ventilation . We will try RATE with two-lung ventilation in the prone position set by bed
rotation for current LDP with anterior tilting. Emergent thoracotomy may be easily performed by restoring
body position with bed rotation. This modification may improve the easiness of left RLN dissection and
contribute to a more meticulous dissection with reducing the assistant’s effort. In addition, one of the ports
for the assistant may be reduced.

CONCLUSION
Our results indicate that RATE in LDP to reproduce the surgical view and manipulation consistent with
open esophagectomy is useful for performing upper mediastinal dissection to secure emergent thoracotomy.

DECLARATIONS
Authors’ contributions
Performed operation: Ninomiya I, Okamoto K
Written the manuscript: Ninomiya I

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
All patients provided written informed consent before treatment, and the study was approved by the Ethics
Committee of Kanazawa University Hospital. This work conforms to the guidelines set forth in the Helsinki
Declaration of 1975 and later versions. This study was approved by Kanazawa University Hospital