THORACIC � Original Submission

Clinical Experience of Thoracoscopic SleeveLobectomy Using a Novel Needle Holder

D1X XTatsuo Nakagawa, D2X XMD, PhD, D3X XYasuaki Tomioka, D4X XMD, D5X XToshiya Toyazaki, D6X XMD, andD7X XMasashi Gotoh, D8X XMD, PhD

FlexDexTM Needle Driver for bronchial suturing.

Central Message

We report two clinical cases of thoracoscopic

sleeve lobectomy using the FlexDexD15X X Needle

Driver, a novel, unique, articulated instrument

TAGGEDH1INTRODUCTION TAGGEDENDAlthough recent technical advances have enabled sur-

geons to perform safe, reliable surgery for anatomical pul-monary resection, thoracoscopic bronchoplasty is stillchallenging. The first case of video-assisted sleeve lobec-tomy was reported in 2002,1 followed by a number ofreports to date. The technical key is undoubtedly how tocontrol stitching to the bronchus. The FlexDex NeedleDriver, a novel, unique articulated instrument designed tobe used for suturing, is expected to offer high performanceduring endoscopic surgery.2,3 We have now performedthoracoscopic sleeve lobectomy using this instrument andreport its clinical feasibility for bronchoplasty.

designed to be used for suturing.

TAGGEDH1MATERIALS AND SURGICAL TECHNIQUE TAGGEDENDThe patient is positioned in the lateral decubitus position

under general anesthesia. A trocar port for the thoracoscopeis then placed at the seventh intercostal space (ICS). Twotrocar ports for the surgeon are placed at the third andfourth ICSs on the anterior side and two assistant's pinports are placed on the posterior side. An additional sub-costal incision is made to remove the resected lung(Fig. 1). The procedure then continues in standard fashionup to and including bronchial resection.

After the FlexDex Needle Driver is attached to a click-onwrist band, its handle, which is attached to the gimbal ofthe instrument with two individual flexible and caterpillar-like connectors, is grasped. The motion of the wrist istransmitted to the tool via wires, making it possible to flexthe tip of the shaft by simply bending the wrist. The tool isthen spun by rotating the handle with the same degreerequired for the suturing (Fig. 2). Opening and closing thegripper is achieved using the trigger on the handle.

Bronchial suturing was performed using continuous sutureswith the V-Loc, as previously described.4 A pericardial fat padwas fixed on the bronchus to cover the suture line.

Department of Thoracic Surgery, Tenri Hospital, 200 Mishima, Tenri,Nara 632-8552, Japan.

Conflict of interest statement: The authors have declared that no con-flict of interest exists and no funding was provided to the study.

Address reprint requests to Tatsuo Nakagawa, MD, Department ofThoracic Surgery, Tenri Hospital, 200 Mishima, Tenri, Nara 632-8552,Japan. E-mail: t-nakaga@tenriyorozu.jp

1043-0679/$�see front matter © 2018 Elsevier Inc. All rights reservhttps://doi.org/10.1053/j.semtcvs.2018.07.001

In our first case, a 75-year-old man underwent right uppersleeve lobectomy for c-T2aN1M0 squamous cell cancer. At thestart of suturing, time was needed to adapt to handling the needledriver, but the manipulation gradually stabilized. Bronchial anas-tomosis time was 120minute. In the second case, a 70-year-oldman underwent right upper sleeve lobectomy for c-T2aN0M0squamous cell cancer. His entire right upper lobe was atelectaticdue to obstruction of the bronchial orifice by the tumor. Havingnow learned the technique, suturing with the needle driver wentmore smoothly than in the first case. Bronchial anastomosis timewas 85minute (Fig. 3). The sealing test showed minor air leakageafter bronchial anastomosis, which was successfully repaired withan additional stitch. The postoperative course was uneventful forboth patients.

Before surgery, written informed consent was obtained fromeach of the patients. The institutional review board at our hospitaland the patients approved publication of the clinical experiences.

TAGGEDH1DISCUSSION TAGGEDENDPulmonary surgery today requires little manual suturing

because staplers are commonly used to cut and close tissues. How-ever, bronchoplasty, which is usually performed D18X Xvia open thora-cotomy, still requires manual suturing. Suturing around thebronchus under thoracoscopic viewing through ports is compli-cated and time-consuming because the stitching movementtoward the bronchial wall is limited. The FlexDex Needle Driver(each is disposable and costs less than US$1000 per package) isextremely useful, particularly because stitching at an angle vertical

1ed.

Figure 1. Schema of the surgical approach. ICS, intercostal space.

TAGGEDENDTHORACIC � EXPERIENCE OF THORACOSCOPIC SLEEVE LOBECTOMY

to the bronchial wall is now achievable at any time during thesuturing, mimicking robotic surgery, which can cost millions ofdollars. Under usual circumstances, stitching at the end of sutur-ing is usually difficult because the inner cavity of the bronchuscannot be opened and observed, especially when using a barbedsuture as in our cases, which cannot be loosened once the stitch isplaced. The Needle Driver described herein, with its flexibility,compensates for the difficulty when using a running barbed sutureat the end of the anastomosis.

Although the Japanese Pharmaceuticals and Medical DevicesAgency (PMDA) approved its clinical application for both lapa-roscopic and thoracoscopic surgery, the device does pose some

Figure 2. Handling of the FlexDex Needle Driver. (A) Rotating the haion is achieved by bending the wrist.

2 Seminars in Th

problems during the latter. For example, the shaft is somewhatlong, because it was originally designed for laparoscopic sur-gery. Hopefully, some changes for better handling of theinstrument are possible.

In conclusion, this novel, uniquely articulated NeedleDriver is expected to improve thoracoscopic bronchoplasty.Although the suturing time of our cases may be relativelylonger than those expected during open surgery, we think itis possible to shorten the suturing time with further experi-ence. The instrument could provide surgeons with a path-way that is more intuitive than traditional surgery and morecost-effective than robotic surgery.

ndle spins the tool at the same number of degrees. (B, C). Flex-

oracic and Cardiovascular Surgery � Volume 00, Number 00

Figure 3. Intraoperative images of bronchial suturing using the FlexDex Needle Driver in the second case.

TAGGEDENDTHORACIC � EXPERIENCE OF THORACOSCOPIC SLEEVE LOBECTOMY

TAGGEDH1SUPPLEMENTARY MATERIAL TAGGEDENDThe following is the supplementary data to this article:

Video 1. Demonstration of the FlexDexTM Needle Driver and itsclinical use for bronchoplasty.

Seminars in Thoracic and Cardiovascular Surgery � Volume 00

TAGGEDH1REFERENCES TAGGEDEND1. Santambrogio L, Cioffi U, De Simone M, RossoL, et al: Video-assisted sleeve

lobectomy for mucoepidermoid carcinoma of the left lower lobar bronchus:A case report. Chest 121:635–636, 2002

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3. Criss CN, Ralls MW, Johnson KN, et al: A novel intuitively controlled artic-ulating instrument for reoperative foregut surgery: A case report. J Lapa-roendosc Adv Surg Tech A 27(9):983–986, 2017. https://doi.org/10.1089/lap.2017.0107. SepEpub 2017 Jul 20

4. Nakagawa T, Chiba N, Ueda Y, et al: Clinical experience of sleeve lobectomywith bronchoplasty using a continuous absorbable barbed suture. Gen Tho-racic Cardiovasc Surg 63:640–643, 2015

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