ABSTRACTIntroductionPrecise spatial understanding of the bronchovascular tree is essential for anatomical lung resection. Three‐dimensional (3D) reconstruction and extended‐reality (XR) technologies have emerged as tools for preoperative planning, navigation, and education. We aimed to assess the current use and efficacy of 3D and XR technologies in thoracic surgery in Japan and develop expert recommendations.MethodsTwo clinical survey questions on the usefulness of 3D imaging in thoracic surgery and that of VR, AR, and MR were sent to 125 certified thoracic surgical centers. PubMed searches targeted thoracic 3D and XR studies, including English‐language randomized, prospective, and retrospective studies, systematic reviews, and meta‐analyses. Draft statements were refined at the Anatomy on the Border Expert Consensus Meeting (Japan Society for Endoscopic Surgery 2024).ResultsFifty of the 125 institutions (40%) responded. 3D imaging was used by 96% of the institutions, and 72% used it in all cases. “Very” or “moderately” useful was reported by 94% of the institutions. Main purposes for using 3D imaging were preoperative simulation (84%) and anatomical understanding (86%); 52% of the institutions used 3D imaging for intraoperative reference. For XR, awareness was moderate, but adoption remained limited (8%). Among respondents, 74% rated its usefulness as uncertain, while only a small proportion found it clearly useful for preoperative simulation, intraoperative localization, and education. Literature search showed that 3D‐planning reduces blood loss, operative time, and complications in segmentectomy, whereas XR studies demonstrated improved nodule localization and workflow efficiency.Conclusions3D imaging should be the standard for complex thoracic resections, particularly segmentectomy. XR is a promising tool, with broader deployment expected as its usability improves and cost decreases.

Lumbar hernia following extreme lateral interbody fusion (XLIF) with iliac crest bone harvest is an uncommon but clinically relevant complication. A man in his 70s presented with left flank discomfort and a bulge 3 years after XLIF for lumbar spinal canal stenosis, performed via a route using the left anterior superior iliac spine. CT showed herniation of the descending colon through an abdominal wall defect. Laparoscopic intraperitoneal onlay mesh repair was undertaken with nerve-sparing fixation. Recovery was uneventful, and no recurrence or postoperative neuropathic pain was observed at 6 months. This case underscores the potential for abdominal wall weakening when XLIF is combined with iliac crest harvest and the value of laparoscopic repair with nerve-sparing fixation. Meticulous fascial closure and long-term follow-up may reduce the risk of delayed lumbar hernia.

Postoperative adhesive small bowel obstruction is common after abdominal surgery, whereas gastric outlet obstruction (GOO) due to adhesions on the anterior surface of the stomach is extremely rare. We report an 81-year-old man who developed persistent vomiting shortly after laparoscopic transverse colectomy. Computed tomography revealed marked gastric dilatation with a beak sign at the pylorus, and upper gastrointestinal endoscopy showed stenosis from the lower gastric body to the gastric angle without intraluminal lesions. Emergency laparoscopy identified a band-like adhesion between the lesser omentum and the remnant greater omentum crossing the anterior wall of the pyloric region and constricting the gastric outlet. Laparoscopic adhesiolysis with intraoperative endoscopic confirmation of patency relieved the obstruction, and the patient recovered uneventfully. This case highlights that omental-lesser omental bands should be considered as a differential diagnosis of early postoperative GOO after colorectal surgery and that laparoscopic adhesiolysis is a safe, minimally invasive treatment option.

Arcuate line hernia (ALH) is a rare internal hernia in which abdominal contents protrude into the retrorectus space through a defect between the arcuate line and rectus abdominis. Because the bulge lies behind the rectus abdominis muscles, symptoms are often non-specific, making diagnosis difficult. A 73-year-old woman presented with intermittent left lower abdominal pain. Thin-slice prone computed tomography obtained during the Valsalva maneuver demonstrated small bowel herniation through the left arcuate line, consistent with ALH, along with a concomitant umbilical hernia. Laparoscopic intraperitoneal onlay mesh (IPOM) repair was performed using a composite mesh covering both defects with adequate overlap, secured with transfascial sutures and absorbable tacks. The postoperative course was uneventful; the patient was discharged on postoperative Day 3 and remained symptom-free without recurrence at 1 year. To our knowledge, this is the first reported case of ALH with a concurrent umbilical hernia repaired laparoscopically using the IPOM technique.

Sinistral portal hypertension is caused by various pancreatic pathologies, including neoplasms. Bleeding from the collateral circulation due to sinistral portal hypertension obscures the operative field during laparoscopic distal pancreatectomy. A female patient in her 40s presented with a mucinous cystic neoplasm complicated by sinistral portal hypertension that was successfully managed with splenic arterial embolization followed by laparoscopic distal pancreatectomy. The intraoperative blood loss was minimal, and the patient did not require blood transfusions during the perioperative period. Preoperative splenic arterial embolization is feasible, safe, and effective in avoiding massive hemorrhage from the collateral circulation due to sinistral portal hypertension during laparoscopic distal pancreatectomy.

Robot-assisted radical prostatectomy (RARP) is the standard treatment for prostate cancer; however, inguinal hernias (IH) development is a common complication. Current guidelines generally recommend an anterior approach following RARP for the initial IH. However, the optimal surgical strategy for patients with recurrent IH after RARP who have a history of anterior mesh repair remains unclear. This report describes the first successful transabdominal preperitoneal (TAPP) repair of a recurrent IH in a patient with a history of RARP and Kugel plug repair. Intraoperative findings revealed displacement of the mesh plug and recurrence of the IH (Japan Hernia Society classification R1, L2). The prevesical space was severely scarred because of the effects of RARP, making dissection of the inner side of the hernia orifice difficult; however, mesh placement was successfully completed. This case demonstrated the feasibility and efficacy of the TAPP approach as a radical treatment for complex recurrences in a specialized patient population.

Morgagni hernia (MH) is a rare diaphragmatic hernia caused by a parasternal defect. We report a case of MH that was successfully repaired using a laparoscopic transabdominal preperitoneal (L-TAPP) approach combined with a self-gripping mesh. A 76-year-old woman was incidentally diagn4osed with MH during a preoperative evaluation of an unrelated knee surgery. Computed tomography revealed herniation of the greater omentum through a diaphragmatic defect measuring ~5 cm × 5 cm. L-TAPP was performed, in which the hernia contents were reduced and wide peritoneal dissection enabled tension-free mesh placement in the extraperitoneal space using a self-gripping mesh. The postoperative course was uneventful, and the patient was discharged on postoperative Day 5, with no recurrence observed at 10 months of follow-up. The L-TAPP approach allows secure mesh placement without direct contact with the intra-abdominal organs, potentially reducing the risk of recurrence and intraperitoneal complications. L-TAPP combined with a self-gripping mesh may be a useful and minimally invasive treatment option for MH.

Lymphangioleiomyomatosis (LAM) is often complicated by chylothorax and may require surgical intervention; however, the treatment is complicated because of difficulties in identifying the location of the fistula intraoperatively. This is the first report to identify the site of a chyle fistula associated with LAM in real time during surgery by using indocyanine green (ICG) lymphangiography. A 56-year-old woman received a diagnosis of a treatment-resistant left chylothorax associated with LAM. To identify the chyle fistula during surgery, 1 mL of ICG (2.5 mg) was injected into both inguinal lymph nodes under ultrasound guidance after anesthesia, with 1 mL per side for a total of 5 mg of ICG. We performed video-assisted thoracic surgery and observed near-infrared light acquisition and overlay technology using Stryker. Approximately 1 h after administration, fluorescence was observed in the anterior mediastinal lymph nodes, and a chyle fistula was observed around them. Although we attempted ligation of the lymph trunk, the surgical procedure damaged well-developed lymph vessels. The damaged area and anterior mediastinal lymph nodes, including the surrounding lymph vessels, were incinerated using soft coagulation and covered with polyglycolic acid sheets and fibrin glue. Consequently, the amount of chylous effusion decreased. The use of ICG allowed visualization of the lymphatic pathway and location of the chyle fistula in real time during surgery, enabling precise local treatment to reduce chyle effusion.

According to the Tokyo Guidelines 2018 (TG-18), delayed laparoscopic cholecystectomy (DLC) after recovering from acute cholecystitis (AC) is recommended for patients with poor status. Moreover, DLC for patients with good status remains controversial, and TG-18 does not include clinical questions regarding fluorescent cholangiography (FC). In this study, we evaluated the clinical value and safety of FC during DLC. We performed DLC in 226 patients after recovering from AC. The electronic medical records of these patients were retrospectively reviewed, focusing on preoperative assessment and intraoperative and postoperative outcomes. Biliary and/or arterial injuries were treated as intraoperative complications. Of the study patients, 144 underwent DLC with FC. Among the remaining 82 patients who underwent DLC without FC, the rate of intraoperative complications was 7.3% (n = 6), which was significantly higher than in those who underwent DLC with FC (0%) (p = 0.002). The rate of conversion to open cholecystectomy during DLC with FC (1.4%) was significantly lower than that during DLC without FC (15.9%). The mean operative time was not significantly different between the patients who underwent DLC with and without FC (p = 0.503). The mean blood loss and postoperative complications in patients who underwent DLC with FC were significantly lower than those who underwent DLC without FC (p = 0.041 and p = 0.002, respectively). Utilizing FC can reduce intraoperative and postoperative complications, the conversion rate, and blood loss during DLC; therefore, DLC with FC is recognized as a safe procedure for patients with AC.

Cesarean scar disorder (CSDi) is a pathological entity involving a myometrial defect at the site of a previous cesarean section, commonly associated with postmenstrual spotting, dysmenorrhea, and secondary infertility. While laparoscopic repair is an established treatment, intraoperative localization of the niche remains challenging. We report a novel application of the Pharus method, which utilizes the full-color IR white-light overlay mode of a commercial imaging platform (ELITE III, Olympus, Tokyo, Japan) to enable real-time visualization of hysteroscopic transillumination as green lights under bright-field conditions. A 32-year-old woman diagnosed with CSDi underwent combined hysteroscopic and laparoscopic niche repair. The margins of the niche were precisely delineated, sharply excised, and the uterine wall was reconstructed in two layers using barbed sutures. This is the first reported use of the Pharus method in the laparoscopic repair of CSDi. The technique enhances intraoperative anatomical guidance without the need for reduced lighting. This method may offer a valuable advancement in laparoscopic repair of CSDi.