Hitoshi Igai1, Jin Ye Yeo2
1Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, Japan; 2JOVS AME Publishing Company
Correspondence to: Jin Ye Yeo. JOVS Editorial Office, AME Publishing Company. Email: jovs@amepc.org
Expert introduction
Dr. Igai (Figure 1) graduated and received his medical degree from Kagawa Medical School in 2002. He then obtained a PhD at Faculty of Medicine of Kagawa University in 2009. Dr. Igai completed his Thoracic Surgery Residency at the Department of General Thoracic, Breast and Endocrinological Surgery, Faculty of Medicine, Kagawa University. He worked at Kurashiki Central Hospital as a Staff Doctor and Kagawa University as an Assistant Professor. In 2010, Dr. Igai was recruited to Japanese Red Cross Maebashi Hospital as an Assistant Director. Between April 2016 and March 2017, he worked as a Postdoctoral Research Fellow at Toronto General Hospital, Research Institute, University Health Network. On April 2017, he restarted working at Japanese Red Cross Maebashi Hospital as an Assistant Director.
Dr. Igai is a Board-Certified Surgeon of Japan Surgical Society and Japanese Association for Chest Surgery. His research includes ongoing studies in Minimally Invasive Surgery, especially uniportal video-assisted thoracic surgery (VATS) or pulmonary segmentectomy. He has published over 150 papers.
Figure 1 Dr. Hitoshi Igai
Expert introduction
JOVS: What drove you to pursue minimally invasive thoracic surgery?
Dr. Igai: Minimally invasive thoracic surgery represents a significant advancement in the field of surgical medicine, offering patients less pain, quicker recovery times, and fewer complications compared to traditional open surgeries. My decision to pursue this specialty stems from a combination of personal inspiration, professional motivation, and a strong desire to improve patient outcomes.
When I was a young physician, open thoracotomy was the primary approach. However, with the advent of thoracoscopic surgery, I recognized its significance through first-hand experience of reduced postoperative pain and faster recovery times. More recently, the introduction of uniportal video-assisted thoracic surgery (VATS) and robotic surgery has further advanced minimally invasive techniques. I strongly believe that all these developments contribute significantly to the early postoperative return to society and the maintenance of quality of life for patients.
JOVS: Could you provide a brief overview of the recent publications in pulmonary segmentectomy? Are there any articles that stood out to you?
Dr. Igai: In recent years, pulmonary segmentectomy has gained attention as a viable alternative to lobectomy, particularly for patients with early-stage non-small cell lung cancer and those with limited pulmonary reserve. The shift towards less invasive surgical techniques has prompted a surge in research exploring the efficacy, safety, and outcomes associated with pulmonary segmentectomy.
As you all know, among many studies, Cancer and Leukemia Group B (CALGB) 140503 and Japan Clinical Oncology Group (JCOG) 0802 have revealed new possibilities for pulmonary segmentectomy. While the standard surgical procedure for non-small cell lung cancer is lobectomy, these results suggest that pulmonary segmentectomy may soon become the standard procedure for early-stage lung cancer.
JOVS: Could you share some of the recent advancements in minimally invasive pulmonary segmentectomy? How have these advancements impacted your practice?
Dr. Igai: We emphasize three key factors to achieve adequate segmentectomies via minimally invasive approach.
1) Preoperative examination of 3D computed tomography bronchoangiography (3D CTBA) and preoperative simulation to ensure sufficient surgical margin.
In pulmonary segmentectomy, it is essential to expose and divide the target pulmonary vessels and bronchi, which requires a deep understanding of anatomy. A 3D CTBA can help us comprehend the branching patterns of these structures. Additionally, ensuring a sufficient surgical margin is of utmost oncological importance in pulmonary segmentectomy. Recent advancements in preoperative simulation methods, which can reveal the surgical margin between the target tumor and the divided intersegmental planes, enable us to obtain an appropriate surgical margin even when the location of the tumor cannot be detected intraoperatively.
2) How to identify intersegmental planes during pulmonary segmentectomy.
There are several techniques to identify intersegmental planes intraoperatively. Among them, the use of infrared thoracoscopic observation with intravenous indocyanine green administration is extremely useful in minimally invasive approaches because it prevents lung inflation, which could obstruct a good surgical view.
3) Surgical approach to perform pulmonary segmentectomy.
Our team performs pulmonary segmentectomy via uniportal thoracoscopic or robotic approaches, both of which are trends in minimally invasive surgery in general thoracic surgery. As you know, the uniportal thoracoscopic approach is less invasive compared to the multiportal approach. However, this method can be technically challenging due to limited operability through a small-sized single skin incision. Therefore, acquiring technical tips is crucial for performing pulmonary segmentectomy via the uniportal approach. The robotic approach offers a 3D high-definition surgical view and tremor-free manipulation, allowing us to expose pulmonary vessels and bronchi in the periphery, which ultimately leads to appropriate pulmonary segmentectomy.
JOVS: What are some of the most pertinent challenges you faced during your research in minimally invasive thoracoscopic surgery? Moving forward, what do you think should be the research direction to overcome these challenges?
Dr. Igai: Although our team usually adopts preoperative simulation methods to obtain a sufficient surgical margin for unpalpable tumors such as ground-glass opacity (GGO), small-sized tumors, or deeply located tumors, there is controversy over the best method to intraoperatively locate these tumors. Several new techniques, including virtual-assisted lung mapping (VAL-MAP) and radiofrequency identification (RFID), are emerging to address this issue. The development of these techniques is essential because the number of surgeries for unpalpable tumors is expected to increase due to recent advancements in computed tomography (CT) technology.
JOVS: You have published many surgical video articles and contributed many surgical tutorial videos in recent years. Could you share what your thought process is when choosing which surgical techniques to cover in your tutorial videos?
Dr. Igai: First, our group places the highest priority on avoiding postoperative air leaks in clinical practice because they prolong postoperative hospitalization and can lead to additional complications. To achieve this, the fissureless or unidirectional dissection technique, which avoids treating a dense fissure, is one of the most useful methods. Therefore, we have incorporated these techniques into our tutorials for all types of lobectomies and segmentectomies.
Second, the number of segmentectomies is expected to increase due to the positive results of the CALGB 140503 and JCOG 0802 studies. Consequently, we have produced numerous tutorial videos describing the techniques for pulmonary segmentectomy, especially for the complex types, which are usually more technically challenging compared to the simple types.
JOVS: High-quality surgical videos play an important role for the education and dissemination of surgical techniques. In your opinion, what makes a good surgical tutorial video?
Dr. Igai: When creating a tutorial video, it is most important to explain how to perform the procedure in a way that is easily understandable for readers, especially young surgeons. Even if the procedure is excellent, it will not become widespread if only highly talented surgeons can perform it. On the contrary, if any surgeon can perform the procedure by watching the tutorial video, many patients worldwide would benefit.
JOVS: How has your experience been as the Editorial Board Member of JOVS?
Dr. Igai: Serving as an Editorial Board Member for JOVS has been an enriching and fulfilling experience. It has provided me with a unique platform to contribute to the advancement of surgical education and practice while staying at the forefront of cutting-edge developments in the field of general thoracic surgery.
The role involves rigorous review and selection of high-quality manuscripts. This process not only ensures that the journal maintains its high standards but also keeps me updated with the latest research and advancements in minimally invasive thoracic surgery. Evaluating these manuscripts requires a deep understanding of the subject matter, critical thinking, and a commitment to academic excellence. It is a challenging yet rewarding task that reinforces my own knowledge and expertise. Furthermore, being part of the editorial board allows me to mentor and guide emerging researchers and surgeons. Providing constructive feedback and support to authors, especially those early in their careers, is an aspect of the role that I find particularly gratifying. It is fulfilling to play a part in their professional development and to help them navigate the complexities of academic publishing.
In conclusion, my tenure as an Editorial Board Member of JOVS has been immensely beneficial both professionally and personally. It has enhanced my knowledge, expanded my professional network, and allowed me to contribute to the surgical community in a meaningful way. I look forward to continuing to support the journal in its mission to disseminate high-quality, visualized surgical education and to foster innovation in the field.
JOVS: As the Editorial Board Member, what are your expectations for JOVS?
Dr. Igai: As an Editorial Board Member, I expect JOVS to maintain high standards through rigorous peer review and ethical practices, promote innovative research, expand its global reach via digital and open access, support emerging talents with constructive feedback, and foster collaboration within the surgical community. Achieving these goals will ensure JOVS remains a leader in advancing surgical practices in general thoracic surgery, especially in minimally invasive approaches, and improving patient care.