“Starting a robotic program in general thoracic surgery: why, how, and lessons learned.”
Cerfolio, R. J., A. S. Bryant, et al. (2011).
Annals of Thoracic Surgery 91(6): 1729-1737.
BACKGROUND: We report our experience in starting a robotic program in thoracic surgery. METHODS: We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients. RESULTS: Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes. CONCLUSIONS: Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed.
“Dissection of thymoma with da Vinci S surgical system in 3 cases.”
Chen, X., B. Han, et al. (2010).
Chinese Journal of Clinical Oncology 37(13): 770-773.
Objective: To summarize the clinical experience of robotic assisted thymoma dissection with the da Vinci S surgical system. Methods: The clinical data of 3 patients with thymoma treated with da Vinci S system between May 2009 and October 2009 were reviewed. The patients were under general anesthesia and had a double-lumen endotracheal tube for selective single lung ventilation during surgery. The patient was positioned at a 30-degree angle and tumor location decided which side was elevated. Patient cart was positioned on a 30-degree angle from the patient head, non-operating side. In the robotic procedure, the port for the robotic endoscope was positioned in the 6th intercostal space between the middle and anterior axillary line. The two robotic instrument ports were placed in the 3rd and 6th intercostal spaces, one handbreadth left and right of the camera trocar, respectively. An auxiliary port was positioned dorsal between the camera and the left instrument trocar. The tumor and thymus were dissected and then the surrounding fatty tissue was removed. Larger vessels (the thymic vein) were clipped, and smaller ones were sealed by electrocautery. The specimen was taken out in an endobag. Results: All three cases of thymoma and thymus were en block dissected and followed perithymic fatty tissue removal. No intraoperative mortality or major complications were experienced; no conversion to median sternotomy and no extra accesses were used. Surgical duration was 80-240 min (136.7 min on average), all patients were extubated at 16-49 h (28.7 h on average) after surgery, blood loss was 30-100 ml (mean 63.3 ml), thoracic tube drainage after 24 h was 100-250 mL (160 mL on average), with no transfusion in the perioperative period. One case using the left side entrance route had transient left diaphragmatic paralysis and recovered before discharge. Pathologically, there were 2 cases of type B1 and 1 case of type B2 according to the WHO standard. Conclusion: Removing the thymoma and dissecting the perithymic fatty tissue in the mediastinum with the da Vinci S system was feasible and the early results are satisfactory.
Puntambekar, S. P., N. Rayate, et al. (2011).
Journal of Thoracic and Cardiovascular Surgery.
“Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy.” Schmid, T., F. Augustin, et al. (2011).
Annals of Thoracic Surgery 91(6): 1961-1965.
PURPOSE: Video-assisted thoracoscopic (VATS) lobectomy has been demonstrated to be safe and feasible. However, only a few reports exist on minimally invasive sleeve lobectomy. In most of these, bronchial anastomoses were accomplished in an open surgical technique through a minithoracotomy. We report on a combined robotic and VATS approach for a true minimally invasive right upper sleeve lobectomy. To our knowledge it is the first report of this kind. DESCRIPTION: A 30-year-old female patient presented with a low grade neuroendocrine tumor occluding the orifice of the right upper lobe bronchus. A complete minimally invasive right upper sleeve lobectomy was performed. Dissection and individual control of the right upper lobe pulmonary vessels was performed through three 1.5 to 2 cm incisions by means of conventional VATS. The specimen was retrieved through the upper thoracocentesis, which was enlarged to 4.5 cm. For airway reconstruction, a bronchial anastomosis between the right intermediate and the right main bronchus was performed with the da Vinci robot through the same incisions. EVALUATION: Intraoperative blood loss was minimal and total operative time was 364 minutes. The postoperative course was uneventful. Chest X-rays showed no sign of atelectasis. The chest tube was removed on postoperative day 9 due to prolonged pleural effusion. Bronchoscopy on postoperative day 14 showed a patent right airway and a well healing anastomosis. The patient was discharged on postoperative day 15. CONCLUSIONS: The da Vinci robot provides a benefit in more complex thoracic procedures like pulmonary sleeve resections. It is an ideal tool to perform delicate surgical maneuvers in vulnerable and difficult to reach anatomic areas. The study of the literature shows that VATS sleeve lobectomy is being performed in dedicated centers only with a low morbidity.