“Robotic brachytherapy and sublobar resection for T1 non-small cell lung cancer in high-risk patients.”Blasberg, J. D., S. J. Belsley, et al. (2010).
Ann Thorac Surg 89(2): 360-367.
BACKGROUND: Sublobar lung resection and brachytherapy seed placement is gaining acceptance for T1 non-small cell lung cancer (NSCLC) in select patients with comorbidities precluding lobectomy. Our institution first reported utilization of the da Vinci system for robotic brachytherapy developed experimentally in swine and applied to high-risk patients 5 years ago. We now report seed dosimetrics and midterm follow-up. METHODS: Eleven high-risk patients with stage IA NSCLC who were not candidates for conventional lobectomy underwent limited resection of 12 primary tumors. To reduce locoregional recurrence, (125)I brachytherapy seeds were robotically sutured intracorporeally over resection margins to deliver 14,400 cGy 1 cm from the implant plane. Patients were followed with dosimetric computed tomography scans at 30 +/- 16 days. Survival and sites of recurrence were documented. RESULTS: Resected tumor size averaged 1.48 +/- 0.38 cm (range, 1.1 to 2.1 cm). Perioperative mortality was 0% and recurrence was 9% (1 of 11 [margin recurrence at 6 months with resultant mortality at 1 year]). Follow-up duration was 31.82 +/- 17.35 months. Dosimetrics confirmed 14,400 cGy delivery using 24.21 +/- 4.6 (125)I seeds (range, 17 to 30 seeds) over a planning target volume of 10.29 +/- 2.39 cc(3). Overall, 84.1% of the planning target volume was covered by 100% of the prescription dose (V100), and 88.2% was covered by 87% of the prescription dose (V87), comparable to open dosimetric data at our institution. Follow-up imaging confirmed seed stability in all patients. CONCLUSIONS: Robotic (125)I brachytherapy seed placement is a feasible adjuvant procedure to reduce the incidence of recurrence after sublobar resection in medically compromised patients. Tailored robotic seed placement delivers an exact dosing regimen in a minimally invasive fashion with equivalent precision to open surgery.
“An update on robotic thoracic surgery and anesthesia.”
Campos, J. H. (2010).
Curr Opin Anaesthesiol 23(1): 1-6.
PURPOSE OF REVIEW: Minimally invasive surgery involving the thoracic cavity continues to increase. With the introduction of robotic systems, particularly the da Vinci robot system more than 10 years ago, thoracic operations have been performed with some provocative results and limited, defined advantages. The present review provides an overview of common thoracic surgical procedures performed with the robotic system and discusses the anesthetic implications. RECENT FINDINGS: The literature on this topic currently includes case reports or series of clinically prospective or retrospective observational reports with the use of robotic systems, involving the thoracic cavity (mediastinal mass resections, lobectomies, and esophagectomies); unfortunately there are very limited reports related to anesthetic implications or complications related to the use of this technology. The majority of the surgical reports involve the use of lung isolation devices for thoracic surgery, specifically the use of a double-lumen endotracheal tube (DLT); a few centers use carbon dioxide (CO2) insufflation as part of their management to achieve maximal surgical exposure while compressing the operative side of the lung away from the operative area. SUMMARY: Anesthesiologists must be familiar with lung isolation techniques and flexible fiberoptic bronchoscopy while participating in thoracic surgical cases that require robotic systems. In addition, prevention and recognition of potential complications, such as crushing injuries or nerve damage, must be sought. Because the potential for converting to an open thoracotomy exists, all measures must be taken to manage patients accordingly if the situation arises.
“Robotic fourth-arm enucleation of an esophageal leiomyoma and review of literature.”
Kernstine, K. H., E. S. Andersen, et al. (2009).
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 4(6): 354-357.
Esophageal leiomyomas are resected in symptomatic and/or malignancy-suspicious cases. Traditionally, they have been removed by laparotomy or thoracotomy and more recently by thoracoscopy and laparoscopy. Mucosal injury is reported as high as 7% of cases but may be higher in unreported general practice. Robotic technology seems to offer advantages. We describe a robotic approach that seems to minimize mobilization of the esophagus, potentially decreasing the likelihood of mucosal injury and postoperative recovery time. We review the literature to evaluate the reports of mucosal injury with the open, minimally invasive, and robotic techniques and describe our own method. To improve efficiency, we use a four-arm technique. Copyright © 2009 by the International Society for Minimally Invasive Cardiothoracic Surgery.
“Thoracoscopic esophagectomy for esophageal cancer: Feasibility and safety of robotic assistance in the prone position.”
Kim, D. J., W. J. Hyung, et al. (2010).
Journal of Thoracic and Cardiovascular Surgery 139(1).
Objective: To assess the feasibility and safety of robot-assisted thoracoscopic esophagectomy for esophageal cancer in the prone position. Methods: Twenty-one patients underwent robot-assisted thoracoscopic esophagectomy in the prone position by a surgical oncologist who had no prior experience with thoracoscopic esophagectomy. Hemodynamic and respiratory parameters were serially recorded to monitor changes in prone positioning. Results: All thoracoscopic procedures were completed with a robot-assisted technique followed by cervical esophagogastrostomy. R0 resection was achieved in 20 patients (95.2%), and the number of dissected nodes was 38.0 ± 14.2. Robot console time was significantly reduced from 176.3 ± 12.3 minutes in the initial 6 patients (group 1) to 81.7 ± 16.5 minutes in the latter 15 patients (group 2) (P = .000). In group 2, there was less blood loss (P = .018), more patients could be extubated in the operating room (P = .004), and the number of dissected mediastinal nodes tended to be increased (P = .093). There was no incidence of pneumonia or 90-day mortality. Major complications included anastomotic leakage in 4 patients, vocal cord palsy in 6 patients, and intra-abdominal bleeding in 1 patient. The prone position led to an elevation of central venous pressure and mean pulmonary arterial pressure and a decrease in static lung compliance. However, cardiac index and mean arterial pressure were well maintained with the acceptable range of partial pressure of arterial oxygen and carbon dioxide. Conclusion: Robotic assistance in the prone position is technically feasible and safe. Prone positioning was well tolerated, but preoperative risk assessment and meticulous anesthetic manipulation should be carried out. © 2010 The American Association for Thoracic Surgery.
“Four-arm robotic lobectomy for the treatment of early-stage lung cancer.”
Veronesi, G., D. Galetta, et al. (2010).
Journal of Thoracic and Cardiovascular Surgery.
Objectives: We investigated the feasibility and safety of four-arm robotic lung lobectomy in patients with lung cancer and described the robotic lobectomy technique with mediastinal lymph node dissection. Methods: Over 21 months, 54 patients underwent robotic lobectomy for early-stage lung cancer at our institute. We used a da Vinci Robotic System (Intuitive Surgical, Inc, Mountain View, Calif) with three ports plus one utility incision to isolate hilum elements and perform vascular and bronchial resection using standard endoscopic staplers. Standard mediastinal lymph node dissection was performed subsequently. Surgical outcomes were compared with those in 54 patients who underwent open surgery over the same period and were matched to the robotic group using propensity scores for a series of preoperative variables. Results: Conversion to open surgery was necessary in 7 (13%) cases. Postoperative complications (11/54, 20%, in each group) and median number of lymph nodes removed (17.5 robotic vs 17 open) were similar in the 2 groups. Median robotic operating time decreased by 43 minutes (P = .02) from first tertile (18 patients) to the second-plus-third tertile (36 patients). Median postoperative hospitalization was significantly shorter after robotic (excluding first tertile) than after open operations (4.5 days vs 6 days; P = .002). Conclusions: Robotic lobectomy with lymph node dissection is practicable, safe, and associated with shorter postoperative hospitalization than open surgery. From the number of lymph nodes removed it also appears oncologically acceptable for early lung cancer. Benefits in terms of postoperative pain, respiratory function, and quality of life still require evaluation. We expect that technologic developments will further simplify the robotic procedure. © 2009 The American Association for Thoracic Surgery.