Intraoperative complications and troubles in robot-assisted anatomical pulmonary resection

Robot-Assisted Thoracoscopic Surgery Can Be Safely Performed in Patients With Obesity from the Early Stages of Implementation

OBJECTIVE

This study aimed to compare the perioperative outcomes of robot-assisted thoracoscopic surgery (RATS) and conventional video-assisted thoracoscopic surgery (VATS) for lung cancer in patients with obesity.

METHODS

Anatomical pulmonary lobectomy or segmentectomy performed at a single institution from April 2018 to September 2023 in patients with obesity (body mass index ≥25 kg/m2) were statistically compared in terms of perioperative clinical factors including operative time, blood loss, chest tube duration, pain score, intraoperative events, and early postoperative complications between RATS and VATS.

RESULTS

In all, 89 patients were evaluated; 43 underwent RATS and 46 underwent VATS. All RATS procedures were performed using the da Vinci Xi system. Patient characteristics were comparable between the 2 groups. The operative time, blood loss, number of dissected lymph nodes, intraoperative events, and conversion rate to open thoracotomy were similar between the 2 groups. The frequencies of postoperative complications and chest tube placement duration between the groups were also similar. The median pain scores were slightly higher in the RATS group on postoperative day 1 but were equivalent between the 2 groups on postoperative day 7. The RATS group had a shorter postoperative hospital stay than the VATS group (P < 0.01).

CONCLUSIONS

A surgical team proficient in conventional VATS can safely introduce RATS in patients with obesity and lung cancer with equivalent perioperative outcomes.

Usefulness of final transection of the proximal pulmonary artery in robotic left upper lobectomy

OBJECTIVES

The pulmonary artery runs around the left upper bronchus, which poses the risk of blood vessel injury when cutting in the blind spot of the bronchus. During robotic surgery, the robotic arm holds the tissue under constant tension; therefore, even if the pulmonary artery is left for final transection, it is not injured by unexpected tension. In this study, we examined the usefulness of final transection of the proximal pulmonary artery in robotic left upper lobectomy.

METHODS

This retrospective single-institution study evaluated patients who had undergone robotic lung resection. Of the 453 robotic lung resections performed at our institution between 2017 and 2022, 49 patients who had undergone left upper lobectomy were evaluated. Patients who had undergone bronchial transection followed by pulmonary artery transection were assigned to the group, bronchus prior transection (BT group, n = 38), and those who had undergone pulmonary artery transection followed by bronchial transection were assigned to the group, pulmonary artery prior transection (AT group, n = 11). Patient characteristics and perioperative outcomes were compared between the groups.

RESULTS

The groups did not differ significantly in age, sex, smoking history, tumour size, complication rates or 30-day mortality. The BT group inclined to shorter operative times and lesser blood loss. No active intraoperative bleeding occurred in the BT group. However, the AT group had 2 cases of intraoperative pulmonary artery bleeding, one of which required urgent conversion to thoracotomy.

CONCLUSIONS

Final transection of the proximal pulmonary artery is a novel and effective surgical technique for robotic left upper lobectomy.

Robot-assisted thoracic surgery for lung cancer patients with incomplete fissure

BACKGROUND

Robot-assisted thoracic surgery has gradually been accepted as an alternative treatment for early-stage non-small-cell lung cancer (NSCLC) owing to its advantages. However, severe incomplete interlobar fissure may lead to a high rate of conversion and postoperative morbidity. This retrospective study was conducted to assess the safety and efficiency of robot-assisted lung resection for patients with incomplete fissures (IFs).

METHODS

A retrospective review of medical records was performed in our institution from March 2021 to November 2021, and 207 patients with NSCLC who underwent robot-assisted anatomic lung resection were included in this study. Patients were divided into the IF group and the complete fissure (CF) group according to the level of fissure, which was determined based on the anatomical classification of pulmonary fissures.

RESULTS

The number of patients in the IF and CF groups was 87 and 120, respectively. In univariate analysis, there were no statistically significant differences between the two groups in terms of operative time (p = 0.66), intraoperative blood loss (p = 0.26), chest tube duration (p = 0.41), incidence of prolonged air leakage (PAL, p = 0.49), or length of postoperative hospital stay (p = 0.25). No patients experienced bronchopleural fistula, pneumonia, or cardiovascular complications. The total cost in the IF group was higher than that in the CF group (¥83,655 ± 13,314 versus ¥78,211 ± 11,980, p = 0.002).

CONCLUSION

IF does not increase the difficulty of lung cancer surgery with robotic platforms. Robot-assisted anatomic lung resection using the tunnel technique is an effective and safe method for IF patients.

Robot-assisted vs. video-assisted thoracoscopic surgery in lung cancer

Background

The major advantages of robot-assisted surgery are the fine field of view provided by the high-precision three-dimensional (3D) images and the good operability provided by the robotic arms that enables precise movements. A growing number of retrospective studies have compared robotic-assisted thoracoscopic surgery (RATS) with video-assisted thoracoscopic surgery (VATS), but the number of cases is limited and the results are contradictory.

Methods

We studied the medical records of primary lung cancer patients who underwent lobectomy with lymph node dissection between 2017 and 2020. Four hundred and eleven patients fulfilled the inclusion criteria in this study (RATS: 103; VATS: 308). We compared the perioperative factors and postoperative results of the VATS and RATS groups. Further, we adjusted background factors using propensity score matching (PSM) then compared the results of 200 patients (100 patients in each group). In this study, we matched interlobar fissure completeness, which affects operative difficulty and operative time; however, this has been superficially compared in previous studies.

Results

After PSM, a significant difference was observed in the intraoperative blood loss (RATS: 53.3 mL, VATS: 120.3 mL, P=0.04). The rates of surgical complications were comparable between the groups (10.0% vs. 13.0%, P=0.66) with similar mean operation times (RATS: 215.0 min, VATS: 210.1 min, P=0.57). The mean postoperative stay in the RATS group was shorter than that in the VATS group (10.0 vs. 11.5 days, P=0.04).

Conclusions

Initial experience of RATS had no obvious drawbacks when compared with that of VATS on propensity-matched analysis.

A new technique for introduction of a surgical stapler in robot-assisted lobectomy for lung cancer

BACKGROUND

The da Vinci Si version of robot lacks a vascular stapler that can be controlled by the operating surgeon at the surgical console for dividing the pulmonary vessels. Therefore, in order to initiate and safely perform robotic anatomical lobectomy for lung cancer, it is important to develop a safe method for introducing the surgical stapler.

METHOD

We performed a retrospective study of the first 42 consecutive patients who underwent robotic lobectomy for lung cancer at Nippon Medical School Hospital between January 2019 and December 2020.

RESULTS

Up to case 18, we performed Robot-assisted thoracoscopic surgery (RATS) lobectomy using the four-arm approach with two assistant ports. For dividing the pulmonary vessels, the surgical stapler was introduced through the assist ports. However, since this is not the port position usually used in video-assisted thoracoscopic surgery (VATS), there were many difficult situations.From case 19 onwards of RATS lobectomy, we began to use a total port approach using three robotic arms and two assistant ports. For resecting the pulmonary vessels or bronchi with endoscopic staplers, the port for the robotic arm was removed and the endoscopic staplers were placed through a 12-mm Xcel bladeless port. This change resulted in a shorter operation time, less blood loss, and less robotic arm interference. There has been no case that developed intraoperative complications during RATS lobectomy.

CONCLUSION

The new total port approach, with three robotic arms, for introducing surgical staplers during RATS using the da Vinci Si robotic system appears to be feasible.

Stapling of an endobronchial suction tube with the bronchus during robot-assisted right lower lobectomy: a case report

Background

Troubleshooting intraoperative complications requires careful management, and the safest technique should be chosen. We recently experienced a unique intraoperative bronchial complication during pulmonary lobectomy in robot-assisted thoracic surgery (RATS). There is no consensus on whether to continue RATS or convert to a more familiar technique, such as video-assisted thoracic surgery (VATS) or thoracotomy, for intraoperative complications that occur during RATS, and the decision should be determined individually.

Case presentation

A 74-year-old woman with primary lung adenocarcinoma (clinical stage IA2) underwent robot-assisted right lower lobectomy under one-lung ventilation and CO₂ insufflation. Intraoperatively, the anesthesiologist placed the endobronchial suction tube in the right bronchus with intention of maintaining the right lung collapse, which was simultaneously stapled with the right lower bronchus during the right lower lobe bronchial closure using a robotic stapler. During robot-assisted manipulation, we removed the staples involved with the suction tube, one by one, using robotic-arm forceps and sutured the partially opened stump. Subsequently, the bronchial stump was covered with a pedicled pericardial fat pad. The postoperative course was uneventful, and the patient developed no complications when followed up 8 months after discharge. Hence, we could rectify this intraoperative bronchial complication using a robot-assisted technique and avoid conversion to VATS or thoracotomy.

Conclusion

The precise manipulation techniques in RATS contributed to facilitate the successful execution of surgical procedures, such as staple removal and re-suturing of the bronchial stump and may be a useful as a method for such troubleshooting such intraoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-021-01278-5.