Robot-assisted thoracoscopic resection of a benign mediastinal neurogenic tumor: technical note

Comprehensive Surgical Management of Thoracic Schwannomas: A Retrospective Multicenter Study on 98 Lesions

BACKGROUND AND OBJECTIVES

The optimal surgical management of thoracic schwannomas (TSs) remains contentious, with various approaches proposed. Video-assisted thoracoscopic surgery (VATS) and combined VATS with neurosurgical procedures have shown promise, particularly for Eden type IV and III lesions. However, unanimous consent on the most effective surgical intervention and understanding of prognostic factors for tumor recurrence needs to be improved. The aim of this study was to elucidate the optimal surgical approach according to the Eden type and investigate predictive factors for TS recurrence.

METHODS

This retrospective, multicentric, observational study analyzed 98 surgically treated patients with TS from 2011 to 2023, assessing preoperative and 6-month follow-up clinical (recurrences, pain, and myelopathy recovery) and surgical parameters (operative time, intraoperative blood loss, extent of resection). Surgical procedures included thoracic laminectomy or hemilaminectomy for type I, laminectomy or thoracic transpedicular (TPD) approach for type II, laminectomy alone or combined laminectomy with VATS for type III, and VATS or thoracotomy (open thoracotomy [OT]) for type IV. Descriptive and deductive analyses were conducted between and within the 4 cohorts, with multivariate analysis assessing the contribution of predictor variables.

RESULTS

No significant differences were found between hemilaminectomy and laminectomy for all analyzed parameters for type I. Type II lesions treated with TPD exhibited similar outcomes to laminectomy, albeit with longer procedure times. Type III lesions benefited from combined approaches compared with neurosurgical-only approaches. Video-assisted thoracoscopic surgery emerged as more favorable than OT for type IV lesions. Multivariate analysis revealed that patient sex, tumor location, extent of resection, and pathology significantly influenced recurrence rates.

CONCLUSION

For Eden type III TSs, neurosurgical and VATS combined surgery achieved better outcomes than neurosurgery alone; for Eden type IV TSs, VATS achieved better results than OT. For Eden types I and II, hemilaminectomy and bilateral laminectomy and laminectomy and TPD achieved similar outcomes, respectively.

Multidisciplinary Surgical Approach Using Augmented Reality Preplanning for Resection of Giant Thoracic Schwannoma With Robotic-Assisted Thoracoscopic Mobilization

BACKGROUND AND IMPORTANCE

In adults, primary spinal cord tumors account for 5% of all primary tumors of the central nervous system, with schwannomas making up about 74% of all nerve sheath tumors. Thoracic schwannomas can pose a threat to neurovasculature, presenting a significant challenge to safe and complete surgical resection. For patients presenting with complex pathologies including tumors, a dual surgeon approach may be used to optimize patient care and improve outcomes.

CLINICAL PRESENTATION

A 73-year-old female previously diagnosed with a nerve sheath tumor of the fourth thoracic vertebra presented with significant thoracic pain and a history of falls. Imaging showed that the tumor had doubled in size ranging from T3 to T5. Augmented reality volumetric rendering was used to clarify anatomic relationships of the mass for perioperative evaluation and decision-making. A dual surgeon approach was used for complete resection. First, a ventrolateral left video-assisted thoracoscopic surgery was performed with robotic assistance followed by a posterior tumor resection and thoracic restabilization. The patient did well postoperatively.

CONCLUSION

Although surgical treatment of large thoracic dumbbell tumors presents a myriad of risks, perioperative evaluation with augmented reality, new robotic surgical techniques, and a dual surgeon approach can be implemented to mitigate these risks.

Retrospective analysis of robot-assisted laparoscopic transabdominal anterior approach for the treatment of lumbar paravertebral schwannoma

BACKGROUND

The main objective of this study was to investigate the impact of robot-assisted laparoscopic resection on paravertebral tumours using the anterior peritoneal approach.

METHODS

A retrospective analysis to identify patients with paravertebral tumours. A total of 21 patients, who underwent robot-assisted laparoscopic transabdominal anterior approach surgery from March 2012 to August 2020.

RESULTS

The median operation time was 66.2 ± 14.5 min, with a range of 0-100 min. Intraoperative blood loss was minimal, with a median of 11.4 ± 7.9 mL and a range of 5-30 mL. The median tumour length was 4.8 ± 2.3 cm, ranging from 2.1 to 11.3 cm. Postoperative hospitalisation lasted for a median of 3.2 ± 0.9 days. During the 48-month follow-up period, no tumour recurrence or residual was observed in any patient.

CONCLUSIONS

Robot-assisted laparoscopic resection of lumbar paravertebral schwannoma proved to be a safe and viable surgical approach. It offers a relatively new treatment option for paraspinal schwannoma.

Analysis of the efficacy of the da Vinci robot in surgery for posterior mediastinal neurogenic tumors

BACKGROUND

The present research is designed to evaluate the short-term outcome of robot-assisted thoracoscopic surgery (RATS) for the treatment of posterior mediastinal neurogenic tumors.

METHODS

We retrospectively analyzed clinical data on 39 consecutive patients with mediastinal neurogenic tumors after RATS treatment completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People's Hospital from January 2016 to September 2022. There were 22 males and 17 females with a mean age of (35.1 ± 6.9) years in this analysis report. The tumors of the patients were localized and evaluated preoperatively using magnetic resonance imaging (MRI) or enhanced CT.

RESULTS

All 39 patients successfully underwent the resection of posterior mediastinal neurogenic tumors under RATS, and no conversion to thoracotomy occurred during the operations. The average operative time was (62.1 ± 17.2) min, the average docking time was (10.1 ± 2.5) min, the average intraoperative bleeding was (32.8 ± 19.5) ml, the average 24-h postoperative chest drainage was (67.4 ± 27.9) ml, the average postoperative chest drainage time was (2.2 ± 1.3) days and the average post-operative hospital stay was (3.2 ± 1.3) days. Postoperative complications occurred in 3 patients, including 2 patients with transient Horner's syndrome after surgery and 1 patient with transient anhidrosis of the affected upper limb after surgery.

CONCLUSION

RATS for posterior mediastinal neurogenic tumors is safe, effective, feasible and bring the superiority of robotic surgical system into full play.

Retroperitoneal robot-assisted resection of a lower posterior mediastinal benign schwannoma using a transdiaphragmatic approach: A case report

INTRODUCTION

Neurogenic tumors are the most frequent neoplasms of the lower posterior mediastinum. Traditionally, lower posterior mediastinal tumors are excised by video-assisted thoracic surgery. However, the available robotic treatment for the lower posterior mediastinum tumors to date are rare. Herein, we report a case of a right lower posterior mediastinal tumors successfully treated with retroperitoneal robot-assisted surgery using a transdiaphragmatic approach.

PATIENT CONCERNS

A 54-year-old male patient without any symptoms was admitted into our department with a right lower posterior mediastinal paravertebral tumor that was detected during a medical check-up.

DIAGNOSIS

A right lower posterior mediastinal paravertebral tumor.

INTERVENTIONS

Retroperitoneal robot-assisted resection using a transdiaphragmatic approach was performed.

OUTCOMES

The patient was treated with retroperitoneal robot-assisted surgery using a transdiaphragmatic approach and remained disease-free throughout a 6-month follow-up. His postoperative course was uneventful. Histopathological examination revealed a benign schwannoma.

CONCLUSION

Our initial experience showed that retroperitoneal robot-assisted resection of a lower posterior mediastinal tumor using a transdiaphragmatic approach is technically feasible and can be considered a potential alternative for either video-assisted thoracic surgery or a thoracotomy.

Primary Intrathoracic Neurogenic Tumors: Clinical, Pathological, and Long-Term Outcomes

BACKGROUND

 Intrathoracic neurogenic tumors (INTs) are uncommon neoplasms arising from nerve tissues. We report our single-center experience in treating these rare INTs.

METHODS

 Using a prospective institutional database, clinical, surgical, and pathological records of patients receiving resection of INT between May 1998 and June 2018 were analyzed. Survival was calculated by Kaplan-Meier method.

RESULTS

 There were 82 patients (24 females) with an average age of 53 years (29-75 years). Mean diameter was 32 mm (range, 12-68 mm). Histology included 49 schwannomas (11 malignant), 15 neurinomas (2 malignant), 14 neurilemmomas, and 4 paragangliomas. Tumor was located in the posterior mediastinum in 52 patients, in the thoracic inlet in 12, in the anterior mediastinum in 7, in the lung parenchyma in 5, and in the chest wall in 3. In three (3.6%) patients, the tumor showed an intraspinal extension. Symptoms were reported in 51 patients (62.2%) and included cough in 23, dyspnea in 15, neurologic symptoms in 11, and wheezing in 2. Operation was performed by thoracotomy in 42 (51.2%) cases and less invasive technique in 40 (48.8%) cases. Resection was completed in 80 patients (97.6%). Postoperative radiotherapy was administered in two cases. Intraoperative and postoperative mortalities were nil. Morbidity occurred in four patients (4.8%) including two prolonged air leaks, one hemothorax, and one chylothorax. Five-year survival was 97% (mean follow-up, 4.9 years). Malignant tumors had a worse prognosis (p = 0.02). No recurrence occurred during the follow-up neither for malignant nor for benign tumors.

CONCLUSION

 The treatment of choice for INTs is complete resection which will be tailored to tumor size, location, and extension. Long-term prognosis is favorable for benign neurogenic tumors.

Clinical efficacy of robot-assisted thoracoscopic surgery for posterior mediastinal neurogenic tumors

Background

Robot-assisted thoracic surgery (RATS) has an increasing usage throughout the world. This retrospective cohort study aimed to objectively compare the surgical results between video-assisted thoracic surgery (VATS) and RATS in posterior mediastinal neurogenic tumors (PMNT).

Methods

We retrospectively reviewed the clinical data of 130 patients diagnosed with posterior mediastinal neurogenic tumor between 2015 and 2018. Magnetic resonance imaging (MRI) or enhanced computed tomography scan (CT-scan) was used to locate the tumor and investigate the Adamkiewicz’s artery preoperatively. The individual surgical approach was determined by both tumor size and patient’s willings.

Results

The surgical time in RATS (43.2±12.6 min) was tended to be less than that in VATS (47.4±11.9 min) (P=0.054). Meanwhile, the estimated blood loss in RATS group (85.8±22.6 mL) was significantly less than that in VATS group (95.3±28.4 mL) (P=0.040). However, the duration of chest tube (days) and volume of drainage (mL) had no significant difference between two groups (P=0.12 and P=0.68, respectively). The postoperative hospital stay (days) of patients in RATS group (2.2±0.4 days) was significantly shorter than that in VATS group (2.4±0.6 days) (P=0.031). There were no significant differences between two groups in the incidence of the postoperative complications and adverse reactions.

Conclusions

RATS has the superiorities in terms of surgical blood loss and postoperative hospital stay over VATS for posterior mediastinal neurogenic tumor. In conclusion, RATS could be a feasible and safe way for resecting posterior mediastinal neurogenic tumor.

Benign Intradural and Paraspinal Nerve Sheath Tumors: Advanced Surgical Techniques

Traditional surgical techniques for benign intradural and paraspinal nerve sheath tumors often consisted of open posterior approaches. However, these were limited by the morbidity of open surgery. In addition, iatrogenic instability is often required for total resection of larger or laterally located tumors, thus necessitating the use of additional hardware for spinal fusion. Advances in surgical techniques and technologies have allowed for a plethora of minimally invasive approaches throughout the cervical, thoracic, and lumbar regions. These approaches and their particular applications for the resection of benign peripheral nerve sheath tumors are described, with special attention to modern surgical strategies.

Robotic paravertebral schwannoma resection at extreme locations of the thoracic cavity

Solitary paravertebral schwannomas in the thoracic spine and lacking an intraspinal component are uncommon. These benign nerve sheath tumors are typically treated using complete resection with an excellent outcome. Resection of these tumors is achieved by an anterior approach via open thoracotomy or minimally invasive thoracoscopy, by a posterior approach via laminectomy, or by a combination of both approaches. These tumors most commonly occur in the midthoracic region, for which surgical removal is usually straightforward. The authors of this report describe 2 cases of paravertebral schwannoma at extreme locations of the posterior mediastinum, one at the superior sulcus and the other at the inferior sulcus of the thoracic cavity, for which the usual surgical approaches for safe resection can be challenging. The tumors were completely resected with robot-assisted thoracoscopic surgery. This report suggests that single-stage anterior surgery for this type of tumor in extreme locations is safe and effective with this novel minimally invasive technique.

Robotic-Assisted Videothoracoscopic Mediastinal Surgery

BACKGROUND

Tumors of the mediastinum as well as normal thymus glands in patients with myasthenia gravis have traditionally been resected using large and morbid incisions. However, robotic-assisted mediastinal resections are gaining popularity because of the many advantages that the robot provides. However, few comprehensive reviews of the literature on robotic-assisted mediastinal resections exist.

METHODS

A systemic review of the current medical literature was performed, excluding cases related to esophageal pathology. These studies were evaluated and their findings are reported in this comprehensive review. Approximately 48 papers met the inclusion criteria for review.

RESULTS

Robotic-assisted surgical systems are increasingly being used in mediastinal resections. Based on the available literature, robotic-assisted thoracoscopic surgery in the mediastinum is feasible and safe. Robotic-assisted mediastinal surgery appears to be superior to open approaches of the mediastinum and is comparable with videothoracoscopic surgery when patient outcomes are considered.

CONCLUSIONS

Increased robotic experience and more studies, including randomized controlled trials, are needed to validate the findings of the current literature.

Robotic thoracic surgery: The state of the art

Minimally invasive thoracic surgery has come a long way. It has rapidly progressed to complex procedures such as lobectomy, pneumonectomy, esophagectomy, and resection of mediastinal tumors. Video-assisted thoracic surgery (VATS) offered perceptible benefits over thoracotomy in terms of less postoperative pain and narcotic utilization, shorter ICU and hospital stay, decreased incidence of postoperative complications combined with quicker return to work, and better cosmesis. However, despite its obvious advantages, the General Thoracic Surgical Community has been relatively slow in adapting VATS more widely.

The introduction of da Vinci surgical system has helped overcome certain inherent limitations of VATS such as two-dimensional (2D) vision and counter intuitive movement using long rigid instruments allowing thoracic surgeons to perform a plethora of minimally invasive thoracic procedures more efficiently.

Although the cumulative experience worldwide is still limited and evolving, Robotic Thoracic Surgery is an evolution over VATS. There is however a lot of concern among established high-volume VATS centers regarding the superiority of the robotic technique. We have over 7 years experience and believe that any new technology designed to make minimal invasive surgery easier and more comfortable for the surgeon is most likely to have better and safer outcomes in the long run. Our only concern is its cost effectiveness and we believe that if the cost factor is removed more and more surgeons will use the technology and it will increase the spectrum and the reach of minimally invasive thoracic surgery.

This article reviews worldwide experience with robotic thoracic surgery and addresses the potential benefits and limitations of using the robotic platform for the performance of thoracic surgical procedures.

Robot-assisted resection of a retrocaval peridiaphragmatic mass

Herein the authors report on the advantages of robotic surgery in the removal of a peridiaphragmatic mass in the retrocaval space.

A peridiaphragmatic mass that is located in the retrocaval space typically requires a wide incision and retraction of the peritoneal organs or great vessels to remove the mass. The laparoscopic method is very challenging because of unsatisfactory visual fields and a lack of range of movement from the instruments. We present the advantages of robotic surgery in the removal of deep retrocaval tumors, a procedure that requires careful dissection and minimal retraction.

Navigation, robotics, and intraoperative imaging in spinal surgery

Spinal navigation is a technique gaining increasing popularity. Different approaches as CT-based or intraoperative imaging-based navigation are available, requiring different methods of patient registration, bearing certain advantages and disadvantages. So far, a large number of studies assessed the accuracy of pedicle screw implantation in the cervical, thoracic, and lumbar spine, elucidating the advantages of image guidance. However, a clear proof of patient benefit is missing, so far. Spinal navigation is closely related to intraoperative 3D imaging providing an imaging dataset for navigational use and the opportunity for immediate intraoperative assessment of final screw position giving the option of immediate screw revision if necessary. Thus, postoperative imaging and a potential revision surgery for screw correction become dispensable.Different concept of spinal robotics as the DaVinci system and SpineAssist are under investigation.

The future of spine surgery: New horizons in the treatment of spinal disorders

Background and Methods:

As with any evolving surgical discipline, it is difficult to predict the future of the practice and science of spine surgery. In the last decade, there have been dramatic developments in both the techniques as well as the tools employed in the delivery of better outcomes to patients undergoing such surgery. In this article, we explore four specific areas in spine surgery: namely the role of minimally invasive spine surgery; motion preservation; robotic-aided surgery and neuro-navigation; and the use of biological substances to reduce the number of traditional and revision spine surgeries.

Results:

Minimally invasive spine surgery has flourished in the last decade with an increasing amount of surgeries being performed for a wide variety of degenerative, traumatic, and neoplastic processes. Particular progress in the development of a direct lateral approach as well as improvement of tubular retractors has been achieved. Improvements in motion preservation techniques have led to a significant number of patients achieving arthroplasty where fusion was the only option previously. Important caveats to the indications for arthroplasty are discussed. Both robotics and neuro-navigation have become further refined as tools to assist in spine surgery and have been demonstrated to increase accuracy in spinal instrumentation placement. There has much debate and refinement in the use of biologically active agents to aid and augment function in spine surgery. Biological agents targeted to the intervertebral disc space could increase function and halt degeneration in this anatomical region.

Conclusions:

Great improvements have been achieved in developing better techniques and tools in spine surgery. It is envisaged that progress in the four focus areas discussed will lead to better outcomes and reduced burdens on the future of both our patients and the health care system.

Single-institution experience on robot-assisted thoracoscopic operations for mediastinal diseases

OBJECTIVE

: After the introduction of video-assisted thoracoscopic surgery 20 years ago, the minimally invasive techniques in thoracic surgery have found a growing application. The recent introduction of robotic technology has increased the potentiality of thoracoscopic technique leading to an expansion of indications and applications, particularly for the management of mediastinal diseases. We reviewed our experience in robot-assisted thoracoscopic resection of benign and malignant mediastinal diseases.

METHODS

: Between 2002 and 2010, 108 patients (79 women and 29 men; median age 38 y) underwent robot-assisted thoracoscopy using the "da Vinci" robotic system for several mediastinal diseases. There were 100 thymectomies, 3 resections of paravertebral tumors, 1 thymic cyst, 1 ectopic goitre, 1 ectopic mediastinal parathyroidectomy, 1 thymic carcinoid, and 1 foregut cyst. Ninety-five (87.9%) patients were affected by myasthenia gravis.

RESULTS

: All procedures were completed successfully using the da Vinci robot; no open conversions were required, but in three (2.8%) cases, a fourth access was added. There was no surgical mortality; four (3.6%) patients had postoperative complications (two hemothorax, one chylothorax, and one fever) treated conservatively. Median operation time was 120 (range 60-300) minutes and median hospitalization was 3 (range 2-14) days. Global benefit rate for patients with myasthenia gravis reached the value of 93.4% with progressive improvement over years.

CONCLUSIONS

: Several mediastinal operations may be feasible by using a robot-aided thoracoscopic approach. The technical innovations offered by robotic instrumentation make all procedures safer and easier when compared with standard thoracoscopic approach, with particular reference for application in mediastinal field.

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.

Extended indications for robotic surgery for posterior mediastinal tumors

Previously, we evaluated use of the da Vinci Surgical System for anterior and middle mediastinal tumors in clinical cases, focusing on feasibility, safety, and appropriate settings. In this study, we evaluated extending the indications for robotic surgical treatment of posterior mediastinal tumors to include those located adjacent to the upper vertebrae or aorta. Three patients with mediastinal tumors located immediately adjacent to the vertebrae or aorta, underwent resection with the da Vinci Surgical System. All resected tumors were benign histologically. Robotic surgery enabled treatment of tumors located in the posterior mediastinum, which are very difficult to reach, making resection with the conventional video-assisted thoracoscopic surgery technique extremely difficult. All procedures were performed safely, smoothly, and extremely precisely. Crucial to the success of these operations were the appropriate placement and angle of the special da Vinci surgical ports in relation to the target and the patient's position, which varied according to the tumor location.

Tandem intercostal thoracic schwannomas resected using a thoracoscopic nerve-sparing technique: case report

BACKGROUND AND IMPORTANCE

To describe a novel nerve-sparing technique for the resection of intercostal nerve schwannomas. This case demonstrates that intercostal neuralgia can be caused by intercostal schwannomas and that it can be relieved by their removal.

CLINICAL PRESENTATION

A young woman with schwannomatosis had progressively worsening intercostal neuralgia caused by compression of the intercostal nerve against the rib by tandem intercostal schwannomas. After the tumors were removed, her symptoms were completely relieved. A thoracoscopic technique was used to define the involved fascicles and to facilitate removal of the tumors while sparing the uninvolved nerve.

CONCLUSION

The patient's radicular pain was relieved completely by the tumor resection. Thoracoscopic surgery offers a safe and minimally invasive technique for removal of intercostal schwannomas and is a valid alternative to open thoracotomy. Removal of thoracic schwannomas can relieve intercostal neuralgia.

Robot-assisted resection of paraspinal Schwannoma

Resection of retroperitoneal tumors is usually performed using the anterior retroperitoneal approach. Our report presents an innovative method utilizing a robotic surgical system. A 50-yr-old male patient visited our hospital due to a known paravertebral mass. Magnetic resonance imaging showed a well-encapsulated mass slightly abutting the abdominal aorta and left psoas muscle at the L4-L5 level. The tumor seemed to be originated from the prevertebral sympathetic plexus or lumbosacral trunk and contained traversing vessels around the tumor capsule. A full-time robotic transperitoneal tumor resection was performed. Three trocars were used for the robotic camera and working arms. The da Vinci Surgical System® provided delicate dissection in the small space and the tumor was completely removed without damage to the surrounding organs and great vessels. This case demonstrates the feasibility of robotic resection in retroperitoneal space. Robotic surgery offered less invasiveness in contrast to conventional open surgery.

Recent advances in minimal-access cardiac surgery using robotic-enhanced surgical systems

Recent advances in interventional cardiology and cardiac surgery have changed traditional therapeutic algorithms by altering indications, timing and patterns of referral for subsequent surgical treatment. Developments in coronary revascularization have focused on reducing both surgical invasiveness and trauma. Patients with significant comorbid pathologies, those undergoing reinterventions and especially the elderly may benefit from such hybrid procedures by avoiding cardiopulmonary bypass and a midline sternotomy. Minimally invasive techniques have revolutionized cardiothoracic surgery by increasing patient satisfaction and by reducing surgical trauma, hospital stay, and consequently overall costs. There are, however, limitations, but robot-assisted surgery endeavors to minimize these technical hindrances and thus allow better and more accurate surgical practice whilst minimizing surgical trauma.

Robotic assisted thoracic surgery for resection of an esophageal cyst

Many centers around the world are now developing robotic surgical programs. The benefit of robotics, particularly in those centers where there is already expertise with minimally invasive surgical techniques, is unclear. We present the case of a 58-year-old man presenting with an esophageal cyst. This was removed using a robotic assisted, VATS (video assisted thoracic surgery) approach. The technical details of the procedure are described. Additionally, a discussion of the relative merits of using a robotic rather than a standard minimally invasive approach is discussed. In a procedure such as the case described, the critical parts of the procedure are focused within a small operative field. We believe that the articulating instrumentation and the 3-dimensional magnified view provided by the robot offers significant advantages over a standard VATS approach.

[Da Vinci advanced robotic laparoscopic surgery: origin and current clinical application in urology, and comparison with open and laparoscopic surgery]

Over the last decade, open surgery, which is able to perform large extirpations and repairs of fragile tissues, is gradually being substituted with laparoscopic surgery due to the high benefits the latter entails for the patients, an also due to the learning difficulties for surgeons who must make up for such deficiencies applying higher efforts and a larger amount of stress. Robotic surgery stands in for the limitations of conventional laparoscopic surgery by means of performing more ergonomic and more accurate surgeries, particularly in the case of the most complex and difficult to access operations, such as radical prostatectomy. This review will perform a reminder of the history and clinical applications of new advanced and robotic technologies, and also a comparison with open surgery and conventional laparoscopy.

The robotic approach for mediastinal lesions

BACKGROUND

We report here our institutional experience and reflect the relevant literature concerning the robotic approach in diagnostic and therapeutic interventions for mediastinal lesions.

METHODS

During August 2001-December 2005, 33 patients (15 males and 18 females aged 18-77 years) with mediastinal masses were operated on minimally invasively using the da Vinci robotic system. There were 22 thymectomies (nine thymomas), four resections of paravertebral neurinomas, one ectopic mediastinal parathyroidectomy, one resection of a lymphangioma, one resection of ectopic goitre, one resection of lymph node metastasis of thyroid carcinoma and three oesophageal procedures (one leiomyoma, one traction diverticulum and one foregut cyst).

RESULTS

There were three (9%) open conversions due to surgical problems, 30 procedures (91%) were completed successfully using the da Vinci robot. There was no surgical mortality, no relevant intraoperative blood loss and no major surgical complication in any of the patients. As a minor complication (3%), an incomplete and transient palsy of the left laryngeal recurrent nerve was observed after resection of a tumour from the aortopulmonary window. The median overall operation time was 134 (range 54-314) min, including 103 (range 39-272) min for the robotic act.

CONCLUSIONS

Various different mediastinal procedures have been shown to be feasible and safe when performed with the robot. As the technical benefits of the da Vinci system are most advantageous in tiny and difficult-to-reach anatomical regions, the mediastinum should remain an area of special interest for robotic surgeons. Randomized trials and follow-up studies have been initiated in order to evaluate the clinical impact of the robotic approach.

In touch with robotics: neurosurgery for the future

The introduction of multiple front-end technologies during the past quarter century has generated an emerging futurism for the discipline of neurological surgery. Driven primarily by synergistic developments in science and engineering, neurosurgery has always managed to harness the potential of the latest technical developments. Robotics represents one such technology. Progress in development of this technology has resulted in new uses for robotic devices in our discipline, which are accompanied by new potential dangers and inherent risks. The recent surge in robot-assisted interventions in other disciplines suggests that this technology may be considered one of a spectrum of frontier technologies poised to fuel the development of neurosurgery and consolidate the era of minimalism. On a more practical level, if the introduction of robotics in neurosurgery proves beneficial, neurosurgeons will need to become facile with this technology and learn to harness its potential so that the best surgical results may be achieved in the least invasive manner. This article reviews the role of robotic technology in the context of neurosurgery.

Robotic long-distance telementoring in neurosurgery

OBJECTIVE

To test the feasibility of long-distance telementoring in neurosurgery by providing subspecialized expertise in real time to another neurosurgeon performing a surgical procedure in a remote location.

METHODS

A robotic telecollaboration system (Socrates; Computer Motion, Inc., Santa Barbara, CA) capable of controlling the movements of a robotic arm, of handling two-way video, and of audio communication as well as transmission of neuronavigational data from the remote operating room was used for the telementoring procedures. Four integrated services digital network lines with a total speed of transmission of 512 kilobytes per second provided telecommunications between a large academic center (Halifax, Nova Scotia) and a community-based center (Saint John, New Brunswick) located 400 km away.

RESULTS

Long-distance telementoring was used in three craniotomies for brain tumors, a craniotomy for an arteriovenous malformation, a carotid endarterectomy, and a lumbar laminectomy. There were no surgical complications during the procedures, and all patients had uneventful outcomes. The neurosurgeons in the remote location believed that the input from the mentors was useful in all of the cases and was crucial in the removal of a mesial temporal lobe glioma and resection of an occipital arteriovenous malformation.

CONCLUSION

Our initial experience with long-distance robotic-assisted telementoring in six cases indicates that telementoring is feasible, reliable, and safe. Although still in its infancy, telementoring has the potential to improve surgical care, to enhance neurosurgical training, and to have a major impact on the delivery of neurosurgical services throughout the world.

Robotics in thoracic surgery

Surgical use of robotics, or computer-assisted surgical systems (CAS), has evolved over the last 10 years; for the treatment of chest diseases, however, the development has really occurred in the last 3 to 4 years. This brief history means that there have been few publications in the medical literature, and those that exist are mostly case reports. Moreover, because of this modest experience, robotic thoracic procedures currently take more time than nonrobotic cases and, thus, are more expensive. The surgical learning curve appears to be steep, especially for the more complex procedures. As surgeons gain greater experience and the complexity and cost of the equipment are reduced, we should expect to see greater utility of CAS in thoracic surgery.

Peripheral nerve tumors: surgical principles, approaches, and techniques

The surgical treatment of peripheral nerve sheath tumors is dependent on the tumor's neoplastic nature and its anatomic location. Surgical principles for nerve sheath tumors focus on surgical decision making common to all peripheral nerve sheath tumor operations and then on that particular to a given tumor type. Surgical approaches for nerve sheath tumors vary according to the local anatomy. Exposure on an extremity is relatively straightforward, but as the location becomes more proximal, anatomy conspires to protect nerves, plexuses, and the spinal cord, making surgical exposure more difficult. As a consequence, selected surgical approaches to nerve sheath tumors in these more protected areas are specifically described.

Robotic-assisted thoracoscopic resection of esophageal leiomyoma

Esophageal leiomyoma represents 70-80% of all benign esophageal tumors but only approximately 0.5% of all esophageal neoplasms; optimal surgical treatment consists of local resection. We present the first reported robotic-assisted thoracoscopic resection of two patients with esophageal leiomyoma using the daVinci Surgical System. Operative technique and technical considerations are presented.