Robotic-assisted double-sleeve lobectomy

Adoption of the Robotic Platform across Thoracic Surgeries

With the paradigm shift in minimally invasive surgery from the video-assisted thoracoscopic platform to the robotic platform, thoracic surgeons are applying the new technology through various commonly practiced thoracic surgeries, striving to improve patient outcomes and reduce morbidity and mortality. This review will discuss the updates in lung resections, lung transplantation, mediastinal surgeries with a focus on thymic resection, rib resection, tracheal resection, tracheobronchoplasty, diaphragm plication, esophagectomy, and paraesophageal hernia repair. The transition from open surgery to video-assisted thoracoscopic surgery (VATS) to now robotic video-assisted thoracic surgery (RVATS) allows complex surgeries to be completed through smaller and smaller incisions with better visualization through high-definition images and finer mobilization, accomplishing what might be unresectable before, permitting shorter hospital stay, minimizing healing time, and encompassing broader surgical candidacy. Moreover, better patient outcomes are not only achieved through what the lead surgeon could carry out during surgeries but also through the training of the next generation via accessible live video feedback and recordings. Though larger volume randomized controlled studies are pending to compare the outcomes of VATS to RVATS surgeries, published studies show non-inferiority data from RVATS performances. With progressive enhancement, such as overcoming the lack of haptic feedback, and future incorporation of artificial intelligence (AI), the robotic platform will likely be a cost-effective route once surgeons overcome the initial learning curve.

Minimally invasive thoracic surgery: robot-assisted versus video-assisted thoracoscopic surgery

Minimally invasive techniques have been widely applied in general thoracic surgery. Compared with video-assisted thoracoscopic surgery (VATS), due to its theoretic superiority, robotic surgery is challenging the traditional position of VATS. With its unique advantages, including 3D vision and a high-freedom endowrist, it leads to easier lymph node dissection, more convenient blood vessel dissection, a shorter learning curve and competence for the completion of complex surgery. However, as a new surgical technology, the safety and efficacy of robotic-assisted thoracoscopic surgery (RATS) still need to be further verified. Thus, in this article, we review and summarize the application of RATS versus VATS in general thoracic surgery.

A universal incision for robot-assisted thoracic surgery

Objective

This paper aimed to design and explore the versatility of the incision for the robot-assisted thoracic surgery.

Methods

The concept of universal incision was designed and put forward. The clinical data of 342 cases of robot-assisted thoracic surgery were summarized, including sex, age, clinical diagnosis, operative method, operative time, conversion to thoracotomy, intraoperative blood loss, number of lymph node dissections, postoperative hospital stays, postoperative pathology, and postoperative complications of the patients.

Results

The 342 cases of robot-assisted surgery included 178 pulmonary surgery cases (94 lobectomy cases, 75 segmentectomy cases, 6 wedge resection cases, and 3 sleeve lobectomy cases), 112 esophageal surgery cases (107 McKeown approach cases and 5 esophageal leiomyoma resection cases), and 52 mediastinal tumor cases (42 anterior mediastinum cases and 10 posterior mediastinum cases). Among these, two cases were converted to thoracotomy (both esophageal cases), and the rest were successful with no massive intraoperative bleeding and no perioperative death.

Conclusion

The universal incision of robot-assisted thoracic surgery is safe and feasible and is suitable for most cases of thoracic surgery.

Robot-Assisted Thoracic Surgery in Non-small Cell Lung Cancer

Lobectomy is the standard treatment for early non-small cell lung cancer. Various surgical techniques for lobectomy have been developed, and minimally invasive thoracic surgery, such as video-assisted thoracic surgery or robot-assisted thoracic surgery, has been considered as an alternative to conventional open thoracotomy. The recently robotic lobectomy technique has developed since the first case series was published in 2002. Several studies have reported that robotic lobectomy has comparable oncologic and perioperative outcomes to those of video-assisted thoracic surgery lobectomy and open lobectomy. However, robotic lobectomy remains a challenge for surgeons because of the steep learning curve, reduced tactile sensation, difficulty in port placement, and challenges in cooperation between the surgeon and assistant. Many studies have reported on robotic lobectomy, but few have presented surgical techniques for robotic lobectomy. In this article, the surgical techniques and optimal performance of robotic lobectomy are described in detail for all 5 types of lobectomy for surgeons beginning with robotic lobectomy.

Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections

Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

Comparison of Sleeve Lobectomy for Lung Cancer Using Mini-Thoracotomy and an Optimized Robot-Assisted Technique

Objective: To evaluate the clinical significance of an optimized approach to improve surgical field visualization and simplify anastomosis techniques using robotic-assisted sleeve lobectomy for lung or bronchial carcinoma. Method: A total of 26 consecutive patients who underwent sleeve lobectomy between January 2017 and April 2020 were enrolled in the study. The cohort included 11 cases of robotic-assisted surgery (RAS group) and 15 cases of mini-thoracotomy (MT group). RAS was performed via an exclusive optimized approach utilizing the "3 to 4-6 to 8/9" four-port technique. Retrieved demographical and clinical data included operation time, anastomosis time, blood loss, chest drainage time and volume, postoperative pain scores, complications, white blood cell (WBC) levels, and duration of hospital stay and follow-up. Results: No cases of perioperative death were recorded. Compared to MT group, the RAS group had a similar anastomosis time (30.82  ±  6.08 vs 33.20  ±  7.73 min, respectively, p > 0.05) and shorter operation time (189.73  ±  36.41 vs 225.33  ±  38.19 min, respectively, p < 0.05). The RAS group had lower pain scores (4.23  ±  0.26 vs 4.91  ±  0.51, p < 0.05), lower levels of WBC (p < 0.05), and no anastomotic complications postoperatively. The RAS and MT groups demonstrated a successful bronchus reconstruction with low risk of angulation (1/11 vs 1/15, p > 0.05) and satisfactory disease-free survival (eight cases, 72.73% and 12 cases, 80%, respectively). Conclusion: The optimized approach to RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes. Further study with a large sample size and evaluation of long-term survival are warranted. Key points: (i) we present a novel, convenient, and efficient approach for robotic-assisted sleeve lobectomy, ie, "3 to 4-6 to 8/9" four-port technique. The optimized approach for RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes; (ii) details for the "3 to 4-6 to 8/9" four-port method: the assistant port was located at the fourth intercostal space. The 1-cm camera port was inserted at the sixth intercostal space in the posterior axillary line. The 0.5-cm da Vinci ports of the instrument arms were placed at the third intercostal space in the anterior axillary line and the eighth or ninth intercostal space in the posterior axillary line. The patient cart was inserted from the back of the patient's head and shoulders at 75° to the longitudinal line.

Robotic sleeve lobectomy for centrally located non-small cell lung cancer: A propensity score-weighted comparison with thoracoscopic and open surgery

OBJECTIVE

To evaluate the surgical and oncologic outcomes of robotic sleeve lobectomy in comparison with video-assisted thoracoscopic surgery (VATS) and open surgery.

METHODS

Surgical outcomes in patients with non-small cell lung cancer who underwent sleeve lobectomy via robotic, VATS, and thoracotomy were assessed using the χ² test, Fisher exact test, and the Kruskal-Wallis rank sum test. Log-rank test and Cox proportional hazards model were used in survival analyses. Propensity score-weighted matching was used to achieve the balance of baseline among the 3 groups.

RESULTS

Between 2012 and 2017, 188 patients were included and divided into robotic (n = 49), VATS (n = 73), and open (n = 66) groups. After weighted matching that retained all patients, no statistical difference in 90-day mortality or morbidity among the 3 groups was shown. Patients in the robotic group had less bleeding loss (P < .001), operative time (P < .001), and tube drainage time (P < .001) than the other 2 groups. No positive bronchial margin or conversion presented in the robotic group. In multivariable analyses, surgical technique was independently associated with neither overall survival nor disease-free survival (P > .050).

CONCLUSIONS

Robotic sleeve lobectomy is a safe, feasible, and effective procedure. Compared with VATS and open techniques, robotic sleeve lobectomy has a similar oncologic prognosis for patients with centrally located non-small cell lung cancer. Further studies with a larger sample size and long-term follow-up are needed.

Ventilation failure after lateral jackknife positioning for robot-assisted lung cancer surgery in a patient after lingula-sparing left upper lobectomy

BACKGROUND

Ventilation failure commonly occurs when a standard left-sided double-lumen tube is used in patients after left upper lobectomy having remarkable angulation of the left main bronchus. We present a female without remarkable angulation, in whom ventilation failure occurred after lateral jackknife positioning.

CASE PRESENTATION

A 73-year-old female after lingula-sparing left upper lobectomy without remarkable angulation was scheduled for robot-assisted right upper lobectomy. Ventilation failure with a standard left-sided double-lumen tube occurred when she was placed not in the lateral position but in the lateral jackknife position required for robotic surgery. After replacement by the Silbroncho® left-sided double-lumen tube, adequate one-lung ventilation became possible.

CONCLUSIONS

Ventilation failure with a standard tube may occur more easily when patients with bronchial angulation are placed in the lateral jackknife than lateral position due to posture-induced exacerbations of bronchial angulation. The Silbroncho® tube seems useful in such situations.

Robot-assisted en bloc anterior mediastinal mass excision with pericardium and adjacent lung for locally advanced thymic carcinoma

Robot-assisted surgery for anterior mediastinal mass resection has been increasingly adopted as an alternative method to open sternotomy and conventional video-assisted thoracic surgery. However, more evidence is needed to expand the indication of this technique to more complicated cases. We present a case of robot-assisted en bloc resection of a 7-cm anterior mediastinal mass with pericardium and adjacent lung for thymic squamous cell carcinoma, accompanied by reconstruction of pericardium with polytetrafluoroethylene patch. In conclusion, complex anterior mediastinal mass excision is feasible with robotic thoracic surgery.

Robotic sleeve resection for pulmonary disease

Background

Few studies have described robotic sleeve resection with pulmonary resection. Here, we report the successful implementation of a completely portal robotic sleeve resection with or without pulmonary resection using a modified suture mode.

Methods

In total, 339 patients underwent curative robotic pulmonary surgery at Ruijin Hospital between May 2015 and September 2017. Three of these patients underwent robotic sleeve resection (right upper lobe, one; left upper lobe, one; and lingular segmental bronchus, one). Five port incisions were utilized, and a simple continuous running suture combined with two interrupted sutures of the membranous and cartilaginous junction portion was preferred for the anastomosis.

Results

The postoperative course was uneventful for two patients with squamous cell carcinoma. The lingular segmental bronchus patient without pulmonary resection (a salivary gland tumor) underwent short-term atelectasis. The median operation time was 155 (range 132–230) minutes. The median anastomosis time was 25 (range 23–32) minutes. The median length of postoperative hospital stay was 7 (range 6–10) days. There was no mortality or conversion to thoracotomy for any of the patients. All patients were followed for 3–6 months, and there is no tumour recurrence.

Conclusions

Our limited experience suggested that robotic sleeve resection for pulmonary disease with or without pulmonary resection may be safe and effective. The anastomosis time can be shortened with more robotic surgery experiences and the modified suture mode.

Left upper lobectomy and pulmonary angioplasty by uniportal video-assisted thoracic surgery

Diego Gonzalez-Rivas and his colleagues performed the first case for pulmonary major resection by the uniportal approach in 2010. In the following years, more and more expert surgeons developed the uniportal approach and even applied it to very complex cases. Many centers have showed that uniportal video-assisted thoracic surgery (VATS) lobectomy is a safe and feasible technique. The patient presented here is a complex case: The lingular segmental artery was invaded seriously by the tumor and it was difficult to divide it freely, and the pulmonary artery plasty was needed. Although this condition made the procedure some technically challenging, the case was performed successfully without any operative complications.

Four arms robotic-assisted pulmonary resection-left lower lobectomy: how to do it

Numerous published articles have shown the safety and efficacy of robotic lung resection, including lobectomy. The robotic approach offers similar survival rate to the open and video-assisted thoracoscopic surgery methods. Potential advantages provided by robotic technology, such as three-dimensional (3D) high-quality camera, wristed tools and ergonomic ease that seems to overcome certain video-assisted thoracic surgery (VATS) limits have been widely described. Several techniques have been developed by different surgeons to perform a robotic lobectomy. In this study, we present our technique for performing a four-arm robotic lobectomy for the treatment of early stage lung cancer. This is shown in clear, sequential steps. We also provide an instrument preference card, some operative tips and a high-quality video.