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Robotically-Assisted Myxoma Resection: Tips and Tricks

Tuesday, June 9, 2020

Ribeiro I, Wierup P, Burns D, Gillinov M. Robotically-Assisted Myxoma Resection: Tips and Tricks. June 2020. doi:10.25373/ctsnet.12448781

This video demonstrates the technique for robotically assisted myxoma resection. Also, it highlights the tips and tricks that have made this approach the authors’ method of choice for nearly all patients. The patient was a 72-year-old woman who had a routine chest CT, which showed an incidental LA mass, as demonstrated in this image. She had neither heart failure nor constitutional symptoms. She also denied a history of embolic events.

The preoperative transesophageal echocardiography showed a left atrial mass attached to interatrial septum, highly suggestive of a left atrial myxoma, as demonstrated in these images. This is the safety algorithm for robotic surgery developed by the authors’ team. Echocardiography and chest, abdomen, and pelvis CT are performed in all patients. The assessment is based on three key components: 1) what the heart looks like, 2) the risk of stroke, and 3) anatomic feasibility. Regarding the heart, patients are excluded if they have either LV dysfunction or dilation, CAD and AS requiring treatment, or pulmonary hypertension. Furthermore, the authors exclude patients who have more than 1+ AI due to concerns with myocardial protection during antegrade cardioplegia delivery. The second key component is the risk of stroke due to retrograde perfusion. The authors exclude patients with moderate to severe aortoiliac atherosclerosis disease. However, alternative perfusion techniques may be applied. The last component is the anatomic feasibility. They don’t offer this approach for patients who have moderate to severe pectus excavatum, which displaces the heart or small arteries due to cannulation concerns.

The patient in this video met the authors’ preoperative safety criteria for robotically-assisted surgery. Their experience shows that most patients with myxoma fulfill this algorithm and therefore are candidates for this approach. The patient was positioned supine with the right chest in 30-degree rotation, and the right arm slightly abducted to expose the axilla. The authors drew the midclavicular and anterior axillary lines on the patient skin as reference points. Also, they mark the nipple as inadvertent nipple cut has been described in males. In females, the breast is pulled upward and to the left to approximate the breast fold to the 4th intercostal space. After prepping and draping, they first performed the femoral cutdown to assess femoral vessel quality before committing to the robotic approach. After the vessels were deemed cannulatable, a 4 cm long incision was performed anteriorly to the anterior axillary line on the fourth intercostal space (ICS). In a woman, the authors make the incision at the breast fold and tunnel it to the fourth intercostal space if need be. If the left pulmonary hilum was easily visible, the correct intercostal space was likely entered. Diaphragm stitch for retraction may be required if the diaphragm sits high in the chest cavity. Next, they place the robotic ports. The right arm port was inserted on the sixth ICS, where it crosses the anterior axillary line. The left atrial retractor arm port was placed on the fourth ICS, where it crossed the midclavicular line. The right arm port was inserted on the second ICS at the place, where it creates an equilateral triangle. Ideally, this triangle is the base of a virtual pyramid that has its tip on the pulmonary hilum. Also, the authors make four holes posterior to the anterior axillary line. The first hole is at the third ICS, and they insert the cross-clamp though it. The other holes are to add a left atrial vent and two angiocaths for pericardial stay sutures. This picture depicted the final set up before cannulation and initiation of cardiopulmonary bypass.

The following key steps are performed in all patients as they increase not only safety but also efficiency. The authors open the pericardium only after initiation of CBP to decompress the heart. They also apply two pericardial stay sutures to pull the heart and the aorta towards the working port. This maneuver facilitates aortic manipulation under direct visualization. Also, both the cardioplegia catheter insertion and the cross-clamp are applied during low flow state to avoid the potential risk of dissection and bleeding. Lastly, they give long-acting single dose antegrade cardioplegia to avoid redosing and retrograde cardioplegia delivery.

After the cardiac arrest and the docking of the robot, the left atrium was opened in the standard fashion. The retractor was placed toward the roof of the left atrial to avoid tumor fragmentation. The left vent was inserted and the atriotomy extended. Then, the LA retractor was adjusted accordingly. The robot allowed for unparalleled magnifying visualization. Also, tumor handling was more precise due to its increased dexterity. The combination of superior visualization and precise tissue handling allowed for accurate dissection of the subendocardial plane, which lead to en-bloc resection of the tumor and its attachment site without tumor fragmentation and creation of atrial septal defect, as shown here.

During the closure, a few strategies were performed to increase efficiency and safety. Two pre-formed looped PTFE sutures were used to close the atriotomy. PTFE suture slides more smoothly through the atrial wall, allowing better tissue approximation. The pre-formed loop avoids knot tying at the corners of the atriotomy, increasing efficiency. After deairing and cross-clamp removal, the bedside assistant tied the PTFE suture. The left atriotomy was reinforced with two 16 cm long 4-0 Prolene. Each Prolene runs from the center to one corner and back to the center where it is robotically tied. Lastly, a 4-0 Prolene purse string suture was applied to the cardioplegia site as a safety net.

The postoperative transesophageal echocardiography showed normal ventricular and valve function and intact interatrial septal. The authors discharged the patient on day four. Myxoma resection done with a robot is a safe and effective operation. Simple modifications on the technique increase safety and efficiency. Robotic surgery has not only the benefits of minimally invasive surgery but also allows for better tumor handling, visualization, and resection. Therefore, the authors believe robotic myxoma resection should be the treatment of choice for nearly all patients.


  1. Gillinov AM, Mihaljevic T, Javadikasgari H, Suri RM, Mick  SL, Navia JL, et al. Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases. J Thorac Cardiovasc Surg. 2018;155(1)82-91.e2.
  2. Malas T, Mick S, Wierup P, Gillinov M. Five maneuvers to facilitate faster robotic mitral valve repair. Semin Thorac Cardiovasc Surg. 2019;31(1):48–50.
  3. Yang M, Yao M, Wang G, Xiao C, Wu Y, Zhang H, et al. Comparison of postoperative quality of life for patients who undergo atrial myxoma excision with robotically assisted versus conventional surgery. J Thorac Cardiovasc Surg, 2015;150(1):152-157.


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I think this is a fantastic video and a great technique. However, I do feel the real value of the robotic platform is not fully realized until a totally endoscopic approach is used. Our team at Jefferson in Philadelphia is currently doing similar intracardiac cases with an 8 mm working port and all percutaneous cannulation (no groin cutdown and no thoracotomy). A myxoma patient we did last week with such small incisions was discharged in 2 days and is already back at work. It does make a difference and your very talented group could easily adopt these far less invasive approaches. The problem with a thoracotomy as you show here is that it is often more painful than a sternotomy and usually does involve rib-spreading. Also, talented port access surgeons can continue to make a valid argument that you can do the operation through that same incision without the complexity and expense of a robot. This is not true for an 8 mm working port and it does impact recovery in a very positive way to go that small. In minimally invasive surgery, size does matter!
Thank you for your comments. We believe that robotic surgery is a means for minimally invasive surgery. Many surgeons have chosen to do minimally invasive procedures without robotic assistance with excellent results. There is no difference in hard endpoints. We opt for robotic assistance because of the benefits of increased dexterity and superior visualization. Based on our experience on the robotic approach over more than 2000 cases, including mitral valve repair and tumours resection, with mortality of less than 0.05% and stroke risk of less than 0.6% after the implementation of the safety algorithm, we believe our approach is justified. Regarding your points about incision size, we do not fragment the tumor or squeeze it out through a small 8 mm port. We tailor the incision and operation to the patient's needs and safety. Safety first, always.
Congrats on your groups’ excellent results. We too have similar safe outcomes. There is no need to fragment the myxoma to get it out of an 8 mm port, as an endobag is used to safely remove the tumor. “Squeezing” the myxoma as you know is of no consequence. The concept that there is no difference in recovery with your approach as opposed to a thoracotomy and no robot is understandable since it’s the same incision. However if you go to an 8-20 mm port, you will see faster recovery. One question, in this case did you at any time use a rib spreader? If so why and for what purpose? Thank you.
It will be interesting to see the recurrence rate of this approach as the interatrial septum is spared. The totipotent cells that become a myxoma originate from the interatrial septum. So leaving the septum at the origin of myxoma intact might lead to increased risk of recurrence.
Thank you for watching our video. We have thought about this. We don't believe this is an issue as pluripotent cells are in the endocardium which is resected with the tumour at its base. Moreover, an extensive septectomy and patch reconstruction is likely not justified in the majority of cases given its low incidence and recurrence (mainly in sporadic cases).
Dear Igo Ribeiro, Congratulations for the excelent job. I also have used the minimally invasive thoracoscopic approach for video-assisted tumor ressection, but without the robotic system. I do think that the robot platform adds a lot providing more degrees of freedom for moviments. This property is very important especially when dealing with cases of soft, gelatinous, type of Mixomas with irregular fronds that often embolize. I do not have concerns about not doing a septectomy in cases of small tumors presenting with a plan of clivage as you beautifully showed . Additionally, you can apply any source of energy on the septum site of implantation. It is my policy in such cases a right atrial approach with a more anterior periareolar (Poffo technique) working port for septal ressection and patch reconstruction. In cases for a left atrial approach, a more lateral thoracotomy incision seems better. In advanced tumors with atrial wall and leaflet attachments a more radical approach is usually necessary. In such cases I use a biatrial access through sternotomy. Regarding pain, it does not seems to me a limitation of a small thoracotomy, four cm or less, since you do not spread the ribs. Well, irrespective of the access , as you said the main message is - patient safety always comes first in surgery.
Josue, thank you for watching our video. As I mentioned above, we use robotic assistance as a means of minimally invasive approach, not the goal. Safety must always come first! We tailor the procedure to the patient's needs, not the other way around. Congratulation on your continuing efforts to develop minimally invasive surgery and improve patients outcomes. Thank you again.

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