Robotic

The authors present a case of a 74-year-old man who underwent a bilateral lung transplant. His transplant was done through a clamshell incision. His history was significant for a symptomatic and chronic right recurrent pleural fluid collection that had not responded to nonsurgical management. The operation was performed with the Intuitive da Vinci Xi robotic system. The authors show the use of monopolar scissors, as well as the robotic suction device. The patient recovered very quickly and the authors feel that patients will have significant benefits when surgeons use similar strategies.

References

1. Tong BC, Hanna J, Toloza EM, Onaitis MW, D’Amico TA, Harpole DH, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg. 2010 Jan;89(1):220-225.
2. Hajjar WM, Ahmed I, Al-Nassar SA, Alsultan RK, Alwgait WA, Alkhalaf HH, et al. Video-assisted thoracoscopic decortication for the management of late stage pleural empyema, is it feasible? Ann Thorac Med. 2016 Jan-Mar;11(1):71-78.

The authors present a procedure performed for a woman who had a peripheral nodule in the lower lobe of her right lung, together with a significant hilar lymphadenopathy, PET-positive, which encased the bronchus intermedius, thus requiring a lower and middle bilobectomy.

The operation was performed with the Intuitive da Vinci Si robotic system. Interestingly, during the operation the authors found a variant of venous anatomy, consisting of an aberrant venous branch leading from the posterior segment of the upper lobe to the apex of the lower lobe.

This video demonstrates the common pitfalls of robot-assisted esophagectomy and presents tips and techniques to performing the Ivor Lewis and McKeown procedures.

To begin making the conduit, it is advisable to begin at the lesser curvature and to use a 4.0 cm silk tie in order to gauge the width of the conduit—this helps to avoid creating a conduit that is either too narrow, too wide, or uneven.  Using a 45 mm staple load, rather than a 60 mm load, affords better control over the length of the conduit, and it assists with maintaining consistent width. This size staple load also allows the surgeon to stretch the conduit and maximize the number of stapler firings, which helps to achieve full conduit length in the neck.

When pulling the conduit and specimen into the chest, two figure-of-eight sutures can be used to prevent any twisting along a singular suture line; this style of suture also helps prevents tears in the tissue and provides added stability as the conduit and specimen are pulled through the diaphragm.

Rather than performing a pyloroplasty, injection of the pylorus with Botox provides similar results. Using a 20 gauge mediastinoscopy aspirating needle affixed to a 5 ml syringe, injection of 100 units of Botox mixed with 4 ml of saline is performed, using 1 ml in each quadrant. It is important to create a wheal in the muscular part of the pylorus at each point and avoid injecting any vessels.

The Kocher maneuver is avoided in this procedure, as it may cause pyloric dysfunction and may facilitate bile reflux.

Placing two marking sutures on the conduit before pulling it up into the chest can help gauge how much of the conduit has been pulled into the chest, as oftentimes it can be misleading how much has been pulled through and how much remains below the diaphragm.

After moving into the chest and dissecting the esophagus, ligation of the azygos vein is performed for two reasons:

1. Often the anastomosis is in this area, and ligating the azygos gives the surgeon a better view.
2. Additionally, if the azygous becomes engorged, it could cause pressure on the conduit or the anastomosis.

As the specimen is pulled up, avoid twisting of the conduit by ensuring that the staple line on the conduit is facing toward the screen. Note that this will only prevent 180 degree twisting, and not 360 degree twisting.

Once the conduit is in the chest, avoid grasping it with the Cadiere graspers or ProGrasp™ forceps as these can cause traumatic injury.

There are several ways to pull up the conduit:

1. Using the lead point of the conduit to pull;
2. Using a Forrester Ring Clamp or Landreneau Ring Clamp;
3. Using 2 ProGrasps as seen in the video; or
4. Rolling up surgicel as a buffer to prevent any traumatic tearing of the conduit.

After incising the esophagus, a Foley catheter with about 30 ml of water can be inserted to dilate the lumen of the esophagus so that it can more easily take the 29 mm anvil. The Foley can also be used to gauge what size of anvil the esophagus will take.

A 3-0 Prolene® on an SH needle is used to baseball stitch the mucosa and submucosa and provide a purse string around the anvil.  A second concentric purse string of the same suture about 5 mm away from the initial one is placed to help secure the anvil in the proximal esophagus. The authors avoid taking too much tissue with wide bites, as this can result in misfiring of the EEA.

After creating the anastomosis, wrapping it with a pedicle of omentum can promote healing and help control any kind of leakage if a leak were to occur. The authors then secure the anastomosis to the pleura to prevent any excessive movement. Finally, they use a suture to tighten the crura where the conduit emerges from the diaphragm in order to prevent any hiatal hernia from occurring. The thoracic duct is often ligated with a large stitch at this time with as well.

To deal with nontechnical skills (Notechs) is a matter of culture and is hard to implement in surgical training. Communication, cooperation, decision-making, leadership, and situational awareness are concepts for many and their application in surgical practice is challenging. The competency framework in cardiothoracic surgery has evolved towards wider components including Notechs as a cornerstone in surgeon training. However, knowledge of Notechs should be associated with practical sessions, using simulation as an innovative teaching tool.

In this video, the authors present their crisis resource management (CRM) program for robot-assisted thoracic surgical (RATS) procedures. The CRM simulation demonstrated allows the team to practice the successful management of major bleeding during a RATS lobectomy.

Additional Resources

1. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368(3):246-253.
2. Cerfolio RJ, Bess KM, Wei B, Minnich DJ. Incidence, results, and our current intraoperative technique to control major vascular injuries during minimally invasive robotic thoracic surgery. Ann Thorac Surg. 2016;102(2):394-399.
3. Wang TT, Ahmed K, Patel VM, et al. A competency framework in cardiothoracic surgery for training and revalidation - an international comparison. Eur J Cardiothorac Surg. 2011;40(4):816-825.

Professor Baste is a proctor for Intuitive Surgery, Medtronic, and Johnson.

This video is part of the series Nontechnical Skills in Cardiothoracic Surgery, brought to you by CTSNet Guest Editor Professor Jean-Marc Baste. Find the whole series here.

This video demonstrates a robot-assisted upper left lobectomy as surgical treatment for a patient with a lung adenocarcinoma that had been previously submitted to immunotherapy. It was performed with the da Vinci Si platform with a 3-arm technique plus a 10 mm assistant port. In the right arm, the authors used the Marlyland bipolar forceps and on the left arm the thoracic grasper forceps. The assistant helped on the lung exposition with a regular laparoscopic grasper and performed all vessel, bronchial, and parenchyma stapling through the 10 mm port. The authors want to highlight the technical difficulties encountered due to the tumor volume plus the previous immunotherapy.

Procedure

The patient was a 64-year-old woman with lung adenocarcinoma who had received three months of immunotherapy with pembrolizumab due to large tumor volume plus a recent myocardial infarction that had been treated with two pharmacological stents, which led to three months of triple antiaggregating therapy. Ports for the camera and for the right arm were placed in the seventh intercostal space with the anterior port for the left arm placed in the sixth intercostal space.

After port placement, the authors started to divide the pleural adhesions, and it took almost 20 minutes to fully free the lung. Then, they started the division of the inferior pulmonary ligament and the harvest of the lymph node station 9. After anterior retraction of the lung, they dissected the hilum posteriorly and harvested stations 8 and 7, but the dissection of the superior part of the artery was extremely difficulty due to tumor volume plus tissue inflammation and enlarged lymph nodes. They tried to reach the artery by the fissure, but this strategy also failed due to tissue inflammation. So they decided to proceed similar to a “fissureless VATS lobectomy” from the front to the back.

They managed to reach, dissect, and divide the first arterial branch from the front, then they divided the upper pulmonary vein. The dissection of the bronchus was difficult but manageable with the Maryland bipolar robotic forceps, and after the bronchus division they could expose the remaining arterial branches. Finally, they divided the fissure with four endoscopic loads. Once the upper left lobe was loose, they used a bag to remove the specimen through the assistant port.

The patient was extubated in the immediate postoperative period, and she recovered from anesthesia without difficulty. The chest tube was removed on the third postoperative day and the patient was discharged uneventfully on postoperative day five. The pathological examination showed a lung adenocarcinoma with a partial response to immunotherapy, and the final staging was T2aN1.

Disclosure

Dr Ricardo M. Terra is on the Johnson & Johnson advisory board, is a Medtronic speaker and preceptor, and is a speaker and preceptor for H. Strattner/Intuitive.

This presentation is about a robotic S9-S10 segmentectomy assisted by a multimodal reconstruction imaging system. In the literature, several series report experiences of robot-assisted segmentectomy for benign or malignant pathologies. However, they were either common to the basal segments interesting segments 7 to 10, or the segment of the Fowler (segment 6). In the series from Cerfolio and colleagues, basal segmentectomies were for the upper, basilar, or posterior segment. The case shown here is an S9 and S10 robotic segmentectomy. The authors report on a 24-year-old woman, with no previous medical history, who presented with a 5 mm nodule located in the S9 segment that was discovered on a chest computed tomography (CT) scan made in 2015, and which increased in size by 40% on follow-up CT scan in 2018.

On the different sections of the thoracic CT, the nodule was very well defined, with a size of almost 14 by 12 mm. There were no other nodules in the ipsilateral or contralateral lung. The tumor extension assessment was negative. On investigation with a multimodal reconstruction imaging system, to achieve complete resection with free margins of 2 cm the resection needed toinclude both segments 9 and 10. The authors could then study each system separately: the pulmonary arteries to be cut, the pulmonary veins draining the S9 and S10 segments, as well as the bronchi. An overview of the tumor, vessels, bronchi, and pulmonary segments to resect could be made with the 3D reconstruction and view.  The differential diagnoses were: hamartoma (but the density of the mass was -40 Hounsfield units on the chest CT scan), a carcinoid tumor of the lung, and lung carcinoma (this was unlikely).

The patient was placed in the left lateral decubitus position, and four trocars were used. The procedure was started by the section of the triangular ligament to the base of the right inferior pulmonary vein. Using the multimodal reconstruction imaging system, the veins for the S9 and S10 segments were identified after excluding bronchial and arterial divisions. The addition of the reconstructions of the segments S9 and S10 made it possible to individualize the veins to be cut. The lymph node dissection was not radical, but an oriented dissection was performed. The first lymph node was negative on frozen section examination, and the lesion did not fix on TEP and had a slow evolution.

After controlling the A9 and A10 arteries, the authors applied a vascular automatic stapler. Below the arterial plane, they dissected the bronchi for the lower lobe, among which they identified B9 and B10. The latter was cut using an automatic stapler. The identification of the section plane of the pulmonary parenchyma was facilitated after injection of indocyanine green. Areas that did not take the green color corresponded to segments to resect. The sectional plan was easily identified by the Firefly technology. The authors applied the stapler then following the marked areas.  They took care not to step over the other segments, as well as the vessels and the corresponding bronchi. After completing the segmental resection, the operative specimen was placed in an endobag before being extracted through one of the trocar orifices. A plate of hemostatic gauze was applied to the areas of pulmonary suture. After reventilation, the remnants of the lower right lobe segments (Nelson, segment 7, and segment 8) inflated properly. The procedure concluded with placement of a chest drain.

The postoperative course was simple. The patient was discharged two days after the surgery with a normal chest radiograph. One month later, the patient was doing well, and she had returned to normal activity and to work.

References

1. Pardolesi A, Veronesi G. Robot-assisted lung anatomic segmentectomy: technical aspects. Thorac Surg Clin. 2014;24(2):163-168.
2.  Toker A,  Ayalp K, Uyumaz E, Kaba E, Demirhan O, Erus S. Robotic lung segmentectomy for malignant and benign lesions. J Thorac Dis. 2014;6(7):937-942.
3. Rinieri P, Peillon C, Salaün M, Mahieu J, Bubenheim M, Baste JM. Perioperative outcomes of video and robot-assisted segmentectomies. Asian Cardiovasc Thoracic Ann. 2016;24(2):145-151.
4. Nguyen D, Gharagozloo F, Tempesta B, Meyer M, Gruessner A. Long-term results of robotic anatomical segmentectomy for early-stage non-small-cell lung cancer [published online ahead of print October 15, 2018]. Eur J Cardiothorac Surg. doi: 10.1093/ejcts/ezy332
5. Cerfolio RJ, Watson C, Minnich DJ, Calloway S, Wei B. One hundred planned robotic segmentectomies: early results, technical details, and preferred port placement. Ann Thorac Surg. 2016;101(3):1089-1095.
6. Wei B, Cerfolio R. Technique of robotic segmentectomy. J Vis Surg. 2017;3:140.