Robotic Sleeve Resection of the Airway: Outcomes and Technical Conduct Using Video Vignettes

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.

Beyond the learning curve: a review of complex cases in robotic thoracic surgery

The number of thoracic surgery cases performed on the robotic platform has increased steadily over the last two decades. An increasing number of surgeons are training on the robotic system, which like any new technique or technology, has a progressive learning curve. Central to establishing a successful robotic program is the development of a dedicated thoracic robotic team that involves anesthesiologists, nurses, and bed-side assistants. With an additional surgeon console, the robot is an excellent platform for teaching. Compared to current methods of video-assisted thoracoscopic surgery (VATS), the robot offers improved wristed motion, a magnified, high definition three-dimensional vision, and greater surgeon control of the operation. These advantages are paired with integrated adjunctive technology such as infrared imaging. For pulmonary resection, these advantages of the robotic platform have translated into several clinical benefits, such as fewer overall complications, reduced pain, shorter length of stay, better postoperative pulmonary function, lower operative blood loss, and a lower 30-day mortality rate compared to open thoracotomy. With increased experience, cases of greater complexity are being performed. This review article details the process of becoming an experienced robotic thoracic surgeon and discusses a series of challenging cases in robotic thoracic surgery that a surgeon may encounter “beyond the learning curve”. Nearly all thoracic surgery can now be approached robotically, including sleeve lobectomy, pneumonectomy, resection of large pulmonary and mediastinal masses, decortication, thoracic duct ligation, rib resection, and pulmonary resection after prior chest surgery and/or chemoradiation.

Robotic-Assisted Complex Pulmonary Resection: Sleeve Lobectomy for Cancer

The use of robotic assistance for complex pulmonary resections such as segmentectomy and sleeve lobectomy has steadily increased in recent years. These operations are technically challenging as they require fine dissection and suturing, which is often difficult to perform using traditional minimally invasive techniques. Robotic surgery is well-suited for complex pulmonary surgery given its specific advantages related to superior optics and precise tissue manipulation and dissection. Herein we describe our technique for robotic-assisted complex pulmonary surgery with a specific focus on right upper sleeve lobectomy for cancer, including associated video case demonstration. The principles discussed are generalizable to other complex lung and tracheobronchial operations and highlight the benefits of the robotic platform.

Extended Robotic Pulmonary Resections

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.