Robotic Surgery of the Mediastinum

Post-Operative Outcomes Associated With Open Versus Robotic Thymectomy: A Propensity Matched Analysis

To compare post-operative outcomes associated with thymectomy performed using either open or robotic approaches. Retrospective cohort study from a single-center prospective registry consisting of patients undergoing thymectomy between 2000 and 2020. Patients were grouped according to surgical approach (open vs robotic). A propensity-score matching analysis was performed in a 2:1 open to robotic ratio, and surgical outcomes were evaluated. We analyzed 234 thymectomies (155 open; 79 robotic). Myasthenia gravis was present in 23.2% and 32.9% (P = 0.249) in the open and in the robotic group, respectively. All covariates were balanced in the matched groups (open n = 114; robotic n =5 9), except lesion size. The robotic approach was significantly associated with shorter surgical time (median 95 vs 65 minutes, P < 0.001), lesser clinical (21.1% vs 6.8%, P = 0.016) and surgical (11.4% vs 1.7%, P = 0.036) complications during the same hospitalization, less Clavien-Dindo grade 2 or higher complication rates (28.1 vs 15.3%, P = 0.048), chest tube duration (median: 3 vs 0 days, P < 0.001) and in-hospital length of stay (median: 5 vs 0 days, P < 0.001). Bleeding (P = 0.214), ICU length of stay (P = 0.167), reoperation rate (open, 1.8% vs robotic 0%), 90-day mortality (P = 0.341) and readmission rate post discharge (P = 0.277) were similar between the groups. In the matched population with primary thymic epithelial tumors, the completeness of resection rate was similar (open, 92.1% vs robotic 96.8%, P = 0.66.). Robotic thymectomy is associated with improved post-operative outcomes when compared to open thymectomy, without compromising the goals of oncologic surgery. Longer follow-up is needed to ensure oncologic equivalence.

Infected Mature Teratoma in the Anterior Mediastinum Removed Using the Da Vinci Robotic System

Mature teratomas have been found to be the most common type of extragonadal primary germ cell tumors found in the anterior mediastinum. Over the past decade, several reports have been published using minimally invasive approaches to remove mediastinal masses. Of these publications, only one reported a teratoma excision from the anterior mediastinum via the Da Vinci Robot. Additionally, there have been few reports regarding teratomas infected with bacteria. This is a case of a 37-year-old man with an incidentally identified Proteus mirabilis infected mature teratoma in the anterior mediastinum that was removed with the Da Vinci Robotic System.

Robot-assisted thoracic surgery in Colombia: a multi-institutional initial experience

Background

Robotic assisted videothoracoscopic surgery (RVATS) adoption has increased worldwide from 3.4% in 2010 to 17.5% in 2015. However, in Latin America, the literature is limited to a report of a series of 10 patients who underwent RVATS lobectomy and one case report of an RVATS thymectomy from Brazil.

Methods

This is a retrospective review of all RVATS performed in Bogotá Colombia since 2012. A single thoracic surgeon (RB) performed all the operations at three institutions: Clínica de Marly, Fundación Clínica Shaio and Instituto Nacional de Cancerología. Preoperative, intraoperative, postoperative and pathology report variables were included. Patients were analyzed in three groups: robotic RVATS pulmonary resections, RVATS mediastinal surgeries and other RVATS procedures. Descriptive statistics were used to report the median and interquartile range (IQR) of the continuous variables, and number and percentage were used to describe categorical variables. The association between total operative time and the year the surgery was analyzed using a linear regression model.

Results

Forty-seven patients underwent RVATS pulmonary resections; 72.3% (n=34) of these patients underwent a RVATS lobectomy. The median total operative time was 220 (IQR: 200 to 250) minutes, 6.4% (n=3) had intraoperative complications, and the most frequent histologic diagnosis was adenocarcinoma (n=24, 51.1%). Of 18 patients who underwent RVATS mediastinal surgeries, 50.0% (n=9) had RVATS thymectomy, the median total operative time was 195.5 (IQR: 131 to 221) minutes and two patients (11.1%) had intraoperative complications. The linear regression model of the association between total operative time and the year the surgery showed a 10.3 minute reduction per year (P=0.006).

Conclusions

This is the second series of RVATS published in Latin America and the first published in Colombia, with comparable perioperative results to other reports.

Hybrid robotic thoracic surgery for excision of large mediastinal masses

Between April 2016 and October 2017, we retrospectively reviewed all patients undergoing excision of large mediastinal masses using a hybrid robotic thoracic approach at the Unit of Thoracic Surgery of Monaldi Hospital in Naples. The inclusion criteria for this approach were: evident unilateral predominance of the mass; absence of invasion to surrounding structures. Planned conversion to sternotomy was necessary in one patient for tenacious adhesions between the mediastinal goiter and the left innominate vein. In all cases the postoperative course was uneventful. The hybrid robotic approach, adopted in our Unit, consists of a thoracic procedure performed completely with articulated surgical instruments under three-dimensional vision and followed by final extension of a port-site incision to retrieve the voluminous specimen. This approach uses all the advantages of robotic technology that enables to perform a fine dissection in the small space of the anterior mediastinum and at the same time, through the simple extension of a minimally invasive access, avoids the painful sequelae of thoracotomy. In selected cases, with increased experience in robotic surgery, it can be proposed for excision of large mediastinal masses, although a longer follow-up period is necessary to validate our findings.

Robotically assisted thymectomy: a review of the literature

The aim of this literature review is to see where the robotic thymectomy stands nowadays. A thorough search of the PubMed revealed eighty-two related articles which reviewed comprehensively. The zero intraoperative mortality, the minimal intraoperative morbidity, as well as the recorded recurrence rate of 0-11.1% and complete stable remission rate of 0-40% suggests that the robotic-assisted thymectomy is a feasible, safe and an upcoming procedure. However, the lack of prospective randomized controlled trials prevents this technique to become the standard approach for the nonce.

Thymectomy via open surgery or robotic video assisted thoracic surgery: Can a recommendation already be made?

BACKGROUND

Robot-assisted minimally invasive surgery (RVATS) is a relatively new technique applied for thymectomies. Only few studies directly compare RVATS to the mainstay therapy, open surgery (sternotomy).

METHODS

A systematic search of the literature was performed in October 2016. The meta-analysis includes studies comparing robotassisted and open thymectomy regarding operation time, length of hospitalization, intraoperative blood loss, and chest-in-tube days, postoperative complications, reoperation, arrhythmic events, pleural effusion, and postoperative bleeding.

RESULTS

Of 626 studies preliminary screened, 7 articles were included. There were no significant differences in comparison of operation time (-3.19 minutes [95% confidence interval, 95% CI -112.43 to 106.05]; P = .94), but patients undergoing RVATS spent significantly less time in hospital (-4.06 days [95% CI -7.98 to -0.13], P = .046). There were fewer chests-in-tube days (-2.50 days [95% CI -15.01 to 10.01]; P = .24) and less intraoperative blood loss (-256.84 mL [95% CI -627.47 to 113.80]; P = .10) observed in the RVATS group; due to a small number of studies, these results were not statistically significant. There were also less post-operative complications in the RVATS group (12 complications in 209 patients vs 51 complications in 259 patients); however, this difference was not statistical significant (odds ratio 0.27, 95% CI 0.07-1.12; P = .06).

CONCLUSIONS

Patients undergoing RVATS spent less time in hospital than patients treated by open surgery (sternotomy). These patients tended to have less postoperative complications, less intraoperative blood loss, and fewer chest-in-tube days. We found evidence for the safety and feasibility of RVATS compared with open surgery, which has to be further confirmed in randomised controlled trials.

Robotically enhanced mediastinal teratoma resection: a case report and review of the literature

Mediastinal teratomata are rare, extragonadal germ cell tumors, which can occur at any age and are often asymptomatic. We present the case of a 57-year-old female with chronic cough diagnosed with a mass in the anterior mediastinum. The mass was successfully resected using the Intuitive Da Vinci® robotic system. The patient had an uneventful recovery. Review of the literature demonstrates that robotic surgery of the mediastinum is a safe and feasible alternative in selected cases.

Thoracoscopic thymectomy versus open thymectomy for the treatment of thymoma: A meta-analysis

BACKGROUND

Some studies compared the safety and efficacy of thoracoscopic thymectomy (OT) with open thymectomy (TT) in the treatment of thymoma, but the results remained controversial. This meta-analysis was designed to determine the safety and efficacy of thoracoscopic thymectomy in comparison with open thymectomy in the treatment of thymoma.

METHODS

Relevant studies were searched in databases of PubMed, EMBASE and Web of Science. Comparative studies of thoracoscopic thymectomy and open thymectomy in the treatment of thymoma were included. Both short-term perioperative and long-term oncologic outcomes were analyzed.

RESULTS

14 Eligible studies were identified through electronic databases. Our analysis suggested, when compared with open thymectomy, patients having thoracoscopy might benefit from less blood loss (p = 0.004), lower blood transfusion rate (p = 0.02), shorter mean duration of chest tube (p = 0.002), hospital stay (p < 0.001) and lower complication (p = 0.03). There was no statistical difference in 5-year OS rate (p = 0.14) and DFS/RFS rate (p = 0.07) between two groups.

CONCLUSION

Our study indicated that thoracoscopic thymectomy could become a valid alternative to open thymectomy in selected patients with thymoma.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Da Vinci Robotic System in the surgery for mediastinal bronchogenic cyst: a report on five patients

BACKGROUND

To present the results of the patients with mediastinal bronchogenic cysts that underwent robotic surgery using Da Vinci Robotic System in our institution.

METHODS

Five patients with mediastinal bronchogenic cyst undergoing robotic resection between October 2011 and September 2015 were retrospectively evaluated. Their pre-, peri- and post-operative results were investigated.

RESULTS

There were five patients (male/female: 3/2) with a mean age of 43±28 years. Three patients (60%) were asymptomatic. The lesions had been detected in the remaining two patients during the investigation of cough and abdominal pain. All the lesions were located at the posterior mediastinum. The mean diameter of lesion was 48±17 mm. One patient underwent robotic decortication in addition to robotic cystectomy. Operative times are outlined as: mean docking time 20±12 min, mean console time 63±32 min, and mean operating time 88±41 min. The mean length of stay was 3.6±2.2 days. There was no mortality or morbidity.

CONCLUSIONS

Bronchogenic cyst is among the commonest congenital lesions. The treatment is surgical resection, and mostly via thoracotomy and video-assisted thoracic surgery (VATS). There exist less than 15 patients who underwent robotic resection in the English literature, and most of them are presented as single case reports. Robotic resection of mediastinal bronchogenic cysts could be considered as a safe method.

Robotic resection of a superior sulcus neurogenic tumor

Neurogenic tumors do not often occur in the superior sulcus or apex of the chest cavity. Historically, surgical approaches have been dictated by the location of the tumor and its relation to the contiguous structures such as the vertebral bodies, subclavian vessels, and chest wall. Resection is hampered by difficulties with visualization and access within a narrow working space. The shortcomings associated with the traditional surgical approaches create a potential of injury to nearby structures. We present a case of a 43-year-old woman with a superior sulcus neurogenic tumor impinging on the left subclavian vein, who underwent a successful resection without injury to nearby structures. We found that a robotic approach improved visualization of the tumor and nearby structures and increased instrument maneuverability relative to a thoracoscopic approach, along with less pain and recovery time compared with a thoracotomy. This experience suggests that robotics provides a promising alternative for excision of superior sulcus neurogenic tumors, which may reduce associated morbidity.

Robotic surgery for primary hyperparathyroidism

BACKGROUND

Open cervical parathyroidectomy is the standard of care for the treatment of primary hyperparathyroidism (PHP). However, in patients with a history of keloid or hypertrophic scar formation, the cosmetic result may sometimes be unsatisfactory. Furthermore, in the presence of mediastinal glands, a more morbid approach is sometimes necessary, involving a sternal split or thoracotomy. Robotic parathyroidectomy, either transaxillary or transthoracic, could be an alternative in both settings.

METHODS

Between 2008 and 2013, 14 patients with PHP and a well-localized single adenoma underwent robotic transaxillary cervical (TAC) (n = 8) or transthoracic mediastinal (TTM) (n = 6) parathyroidectomy at an academic tertiary medical center and their outcomes were analyzed.

RESULTS

All 14 operations were completed successfully as planned. For TAC and TTM parathyroidectomies, mean operative time was 184 and 168 min, respectively. With the exception of one TTM patient, intraoperative PTH determination indicated a >50 % drop in all patients 10 min after excision and no patients presented with recurrent disease on follow-up. Average length of hospital stay was 1 day after TAC parathyroidectomy and 2.2 days after TTM. On a visual analog pain scale (0-10), average pain scores after TAC were 6/10 on postoperative day 1 and 1/10 on day 14, compared to 7.7/10 and 1.5/10, respectively, after TTM. Complications included development of seroma in 1 patient in the TAC group and pericardial and pleural effusion in 1 patient in the TTM cohort.

CONCLUSIONS

This initial study shows that robotic TAC and TTM parathyroidectomy are feasible in selected PHP patients with preoperatively well-localized disease. Although the TAC approach offers a potential cosmetic benefit in patients with a history of keloid or hypertrophic scar formation, a more generalized use cannot be recommended based on current evidence. The robotic TTM approach presents a minimally invasive alternative to resections previously performed through thoracotomy and sternotomy.

Da Vinci robot-assisted system for thymectomy: experience of 55 patients in China

BACKGROUND

Da Vinci robot-assisted thymectomy has been used in the past several years in China, however, practical experience in performing this approach in China remains limited. Thus, the study aimed to evaluate the experience of da Vinci robot-assisted thymectomy in China.

METHODS

From June 2010 to December 2012, 55 patients with diseases of the thymus underwent thymectomy using the da Vinci surgical HD robotic system. The clinical data of the da Vinci robot-assisted thymectomies were compared with the data of video-assisted thoracoscopic thymectomies in the same period.

RESULTS

All da Vinci robot operations were successful. This is a retrospective analysis which demonstrated that compared with video-assisted thoracoscopic thymectomy in the same period, the clinical outcomes of da Vinci robot-assisted thymectomy were not significantly different.

CONCLUSION

The da Vinci robot-assisted thymectomy is a safe, minimally invasive, and convenient operation, and shows promise for general thoracic surgery in China.