Brachial plexus injury after robotic-assisted thoracoscopic thymectomy

Anesthetic Management during Robotic-Assisted Minimal Invasive Thymectomy Using the Da Vinci System: A Single Center Experience

Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020−01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient’s age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH2O versus 19.3 ± 3.9 cmH2O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusions: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures.

Anesthesia for robotic thoracic surgery

Robotically assisted thoracic surgery (RATS) to date is performed as a small proportion of thoracic surgical procedures and only at a few centres, but is rapidly gaining more widespread interest. In this article, we present our anesthetic perspective of planning and performing RATS and highlight specific points to consider when managing these patients.

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.

Robotic Thymectomy: Learning Curve and Associated Perioperative Outcomes

INTRODUCTION

Recently, robotic-assisted thymectomy (RAT) has emerged as an alternative to either, an open transsternal approach or to a video-assisted thoracoscopic approach, for both thymic tumors and benign lesions. We have reviewed our early experience with RAT to assess the associated learning curve as well as the short-term perioperative outcomes.

METHODS

A prospectively collected database was reviewed for patients who underwent RAT for all causes in the period 2012-2016. Robotic thymectomy cases were stratified and compared according to the number of cases performed by each surgeon (≤15 versus >15 cases). A propensity score matching was done to compare perioperative outcomes in patients undergoing robotic and transsternal resection of thymomas.

RESULTS

Seventy patients (47 females) with a median age of 52, underwent RAT. The median operative time was 102 min with 5 conversions to an open approach for local invasion (n = 3) or for complete pleural symphysis (n = 2). There were 2 rib fractures and 1 recurrent laryngeal nerve palsy. Median length of chest tube drainage and length of stay were 1 and 3 days, respectively. Operative time and estimated blood loss plateaued after surgeon's initial 15-20 cases, which may reflect the initial learning curve. A comparison between early and late robotic cases showed that with the growing experience, the operative time becomes shorter (94 versus 107 min, P = .018). Propensity score analysis between robotic and transsternal resection of thymoma (n = 22 in each group) showed no significant differences in operative time (P = .79), intraoperative complications (P = .99), or postoperative complications (P = .99).

CONCLUSIONS

Robotic thymectomy is feasible and safe, and is associated with comparable perioperative outcomes to the traditional transsternal approach in patients undergoing thymomectomy. An initial learning curve of 15-20 robotic thymectomy cases may be required by the surgeons to adequately perform this relatively novel technique.

Robotic thoracic surgery: The state of the art

Minimally invasive thoracic surgery has come a long way. It has rapidly progressed to complex procedures such as lobectomy, pneumonectomy, esophagectomy, and resection of mediastinal tumors. Video-assisted thoracic surgery (VATS) offered perceptible benefits over thoracotomy in terms of less postoperative pain and narcotic utilization, shorter ICU and hospital stay, decreased incidence of postoperative complications combined with quicker return to work, and better cosmesis. However, despite its obvious advantages, the General Thoracic Surgical Community has been relatively slow in adapting VATS more widely.

The introduction of da Vinci surgical system has helped overcome certain inherent limitations of VATS such as two-dimensional (2D) vision and counter intuitive movement using long rigid instruments allowing thoracic surgeons to perform a plethora of minimally invasive thoracic procedures more efficiently.

Although the cumulative experience worldwide is still limited and evolving, Robotic Thoracic Surgery is an evolution over VATS. There is however a lot of concern among established high-volume VATS centers regarding the superiority of the robotic technique. We have over 7 years experience and believe that any new technology designed to make minimal invasive surgery easier and more comfortable for the surgeon is most likely to have better and safer outcomes in the long run. Our only concern is its cost effectiveness and we believe that if the cost factor is removed more and more surgeons will use the technology and it will increase the spectrum and the reach of minimally invasive thoracic surgery.

This article reviews worldwide experience with robotic thoracic surgery and addresses the potential benefits and limitations of using the robotic platform for the performance of thoracic surgical procedures.

Navigating the pathway to robotic competency in general thoracic surgery

OBJECTIVE

Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills.

METHODS

Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures were performed. Data on patient characteristics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility.

RESULTS

The robot-assisted procedures performed included lung resection (n = 38), mediastinal mass resection (n = 19), hiatal or paraesophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thoracoscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice.

CONCLUSIONS

Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway.

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.

Unilateral extended thoracoscopic thymectomy for nontumoral myasthenia gravis--a new standard

Myasthenia gravis (MG) is a heterogeneous disorder with a fluctuating, clinical, pathologic, and immunobiological picture. Today, it is believed that effective treatment of MG must include both immunosuppression and surgery. Thymectomy is recommended by neurologists for patients with nontumoral MG as an option to increase the probability of remission or improvement. Currently, thoracoscopic thymectomy is considered a good alternative to the standard open approach because of its higher rate of acceptance, low morbidity, and high efficacy, as measured by complete stable remission rates. We present a review of the experience of unilateral extended thoracoscopic thymectomy for nontumoral MG, a technique that could became a new standard in the complex management of MG treatment.

Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns

BACKGROUND

Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy.

PATIENTS AND METHODS

The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry.In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered.

RESULTS

Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 +/- 2 to 28 +/- 2.7 cmH2O and central venous pressure increased from 12.9 +/- 1 to 19.2 +/- 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice.

SUMMARY

Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.

An update on robotic thoracic surgery and anesthesia

PURPOSE OF REVIEW

Minimally invasive surgery involving the thoracic cavity continues to increase. With the introduction of robotic systems, particularly the da Vinci robot system more than 10 years ago, thoracic operations have been performed with some provocative results and limited, defined advantages. The present review provides an overview of common thoracic surgical procedures performed with the robotic system and discusses the anesthetic implications.

RECENT FINDINGS

The literature on this topic currently includes case reports or series of clinically prospective or retrospective observational reports with the use of robotic systems, involving the thoracic cavity (mediastinal mass resections, lobectomies, and esophagectomies); unfortunately there are very limited reports related to anesthetic implications or complications related to the use of this technology. The majority of the surgical reports involve the use of lung isolation devices for thoracic surgery, specifically the use of a double-lumen endotracheal tube (DLT); a few centers use carbon dioxide (CO2) insufflation as part of their management to achieve maximal surgical exposure while compressing the operative side of the lung away from the operative area.

SUMMARY

Anesthesiologists must be familiar with lung isolation techniques and flexible fiberoptic bronchoscopy while participating in thoracic surgical cases that require robotic systems. In addition, prevention and recognition of potential complications, such as crushing injuries or nerve damage, must be sought. Because the potential for converting to an open thoracotomy exists, all measures must be taken to manage patients accordingly if the situation arises.