Robotic assisted thoracic surgery for resection of an esophageal cyst

Robot-assisted thoracic surgery for complex procedures

Background

As an option for minimally invasive thoracic surgery, robot-assisted thoracic surgery (RATS) has shown comparable perioperative outcomes to those achieved by traditional video-assisted thoracic surgery (VATS). It is unknown whether RATS might have any potential benefits in more complex thoracic surgical procedures, which usually require open surgery instead of VATS. The current study presents a preliminary result regarding the use of RATS in complex thoracic operations in an attempt to address this unresolved question.

Methods

Data from a prospectively collected and maintained surgical database were collected on patients who underwent RATS between February 2012 and August 2014. We defined complex RATS as those operations involving difficult dissections, complex sutures or excision of very large tumors (>8 cm) which would have required open surgery in our hospital before the introduction of RATS. The characteristics and peri-operative outcomes of patients receiving complex RATS were reviewed.

Results

Of the 120 patients undergoing RATS, 30 of them were classified as having undergone complex RATS, 21 to remove lung tumors and 9 to remove mediastinal tumors. The indications for complex RATS included 21 difficult dissections, 10 complex sutures, and 7 very large tumors (8 patients had two indications). There are three conversions to thoracotomy for pulmonary arterial bleeding. There was one mortality resulted from post-pneumonectomy pulmonary hypertension and sepsis. Patients with difficult dissection had longer operative time and hospital stay, and more bleeding and postoperative morbidity.

Conclusions

RATS for complex thoracic procedures is feasible, especially for complex suturing and excision of very large mediastinal tumors, but more attention is needed for patients needing difficult dissections. Advanced preparation for conversion is necessary during this difficult operation.

Oesophageal duplication cysts, a rare cause of neck lump treated by ultrasound guided drainage: case report and review of the literature

Oesophageal duplication cysts are a rare congenital anomaly of the foregut which usually present in infancy with respiratory symptoms, recurrent pneumonia and feeding difficulty. Other presenting symptoms depend on the location of the cyst and can include dysphagia, chest pain, arrhythmias and features of mediastinal compression. Treatment is usually surgical resection, recommended for complete resolution of symptoms, histological diagnosis and exclusion of malignancy. Here, we present a case of infected oesophageal duplication cyst which presents as a neck lump in a 43-year-old female with a background of Goltz syndrome, azygos fissure and congenital aortic stenosis. Surgical resection was decided against owing to the patient's high risk secondary to co-morbidities and instead ultrasound guided drainage was carried out successfully. The patient was symptom free and well at 1-year follow-up. Oesophageal duplication is an unusual presentation of a neck lump in an adult and whilst the usual treatment is surgical resection, we present here a case treated in an entirely different manner.

Laparoscopic excision of intra-abdominal oesophageal duplication cyst in a child

Duplication cysts are congenital cystic malformation of the alimentary tract consisting of a duplication of the segment to which it is adjacent. It can occur anywhere from mouth to anus. Oesophageal duplication cysts comprise 4% of the same. Of these, total intra-abdominal oesophageal duplication cysts are extremely rare. On review of literature, only 3 case reports of total intra-abdominal oesophageal duplication managed laparoscopically are found. All these cases were adults. We report the first paediatric case of intra-abdominal oesophageal duplication cyst excised laparoscopically.

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.

Three-field minimally invasive esophagectomy: current results and technique

The adoption of minimally invasive esophagectomy has increased worldwide since its first description more than 15 years ago. The technique has evolved from a transhiatal to a 3-hole McKeowan approach and, more recently, to a minimally invasive Ivor Lewis approach. We reviewed the technique and results of 3-hole minimally invasive esophagectomy. We favor thoracoscopic esophageal mobilization with the patient in a lateral decubitus position, although other groups have reported this with a prone or robotic approach. Several series have demonstrated low perioperative mortality with minimally invasive esophagectomy. A major advantage compared with esophagectomy with thoracotomy is a lower incidence of respiratory complications, which have been shown to be a significant predictor of mortality in other studies.