Robotic-Assisted Videothoracoscopic Mediastinal Surgery

Robotic portal resection for mediastinal tumours: a prospective observational study

BACKGROUND

To demonstrate the effectiveness and feasibility of robotic portal resection (RPR) for mediastinal tumour using a prospectively collected database.

METHODS

Data from 73 consecutive patients with mediastinal tumours who underwent RPRs were prospectively collected from August 2018 to April 2023. All patients underwent chest and abdominal enhanced computed tomography (CT) and preoperative multidisciplinary team (MDT) discussion. The patients were stratified into two groups based on tumour size: Group A (tumour size < 4 cm) and Group B (tumour size ≥ 4 cm). General clinical characteristics, surgical procedures, and short outcomes were promptly recorded.

RESULTS

All of the cases were scheduled for RPRs. One patient (1/73, 1.4%) was switched to a small utility incision approach because of extensive pleural adhesion. Two patients (2.8%) converted to sternotomy, however, no perioperative deaths occurred. Most of the tumours were located in the anterior mediastinum (51/73, 69.9%). Thymoma (27/73, 37.0%) and thymic cyst (16/73, 21.9%) were the most common diagnoses. The median diameter of tumours was 3.2 cm (IQR, 2.4-4.5 cm). The median total operative time was 61.0 min (IQR, 50.0-90.0 min). The median intraoperative blood loss was 20 mL (IQR, 5.0-30.0 ml), and only one patient (1.4%) experienced an intraoperative complication. The median length of hospital stay was 3 days (IQR, 2-4 days). Compared with Group A, the median total operative time and console time of Group B were significantly longer (P = 0.006 and P = 0.003, respectively). The volume of drainage on the first postoperative day was greater in group B than in group A (P = 0.013).

CONCLUSION

RPR is a safe and effective technique for mediastinal tumour treatment, which can expand the application of minimally invasive surgery for the removal of complicated mediastinal tumours.

Outcomes of robot-assisted versus video-assisted mediastinal mass resection during the initial learning curve

To compare the learning curve of mediastinal mass resection between robot-assisted surgery and thoracoscopic surgery. Retrospective perioperative data were collected from 160 mediastinal mass resection cases. Data included 80 initial consecutive video-assisted thoracoscopic surgery (VATS) resection cases performed from February 2018 to February 2020 and 80 initial consecutive robotic-assisted thoracic surgery (RATS) resection cases performed from March 2020 to March 2023. All cases were operated on by a thoracic surgeon. The clinical characteristics and perioperative outcomes of the two groups were compared. The operation time in both the RATS group and VATS group was analyzed using the cumulative sum (CUSUM) method. Based on this method, the learning curves of both groups were divided into a learning period and mastery period. The VATS group and the RATS group crossed the inflection point in the 27th and 21st case, respectively. Subsequently, we found that the learning period was longer than the mastery period with statistically significant differences in terms of the operating time, and postoperative hospital stay in the VATS group and the RATS group. A certain amount of VATS experience can shorten the learning curve for RATS.

[Robot-assisted Mediastinal Surgery]

Because of the many important anatomical structures located closely together at very small distances, mediastinal surgery has been traditionally demanding and challenging within thoracic surgery. With their great variability, mediastinal masses in the anterior, middle or posterior mediastinal compartment result in surgical indications with different principle focuses. The technical opportunities of robotic assistance can thereby most effectively support the requirement of precision for all oncological aspects. Anterior mediastinal operations are most often performed, thymectomy being the most common operation. The radicality of thymectomy is of special importance. The worldwide tremendous development of robot-assisted mediastinal surgery confirms its initial and continuous role as a pacemaker for minimally invasive thoracic surgery.

Approaches and outcomes of Robotic-Assisted Thoracic Surgery (RATS) for lung cancer: a narrative review

Robotic-Assisted Thoracic Surgery (RATS) is considered one of the main issues of present thoracic surgery. RATS is a minimally invasive surgical technique allowing enhanced view, accurate and complex movements, and high ergonomics for the surgeon. Despite these advantages, its application in lung procedures has been limited, mainly by its costs. Since now many different approaches have been proposed and the experience in RATS for lungs ranges from wedge resection to pneumonectomy and is mainly related to lung cancer. The present narrative review explores main approaches and outcomes of RATS lobectomy for lung cancer. A non-systematic review of literature was conducted using the PubMed search engine. An overview of lung robotic surgery is given, and main approaches of robotic lobectomy for lung cancer are exposed. Initial experiences of biportal and uniportal RATS are also described. So far, retrospective analysis reported satisfactory robotic operative outcomes, and comparison with VATS might suggest a more accurate lymphadenectomy. Some Authors might even suggest better perioperative outcomes too. From an oncological standpoint, no definitive prospective study has yet been published but several retrospective analyses report oncological outcomes comparable to those of VATS and open surgery. Literature suggests that RATS for lung procedures is safe and effective and should be considered as a valid additional surgical option.

Clinical efficacy of robot-assisted thoracoscopic surgery for posterior mediastinal neurogenic tumors

Background

Robot-assisted thoracic surgery (RATS) has an increasing usage throughout the world. This retrospective cohort study aimed to objectively compare the surgical results between video-assisted thoracic surgery (VATS) and RATS in posterior mediastinal neurogenic tumors (PMNT).

Methods

We retrospectively reviewed the clinical data of 130 patients diagnosed with posterior mediastinal neurogenic tumor between 2015 and 2018. Magnetic resonance imaging (MRI) or enhanced computed tomography scan (CT-scan) was used to locate the tumor and investigate the Adamkiewicz’s artery preoperatively. The individual surgical approach was determined by both tumor size and patient’s willings.

Results

The surgical time in RATS (43.2±12.6 min) was tended to be less than that in VATS (47.4±11.9 min) (P=0.054). Meanwhile, the estimated blood loss in RATS group (85.8±22.6 mL) was significantly less than that in VATS group (95.3±28.4 mL) (P=0.040). However, the duration of chest tube (days) and volume of drainage (mL) had no significant difference between two groups (P=0.12 and P=0.68, respectively). The postoperative hospital stay (days) of patients in RATS group (2.2±0.4 days) was significantly shorter than that in VATS group (2.4±0.6 days) (P=0.031). There were no significant differences between two groups in the incidence of the postoperative complications and adverse reactions.

Conclusions

RATS has the superiorities in terms of surgical blood loss and postoperative hospital stay over VATS for posterior mediastinal neurogenic tumor. In conclusion, RATS could be a feasible and safe way for resecting posterior mediastinal neurogenic tumor.

Robotic Thoracic Surgery

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.

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.

Robot-assisted thymectomy via subxiphoid approach: technical details and early outcomes

Background

Trans-subxiphoid thoracoscopic thymectomy is a promising procedure but technically demanding associated with ergonomic discomfort. In order to facilitate this complex procedure, the authors present a modified trans-subxiphoid thymectomy by the use of the Da Vinci robotic system.

Methods

A 2-cm longitudinal incision for camera was made below the xiphoid process. Through this incision, the space among the posterior surface of the sternum, bilateral mediastinal pleura and diaphragm (extra pleural space) was enlarged blindly with a finger. Additional two operation holes were created below bilateral costal arches, and then two 8-mm robotic trocars were inserted into the extra pleural space. A third robotic instrument was placed in the 5th intercostal space after bilateral mediastinal pleura were dissected. The whole thymus was excised for patients with thymic tumor, and simultaneous resection of surrounding adipose tissues was performed for patients with myasthenia gravis. Clinical characteristics and early surgical outcomes of the patients were retrospectively collected and analyzed.

Results

Between August 2016 and September 2017, 70 consecutive patients with myasthenia gravis or thymic neoplasm were successfully treated by the described surgical procedure. The median overall operative time was 115 (range, 60-150) min. The median hospital stay was 5 (range, 4-7) days. The median duration of chest tube was 3 (range, 1-8) days. The blood loss was minimal for all the patients. There was no mortality, conversion or postoperative complication during the postoperative and follow-up period.

Conclusions

Based on our preliminary experience, the described technique of thymectomy is safe and feasible, and provides an optimal access for the robot camera and the instruments.

The Learning Curve for Robotic McKeown Esophagectomy in Patients With Esophageal Cancer

BACKGROUND

Robot-assisted McKeown esophagectomy is a promising but technically demanding procedure; thus, a learning curve should be defined to guide training and allow implementation of this technique.

METHODS

This study retrospectively reviewed the prospectively collected data of 72 consecutive patients undergoing robot-assisted McKeown esophagectomy by a single surgical team experienced in open and thoracolaparoscopic esophagectomy. The cumulative sum method was used to analyze the learning curve. Patients were divided into two groups in chronological order, defining the surgeon's early (group 1: the first 26 patients) and late experience (group 2: the next 46 patients). Demographic data, intraoperative characteristics, and short-term surgical outcomes were compared between the two groups.

RESULTS

Cumulative sum plots revealed decreasing thoracic and abdominal docking time, thoracic and abdominal console time, and total surgical time after patient 9, 16, 26, 14, and 26, respectively. The mean number of lymph nodes resected was greater in group 2 than in group 1 (22.6 ± 8.2 vs 17.4 ± 6.7, p = 0.008). No other clinic or pathologic characteristics were observed as significantly different.

CONCLUSIONS

For a surgeon experienced in open and thoracolaparoscopic esophagectomy, experience of 26 cases is required to gain early proficiency of robot-assisted McKeown esophagectomy. A learning curve for robot-assisted esophagus dissection would require operations on 26 patients and stomach mobilization would require operations on 14 patients. For the tableside assistant, experience of at least nine cases is needed to achieve an optimal technical level for thoracic docking and 16 cases for abdominal docking.

Anterior bronchogenic mediastinal cyst as priority procedure for robotic thoracic surgery

We report a case of anterior bronchogenic mediastinal cyst (ABMC) in old age patient underwent Robotic Thoracic Surgery (da Vinci Surgical System). Video-assisted thoracoscopic surgery (VATS) represents the routine approach in posterior bronchogenic mediastinal cyst, but some limitation for resection of mediastinal mass located in the anterior mediastinum has been reported. The introduction of da Vinci surgical system has overcome the surgical limits of VATS as two dimensional vision (2D) and the use of long rigid instruments with poor maneuverability in case of fine dissection.

Robotic Transnasal Endoscopic Skull Base Surgery: Systematic Review of the Literature and Report of a Novel Prototype for a Hybrid System (Brescia Endoscope Assistant Robotic Holder)

BACKGROUND

Although robotics has already been applied to several surgical fields, available systems are not designed for endoscopic skull base surgery (ESBS). New conception prototypes have been recently described for ESBS. The aim of this study was to provide a systematic literature review of robotics for ESBS and describe a novel prototype developed at the University of Brescia.

METHODS

PubMed and Scopus databases were searched using a combination of terms, including Robotics OR Robot and Surgery OR Otolaryngology OR Skull Base OR Holder. The retrieved papers were analyzed, recording the following features: interface, tools under robotic control, force feedback, safety systems, setup time, and operative time. A novel hybrid robotic system has been developed and tested in a preclinical setting at the University of Brescia, using an industrial manipulator and readily available off-the-shelf components.

RESULTS

A total of 11 robotic prototypes for ESBS were identified. Almost all prototypes present a difficult emergency management as one of the main limits. The Brescia Endoscope Assistant Robotic holder has proven the feasibility of an intuitive robotic movement, using the surgeon's head position: a 6 degree of freedom sensor was used and 2 light sources were added to glasses that were therefore recognized by a commercially available sensor.

CONCLUSIONS

Robotic system prototypes designed for ESBS and reported in the literature still present significant technical limitations. Hybrid robot assistance has a huge potential and might soon be feasible in ESBS.