Fig. 7.1
(a) Layout of the external anatomy of the lower chest wall. (b) Introduction of 12-mm assistant port at confluence of anterior 10th intercostal muscle and diaphragm. (c) Port placement for three-arm robotic assisted lobectomy. (Asterisk) When optional posterior #3 arm port is utilized, the #1 arm is placed in the anterior port side. (d) Port placement in relationship to the major oblique fissure. (e) Docking for a three-arm robotic-assisted lobectomy
The initial access to the chest cavity is achieved by placing a 5-mm port in the anterior axillary location approximately at the level of the 5th intercostal space. A pneumothorax is induced with CO2 (pressure/flow 8 mmHg and 8 ml/s). Using a 5-mm 30° laparoscopic camera focus on the anterior aspect of the diaphragm where the diaphragmatic muscles intertwine with the 10th intercostal muscles. The 12-mm assistant port is placed under direct visual assistance. The port enters the chest at the confluence of the muscle fibers of the diaphragm and the anterior 10th intercostal muscle (Fig. 7.1b).
Utilizing the 5-mm thoracoscope, placed through the 12-mm assistant port, two additional trocars are positioned along the major pulmonary fissure between either the 6th or 7th interspace. Successful complete port-access robotic-assisted pulmonary surgery is dependent on proper placement of the midaxillary camera and posterior thoracic port. Port placement is based on the relationship of the major pulmonary fissure to the internal chest wall rather than external landmarks (Fig. 7.1c, d).
For this reason, initial placement of a low-lying camera will provide the best vantage point in order to visualize the pulmonary fissure and chest wall simultaneously, thus facilitating accurate port placement.
It is important to maintain 10 cm or a handbreadth of space between each port. The camera trocar (8 mm) is positioned in the midaxillary location one interspace below the major oblique fissure. A good rule of thumb is to utilize the anterior sternal–xiphoid junction as a landmark to confirm proper positioning for the midaxillary camera port. The initial 5-mm port is replaced with a (8 mm) trocar in the anterior axillary location. A larger port (12 mm) can be placed in the anterior axillary location if a secondary access is needed for stapling. When utilizing a 12-mm anterior axillary port, the robotic 8-mm port needs to be introduced through the 12-mm port. The posterior (5 mm or 8 mm) trocar is positioned one or two interspace below the superior aspect of the oblique fissure within the corresponding rib space. As a result of the paraspinous muscles, the posterior intercostal space is restrictive. The superior and inferior movements of the robotic instruments can be significantly affected by the inflexible paraspinous musculature and narrow ribs space. Improper positioning of the posterior port will hinder instrument movement. Limiting the size of the posterior operating port to (8 mm or less), when possible, is recommended to minimize postoperative pain. If elected, an additional 5-mm port can be placed in the posterior location approximately the 8th interspace and used with a 5-mm retracting grasper. Three or four robotic arms are then docked to their respective trocars (Fig. 7.1e).
A 0° 3D (8 mm) camera is placed in the midaxillary port. The 5-mm lung grasping forceps are placed in the right robotic arm, and a bipolar dissector forceps (Intuitive Surgical, Inc., Sunnyvale, CA) is placed in the left robotic arm. The bipolar cautery is utilized for precise dissection and isolation of the pulmonary vascular structures. Avoidance of an access thoracotomy incision maintains positive pressure within the chest cavity with CO2 insufflation. When the CO2 pressure is maintained below 10 mmHg, hemodynamic side effects are minimal and can be addressed with minor adjustments by the anesthesiologist.
We prefer the three-arm robotic technique with docking of the #3 robotic arm to the anterior port. As the #3 robotic arm is a five-joint arm, which is uniquely different from the mirror image arms #1 and #2. Instruments held with robotic arm #3 have an increased range of motion compared to the other two robotic arms. The #3 arm can be utilized to hold the primary dissecting instrument. For right-sided procedures, the robotic arms #2 and #3 are utilized, with #3 positioned anteriorly as noted, and #2 is placed posteriorly. For left-side procedures, robotic arms #2 and #3 are utilized; robotic arm #3 is positioned anteriorly, and #2 is placed posteriorly. When utilizing the four-arm robotic technique, it is necessary to use the #3 robotic arm for retraction assistance, and arms #1 and #2 are positioned anterior or posterior depending on the laterality of the case. When utilizing a four-arm robotic technique, it is necessary to dock the #3 arm posteriorly for retraction assistance only. The #1 and #2 arms become the primary dissecting instruments. One of the main disadvantages to the four-arm technique is the increased likelihood of external instrument conflict particularly in patients with small chest cavities. Utility access can be achieved through the subcostal assistant trocar for retraction, suctioning, and access for passage of staplers. With rare exceptions, all stapling can be provided through the subcostal accessory port. By utilizing the accessory port in this manor, instrument exchange, as well as the need to undock and re-dock the arms to the ports, substantially reduces the overall operating room time. As experience with this technique is gained, this arrangement requires only one bedside operative assistant and surgical technician. Following the initial trocar positioning and docking of the robot, the primary operating surgeon remains unsterile at the surgical console until it is time to extract the lung specimen from the chest cavity.
Hilar and Mediastinal Lymph Node Dissection
Once the indications for lung resection are met, the procedure begins with mediastinal and hilar lymph node dissection based on the disease process. The lymph node dissection begins with division of the inferior pulmonary ligament. A 0° scope is placed in direct upright position with minimal rotation from the horizon. Proper camera port placement allows for visualization from the base of the pulmonary ligament to the apex of the chest. Complete visualization of the anterior, posterior, and superior aspects of the hilum is attained, allowing for precise anatomic dissection. Exposure of the ligament is achieved by lifting the lower lobe superiorly with “passive” retraction. “Passive” retraction is best achieved by utilizing the full length of the shaft of the instruments to “push” the lung as needed around the chest cavity rather than to grasp and “pull” the lung where needed. Utilizing a 3 × 3 rolled gauze held by a robotic instrument can improve the surgeon’s ability to manipulate the lung for exposure. The console surgeon should not attempt to “actively” grab the lung in an effort to reduce iatrogenic parenchymal trauma. Instead “passive” retraction should be used to push the lung upward until the ligament is visualized and the bedside assistant can grab the base of the ligament to provide exposure of the ligament for bimanual robotic dissection. While the bedside assistant maintains gentle cephalad traction on the lung, the inferior ligament is divided with electrocautery. Level 8 and 9 lymph nodes are removed during this maneuver. As the dissection progresses towards the superior aspect of the ligament, the ligament divides into anterior and posterior veils which envelope the hilum. Dividing these veils anteriorly and posteriorly to the supra-hilar area allows for a circumferential release of the mediastinal pleura from the hilum. During the dissection of the posterior veil, the lung is rotated anteriorly and held in position with an external atraumatic grasper by the bedside assistant via the assistant port. Next, the console surgeon proceeds with a subcarinal lymphadenectomy.
Before forfeiting the posterior hilar exposure, additional maneuvers can be performed to facilitate division of an incomplete oblique fissure. On the right side, thorough dissection of the junction between the right upper lobe bronchus and bronchus intermedius should be completed. The landmark to identify is the posterior aspect of the descending pulmonary artery. On the left side, exposure of the main pulmonary artery and the origin of the ascending posterior pulmonary artery and superior segmental artery should be thoroughly dissected free of adjacent tissue. If these steps are performed correctly, a plane beneath the posterior oblique fissure can be easily created once the descending artery is exposed from within the mid-oblique fissure. During the dissection of the oblique fissure and isolation of the individual arteries, N1 lymph nodes are removed and collected for examination. Throughout the process of the lymph node dissection, a frozen section examination is performed on any suspicious hilar (N1) and mediastinal (N2) lymph nodes to determine a clinically appropriate anatomical resection. Following the hilar dissection and removal of the subcarinal lymph nodes, dissection should be carried cephalad to the hilum. On the right side, levels 2, 3, and 4 lymph nodes are resected. On the left, level 5 and 6 para-aortic lymph nodes are resected.
Dissection and Division of Hilar Structures
The major oblique fissure is separated, and the arteries to the designated lobe are isolated and individually divided. The bipolar dissector forceps are utilized to meticulously divide the pulmonary parenchyma when necessary. With the use of the high-definition, three-dimensional camera, the surgeon can visualize the thin visceral pleural layer between the fissures and avoid violating the parenchyma of the uninvolved lobe. Careful attention to this maneuver is important to avoid excessive bleeding that may interfere with identification of vascular structures. Blunt dissection through the lung parenchyma should be avoided. Division of the pulmonary vein prior to division of the arteries to the corresponding lobe is not recommended because of the risk of engorgement of the pulmonary parenchyma. Such engorgement will lead to increased bleeding during dissection of the hilar structures and lung parenchyma. In circumstances where there is an incomplete fissure, we recommend initially dividing the posterior parenchymal bridge. This is accomplished by exposing the common descending branch of the pulmonary artery within the mid-oblique fissure. Following the identification of the ascending posterior segmental artery to the upper lobe and the superior segmental artery to the lower lobe, dissection with a blunt dissector is performed beneath the posterior parenchymal bridge. A tissue stapler is passed through the assistant trocar and utilized to divide the posterior parenchymal bridge. The order of the hilar structures divided for the right upper lobe is as follows: ascending posterior artery, right upper lobe bronchus, and common truncus anterior artery. Dividing the right upper lobe bronchus facilitates isolation of the truncus anterior branch of the pulmonary artery. The venous structures are typically divided last in order to avoid engorgement of the corresponding lobe. In situations where dissection through the fissure is difficult, a fissure–less technique can be utilized. However, the authors recommend performing isolation of all major vessels prior to dividing the pulmonary vein to the respective lobe. This will facilitate rapid division of the major arterial supply and limit the risk of lobar engorgement. In the case of a middle lobectomy, the segmental pulmonary arterial branches to the respective lobe are individually isolated and divided with a vascular stapler. When performing a lower lobectomy, isolation and division of the common descending pulmonary artery is performed when feasible.
When performing a left upper lobectomy, separation of the oblique fissure is initially performed. The order of the hilar structures divided for a left upper lobe is as follows: lingual arteries, ascending posterior artery, left superior pulmonary vein, apical and anterior arterial branches, and left upper lobe bronchus. Division of the left superior pulmonary vein will facilitate exposure of the apical and anterior arterial branches during a left upper lobectomy. For lower lobectomies, the common descending pulmonary artery is divided before the inferior pulmonary vein. The vein and arteries are stapled with a 45-mm vascular tissue stapler, and bronchi are stapled and divided with a 45-mm medium thick tissue stapler.
Extraction of the Specimen
Once the anatomical resection is completed, the specimen is placed in a 5 × 8-cm Lapsac (Cook Group Inc., Bloomington, IN). The Lapsac string is then pulled out through the subcostal trocar (Fig. 7.2a, b).
Fig. 7.2
(a) Retrieval of specimen bag through assistant port. (b) Opening of the assistant port site for specimen removal. (c) Exposure of specimen removal site for repair of diaphragm
A small 2–3-cm subcostal incision is created at the tip of the 11th rib. Once the anterior aspect of the 11th rib is identified, the edge of the diaphragm is separated from its attachments to the anterior 10th intercostal muscle fibers as they insert into the anteroinferior aspect of the tenth rib. The extraction of the specimen from the chest cavity is not performed through a traditional transthoracic approach. It is removed through a para-diaphragmatic, subcostal approach. Repair of the diaphragm is accomplished using 0-vicryl on CT1 needle (Fig. 7.2c).
The suture is passed initially through the upper posterior edge of the divided oblique muscles. It is then run as a semi-purse-string alone the open edge of the diaphragm from superior to inferior. The suture is then run through the inferior posterior edge of the divided oblique muscles. Tying the suture will reapproximate the diaphragm to the anterior tenth intercostal musculature. After a final inspection of the thorax, paravertebral blocks are performed using 0.5 % bupivacaine with epinephrine for analgesia. A single 24 F Blake drain is placed and has been found to be sufficient for closed chest drainage in this patient population.
Result
A review of our complete experience from December 2006 through September 2010 identified 200 consecutive patients who underwent a robotic video-assisted lung resection [14]. The patient characteristics are listed in Table 7.1. Of the study cohort, 154 patients underwent an anatomical lobectomy, four patients required a bilobectomy, one patient had a pneumonectomy, and 35 patients underwent a formal segmentectomy. Three patients underwent a sleeve lobectomy. Three patients underwent an en bloc chest wall or diaphragm resection concurrently with lobectomy. Robotic video-assisted lung resection was successfully completed in 197 (98.5 %) patients. Three patients required conversions to a muscle-sparing mini-thoracotomy for either bleeding, central tumor invasion, or completion of a sleeve lobectomy. Every type of lobectomy was performed (Table 7.1).
Table 7.1
Patient characteristics (n = 200)
Male/female | 90/110 |
Median age (years) | 68.0 (20–92) |
Median tumor diameter (cm) | 2.0 (0.5–8.5) |
Tumor location | |
RUL | 52 |
RML | 18 |
RLL | 27 |
RML and RLL | 4 |
LUL | 36 |
LLL | 21 |
Histology | |
NSCLC | 125 |
Small cell carcinoma | 1 |
Carcinoid | 18 |
Benign | 26 |
Metastatic | 29 |
Lymphoma
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