Robotic Lobectomy

Rigidity of the chest wall hinders ability to visualize thoracic structures through a thoracotomy incision. The view of the mediastinum, hilum, and the lung is dependent on multiple factors: the size of the incision, the choice of intercostal space, the rigidity of the ribs, the surgical removal of a small portion or an entire rib, the ability to achieve single-lung ventilation, the presence of adhesions and/or presence of thoracic pathology, and unyielding bullous/lung disease. Simply, the view in the thoracic cavity can be divided into three regions: the visible region, where visibility is fairly easily achieved; the border region, where visibility is achieved only with significant effort; and the nonvisible region, where even with extensive efforts there is no visibility. With the advent of minimally invasive surgery, the view is only limited by the visualization system utilized (two-dimensional versus three-dimensional and angled versus nonangled viewing systems) and the planning and skills of the surgical team. It is this issue alone that may encourage our move away from the open thoracotomy for the majority of patients, especially those with cancer, where a thorough examination is critical to prognosis and treatment.

Comparison of VATS lobectomy to robotic lobectomy: similar approach, but two very different procedures. The two patients shown are undergoing hilar dissection. (A) The patient is undergoing a VATS resection. There are three incisions shown, one for the videoscope and the other two for the right-angle clamp and stapler. The manipulation of the instrumentation and arcs of rotation occur outside of the chest. The fulcrum of the instrumentation occurs at the chest wall, compressing and distending the intercostal nerves. (B) This patient is undergoing a robotic resection; with this technique, the arcs of rotation and management of the instrumentation for dissection are within the chest, allowing surgical dissection to occur in small spaces. The addition of three-dimensional visibility provides additional benefit, assisting in reducing the likelihood for damaged intravascular structures.

Intuitive Da Vinci System. (A) Shows the three components of the Da Vinci system and (B) shows the Da Vinci S. (C) Demonstrates the typical operating room setup. Panel (D) is a side view of the video port arm. The other three arms are somewhat similar and instrumentation can be interchanged as necessary for the procedure. (E) Demonstrates the three-dimensional view available to the surgeons sitting at the consult and (F) shows the two-finger controls.

Ring clamp with Surgicel (A) or mini-laparotomy sponge (B). When performing a robotic chest procedure, the team should be ready for a vascular disaster. A ring clamp with an affixed group of Surgicel (usually two to three) or a mini-laparotomy pad should be ready. A thoracotomy tray should be ready in the room as well.

Patient position. The patient is placed in the lateral decubitus position with a supporting axillary roll and beanbag as usual for a VATS or open thoracotomy. Patients are placed in the reverse Trendelenburg position to allow the diaphragm and abdominal contents to fall away from the thoracic cavity. This also allows for any bleeding that might occur to pool away from the operative site. In patients with large hips, a slight reverse bend at the midportion of the table will help move the hips out of the way. For the upper lobe the patient is rotated 15 to 30° posteriorly. For lower lobes, the patient is rotated 15 to 30° anteriorly.

Port placement for the right upper lobectomy. The four 10-12-mm thoracoports are placed in the following fashion (A, C, D, F) with adjustment made according to whether an upper or lower lobe is to be performed. The Target for the routine lobectomy is the hilum and the approximate location is drawn onto the patient's chest; this is a 4-cm-diameter circle whose center is approximately 3 cm anterior and 2 cm cephalad to the tip of the scapula. The camera port (A) is placed in the eighth or ninth intercostal space adjacent to the anterior costal margin. We make a small transverse incision and use a tonsil clamp to enter the pleural space while the patient is apneic. After the port is slowly screwed into position, the pleural space is visualized to make certain that there has been no damage to the lung or the diaphragm and that the thoracic cavity has been entered, rather than the peritoneal cavity. Once confirmed, CO₂ is slowly infused at progressively increasing pressures, dependent on the patient's hemodynamic tolerance up to approximately 10 to 15 mmHg. If there is no evidence of pleural metastatic disease, then the other ports are placed. The two robotic arm ports, B and E, 8-mm each, are placed 10-14 cm away from the camera port (A) and outside the triangular area from the width of the Target (hilum) and the camera port (A).

Preparation for docking: robot position. Using the robotic videoscope, all four 10-12-mm thoracoports are placed under direct vision avoiding injury to intrathoracic structures and the intercostal neurovascular bundles. Once completed, the operating table is positioned as described above (A), slightly reverse Trendelenburg, as necessary, reverse flexion at the waist, and 15 to 30° rotation posteriorly for the upper lobes, and anteriorly for the lower lobes. The robot is then rolled into position approximately 30° from directly over the head and in line with the camera port and the Target. For lower lobes, the robot is brought in anteriorly (C and E) and for upper lobes, posteriorly (B and D). To position the robotic arms, a triangle is drawn on the chest, with the apex of the triangle being the camera port site and the base of the triangle being the Target. The right and left arms are then placed 10 to 12 cm from the camera port outside of the triangle and positioned so that the robot arms will be working toward the base of the robotic chassis. AN = anesthesiologist; S = surgeon; SN = scrub nurse; TS = table-side surgeon; TV = television.

Preparation for docking: robot position. Using the robotic videoscope, all four 10-12-mm thoracoports are placed under direct vision avoiding injury to intrathoracic structures and the intercostal neurovascular bundles. Once completed, the operating table is positioned as described above (A), slightly reverse Trendelenburg, as necessary, reverse flexion at the waist, and 15 to 30° rotation posteriorly for the upper lobes, and anteriorly for the lower lobes. The robot is then rolled into position approximately 30° from directly over the head and in line with the camera port and the Target. For lower lobes, the robot is brought in anteriorly (C and E) and for upper lobes, posteriorly (B and D). To position the robotic arms, a triangle is drawn on the chest, with the apex of the triangle being the camera port site and the base of the triangle being the Target. The right and left arms are then placed 10 to 12 cm from the camera port outside of the triangle and positioned so that the robot arms will be working toward the base of the robotic chassis. AN = anesthesiologist; S = surgeon; SN = scrub nurse; TS = table-side surgeon; TV = television.

Docking: position of the robotic arms. The robotic chassis is rolled toward the patient to a point where, when the video arm is in position but not attached to the thoracoport, the base of the robotic chassis is one fist away from the base of the central unit of the videoscope arm. (A) Once the chassis is locked into correct distance from the operating table, the “setup” button or joint is compressed to pull the robotic arm into position. Typically, it is best to have it at a fairly high and lateral position to achieve maximal function. Then, the robotic ports are placed through puncture wounds into the chest (B). Once in position, the “clutch” button or joint (C) is pressed to direct the instrument guide toward the visualized Target.

Robotic port in the thoracoport technique. The 8-mm robotic port can be inserted into the 10-12-mm thoracoport, if desired, to reduce the number of puncture wounds used for the procedure. For the upper and middle lobes specifically, the most superior-anterior thoracoport can be used instead of making an additional incision. If performed, it is best to place the robotic port flush with the thoracoport (B). If placed as in (A), the computer feedback to the robotic controls will make it difficult to use this arm. It is important to keep the robotic port flush with the thoracoport.

Start of the right upper lobectomy. The superior pulmonary vein to the right upper lobe is identified and the adjacent nodal tissue is taken en bloc with it. Effort should be made to separate it from and preserve the middle lobe vein. v. = vein.

Division of the right upper lobe pulmonary artery. The hilar tissue is resected away from the right upper lobe pulmonary artery to expose it for transection. a. = artery; ULPV = upper lobe pulmonary vein.

Division of the right upper lobe bronchus. After the division of the recurrent branch of the pulmonary artery to the right upper lobe and clearing of the hilar tissue between the right upper lobe and the bronchus intermedius, the right upper lobe is divided with an endostapler.

Division of the minor fissure of the right upper lobe. The 3.5-mm endostapler is introduced through the anterior-superior thoracoport to divide the minor fissure, completing the right upper lobectomy.

Resection of the subcarinal lymphatic tissue. The lung is retracted anteriorly and the harmonic scalpel or hook cautery can be used to resect the nodal tissue from the airway and the esophagus. The right paratrachea is addressed in the same fashion, resecting all the lymphatic tissue cleanly from the trachea and the superior vena cava. However, in many of our cases, the cervical mediastinoscopy has proven to provide a complete resection.

Division of the right middle lobe pulmonary vein for the right middle lobectomy. Division of the right middle lobe vein exposes the right middle lobe bronchus. RMLA = right middle lobe pulmonary artery; RMLB = right middle lobe bronchus; RMLV = right middle lobe vein.

Completion of the hilar division of the right middle lobe. The right middle lobe vein is divided first, then the bronchus, and then the pulmonary artery.

Start of the left upper lobectomy. The superior pulmonary vein to the left upper lobe is identified and the adjacent nodal tissue is taken en bloc with it. LULPV = left upper lobe pulmonary vein.

Left upper lobe bronchus transection. After the vein is ligated, the left upper lobe bronchus is divided with a 3.5-mm endostapler. LULB = left upper lobe bronchus.

Completion of hilar resection of the left upper lobe. The remaining arterial branches of the left upper lobe are taken with an 2.5-mm endostapler.