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Robotic Lobectomy

      Lobectomy has the highest cure rate for lung cancer. Current standards define lobectomy as an anatomic resection of the lobe with individual ligation of the vein, artery, and bronchus. Management of the lymph nodes is controversial, but resection and pathological analysis of 11 to 16 nodes including two to three different mediastinal stations and the hilum appear to provide sufficient staging information.
      • Ludwig M.S.
      • Goodman M.
      • Miller D.L.
      • et al.
      Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer.
      • Gajra A.
      • Newman N.
      • Gamble G.P.
      • et al.
      Effect of number of lymph nodes sampled on outcome in patients with stage I non-small-cell lung cancer.
      In the 1960s lung resection morbidity and mortality were high but improved with greater knowledge of the anatomy and superior surgical, anesthetic, and postoperative care. Video-assisted thoracic surgery (VATS) lobectomy evolved in the early 1990s to an efficient oncologic procedure that appears to have less blood loss, surgically related disability, pain, and hospital stay compared to lobectomy by thoracotomy
      • Cheng D.D.R.
      • Kernstine K.
      • Stanbridge R.
      • et al.
      Video-assisted thoracic surgery in lung cancer resection, a meta-analysis and systematic review of controlled trials.
      (Fig. 1). With the introduction of robotics in the later 1990s, lobectomies and minor thoracic procedures were performed initially. The time for procedure completion was long and the early robotic equipment was cumbersome. In the United States, the first thoracic procedures were performed in 2002. Adopting this technology for the lobectomy is slow, likely due to the expense and the knowledge necessary to use the device.
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      Figure 1Rigidity 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.
      Compared with VATS, robotic thoracic surgery is an advancement in technology, providing a three-dimensional view of the thoracic cavity and the dexterity necessary to carefully perform precision surgical maneuvers in small spaces (Fig. 2). Simply, VATS does not offer these features and as a result may be less appealing to thoracic surgeons. It is estimated that only 5 to 10% of thoracic surgeons perform minimally invasive lobectomies. For some who perform it, VATS lobectomy may not sufficiently address the hilar structures and the mediastinal, lymph node-bearing tissues. As a result, conversions to open thoracotomy are 10 to 15%.
      • Swanson S.J.
      • Herndon 2nd, J.E.
      • D'Amico T.A.
      • et al.
      Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study.
      Robotic surgery may reduce conversions and simplify minimally invasive thoracic surgery. Furthermore, robotic surgery is at the earliest developmental stage and continued advancements will be made to improve the equipment. The purpose of this article is to provide the reader with the details of a robotic lobectomy with the currently available equipment. With more thoracic surgeons using the technology, robotics will continue to evolve, enhancing the speed, accuracy, and safety of the minimally invasive lobectomy.
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      Figure 2Comparison 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.
      The indications for robotic resection are similar to the VATS and open thoracotomy technique, but robotics may, in many cases, be performed without single-lung ventilation and enable the safe resection of larger tumors and additional structures, such as the chest wall and pericardium (Table 1). Comparing the three potential approaches, open thoracotomy, VATS, and robotics, the open thoracotomy approach provides the ability to palpate the extent of the tumor at the expense of increased pain, reduced postoperative pulmonary function, and longer recovery time. Approximately 20 to 30% of patients will recur locally. VATS, on the other hand, provides a better view of the thoracic cavity and still allows some palpation with a reduction in pain, improved postoperative function, and potentially earlier return to preoperative/predisease status.
      • Cheng D.D.R.
      • Kernstine K.
      • Stanbridge R.
      • et al.
      Video-assisted thoracic surgery in lung cancer resection, a meta-analysis and systematic review of controlled trials.
      The likelihood for local recurrence and disease-free survival has not been sufficiently determined, given that most studies are retrospective. The robotic approach may potentially further reduce the likelihood for local recurrence as a result of the improved visibility and dexterity, and minimize pain and debility by decreasing the torque on the intercostal nerves adjacent to port sites. Using robotics, resection of the aorto-pulmonary window, hilar, subcarinal, and paratracheal lymph can be performed simply. The left paratracheal area from the left-sided approach is more challenging due to the presence of the aorta, but as techniques and equipment evolve, will likely be achieved as well. As with any device, the capability of the robotic surgical instrument is surgeon and technology dependent.
      Table 1Comparison of Open Thoracotomy Lobectomy to the Video-Assisted Thoracoscopic (VATS) Lobectomy to the Robotic Lobectomy
      No. of IncisionsTactilePatient Preoperative Functional StatusRequirement for Single-Lung VentilationPostoperative PainPostoperative PerformanceLocal RecurrenceDisease-Free Survival
      Open thoracotomy2-3 dependent on number of drains placedExcellentLarge incisions appear to increase pain and compromise postoperative lung function and recoveryNot absolutely requiredCommonly significant and debilitating, recovery in 4-6 weeks for majority of patientsCompromised return to normal function20-30% will recur locallyGood for early, nonlocally advanced disease
      VATS2-4; often an access incision ± rib spreadingGood to excellent, dependent on size of access incision and location/size of the tumorMay have benefit in the compromised patientRequired for most all patientsAppears to be lessReturn to preoperative status appears to be improved, studies underwayLikely similar to or potentially worse, dependent on the care of the hilar/mediastinal dissectionNot clear yet. Bias as patients selected with smaller, less locally advanced disease
      Robotic4-6None, requires significant preoperative planning and familiarity with the anatomy and its variationsMay have benefit in the compromised patientNot absolutely requiredMay potentially be the leastReturn to preoperative status, appears to be improved, studies underwayPotentially with cleaner dissection of nodal tissue may reduce likelihood for local recurrencePotentially greater applicability of minimally invasive surgical resection and similar results for even locally advanced disease

      General Considerations

      The currently available Food and Drug Administration approved robotic system is the Intuitive Da Vinci (Sunnyvale, CA; www.intuitivesurgical.com) that comes in two models, the Da Vinci and the Da Vinci S systems (Fig. 3). They are similar in that they have three components: (1) an operating console for the surgeon; (2) a “praying mantis-like” robotic arms chassis from which spring the robotic video unit and three robotic arms; and (3) the electronic communications tower system between the console and the chassis. Compared with the original Da Vinci system, the newer Da Vinci S provides some enhancements. Thoracoport attachments can be connected more easily to the chassis arms and the robotic arms are collapsible, resulting in less arm collision outside the patient, and adds more functionality over a wider range of movement. In addition, there is a high-definition screen and patient monitoring system within the operator-console. Unfortunately, the detachable and replaceable surgical instruments that attach to the robotic arms are not interchangeable between the two systems. Therefore, owning and servicing both types of units are difficult. The S system is preferable for thoracic surgical purposes as the collapsible arms and a greater range of motion are a benefit for thoracic procedures. Hopefully, new robotic systems will be developed by Intuitive and other technology companies that will provide a less expensive and less cumbersome alternative to the currently available Da Vinci system.
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      Figure 3Intuitive 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.
      Before performing a robotic lobectomy, the surgeon and the surgical team need to be educated in the technology. Intuitive Inc. offers an educational series in Sunnyvale and at several centers in the United States. These are 1- to 2-day courses and combine instruction in the mechanics as well as animal and cadaver experience. Contacting your Intuitive representative will be the first step to achieving the knowledge and skills necessary to perform the first case, especially since most hospitals now have regulations that will allow only those certified in robotics to perform a procedure. Several companies and institutions are working on simulators but are not yet available for general use.
      The final and most important aspect is surgeon proctoring. Your hospital should be encouraged to provide proctoring on each of the thoracic procedures to be performed until each surgeon feels comfortable with the patients, strategies, and the Da Vinci equipment.
      Before each case and somewhat unlike other surgical procedures, adequate time should be given for procedure planning. Inappropriate port placement or patient positioning can result in a long frustrating procedure for the entire team. In planning, start with the computed tomogram to select the correct approach for the patient. We routinely perform cervical mediastinoscopy on our patients, widely resecting three to five nodal stations. We recommend the novice team to initially select healthier patients with peripheral lesions less than 2 to 3 cm in size who have not had prior thoracic procedures and no evidence of pleural symphysis on the chest tomogram. The anesthesiologist is critical in this procedure but becomes less important with greater robotic experience. For the first several cases, providing single-lung ventilation is important and for all cases adequate hemodynamic support is essential for a successful procedure. The operating room team is another key element. The experienced scrub nurse/technician and operating room circulator can save time by having the correct equipment available to anticipate issues that may arise. The team should be prepared for a disaster and be knowledgeable of the plan should a problem arise. We always have a thoracotomy tray in the room, but we also include a ring clamp with a heavy sponge attached and ready for immediate use (Fig. 4). The clamped sponge can be placed through an extended, previously made port site or a new incision made to provide the access necessary to compress a severely bleeding vessel. The final important aspect for a good case is the bedside assistant surgeon. This individual should be a trained in minimally invasive surgery, capable of performing a thoracotomy if need be. The coordination of the surgical team will dictate the flow and efficiency of the procedure.
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      Figure 4Ring 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.

      Anesthesia Considerations for Robotic-Assisted Lung Resection

      The same principles for thoracoscopic surgery can be applied to robotic-assisted lung resection. The combination of patient position, one-lung anesthesia, and surgical manipulation alters ventilation and perfusion. Double lumen intubation is the preferred method for lung isolation during robotic-assisted lobectomy because the lung collapses faster and provides ready access for bronchoscopic evaluation of the airway during surgical resection. Careful attention should be given to airway devices as changes in body position may cause tube migration. Single-lung anesthetic management is somewhat more challenging during the robotic lobectomy due to the presence of the robot chassis that is stationed over the head of the patient.
      Robotic-assisted thoracic surgery may be enhanced by continuous intrathoracic CO2 insufflation, which may increase airway pressures. We often use CO2 intrathoracic pressures of 10 to 15 mmHg. We have found that gradual pressure elevations are less likely to result in hemodynamic compromise. Increasing the intrathoracic pressure can decrease venous return and cardiac compliance. At the same time, the dependent lung develops higher airway pressures and ventilation can become difficult. During surgery, as necessary, the FiO2 should be maintained at 1.0 and the airway pressure below 30 cmH2O, if possible. The ventilation should be adjusted to keep Paco2 at approximately 40 mmHg. Blood gasses should be obtained on a routine basis and the application of ventilated-lung positive end-expiratory pressure or collapsed-lung continuous positive-airway pressure may assist with oxygenation.

      Case Setup

      We prefer double-lumen intubation to provide single-lung ventilation. For the surgical procedure, single-lung ventilation decreases lung movement, improves the visibility, and reduces blood supply to the pulmonary parenchyma to allow for precise dissection. After intubation, the patients are placed in the lateral decubitus position, the operated side exposed. As tolerated, all patients are positioned in the reverse Trendlenberg position (Fig. 5). This allows for the diaphragm/intra-abdominal contents to drop away from the operative field, increasing exposure, and allows for any bleeding that might occur to pool away from the operative field. For upper and middle lobectomies, the patient bed position is rotated 15 to 30° posteriorly and, for lower lobectomies, 15 to 30°, anteriorly. This slightly improves the visibility of the hilum but is not critical. The operating table is then positioned so that the head of the patient goes in toward the robotic arm chassis; the precise position is discussed later. Once the robot arms are in place, the patient position cannot be changed, unless the robotic arms are removed from the patient.
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      Figure 5Patient 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.
      Using the preoperative chest computed tomogram, the topographical location of the hilum is identified in relation to the sternal angle and the tip of the scapula and drawn on the patient (Fig. 6). This is typically a 4-cm circle, the center of which is 2 to 3 cm superior and anterior to the tip of the scapula. Then, four other marks are made to estimate the location of the thoracoports. The first is the most anterior-superior port site, usually in the anterior axillary to lateral clavicular line in the fourth intercostal space (ICS). The next port is the inferior-anterior port, located in the anterior axillary line in the eighth to ninth ICS. The superior-posterior site is marked at roughly the fourth ICS posteriorly about 8 to 10 cm from the posterior spinous processes so that it enters the chest at or just below the posterior aspect of the major fissure. The inferior-posterior port site is located at the 10th ICS along the same longitudinal line as the superior-posterior port site. Both posterior ports are often placed just lateral to the longitudinal spinous muscle and are chosen to provide the greatest flexibility to the operating team and the efficiency of the robotic instruments, allowing the passage of staplers and suctioning and retracting equipment. For lower lobectomies, the most inferior-posterior port site should be approximately 8 to 10 cm anterior along the same lateral plane. For the novice team, a potential thoracotomy site should be drawn to allow for quick thoracotomy should the occasion arise.
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      Figure 6Port 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).
      After surgically preparing the operating site, placing surgical drapes, and placing the thoracoports, the robot is then brought into position so that the previously marked hilar area will be centrally located between the center portion of the robot chassis and the intended location of the videoscope (Fig. 7). The videoscope will be placed into the anterior-inferior port for upper and middle lobes and the posterior-inferior port for the lower lobes. To achieve the greatest instrument range, the robotic chassis is set into position where the video arm base is a fist breadth from the first base joint of that arm to the chassis base of that arm (Fig. 8). Before attaching the videoarm to the port, use the flexibility of the undocked robotic videoscope to visualize placement of the remaining two robotic arms. Once the robot is in position, the robotic arms are placed outside a triangular area marked between the camera port and the hilum. To reduce the number of puncture wounds from six to five, the surgical team can for the upper and middle lobes place the leftward robotic arm into the upper anterior 10-12-mm thoracoport (Fig. 9). We prefer and suggest using six port sites for lobectomies.
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      Figure 7Preparation 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.
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      Figure 7Preparation 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.
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      Figure 8Docking: 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.
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      Figure 9Robotic 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.
      Instrument choice is surgeon dependent. Initially, it might be helpful to place the ProGrasp or the Cadiere Grasper in the left arm and the Harmonic Scalpel or Hook Cautery in the right arm. We use the Landreneau ring grasper (Teleflex Medical; Weck Corp., Triangle Park, NC) to grasp the lobe just superior to the hilar location where the surgery is planned and, once set to the best location for visibility, is rarely moved during the case. The weight of the instrument provides sufficient traction and the assistant can let the clamp sit at rest, directing their efforts to other locations. For upper and middle lobes, the grasper is brought through the posterior-superior port and, for lower lobes, can be brought through either the upper anterior or the upper posterior ports, the goal being to provide exposure and counter-tension for dissection. Even friable lung can be grasped with the Landreneau with little, if any, damage to the lung.
      Once the chosen instrument arms are placed into the robotic arms, the procedure is ready to be performed. Grasping the lung or friable hilar structures with any of the robotic grasping instruments should be avoided to minimize the risk of injury and bleeding. Ligating the pulmonary vessels in succession, pulmonary vein first then pulmonary artery, is considered simplest and provides the exposure necessary to safely perform an anatomical resection, but some would criticize, without scientific merit, that ligating the veins first results in pulmonary edema and an edematous lung, making the eventually completed lobe specimen more difficult to remove from the chest.

      Right Upper Lobectomy

      At the outset of the case, the 0° scope allows a wider view of the chest, but once the hilar dissection begins, a 30° down position might provide a better view. After sitting at the operating console, at the rightward side of the console panel, set the movement detail to normal and turn off the fourth arm and make sure that the video site is set to the appropriate setting, from 0° or 30° down. The operative approach is then directed to the upper anterior hilum. The harmonic scalpel is used to divide the mediastinal tissue/pleura adjacent to the phrenic nerve up to the level of the upper hilum and azygous vein. The ProGrasp is used to sweep the tissue cleanly away from the proximal pulmonary vein. The bifurcation between the right middle and right upper lobe veins is identified. Using the ProGrasp and the Harmonic scalpel, the hilar lymphatic tissue between the middle and upper lobe veins is bluntly cleaned and lifted away from the intermedius and middle lobe pulmonary arteries. The hilar tissue is bluntly swept toward the resection specimen, clearing the pulmonary artery and under-aspect of the right upper lobe vein. Blunt and Harmonic scalpel dissection are used to clear away the tissue from the azygous vein and continue the en-bloc dissection to the main pulmonary artery. The ProGrasp is used like a spatula to help push the tissue toward the resected specimen. The hook cautery or the Harmonic scalpel may be used at this point to clean the main pulmonary artery of hilar tissue. An 8 cm 0 silk tie is passed around the vein to retract it away from the pulmonary artery beneath it. Passed from the inferior-posterior port site, an Ethicon Vacular endostapler is used to transect the right upper lobe pulmonary vein (Fig. 10). Once the pulmonary vein is ligated, the Landreneau clamp may need to be readjusted to provide better retraction to expose the main pulmonary artery and its branches.
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      Figure 10Start 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.
      The next step is to identify and clean the pulmonary artery branches. The cephalad aspect of the pulmonary artery is cleared of hilar tissue and, using the ProGrasp to sweep and grasp the tissue, the pulmonary artery to its junction with the middle lobe artery and the recurrent branch are cleanly exposed. Each can be identified at its origin and ligated with the vascular endostapler, exposing the nodes just anterior to the main stem bronchus (Fig. 11). Once these are cleaned from the anterior aspect of the airway, the bifurcation of the bronchus intermedius and the right upper lobe is cleared with the ProGrasp and the Harmonic or hook cautery. Slight bleeding commonly occurs here and visibility can be improved with suctioning. The temptation to punch into tissue or blindly pass around the right upper lobe airway should be avoided. Rather, the Landreneau lung retractor retracting the right upper lobe is released and the lobe parenchyma can be retracted anteriorly to expose the posterior hilum and airway. At this point, the posterior aspect of the major fissure can be identified and if not already separate, the posterior aspect of the major fissure may be divided by using the 3.5- or 4.8-mm endostapler. Also, the pleura over the posterior hilum can be divided and swept toward the specimen. Ideally, prominent bronchial arteries should be preserved to provide blood supply to the eventually divided bronchial stump. Cleaning the bifurcation between the bronchus intermedius and the right upper lobe bronchus will provide better exposure to the airway before dividing it. Also, in this location, the subcarinal lymph nodes may be identified and resected (see Fig. 14). The hook cautery or the Harmonic scalpel is suited for this procedure. Dissected specimens are then placed in an Endobag and brought out through one of the thoracoports. There may be one to two bronchial arteries that pass within the nodal tissue and, by avoiding grasping the tissue and using the ProGrasp to push away the tissue from the bronchus, should enable the visualization and as necessary ligation of these large vessels. Bleeding in this area can significantly reduce the visibility and increase the hazards of dissection.
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      Figure 11Division 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.
      Once the subcarinal nodes are excised, the attention is then turned back to the anterior aspect of the main bronchus. To do so, the lung is again retracted posteriorly, grasping the intended specimen with the Landreneau ring clamp from the posterior-superior port. As a result of the posterior dissection accomplished earlier, there should be minimal tissue in the angle between the bronchus intermedius and the right upper lobe airway and it helps to confirm the anatomy of the right upper lobe origin. The ProGrasp is then carefully passed behind the right upper lobe airway and a silk tie is used to retract the bronchus to facilitate stapling (Fig. 12). Through the posterior-inferior thoracoport, a 3.5-mm endostapler is passed and clamped down but not fired. To make certain that the correct airway has been identified, we perform two maneuvers: First, the anesthesiologist bronchoscopically examines the airway and the surgeon visually confirms the location of the bronchoscope by the transilluminated light through the airway. Second, while the CO2 insufflation is turned off, the remaining lung is inflated, making certain that it can both inflate and deflate. After the bronchial transection, the hilum and mediastinum is flooded with irrigation fluid and the remaining lung inflated to 25 cm H2O to make certain there is no leak at the bronchial stump. If one is found, the two robotic needle holders are placed in the two instrument arms and a 5-0 Prolene with an RB-1 needle can be used to provide an airtight closure of the bronchial stump.
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      Figure 12Division 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.
      Now with all of the hilar structures and the bronchial stump transected, the right and left arm instruments are each changed to a ProGrasp grasper. They are then used to position the right upper lobe and the middle lobe fissure (Fig. 13). The anterior-superior port site is used to place a 3.5-mm endostapler to complete the fissure. Identification of the middle lobe vein assists in identifying the anterior aspect of the minor fissure. Once the fissure has been completed, the resected lobe is placed into the lower thorax, out of the way of the next series of dissections (Fig. 14). First, the anterior aspect of the bronchus intermedius and right mainstem airway are examined for any other nodal tissue. The pulmonary artery is gently retracted, not grasped, away from the main stem airway, exposing nodal tissue along the anterior aspect of the airway. This dissection is continued along the anterior aspect of the tracheal bifurcation. To improve access, the origin of the azygous vein at the superior vena cava may need to be transected. The mediastinal pleura along the superior aspect of the azygous vein and the posterior aspect of superior vena cava are incised. The right and anterior paratracheal tissue (levels 10R, 4R, and 3) is resected up to the level of the origin of the innominate artery. The level 2R or upper paratracheal tissue may be additionally resected, and there is risk of injuring the recurrent laryngeal nerve as the nerve crosses over the right subclavian artery. Even using the Harmonic scalpel at this location will not eliminate the risk of permanent or temporary palsy. For patients who have a nearly complete fissure between the right middle and right lower lobes, to prevent postoperative torsion of the right middle lobe, the most anterior-inferior aspect of the right middle lobe is stapled to the most inferior-anterior aspect of the right lower lobe with a knifeless stapler.
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      Figure 13Division 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.
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      Figure 14Resection 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.
      With all of the nodal tissue areas removed and the lobe completely transected, a medium-sized Anchor bag is inserted into the apex of the chest from the anterior-superior thoracoport site. The lobe is then pushed into the bag. Once completed, carbon dioxide is turned off and the right pleural space vented by opening up the air vents of each of the four ports. Robotic instrument and arms are removed and the robot pushed away from the patient.

      Right Middle Lobectomy

      The patient, table position, ports, and instrumentation are the same as for an upper lobectomy. With the Landreneau ring clamp from the posterior-superior port site grasping the anterior aspect of the middle lobe providing counter-tension for the hilar dissection, the anterior hilum is approached first. A harmonic scalpel is used to dissect along the posterior aspect of the phrenic nerve and the tissue is cleaned en bloc with the eventual specimen. Blunt dissection is performed with a sweeping motion of the ProGrasp to identify the origin of the upper pulmonary vein. The dissection is continued into the hilum where the middle lobe vein can be found branching from the upper lobe vein. Hilar tissue from the inferior aspect of the vein is cleaned from the pericardium and the origin and superior aspect of the inferior pulmonary vein. The ProGrasp is used as an angled retractor to expose the main pulmonary artery to the lower lobe and the middle lobe pulmonary artery. Once identified, a silk suture is passed around the vein and a 2.5-mm endostapler is passed from the posterior-inferior thoracoport. With the vein divided, this exposes the hilar tissue surrounding the pulmonary artery branch or branches to the middle lobe and the origin of the right middle lobe bronchus. After thoroughly cleaning the origin of the vessels and bronchus, a silk suture is passed around the bronchus, retracting it laterally, pulling the lobe out of the hilum, exposing the origin of the bronchus intermedius. The middle lobe bronchus is transected with a 3.5-mm endostapler through the same port. The Landreneau is replaced, grasping the lung closer to the hilum to provide better exposure of the anterior hilum. Each of the arteries is then ligated in the same fashion, resecting the hilar tissue cleanly from the lower lobe/intermedius pulmonary artery. The bronchial stump is then covered with irrigant, using the suction-irrigator. If a leak is found, the bronchus is further secured with one or more 5-0 Prolene sutures with an RB-1 needle as described (Fig. 15).
      Figure thumbnail gr15
      Figure 15Division 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.
      Once the hilum is completely cleaned, attention is turned to the minor fissure. Both robotic arms are exchanged for a ProGrasp or Cadiere grasper. For those patients who have an incomplete fissure, the right arm grasps the right upper lobe and the left arm grasps the middle lobe. Through the posterior-superior port site, the 3.5- to 4.8-mm endostapler, the fissure is created. Once transected, the lobe is placed in the lower aspect of the chest cavity.
      To remove the subcarina and right and anterior mediastinal tissue, the same exposure and dissection can be performed as with the upper lobe. Once the nodal tissue is removed, the small or medium Anchor endobag is introduced into the superior-anterior thoracoport. Once the specimen is placed in the endobag, it is brought out through the port site as with the right upper lobe (Fig. 16).
      Figure thumbnail gr16
      Figure 16Completion 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.

      Right Lower Lobectomy

      Using the body position as demonstrated in Figs. 6 and 7, the left robot arm instrument is a ProGrasp and the right arm is a Harmonic scalpel. Through the anterior-superior thoracoport, the Landreneau ringed clamp is used to retract the most lateral inferior aspect of the lower lobe laterally and superiorly, placing the inferior pulmonary ligament on tension. The inferior pulmonary ligament is divided with all of the adjacent nodal tissue, completely cleaning the pericardium at this location and avoiding injury to the esophagus and vagus and phrenic nerves. The lung is retracted anteriorly to expose the posterior aspect of the right lower lobe. The tissue along the esophagus and vagus nerve is resected, taking the hilar/mediastinal tissue with the intended specimen and exposing the inferior pulmonary vein that is then divided with a 2.5-mm endostapler. Once this is completed, the dissection is continued along the inferior aspect of the right bronchus intermedius up to the carina and deep to the pericardium, avoiding injury to the esophagus and the left main stem bronchus. Once resected, the subcarinal tissue is removed from the chest through one of the available thoracoports, usually requiring a separate endobag. The superior aspect of the right lower lobe is divided with a 3.5-mm endostapler to the intrafissure pulmonary artery.
      The lung is then retracted posteriorly, exposing the anterior hilum to allow for complete resection of all of the hilar tissue in that location. The ProGrasp is used to bluntly dissect the anterior and lateral aspect of pulmonary artery to the right lower lobe and expose the right middle lobe airway. For those patients who have a complete fissure, the lateral aspect of the pulmonary artery may be exposed, allowing the pulmonary artery to be completely exposed and encircled at this juncture and allowing for transection of the artery. The hilar tissue along the anterior aspect of the bronchus can then be transected with a Harmonic scalpel, exposing the base of the inferior aspect of the middle lobe and continued to the superior aspect of the superior segment bronchus. If there is an incomplete fissure, the dissection is continued to the deep aspect of the pulmonary artery.
      The Landreneau is repositioned closer to the hilum to expose the posterior aspect of the hilum. The right middle lobe airway origin is identified. The right arm Harmonic scalpel instrument is replaced with a ProGrasp or a Cadier grasper. Just along the superior aspect of the superior segment airway, the ProGrasp is passed along the bronchus intermedius. A silk suture is passed around the airway and used to retract the airway away from the pulmonary artery. A 3.5-mm stapler is used to obliquely divide the bronchus. The stapler is not fired until it is verified that the remaining lung, especially the middle lobe, can be inflated and deflated. However, if it appears that the stapler does not adequately allow inflation or deflation, the superior segment and basilar segment airways may be taken separately. This exposes the posterior aspect of the pulmonary artery, where a suture is passed again for retraction and transected with a 2.5-mm endostapler from the superior-posterior thoracoport. The remaining fissure is then completed with a 3.5- or 4.5-mm endostapler. Once completed, this exposes further hilar tissue that should be resected separately and brought out through one of the available thoracoports. The bronchial stump is then covered with irrigant. If a leak is found, the bronchus is further secured with one or more sutures of the RB-1 needle with 5-0 Prolene. Once the lung has been completely resected, anterior pericardial tissue/vestige of the thymus supplied by the inferior thymic artery is then prepared by cleanly separating it from the pericardium and away from the sternum, from the diaphragm up to the mid-mediastinum. The vascularized pedicle may be sutured to the airway and the base of the resection with 3-0 Vicryl on an RB-1 needle.
      Further nodal tissue can be removed from the superior hilum by retracting the lower lobe inferiorly and creating a plane along the superior aspect of the right upper lobe bronchus and the pulmonary artery as described for the right upper lobectomy. The lobe is then placed in an Anchor endobag and brought out through the most anterior-superior port site.

      Left Upper Lobectomy

      Using the left upper chest approach seen in Figure 7D with the ProGrasp in the left robotic arm and the Harmonic scalpel in the right arm and a 30° down scope, the dissection is started along the posterior aspect of the phrenic nerve and continued into the aorto-pulmonary window, exposing the under-aspect of the aortic arch. The Landreneau clamp is brought through the posterior-superior thoracoport and placed on an anterior aspect of the lobe directly anterior to the superior pulmonary vein. Then, the tissue in the aorto-pulmonary window is completely resected. This can be removed separately in an endobag.
      Using blunt dissection, the origin of the superior vein is dissected cleanly, identifying the bifurcation between the upper and lower pulmonary veins and dissecting the tissue from the posterior and anterior aspect of the main pulmonary artery. Then under direct vision, the pulmonary vein is gently teased away from the pulmonary artery and main stem airway underneath. This is performed by increasing the amount of dissection superiorly and inferiorly until the entire vein is encircled. One should make certain that the upper lobe vein is transected as the upper and lower lobe vein may have a common trunk. The 2.5-mm endostapler is brought through the inferior-posterior port site. Once transected, the Landreneau clamp is repositioned on the anterior aspect of the left upper lobe at a location closer to the hilum to expose the airway. It may be difficult to identify the upper lobe bronchus from the main stem bronchus. A couple of techniques may be used for the identification. First, the anterior-inferior aspect of the major fissure may be divided with a 3.5-mm endostapler brought through the posterior-inferior port site. Another way is to follow the left main pulmonary artery from its origin and the medial aspect of the artery will run into the bifurcation of the left upper and left lower airway. To expose the superior aspect of the airway, the first one to two branches of the pulmonary artery are cleaned of hilar tissue at the origin and transected with a 2.5-mm endostapler introduced from the posterior-inferior port site. Further dissection of the superior hilum and nodal tissue is performed. The upper lobe bronchus is dissected from the pulmonary artery and a silk suture is passed around it. Assistance with retraction using the EndoPeanuts and suctioning by the assistant surgeon helps to perform this dissection of the subcarina with adequate visualization. Retraction of the pericardium will provide sufficient exposure to resect subcarinal tissue, avoiding injury to the esophagus underneath. Also, as long as the dissection is anterior, injury to the posterior aspect of the airway can be avoided, as injury is more likely when a left-sided balloon single-lung technique is used. The balloon pushes the membranous airway outward and increases the likelihood of bronchial membranous injury by the surgeon. These nodes are then brought out in an endobag. If this is felt to be too difficult, then the upper lobe may be pushed into the anterior aspect of the chest cavity with the Landreneau grasper. The tissue from the superior aspect of the pulmonary vein and the inferior aspect of the airway can be resected after the mediastinal pleura are incised. Again the EndoPeanut or the suction-irrigator through the inferior-posterior port site is used to help retract adjacent structures from the mediastinal tissue to be resected (Fig. 17).
      Figure thumbnail gr17
      Figure 17Start 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.
      Next, the left upper lobe bronchus is transected with a 3.5-mm endostapler from the posterior-inferior port site. Before firing the stapler, as with the other lobectomies described, the correct airway is confirmed with a bronchoscope and then additionally confirmed by inflating and deflating the lower lobe. The CO2 insufflation is turned off for this examination. Once the airway is transected, further dissection is performed to remove all hilar tissue from the deep, anterior, and lateral aspect of the pulmonary artery. Nodal tissue that is not attached to the main specimen should be removed in a separate endobag. The Landreneau is again placed closer to the hilum and in some cases the specimen-side left upper lobe bronchus stump to expose the underlying lower lobe pulmonary artery and the pulmonary artery branches to the lingua. Using the ProGrasp or Cadiere in each arm, the origin of each of the pulmonary arteries is transected with a 2.5-mm endostapler from the posterior-inferior port site. Once all of the arteries have been transected, the major fissure is completed with the Ethicon Echelon 60-mm yellow load stapler (Fig. 18). Once completed, the lobe is placed into the inferior aspect of the chest cavity and the hilum is then covered with irrigant using the suction-irrigator. If a leak is found, the bronchus stump is repaired with one or more sutures of 5-0 Prolene with an RB-1 needle.
      Figure thumbnail gr18
      Figure 18Left 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.
      To complete the hilar and left paratracheal lymphatic resection, dissection is then performed in the superior hilum on the cephalad aspect of the pulmonary artery and to the lateral aspect of the vagus nerve. A Harmonic scalpel is advisable during this portion of the procedure to reduce lateral heat injury to the recurrent laryngeal nerve. Under direct vision, all of the nodal tissue is swept bluntly from the aorta, left main stem bronchus, and the trachea. The specimen once resected is brought out through an endobag.
      The resected lobe is then placed in an endobag and brought out through the anterior-superior port site and the case completion is performed as outlined in the Postoperative Management section (Fig. 19).
      Figure thumbnail gr19
      Figure 19Completion 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.

      Left Lower Lobectomy

      The patient, table position, and the thoracoport sites are as described in Figures 6 and 7, using first a 0° and later a 30° down scope. The dissection is initiated after the Landreneau ring clamp is placed through the anterior-superior thoracoport site and grasped on the most lateral and inferior aspect of the left lower lobe, exposing and placing tension on the inferior pulmonary ligament. In the left robotic arm is the ProGrasp and the right robotic arm is the Harmonic scalpel or hook cautery. The inferior ligament may be taken cleanly from the pericardium and esophagus, resecting adjacent hilar/lymphatic tissue, avoiding injury to the esophagus, vagus, and phrenic nerves. The dissection is continued to the inferior pulmonary vein at its origin from the pericardium. Then, the lung is retracted anteriorly with the Landreneau to expose the posterior hilum and to clean all of the hilar tissue posteriorly. The Landreneau may be removed at this point and placed closer to the inferior pulmonary vein. Then, using the suction-irrigator or an EndoPeanut for retraction, the subcarina is dissected bluntly cleaning all lymphatic tissue, avoiding injury to the left and right mainstem airways and the underlying esophagus. The specimen is brought out in an endobag.
      At this point, the right and left arm instruments are both ProGrasps or Cadières. At the upper aspect of the major fissure, the left upper and lower lobes are grasped separately on either side of the fissure. The superior aspect of the fissure is then created with a 3.5-mm endostapler through the posterior-superior port site to the point of the main pulmonary artery. Once completed, the inferior aspect of the fissure is divided to the basilar pulmonary artery, after the takeoff of the lingular branches. The 3.5-mm endostapler is introduced from the anterior-inferior port site. From the posterior-superior port site, the Landreneau clamp then provides exposure of the inferior pulmonary vein by grasping the lung lateral to the pulmonary vein and retracting is cephalad and laterally. After widely dissecting the adjacent pulmonary ligament and mediastinal tissue with a Harmonic scalpel or Hook cautery, a silk is passed around the vein and is transected with a 2.5-mm endostapler passed through the anterior-superior port site. The lung is again retracted anteriorly and the posterior hilar tissue is resected away from the hilum, exposing the bronchial bifurcation between upper and lower lobes. Confirmation of the bifurcation is made by locating the pulmonary artery at that location. The dissection is continued along the superior aspect of the bronchus to resect all of the adjacent nodal tissue to the left of the paratrachea, avoiding injury to the recurrent laryngeal nerve. The tissue is brought out separately in an endobag. At this point, the right arm can be replaced with the grasper and the lower lobe bronchus is carefully dissected away from the pulmonary artery. A silk suture is placed around the airway and the ProGrasp is used to pull the lobe up and away from the pulmonary artery. Lateral retraction from the anterior-superior port site can expose the subcarina and using either a harmonic scalpel or a hook cautery the subcarina lymphatic tissue can be completely resected and brought out in a separate endobag. From the anterior-inferior port site a 3.5-mm endostapler is used to transect the lower lobe bronchus. Before firing the stapler, the correct location of the stapler is confirmed by bronchoscope and by demonstrating correct inflation and deflation of the upper lobe. This exposes the superior segment artery and basilar segment arteries. These are encircled individually and transected with a 2.5-mm endostapler through the anterior-inferior port site. Once completed, the fissure is completed with the Echelon 60-mm yellow load endostapler. The lobe is then pushed into the lower chest cavity. The hilum is then covered with irrigant using the suction-irrigator. If a leak is found, the bronchus is further secured with one or more sutures of 5-0 Prolene with an RB-1 needle.
      The lobe is then placed in an endobag and brought out through the anterior-superior port site and the final details are described in Postoperative Management.

      Postoperative Management

      Patients are typically sent to a monitored bed until discharge. The average hospital stay is 2 to 3 days. We place the patients on strict aspiration precautions, not letting them eat or drink until they are fully awake and capable of sitting upright. Intravenous fluids are minimized and the patients are kept on a 1.5- to 2-L fluid restriction for the first few days. At case completion prior to closure, we typically place a 19-French Blake drain (Ethicon Corporation, Johnson and Johnson, Cincinnati, OH) for chest drainage. The chest drain can be removed once the output is less than 300 to 400 mL per day. If the bulb does not hold suction, it can be attached to a chest tube suction system. Ambulation should be initiated either the same day or the first postoperative day. Unless there is contraindication, Toradol is provided for the first 2 to 3 days and then the patient is started on Celebrex for the next 2 weeks. For patients who have pain, a patient-controlled anesthesia infusion of narcotic may be used, on the rare occasion that it is required. Respiratory suppression is avoided. We see the patients back in 5 to 7 days after discharge. Adjuvant therapy can be started in 2 to 6 weeks of the procedure, dependent on the health of the patient and our confidence in the blood supply to the bronchus and the parenchyma.

      Results

      We have performed nearly 200 chest robotic procedures over the course of 5 years and have found the robotic approach to be safe. There appears to be a steep learning curve for the surgeon and the surgical team. From our single institutional experience combined with other reportable series, the robotic lobectomy has a low mortality and morbidity. The conversion rate appears to be less than 3%. The median operating time and the median length of stay are no different than the thoracoscopic lobectomy. The advantage of robotic surgery to the patient is the potential of performing complex nodal resections, primary tumor resections, on patients with more advanced disease with potentially a better resection rate than with thoracoscopic surgery. In early stage disease, it may offer a more detailed resection of the hilar tissue for staging, potentially reducing the likelihood for local recurrence.

      Conclusions

      The robotic minimally invasive approach is an advancement of the thoracoscopic approach, offering the surgeon and the patient the potential of performing even more complex surgery than we were capable of performing by thoracoscopy. Robotic surgery requires an educated surgeon and surgical team. Robotics offers an even more detailed surgical resection of the lobe, potentially offering a better understanding of the biology of the malignancy and potentially a reduced local recurrence and mortality in more advanced disease. With refined instrumentation, improved efficiency and results should be anticipated.

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