Total P o r t A pproac h f or Robotic Lobectomy Robert J. Cerfolio, MD, MBA KEYWORDS Lobectomy Robotic lobectomy Thoracic surgery Lung cancer Lymph node dissection
KEY POINTS
Robotic surgery is not only becoming the standard of care in urology and gynecology but it is also gaining momentum in thoracic surgery. Some types of minimally invasive surgery (MIS) such as video-assisted thoracoscopic surgery (VATS) are limited by two-dimensional visualization, a camera that often requires cleaning, nonwristed instruments, and ergonomic discomfort. Because minimally invasive platforms have now been shown to improve outcomes from lung resection,1,2 patient and surgeon alike have accepted MIS. Robotics is an MIS platform that offers distinct advantages compared with VATS and has led to the growth of robotic surgery. Robotic pulmonary resection may also lead to improved lymph node dissection, less blood loss, and improved
resection of hilar (N1) lymph nodes off the pulmonary artery.3–7 It also has been purported to cause less pain then VATS.8 However, robotic surgery has limitations, which include a longer setup time (more trocars and ports are used and docking time is required), higher initial capital costs, lack of ability to palpate the lung or have haptic feedback, and it requires more specialized equipment. Enthusiasm for robots has stemmed from the success in mediastinal resections and esophageal resections. Although this article is limited to pulmonary resections, robots have been successful in the mediastinum and esophagus for both malignant and benign esophageal lesions, so thoracic surgeons have extended the use of the robot for pulmonary resection.
Disclosure: Proctor for Intuitive. Lung Cancer Research, 739 Zeigler Research Building, 703 19th Street South, Birmingham, AL 35294-0007, USA E-mail address: [email protected] Thorac Surg Clin 24 (2014) 151–156 http://dx.doi.org/10.1016/j.thorsurg.2014.02.006 1547-4127/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
thoracic.theclinics.com
The current literature shows that robotic surgery is safe and efficient and has similar survival rates compared with the open and video-assisted thoracoscopic surgery (VATS) approaches. The surgeon can provide an R0 resection in patients with cancer; even those with large tumors (up to 10 cm). Outstanding mediastinal and hilar lymph node resections are achievable. Technical modifications lead to decreased operative times and may improve the ability to teach as well as decreasing patient morbidity and surgeon frustration during the learning process. Although hospitals are acquiring more robots for other specialties besides thoracic surgery, the capital cost, service contract costs, and equipment costs have to be carefully considered and studied. Patient selection is critical, especially during the learning process. In our opinion, there are few, if any, achievable benefits of using a robotic system compared with VATS when performing a sympathotomy for patients with hyperhidrosis or a pulmonary wedge resection for tissue diagnosis for patients with interstitial lung disease. Although further studies are needed, there has been an expansion of interest in robotics in general thoracic surgery and longer survival studies are needed.
152
Cerfolio midaxillary line or as anteriorly as possible and guided by a 5-mm scope. A 5-mm VATS camera is used to ensure entry into the pleural space and warmed CO2 is insufflated to drive the diaphragm inferiorly. This incision is eventually enlarged to allow a 12-mm port and it serves as robotic arm 1 (for right-sided operations). A paravertebral block is performed posteriorly using a local anesthetic and a 21-gauge needle from ribs 3 to 11. The needle is used to help select the ideal location for the second incision, which is the most posterior incision. The location chosen is 2 ribs below the major fissure and as far posterior in the chest as possible, just anterior to the spinal processes of the vertebral body. A 5-mm incision is made and a 5-mm reusable metal da Vinci trocar is placed. This is the position for robotic arm 3. The next few incisions are carefully planned and marked on the skin before making them. Ten centimeters anterior to the most posterior incision and along the same rib (most commonly rib 8) a third incision is planned. It is an incision for an 8-mm port and its trocar is an 8-mm metal reusable da Vinci trocar, which is docked with robotic arm 2. A fourth incision is marked on the skin and again planned but not made 9 cm anteriorly to this port, along the same rib as shown in Fig. 2. This mark will eventually be used for the robotic camera. A 12-mm plastic disposable port is used for the 12-mm camera and, if the 8-mm camera is used, an 8-mm metal reusable trocar is placed. Before making these 2 incisions a 21-gauge needle is used to identify the most anteriorly inferior aspect of the chest
An international writing committee has suggested nomenclature for robotic pulmonary resection (Table 1). In this article (not yet published), completely portal is abbreviated as CPRL-4 and robotic assisted is abbreviated as RATS. This nomenclature differentiates the different ways of performing robotic pulmonary resection. The important point is that the robot has now been used on more than 1000 patients to safely perform pulmonary resections and provides a minimally invasive surgical method. On comparing CPRL-4 with RATS, CPRL-4 offers a completely closed environment; less third spacing, introducing warm humidified CO2; and more working room. But, CRPL-4 does not allow palpation of the lung.
OPERATIVE METHODS There are several different techniques used to perform the operation. Veronesi and Melfi9 in 2011 reported the safety of a 4-arm robotassisted (not completely portal) lobectomy (using a access incision of 3–4 cm as used by VATS surgeons). Ninan and Dylewski3 in 2010 reported the effectiveness of a completely portal robotic lobectomy using 3 arms (CPRL-3) in 74 patients. Gharagozloo and colleagues7 in 2009 reported outcomes using a hybrid technique.1 Fig. 1B shows the procedure. We prefer the CPRL-4 method. As shown in Fig. 2, the pleural space is entered over the top of the seventh rib using a 5-mm port in the
Table 1 Operative characteristics for the proposed nomenclature system for general thoracic robotic operations
Abbreviation suggested Designation uses the number of robotic arms used Example provided for lobectomy using 4 arms Example provided for thymectomy using 3 arms Rib spreading Access or utility incision made CO2 insufflation used Communication between pleural space air and ambient air in operating room Trocars placed through all incisions Incisions bigger than the trocars used Site of specimen removal
Completely Portal Robotic
Robotic Assisted
Yes - CPRL Yes
Yes - RAL Yes
CPRL - 4 CPT - 3
RAL - 4 RAT - 3
No No Yes No
No Yes Sometimes Yes
Yes No Usually over anterior aspect of 10th rib
No Yes Usually over anterior aspect of fourth rib
Total Port Approach for Robotic Lobectomy
Fig. 1. (A) Intraoperative view of port placement for a CPRL-4 in the right chest. The patient’s head is at the left of the picture, and the feet are at the right. The anterior chest is at the top and the back is at the bottom. The scapula is outlined. (B) Intraoperative view of port placement and utility incision for a robotic assisted lobectomy in the right chest using 3 arms. The patient’s head is at the top of the picture and the anterior chest is to the right of the picture.
that is just above the diaphragmatic fibers. This incision has a 15-mm port and serves as the access port. A plastic disposable trocar is used. No robotic arms are attached to the trocar that is placed in this incision. This incision is carefully planned. It is made just above the diaphragm as anterior and inferior as possible in order to be between the ports used for robotic arm 1 and the camera. The access port can alternatively be
placed more posteriorly if anatomy dictates; between the camera and robotic arm 2. It should be 2 or 3 ribs lower than these two ports. This position affords room for the bedside assistant to work. Once these incisions are carefully planned and their location is confirmed, they are made and the appropriate trocars are placed. In addition, the initial 5-mm anterior port that was made first and used to introduce the VATS camera to identify the internal landmarks is then dilated to a 12-mm double cannulated port for robotic arm 1. The robot is driven over the patient’s shoulder on a 15 angle and attached to the 4 ports. In general, only 4 robotic instruments are used for all of these operations: the Cadierre grasper, a 5-mm bowel grasper (used exclusively through the most posterior port that is attached to robotic arm 3, which serves as a retractor of the lung), the Maryland forceps, and a cautery spatula. See Fig. 1A for interoperative views.
RESULTS Fig. 2. The CPRL-4 technique developed in this study. It features entering the pleural space using a 5-mm port anteriorly in the midaxillary line (MAL) over the top of the seventh rib and then using a 5-mm VATS camera to make all the other incisions based on internal anatomy. The circled numbers represent the robotic arms used. C is for the camera port, A is for the 15-mm access port (which can also be placed between the camera and robotic arm 2 if space is not adequate more anteriorly). Note that robotic arm 3 is a 5-mm port, robotic arm 2 is an 8-mm port, the camera can be an 8-mm or 12-mm port depending on the camera used, and robotic arm 1 is a 12-mm port. The area with the dashed lines is the area where no incisions are made, and this is the most posterior third of the area between the midspine and the posterior edge of the scapula.
Recent literature shows that robotic pulmonary resection is safe and oncologically sound by allowing R0 resection with excellent lymph node removal.3,4,8,10 Our series reports on 168 patients who underwent robotic resection for non–small cell lung cancer (NSCLC) and were matched (3:1) with patients who had a pulmonary resection via nerve-sparing and rib-sparing thoracotomy. There was no statistically significant difference in the total number of lymph nodes removed or in the median number of N2 or N1 lymph node stations assessed. In addition, there was significantly less blood loss (35 vs 90 mL, P 5 .03), shorter chest tube duration (1.5 vs 3.0 days, P
KEY POINTS
Robotic surgery is not only becoming the standard of care in urology and gynecology but it is also gaining momentum in thoracic surgery. Some types of minimally invasive surgery (MIS) such as video-assisted thoracoscopic surgery (VATS) are limited by two-dimensional visualization, a camera that often requires cleaning, nonwristed instruments, and ergonomic discomfort. Because minimally invasive platforms have now been shown to improve outcomes from lung resection,1,2 patient and surgeon alike have accepted MIS. Robotics is an MIS platform that offers distinct advantages compared with VATS and has led to the growth of robotic surgery. Robotic pulmonary resection may also lead to improved lymph node dissection, less blood loss, and improved
resection of hilar (N1) lymph nodes off the pulmonary artery.3–7 It also has been purported to cause less pain then VATS.8 However, robotic surgery has limitations, which include a longer setup time (more trocars and ports are used and docking time is required), higher initial capital costs, lack of ability to palpate the lung or have haptic feedback, and it requires more specialized equipment. Enthusiasm for robots has stemmed from the success in mediastinal resections and esophageal resections. Although this article is limited to pulmonary resections, robots have been successful in the mediastinum and esophagus for both malignant and benign esophageal lesions, so thoracic surgeons have extended the use of the robot for pulmonary resection.
Disclosure: Proctor for Intuitive. Lung Cancer Research, 739 Zeigler Research Building, 703 19th Street South, Birmingham, AL 35294-0007, USA E-mail address: [email protected] Thorac Surg Clin 24 (2014) 151–156 http://dx.doi.org/10.1016/j.thorsurg.2014.02.006 1547-4127/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
thoracic.theclinics.com
The current literature shows that robotic surgery is safe and efficient and has similar survival rates compared with the open and video-assisted thoracoscopic surgery (VATS) approaches. The surgeon can provide an R0 resection in patients with cancer; even those with large tumors (up to 10 cm). Outstanding mediastinal and hilar lymph node resections are achievable. Technical modifications lead to decreased operative times and may improve the ability to teach as well as decreasing patient morbidity and surgeon frustration during the learning process. Although hospitals are acquiring more robots for other specialties besides thoracic surgery, the capital cost, service contract costs, and equipment costs have to be carefully considered and studied. Patient selection is critical, especially during the learning process. In our opinion, there are few, if any, achievable benefits of using a robotic system compared with VATS when performing a sympathotomy for patients with hyperhidrosis or a pulmonary wedge resection for tissue diagnosis for patients with interstitial lung disease. Although further studies are needed, there has been an expansion of interest in robotics in general thoracic surgery and longer survival studies are needed.
152
Cerfolio midaxillary line or as anteriorly as possible and guided by a 5-mm scope. A 5-mm VATS camera is used to ensure entry into the pleural space and warmed CO2 is insufflated to drive the diaphragm inferiorly. This incision is eventually enlarged to allow a 12-mm port and it serves as robotic arm 1 (for right-sided operations). A paravertebral block is performed posteriorly using a local anesthetic and a 21-gauge needle from ribs 3 to 11. The needle is used to help select the ideal location for the second incision, which is the most posterior incision. The location chosen is 2 ribs below the major fissure and as far posterior in the chest as possible, just anterior to the spinal processes of the vertebral body. A 5-mm incision is made and a 5-mm reusable metal da Vinci trocar is placed. This is the position for robotic arm 3. The next few incisions are carefully planned and marked on the skin before making them. Ten centimeters anterior to the most posterior incision and along the same rib (most commonly rib 8) a third incision is planned. It is an incision for an 8-mm port and its trocar is an 8-mm metal reusable da Vinci trocar, which is docked with robotic arm 2. A fourth incision is marked on the skin and again planned but not made 9 cm anteriorly to this port, along the same rib as shown in Fig. 2. This mark will eventually be used for the robotic camera. A 12-mm plastic disposable port is used for the 12-mm camera and, if the 8-mm camera is used, an 8-mm metal reusable trocar is placed. Before making these 2 incisions a 21-gauge needle is used to identify the most anteriorly inferior aspect of the chest
An international writing committee has suggested nomenclature for robotic pulmonary resection (Table 1). In this article (not yet published), completely portal is abbreviated as CPRL-4 and robotic assisted is abbreviated as RATS. This nomenclature differentiates the different ways of performing robotic pulmonary resection. The important point is that the robot has now been used on more than 1000 patients to safely perform pulmonary resections and provides a minimally invasive surgical method. On comparing CPRL-4 with RATS, CPRL-4 offers a completely closed environment; less third spacing, introducing warm humidified CO2; and more working room. But, CRPL-4 does not allow palpation of the lung.
OPERATIVE METHODS There are several different techniques used to perform the operation. Veronesi and Melfi9 in 2011 reported the safety of a 4-arm robotassisted (not completely portal) lobectomy (using a access incision of 3–4 cm as used by VATS surgeons). Ninan and Dylewski3 in 2010 reported the effectiveness of a completely portal robotic lobectomy using 3 arms (CPRL-3) in 74 patients. Gharagozloo and colleagues7 in 2009 reported outcomes using a hybrid technique.1 Fig. 1B shows the procedure. We prefer the CPRL-4 method. As shown in Fig. 2, the pleural space is entered over the top of the seventh rib using a 5-mm port in the
Table 1 Operative characteristics for the proposed nomenclature system for general thoracic robotic operations
Abbreviation suggested Designation uses the number of robotic arms used Example provided for lobectomy using 4 arms Example provided for thymectomy using 3 arms Rib spreading Access or utility incision made CO2 insufflation used Communication between pleural space air and ambient air in operating room Trocars placed through all incisions Incisions bigger than the trocars used Site of specimen removal
Completely Portal Robotic
Robotic Assisted
Yes - CPRL Yes
Yes - RAL Yes
CPRL - 4 CPT - 3
RAL - 4 RAT - 3
No No Yes No
No Yes Sometimes Yes
Yes No Usually over anterior aspect of 10th rib
No Yes Usually over anterior aspect of fourth rib
Total Port Approach for Robotic Lobectomy
Fig. 1. (A) Intraoperative view of port placement for a CPRL-4 in the right chest. The patient’s head is at the left of the picture, and the feet are at the right. The anterior chest is at the top and the back is at the bottom. The scapula is outlined. (B) Intraoperative view of port placement and utility incision for a robotic assisted lobectomy in the right chest using 3 arms. The patient’s head is at the top of the picture and the anterior chest is to the right of the picture.
that is just above the diaphragmatic fibers. This incision has a 15-mm port and serves as the access port. A plastic disposable trocar is used. No robotic arms are attached to the trocar that is placed in this incision. This incision is carefully planned. It is made just above the diaphragm as anterior and inferior as possible in order to be between the ports used for robotic arm 1 and the camera. The access port can alternatively be
placed more posteriorly if anatomy dictates; between the camera and robotic arm 2. It should be 2 or 3 ribs lower than these two ports. This position affords room for the bedside assistant to work. Once these incisions are carefully planned and their location is confirmed, they are made and the appropriate trocars are placed. In addition, the initial 5-mm anterior port that was made first and used to introduce the VATS camera to identify the internal landmarks is then dilated to a 12-mm double cannulated port for robotic arm 1. The robot is driven over the patient’s shoulder on a 15 angle and attached to the 4 ports. In general, only 4 robotic instruments are used for all of these operations: the Cadierre grasper, a 5-mm bowel grasper (used exclusively through the most posterior port that is attached to robotic arm 3, which serves as a retractor of the lung), the Maryland forceps, and a cautery spatula. See Fig. 1A for interoperative views.
RESULTS Fig. 2. The CPRL-4 technique developed in this study. It features entering the pleural space using a 5-mm port anteriorly in the midaxillary line (MAL) over the top of the seventh rib and then using a 5-mm VATS camera to make all the other incisions based on internal anatomy. The circled numbers represent the robotic arms used. C is for the camera port, A is for the 15-mm access port (which can also be placed between the camera and robotic arm 2 if space is not adequate more anteriorly). Note that robotic arm 3 is a 5-mm port, robotic arm 2 is an 8-mm port, the camera can be an 8-mm or 12-mm port depending on the camera used, and robotic arm 1 is a 12-mm port. The area with the dashed lines is the area where no incisions are made, and this is the most posterior third of the area between the midspine and the posterior edge of the scapula.
Recent literature shows that robotic pulmonary resection is safe and oncologically sound by allowing R0 resection with excellent lymph node removal.3,4,8,10 Our series reports on 168 patients who underwent robotic resection for non–small cell lung cancer (NSCLC) and were matched (3:1) with patients who had a pulmonary resection via nerve-sparing and rib-sparing thoracotomy. There was no statistically significant difference in the total number of lymph nodes removed or in the median number of N2 or N1 lymph node stations assessed. In addition, there was significantly less blood loss (35 vs 90 mL, P 5 .03), shorter chest tube duration (1.5 vs 3.0 days, P
