Robotic-assisted pulmonary resection - Right upper lobectomy.

Abstract

General thoracic surgery is the fastest growing sector of robotic surgery. The reason is advantage the robot offers in mediastinal work such as thymectomy, resection of esophageal leiomyoma, removal of bronchogenic or esophageal duplication cysts, and even diaphragmatic plication. Once general thoracic surgeons try the robot and see the improved visualization they are often willing to continue to learn to do more with it. We have now applied it to pulmonary resections. There are multiple published articles that have shown the efficacy and safety of robotic pulmonary resection including lobectomy, segmentectomy, and even several reports of pneumonectomy (1-4). However, there are difficulties in learning robotic surgery. It is a “team sport” where the bedside assistant is the one currently placing the stapler on the arteries and the veins, which makes everyone anxious. Another difficulty relates to the high capital cost of a robotic surgery program, including purchasing a robot, the additional expenses of buying a second console and replacing robotic surgical equipment and finally getting time on the robotic platform for the patients. Despite the debate, cardiac and thoracic surgeons are currently learning many robotic surgery techniques. We recently helped design and develop a CPRL-4 technique and have published the world’s largest experience with it - in over 100 lobectomies. We now have completed over 180 robotic lobectomies with only one 30 or 90 day mortality. In addition, with other authors, we have written an international nomenclature paper on this issue (JTCVS 2012, publication pending) and have proctored many surgeons and trained two robotic surgery fellows. We have also published the largest series on robotic Ivor Lewis esophageal resection with a two-layered hand-sewn anastomosis. In addition, we have the world’s largest series on the robotic resection of posterior mediastinal tumors. Based on our experience, we know all too well the difficulties in establishing robotic programs in North America. Some of these difficulties include: anesthesia push- back because of the safety concerns, and increased time, the limited degree of robot platform availability, and the fact that teams are best if they perform several robotic operations a week to get experience. In this Art of Operative Technique Teachers’ Section, we will display the specific step-by-step approach for a robotic right upper lobectomy.