Robotic Lobectomy: Left Lower Lobectomy by Surgery

Abstract

According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation. According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation. Robotic left lower lobectomy is considered a simple procedure within the corollary of major lung resections. However, it can be extremely challenging if not performed correctly. Over the years, 2 robotic platforms have been developed and are currently available, the da Vinci SI model and Da Vinci XI (Intuitive Surgical, Inc., Sunnyvale, CA). The specific features of these systems have greatly influenced the surgery in terms of port mapping, docking time, and indications. On the following pages, the surgical technique to perform a left lower lobectomy is described (Figure 1, Figure 1, Figure 1, Figure 1, Figure 1, Figure 2, Figure 3, Figure 4, Figure 5), including the differences in terms of surgical cart positioning and port mapping, which vary based on whether one uses the SI or the XI system. The operative technique is described on the following pages (Figure 1, Figure 1, Figure 1, Figure 1, Figure 1, Figure 2, Figure 3, Figure 4, Figure 5).Figure 1Continued (B) Port mapping. The camera port is positioned in the seventh or eighth intercostal space on the posterior axillary line. CO2 insufflation (5-8 mm Hg) is applied at this point to facilitate lung collapse and to push the diaphragm downward. The posterior ports are then positioned (when possible, depending of the chest dimension) along the same intercostal space (seventh to eighth intercostal space) and in the auscultatory area (between the posterior rime of the scapula and the spine). The anterior port is positioned in the fifth to sixth intercostal space on the anterior axillary line, just over the diaphragm. Considering the variability of individual chest dimensions, it is recommended to check the position of each port through the internal camera view to ensure the highest posterior port access at the level of posterior interlobar fissure. With the XI system, it is possible to place the access ports at closer distances, maintaining alignment within the same intercostal space, to decrease postoperative pain. When using robotic staplers, it is advisable to make the surgical access incisions as low as possible to increase robotic arm maneuverability.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 1Continued (C) SI port mapping with utility incision. A utility incision between the camera port and the anterior port is recommended during one's initial robotic surgical experience. This port mapping is applicable on the right and the left side for all lobectomies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 1Continued (D) (SI) Surgical cart positioning. When the SI system is used, the cart is positioned at the head of the patient, and the central point of the column of the cart must be in line with the longitudinal axis of the camera port. A correct distance between the cart and the patient is identified when the marker is at the center of the blue line.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 1Continued (E) (XI) Surgical cart positioning: laser line allows correct position of the cart. When using the XI system, the cart can be positioned either in the back or in front of the patient. When the robot is driven for docking, a laser line is activated to facilitate the correct positioning. The laser crosshairs must be pointed to the camera port. When the camera is inserted and pointed toward the hilum, the auto-targeting feature can be activated, identifying optimal robotic arm placement. When the cart is placed in the back of the patient, the anesthesiological station is located behind the patient's head. To give the surgical assistant at the table a better view and ability to check the robotic control unit, the control and vision unit should be positioned near the patient's feet. Surgical console can be placed in a corner of the operative room.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2(A, B) Dissection of the ligament and section of the vein by stapler. Currently, the instruments used during all major lung resections, including left lower lobectomy, are standardized. A monopolar (eg, Hook, Scissors, Intuitive Surgical, Inc., Sunnyvale, CA) or bipolar instruments (eg Maryland, Intuitive Surgical, Inc. Sunnyvale, CA) and a grasper (eg, Cadiere, ProGrasp, Intuitive Surgical, Inc. Sunnyvale, CA) are used for the hilum dissection to hold the lung and to surround the vessels and the bronchus. The dissection of the hilar structures can be performed by action of monopolar and/or bipolar instruments, whereas a grasper, through the fourth arm, is used to retract the lung to obtain the optimal exposure of the mediastinum thanks to the right tension of the structures. The left lower lobectomy is performed using a caudal approach. After the retraction of the lung cephalad, the pulmonary ligament is the first structure to be identified; it is incised up to the inferior pulmonary vein and any lymphadenopathy present in station 9 is removed. The inferior pulmonary vein is isolated and surrounded by a vessel loop and then divided with the stapler. During the isolation of the vein, it is advisable to stop the CO2 insufflations to reduce the vein's collapse and to obtain an easier dissection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2(A, B) Dissection of the ligament and section of the vein by stapler. Currently, the instruments used during all major lung resections, including left lower lobectomy, are standardized. A monopolar (eg, Hook, Scissors, Intuitive Surgical, Inc., Sunnyvale, CA) or bipolar instruments (eg Maryland, Intuitive Surgical, Inc. Sunnyvale, CA) and a grasper (eg, Cadiere, ProGrasp, Intuitive Surgical, Inc. Sunnyvale, CA) are used for the hilum dissection to hold the lung and to surround the vessels and the bronchus. The dissection of the hilar structures can be performed by action of monopolar and/or bipolar instruments, whereas a grasper, through the fourth arm, is used to retract the lung to obtain the optimal exposure of the mediastinum thanks to the right tension of the structures. The left lower lobectomy is performed using a caudal approach. After the retraction of the lung cephalad, the pulmonary ligament is the first structure to be identified; it is incised up to the inferior pulmonary vein and any lymphadenopathy present in station 9 is removed. The inferior pulmonary vein is isolated and surrounded by a vessel loop and then divided with the stapler. During the isolation of the vein, it is advisable to stop the CO2 insufflations to reduce the vein's collapse and to obtain an easier dissection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3(A, B) Artery dissection and apical segmental artery surrounded with vessel loop. Artery phase. The fissure is incised, when incomplete, dissecting the lymph nodes to expose the arterial branches of the basal and superior segments. Taking into account anatomic variability, each branch of the artery is isolated, surrounded with a vessel loop, and divided with a stapler. Smaller vessels can be ligated with titanium clips or Hem-o-lok clips (Teleflex Incorporated, Wayne, PA), binding (linen 2.0) or specific sealing or cutting instrument, like Vessel Sealer (Intuitive Surgical Inc., Sunnyvale, CA).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3(A, B) Artery dissection and apical segmental artery surrounded with vessel loop. Artery phase. The fissure is incised, when incomplete, dissecting the lymph nodes to expose the arterial branches of the basal and superior segments. Taking into account anatomic variability, each branch of the artery is isolated, surrounded with a vessel loop, and divided with a stapler. Smaller vessels can be ligated with titanium clips or Hem-o-lok clips (Teleflex Incorporated, Wayne, PA), binding (linen 2.0) or specific sealing or cutting instrument, like Vessel Sealer (Intuitive Surgical Inc., Sunnyvale, CA).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4(A, B) Bronchus phase. The lower lobe is retracted medially and cephalad divided with the stapler after an accurate dissection. Finally, the lobe is removed in a sterile bag through the anterior port enlarged approximately about 3 cm.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4(A, B) Bronchus phase. The lower lobe is retracted medially and cephalad divided with the stapler after an accurate dissection. Finally, the lobe is removed in a sterile bag through the anterior port enlarged approximately about 3 cm.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5(A, B) Mediastinal lymphadenectomy phase. Usually, dissection of hilar lymph nodes (N10, N11) is performed simultaneously with vascular and bronchial isolation. The mediastinal lymphadenectomy is performed after the removal of specimen, paying specific attention to N5, N6, N7, N8, and N9 stations, according to the Naruke map.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5(A, B) Mediastinal lymphadenectomy phase. Usually, dissection of hilar lymph nodes (N10, N11) is performed simultaneously with vascular and bronchial isolation. The mediastinal lymphadenectomy is performed after the removal of specimen, paying specific attention to N5, N6, N7, N8, and N9 stations, according to the Naruke map.View Large Image Figure ViewerDownload Hi-res image Download (PPT) At the end of the surgical procedure, a 28-French chest tube is placed through the previous camera port. A chest X-ray is performed about 3 hours after the surgical procedure. Typically, the chest tube is removed on the second postoperative day, and the patient is discharged the day after. Usually intraoperative complications, such as bleeding or chyle leak, can be easily managed thanks to the optimal, 3-dimensional and magnified vision (Table).TableTips to Prevent Intraoperative Difficulties and ProblemsPatient position•Lateral decubitus.•A pillow under the kidney region to prevent the collision between camera and hip is useful, especially in women.Port mapping•Adequate distance between ports (> 8 cm).•When possible, camera and 2 posterior trocars in the same intercostal space, to reduce postoperative pain. Anterior port as low as possible, just above the diaphragm.Cart positioning•SI system: After introduction through the trocar, the camera is directed to the main target region (hilum). The central point of the robotic cart (central column) should come from imaginary extension of the line between the camera port and the target area. Distance of the cart is regulated by the blue arrow on the central column, which should be in the middle of the blue line.•XI system: During the docking, a laser line is activated to facilitate the correct positioning of the cart. The laser crosshairs must be pointed to the camera port. When the camera is inserted and pointed toward the target area, the auto-targeting feature can be activated. Distance between the upper portion of the arms must be about 10 cm to avoid collision.Suggestions•Use of CO2 allows the pulmonary collapse and smoke evacuation•CO2 insufflation should be stopped during the vein phase, to avoid collapse of wall and to simplify the dissection. Open table in a new tab About 10 years after the first robotic lobectomy, the robotic surgery for non–small cell lung cancer is consolidated.1NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Non Small cell lung cancer.2017Google Scholar, 2Nakamura H. Systematic review of published studies on safety and efficacy of thoracoscopic and robot-assisted lobectomy for lung cancer.The Annals of Thoracic and Cardiovascular Surgery. 2014; 20: 93-98Crossref PubMed Scopus (26) Google Scholar At the beginning of surgical experience with a robotic system for pulmonary lobectomies, it is recommended that cases with small lesion and complete fissure be selected to obtain an easy manipulation of the parenchyma.3Park B.J. Flores R.M. Rusch V.W. Robotic assistance for video-assisted thoracic surgical lobectomy: Technique and initial results.J Thorac Cardiovasc Surg. 2006; 131: 54-59Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar With experience, it is possible to increase the surgical indications. In recent years, surgeons have extended the inclusion criteria and have used the robotic approach to treat patients with advanced stages, achieving good perioperative outcomes and oncologic results.4Melfi F.M. Fanucchi O. Davini F. et al.Robotic lobectomy for lung cancer: Evolution in technique and technology.Eur J Cardiothorac Surg. 2014; 46: 626-630Crossref PubMed Scopus (28) Google Scholar, 5Nasir B.S. Bryant A.S. Minnich D.J. et al.Performing robotic lobectomy and segmentectomy: Cost, profitability, and outcomes.Ann Thorac Surg. 2014; 98 (discussion 208-9): 203-208Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar