Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks.

The uniportal access for robotic thoracic surgery presents itself as a natural evolution of minimally invasive thoracic surgery (MITS). It was developed by surgeons who pioneered the uniportal video-assisted thoracic surgery (U-VATS) in all its aspects following the same principles of a single incision by using robotic technology. The robotic surgery was initially started as a hybrid procedure with the use of thoracoscopic staplers by the assistant. However, due to the evolution of robotic modern platforms, the staplers can be nowadays controlled by the main surgeon from the console. The pure uniportal robotic-assisted thoracic surgery (U-RATS) is defined as the robotic thoracic surgery performed through a single intercostal (ic) incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers. There are presented the advantages, difficulties, the general aspects and specific considerations for U-RATS. For safety reasons, the authors recommend the transition from multiportal-RATS through biportal-RATS to U-RATS. The use of robotic dissection and staplers through a single incision and the rapid undocking with easy emergent conversion when needed (either to U-VATS or to thoracotomy) are safety advantages over multi-port RATS that cannot be overlooked, offering great comfort to the surgeon and quick and smooth recovery to the patient.

Salvage Surgery for Small-Cell Lung Cancer-A Literature Review.

(1) Background: Salvation surgery for small-cell lung cancer (SCLC) is exceptionally performed, and only a few cases are published. (2) Methods: There are 6 publications that present 17 cases of salvation surgery for SCLC-the salvation surgery was performed in the context of modern clearly established protocols for SCLC and after including SCLC in the TNM (tumor, node, metastasis) staging in 2010. (3) Results: After a median follow-up of 29 months, the estimated overall survival (OS) was 86 months. The median estimated 2-year survival was 92%, and the median estimated 5-year survival was 66%. (4) Conclusion: Salvage surgery for SCLC is a relatively new and extremely uncommon concept and represents an alternative to second-line chemotherapy. It is valuable because it may offer a reasonable treatment for selected patients, good local control, and a favorable survival outcome.

Comparison of uniportal robotic-assisted thoracic surgery pulmonary anatomic resections with multiport robotic-assisted thoracic surgery: a multicenter study of the European experience.

Background: Robotic-assisted thoracic surgery (RATS) has seen increasing interest in the last few years, with most procedures primarily being performed in the conventional multiport manner. Our team has developed a new approach that has the potential to convert surgeons from uniportal video-assisted thoracic surgery (VATS) or open surgery to robotic-assisted surgery, uniportal-RATS (U-RATS). We aimed to evaluate the outcomes of one single incision, uniportal robotic-assisted thoracic surgery (U-RATS) against standard multiport RATS (M-RATS) with regards to safety, feasibility, surgical technique, immediate oncological result, postoperative recovery, and 30-day follow-up morbidity and mortality. Methods: We performed a large retrospective multi-institutional review of our prospectively curated database, including 101 consecutive U-RATS procedures performed from September 2021 to October 2022, in the European centers that our main surgeon operates in. We compared these cases to 101 consecutive M-RATS cases done by our colleagues in Barcelona between 2019 to 2022. Results: Both patient groups were similar with respect to demographics, smoking status and tumor size, but were significantly younger in the U-RATS group [M-RATS =69 (range, 39-81) years; U-RATS =63 years (range, 19-82) years; P<0.0001]. Most patients in both operative groups underwent resection of a primary non-small cell lung cancer (NSCLC) [M-RATS 96/101 (95%); U-RATS =60/101 (59%); P<0.0001]. The main type of anatomic resection was lobectomy for the multiport group, and segmentectomy for the U-RATS group. In the M-RATS group, only one anatomical segmentectomy was performed, while the U-RATS group had twenty-four (24%) segmentectomies (P=0.0006). All M-RATS and U-RATS surgical specimens had negative resection margins (R0) and contained an equivalent median number of lymph nodes available for pathologic analysis [M-RATS =11 (range, 5-54); U-RATS =15 (range, 0-41); P=0.87]. Conversion rate to thoracotomy was zero in the U-RATS group and low in M-RATS [M-RATS =2/101 (2%); U-RATS =0/101; P=0.19]. Median operative time was also statistically different [M-RATS =150 (range, 60-300) minutes; U-RATS =136 (range, 30-308) minutes; P=0.0001]. Median length of stay was significantly lower in U-RATS group at four days [M-RATS =5 (range, 2-31) days; U-RATS =4 (range, 1-18) days; P<0.0001]. Rate of complications and 30-day mortality was low in both groups. Conclusions: U-RATS is feasible and safe for anatomic lung resections and comparable to the multiport conventional approach regarding surgical outcomes. Given the similarity of the technique to uniportal VATS, it presents the potential to convert minimally invasive thoracic surgeons to a robotic-assisted approach.

Uniportal fully robotic-assisted sleeve resections: surgical technique and initial experience of 30 cases.

Since the first uniportal video-assisted thoracoscopic surgery (uVATS) performed in 2010, the uniportal approach has evolved up to a point where even the most complex cases can be done. This is thanks to the experience acquired over the years, the specifically designed instruments and improvements in imaging. However, in these last few years, robotic-assisted thoracoscopic surgery (RATS) has also shown progress and distinct advantages compared to the uniportal VATS approach, thanks to advanced maneuverability of the robotic arms as well as the three-dimensional (3D) view. Excellent surgical outcomes have been reported and so too, the ergonomic benefits to the surgeon. The main limitation we find of the robotic systems is that they are designed for a multiport approach, requiring between three to five incisions to be able to perform surgeries. With the aim to offer the least invasive approach, using the robotic technology we decided to adapt the Da Vinci Xi® in September 2021 to develop the uniportal pure RATS approach (uRATS) performed by a single intercostal incision, without rib spreading and using the robotic staplers. We have now reached a point where we perform all type of procedures, including the more complex sleeve resections. Sleeve lobectomy is now widely accepted as a reliable and safe procedure to allow complete resection of centrally located tumors. Although it is a technically challenging surgical technique, it offers better outcomes when compared to pneumonectomy. The intrinsic characteristics of the robot such as the 3D view and improved maneuverability of instruments make the sleeve resections easier compared to thoracoscopic techniques. As in uVATS vs. multiport VATS, the uRATS approach, due to its geometrical characteristics, requires specific instrumentation, different movements and learning curve compared to multiport RATS. In this article we describe the surgical technique and our initial uniportal pure RATS experience with bronchial, vascular sleeves and carinal resections in 30 patients.

Uniportal robotic versus thoracoscopic assisted surgery: a propensity score-matched analysis of the initial 100 cases.

Background: Minimally invasive surgery (MIS) is becoming the standard of care for anatomic lung resections. The advantages of the uniportal approach compared to the conventional multiple incision approach, multiportal video-assisted thoracic surgery (mVATS) and multiportal robotic-assisted thoracic surgery (mRATS), have been previously described. However, no research studies comparing early outcomes between uniportal video-assisted thoracic surgery (uVATS) and uniportal robotic-assisted thoracic surgery (uRATS) have been reported. Methods: Anatomic lung resections performed by uVATS and uRATS from August 2010 to October 2022 were enrolled. Early outcomes were compared after propensity score-matched (PSM) analysis by applying a multivariable logistic regression model including gender, age, smoking habit, forced expiratory volume in the first second (FEV1), cardiovascular risk factors (CVRF), pleural adhesions and tumor size. Results: A total of 200 patients who underwent anatomic lung resections by the same surgeon were recruited in this study, including the initial 100 uVATS patients and the initial 100 uRATS patients. After PSM analysis, each group included 68 patients. The comparison of the two groups showed no significant differences according to the TNM stage in patients with lung cancer, surgical time, intraoperative complications, conversion, number of nodal stations explored, opioid usage, prolonged air leak, length of intensive care unit (ICU) and hospitalization, reintervention and mortality. However, there were significant differences concerning the histology and type of resection (anatomic segmentectomies, the proportion of complex segmentectomies and the sleeve technique were significantly higher in the uRATS group), number of resected lymph nodes (significantly higher in the uRATS group), postoperative complications and duration of chest drain (significantly lower in the uRATS group). Conclusions: Judging from the short-term outcomes, our results confirm the safety, feasibility and efficacy of uRATS as a new minimally invasive technique that combines the benefits of the uniportal method and robotic systems.

Uniportal fully robotic-assisted major pulmonary resections.

Robotic-assisted thoracoscopic surgery (RATS) has proven advantages over that of conventional thoracic surgery, primarily by offering a three-dimensional view and excellent maneuverability, and by providing great ergonomic comfort to the surgeon. The instrumentation specifically offers seven degrees of freedom, allowing for safe, yet complex dissections and radical lymphadenectomies. However, the robotic platform was initially designed with four robotic arms in mind, and therefore four to five incisions were needed for most thoracic approaches. The uniportal video-assisted thoracoscopic surgery (UVATS) approach, the philosophical predecessor to the uniportal robotic-assisted thoracoscopic surgery (URATS) approach, evolved very quickly with the help of the latest technologies during the last decade. Since the first cases of UVATS in 2010, we have improved upon the technique, such that we are now able to do increasingly more complex cases. This is due to the acquired experience, specifically designed instruments, better high-definition cameras and more angulated staplers. In our efforts to improve and adapt robotic surgery to the uniportal approach, we utilized the initial available platforms (Davinci Si and X) to test the feasibility of this approach, in terms of safety and possibilities. The latest platform, the Da Vinci Xi, due to the configuration of its arms, did indeed allow for us to reduce the number of incisions to two initially and finally to one. We hence decided to fully adapt the Da Vinci Xi® to allow for the URATS approach routinely, and performed the first fully robotic anatomic resections in the world in September 2021, in Coruña, Spain. We define pure or fully robotic URATS as robotic thoracic surgery performed by a single intercostal incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers.

Oncologic Outcome after Pulmonary Metastasectomy as Part of Multidisciplinary Treatment in a Tertiary Oncological Center.

(1) Background: Pulmonary metastases are encountered in approximately one-third of patients with malignancies, especially from colorectal, lung, breast, and renal cancers, and sarcomas. Pulmonary metastasectomy is the ablative approach of choice, when possible, as part of the multidisciplinary effort to integrate and personalize the oncological treatment. (2) Methods: The study includes 58 consecutive cases of pulmonary metastasectomies, retrospectively analyzed, performed in 12 consecutive months, in which the pathology reports confirmed lung metastases. (3) Results: Most frequent pathological types of metastases were: 14 of colorectal cancer, 10 breast, 8 lung, and 8 sarcomas. At the time of primary cancer diagnosis, 14 patients (24.14%) were in the metastatic stage. The surgical approach was minimally invasive through uniportal VATS (Video-Assisted Thoracic Surgery) in 3/4 of cases (43 patients, 74%). Almost 20% of resections were typical (lobectomy, segmentectomy). Lymphadenectomy was associated in almost 1/2 of patients and lymph node metastases were found in 11.11% of cases. The mortality rate (intraoperative and 90 days postoperative) is zero. The OS after pulmonary metastasectomy is 87% at 18 months, and the estimated OS for cancer is 90% at 5 years. The worst outcome presents the patients with sarcomas and the best outcome-colorectal and lung cancer. The patients with 1 or 2 resected metastases presented 96% survival at 24 months. (4) Conclusions: After pulmonary metastasectomy, survival is favored by the small number of metastases resected (1 or 2), and by the dimension of metastases under 20.5 mm. The non-anatomic (wedge) type of lung resection may present a lower risk of death compared to lobectomy. No statistical significance on survival has the presence of lymphadenectomy, the laterality right/left lung, the upper/lower lobes. In the future, longer follow-up and prospective randomized trials are needed for drawing definitive conclusions.

Tensioned space after pneumonectomy for cancer with mediastinal shift and cardiac tamponade-causes and treatment (Review).

Regarding the pleural space after pneumonectomy for malignancy, a vast number of studies have assessed early drop in the fluid level, suggesting a broncho-pleural fistula, but only a small number of studies reported on the abnormal increase in the fluid level-a potentially lethal complication. In the present study, the available databases worldwide were screened and 19 cases were retrieved, including 14 chylothorax and 3 hydrothorax cases, 1 pneumothorax and 1 haemothorax case. Tension chylothorax is caused by mediastinal lymph node dissection as an assumed risk in radical cancer surgery. For tensioned haemothorax, the cause has not been elucidated, although lymphatic stasis associated with deep venous thrombosis was suspected. Tensioned pneumothorax was caused by chest wall damage after extrapleural pneumonectomy combined with low aspiration pressure on the chest drain. No cause was determined for none of the tensioned hydrothorax-all 3 cases had the scenario of pericardial resection in addition to pneumonectomy in common. Tensioned space after pneumonectomy for cancer manifests as cardiac tamponade. Initial management is emergent decompression of the heart and mediastinum. Final management depends on the fluid type (chyle, transudate, air, blood) and the medical context of each case. Of the 19 cases, 12 required a major surgical procedure as the definitive management.

Uniportal robotic-assisted thoracic surgery for lung resections.

Pure uniportal robotic-assisted thoracic surgery (U-RATS) is the robotic thoracic surgery performed through a single intercostal incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers. Compared to multiport, U-RATS simplifies the management of possible intraoperative bleeding, mainly due to rapid undocking and the necessary uniportal experience of the surgeon. U-RATS offers a possible uniportal robotic surgical management of lung resections, with comfort for surgeons and quick and smooth recovery for patients.

Minimally Invasive Thoracic Surgery - Video Assisted Thoracic Surgery: Technique and Indications.

Video-Assisted Thoracic Surgery (VATS) is already practised worldwide, in almost every condition addressed by open thoracic surgery. As part of minimally invasive thoracic surgery (MITS), VATS offers to patients and to healthcare providers excellent results and great satisfactions. Learning and performing VATS use different pathways in trainees and in experienced surgeons. This article presents VATS in its essence: classification, indications, contraindications, instruments and tools, incisions and access, troubleshooting, learning curve and training. We wish that the information helps our colleagues, both trainees and experienced thoracic surgeons, to start and continue performing VATS as standard care in thoracic surgery.

Immediate Postoperative Results in the Surgical Treatment of Neoplastic Pericarditis - 76 Consecutive Cases.

Introduction: Pericardial effusion, accumulation of fluid in the pericardial sac, may develop in any type of cancer. It was revealed in up to 20% of oncological patients. Method: We made a retrospective study of patients with pericardial efusion presented in our clinic between 2010 and 2015. We included 76 consecutive patients with indication for peri cardial drainage - we performed on them 80 surgical procedures: pericardocentesis, subxiphoid pericardial window, left paraxifoidian pericardial window, intercostal video-assisted thoracic surgery (VATS) pericardial fenestration, and classical thoracic surgery (fenestration or partial pericardiectomy). We had patients with ages between 28 and 83 years. 23 patients were admitted with cardiac tamponade. The immediate postoperatory survival is 97.3 % and the 30-days-postoperatory survival is 81.5 %. Results: The immediate postoperatory mortality is 2.7% and the 30-days-postoperatory mortality is 8.5%. Conclusions: The immediate prognosis of the patient with malignant pericardial effusion is influenced by the risk of postoperative Low-Cardiac-Output-Syndrome (LCOS), or pericardial decompression syndrome (PDS), which remains the main cause of mortality. The long-term prognosis is related to the type of malignant tumor. The most effective tehnique with the lowest rate of recurrence is pericardo-pleural window done thoracoscopically/ by VATS; pericardocentesis has the highest rate of recurrence - 90% and is associated with high rates of cardiac complications and mortality.