Successful Sleeve Resection as a Marker for Proficiency for Robotic Pulmonary Resection.

BACKGROUND: Robot technology is a revolutionary technique to overcome limitations of minimal invasive surgery. The proficiency level varies from study to study. We considered the first sleeve lobectomy as a benchmark procedure to evaluate the proficiency level. METHODS: We retrospectively analyzed 197 patients who underwent robot-assisted thoracoscopic surgery (RATS) for primary lung cancer between December 2011 and May 2018. Patients were divided into two groups based on undergoing surgery earlier period (EP) or later period (LP) than the first sleeve lobectomy by RATS (May 25, 2015). The preoperative, operative, and short- and long-term postoperative outcomes were compared. Seven-year survival was also compared between two periods for T1N0 and T2N0 diseases. RESULTS: Preoperative features were similar. The mean operative time was 166.8 ± 55.1 and 142.4 ± 43.9 minutes in EP and LP, respectively (p = 0.005). The mean number of dissected lymph nodes in LP was also significantly higher than that in EP (24.4 ± 9.4 vs. 20.8 ± 10.4, p = 0.035). The complication rate was significantly lower in LP (29/86 vs. 25/111, p = 0.048). The extended resection (ER) rate was significantly higher in LP (p = 0.023). The 7-year survival was comparable in EP and LP in both patients with T1N0 and T2N0 (p = 0.28 and p = 0.11, respectively). CONCLUSION: Perioperative outcomes, such as duration of surgery, number of dissected lymph nodes, complications, and ERs are favorable in patients who underwent surgeries after the first sleeve resection. The first sleeve lobectomy may be considered as the benchmark procedure for the proficiency level in RATS.

Robotic anatomic lung resections: the initial experience and description of learning in 102 cases.

BACKGROUND: The aim of this study was to analyze our initial pulmonary resection experience with robotic surgery (Da Vinci, Intuitive Surgical, Inc., Mountain View, California, USA) and define the learning curve based on the duration of operations. METHODS: A retrospective review was conducted on patients undergoing robotic pulmonary resections from October 2011 to December 2014. The operating time, including the docking and console times, postoperative hospitalization, and peri- and postoperative complications were studied. RESULTS: Hundred patients underwent 102 robotic anatomic pulmonary resections due to various pathologies. Fifty-three percent of the patients underwent lobectomy procedure, whereas 45% underwent segmentectomy. The mean operating time was 104 ± 34 min. The learning curve was calculated to be 14 patients (R(2) = 0.57). The complication rate in our series was 24% (n = 24) and higher in elderly patients (p = 0.03) and in patients with longer operating times (p = 0.03). Prolonged air leaks were observed in 10, and arrhythmia developed in nine patients. Two patients died, due to a concurrent lymphoblastic leukemia diagnosed at the postoperative period and exacerbation of interstitial fibrosis, respectively. CONCLUSIONS: Robotic pulmonary resections prove to be safe and effective even at the initial learning experience. The duration of operations is considered to be acceptable. The learning curve could be established after 14 cases.

Hybrid vascular surgery approaches for multilevel arterial occlusive disease.

BACKGROUND: The incidence of multilevel vascular occlusive disease is increased with patient age. Multilevel arterial occlusive disease cases are some of the hardest in the vascular surgical realm because of the comorbidities. In these high-risk patients inflow constrictions may limit the success of distal bypasses. At the same time the constrictions in the outflow may necessitate long bypass circuits that have less long-term patency rates. METHODS: Our study included 38 patients with multilevel arterial occlusive disease to whom hybrid vascular approaches were applied between January 2005 and December 2011 in Sisli Florence Nightingale Hospital. The patient group had a mean age of 68.1 (48-98) and included 29 male (89%) and 9 female (11%) patients. Complaints were claudication under 100 meters of walking in 19 patients (50%), resting pain in 14 patients (36%), and disturbed tissue integrity in 5 patients (14%). Mean in-hospital stay was calculated to be 6.4 days (4-15). In one patient (2.6%), a second procedure was necessary due to graft thrombosis and this case resulted in amputation under the level of the knee. Minor toe amputations in a second session were applied to 5 patients (14%) with symptoms of foot sores. Wound infections occurred in two patients (5%) and were treated with antibiotherapy and wound care. RESULTS: At the end of the follow-up time, extremity survival was found to be 94.1%. CONCLUSIONS: In the treatment of multilevel peripheral arterial occlusive disease, a hybrid approach is a treatment option which is less invasive and sufficient.

Superior Vena Cava Reconstruction in Masaoka Stage III and IVa Thymic Epithelial Tumors.

BACKGROUND: We present here a case series of patients who underwent resection for Masaoka stage III and IVa thymic epithelial tumors (TETs) with invasion into the superior vena cava (SVC). METHODS: A total of 29 patients with stage III and IVa TETs were treated surgically in 3 institutions. Operative resections involved replacing the SVC from one of the innominate veins (n = 18) or via reconstruction by truncal replacement (n = 2) or patch plasty (n = 9). RESULTS: Fifteen patients underwent neoadjuvant treatment. Thirty- and 90-day mortality rates were 3.4% and 10.3%, respectively. For stage III patients, the median overall survival and disease-free survival (DFS) were 39 and 30 months, respectively. The median overall survival and DFS in patients with Masaoka stage IVa disease were 67 and 21 months, respectively. Undergoing only preoperative chemotherapy (P = .007) or receiving no chemotherapy (P = .009) had a DFS that was significantly higher than receiving both preoperative and postoperative chemotherapy. CONCLUSIONS: SVC resection and reconstruction in Masoaka stage III and IVa TETs can be performed with acceptable morbidity and mortality. Stage IVa patients with SVC involvement can be treated with similar results as stage III patients with multimodality treatment.

Intraosseous leiomyoma in a rib. A case report.

Intraosseous leiomyomas are very rare. To the best of our knowledge, this is the first published case of primary intraosseous leiomyoma in a rib. This rare benign tumour should be included in the differential diagnosis of any relatively small intraosseous lesion with benign imaging findings, but with gradually worsening, long-standing pain.

An antiquated contraindication for minimally invasive lung surgery: No place to staple the bronchus.

BACKGROUND: This study aims to evaluate the feasibility and outcomes of lobectomy operations without using a stapler for bronchial closure. METHODS: Between December 2014 and August 2018, a total of 108 patients (72 males, 36 females; mean age 62.1±9.8 years; range, 19 to 83 years) with primary lung cancer who underwent lobar resection with robot-assisted thoracoscopic surgery were included in this study. Primary bronchial closure (n=7) and sleeve anastomosis (n=9) were performed in some cases. These 16 patients were compared with other lobectomy cases (n=92) who had bronchial stapling for bronchial closure. RESULTS: There was no statistically significant difference in the mean duration of operation, amount of intraoperative bleeding, length of postoperative stay in the hospital, and morbidity and readmission rates between the two groups (p=0.3, p=0.5, p=0.06, p=0.4, and p=0.63, respectively). No bronchial fistula developed in any of the patients. CONCLUSION: Primary bronchial closure and sleeve anastomosis can be safely performed with robot-assisted thoracoscopic surgery without conversion to thoracotomy, or a larger assistance incision with a similar success rate of the stapled bronchus.

Haemangioendothelioma: a disease with surgical options from robotic surgery to open superior vena cava replacement.

Epithelioid haemangioendothelioma is a malignant tumour of vascular origin that can occur in the mediastinum. Operative treatment techniques may vary depending on the localization. Our goal was to focus on different surgical techniques, ranging from simple stapling of the vascular structure to replacement of the superior vena cava.

Superior vena cava resection and reconstruction in mediastinal tumors and benign diseases.

BACKGROUND: This study aims to evaluate our results of resection and reconstruction of the superior vena cava invaded by mediastinal tumors and benign diseases. METHODS: Seventeen patients (8 males, 9 females; mean age 46±17 years; range 9 to 74 years) undergoing superior vena cava resection and reconstruction due to mediastinal pathologies between September 2006 and September 2016 were retrospectively reviewed. Patients who had angioplasty with primary suturing or partial resection with stapler were excluded. Mortality and morbidity rates were analyzed based on the demographic, and intra- and postoperative measures. RESULTS: Majority of patients (94%) had mediastinal tumors. Twelve patients (71%) had thymic epithelial tumors. Tubular graft interposition was performed using ringed polytetrafluoroethylene prosthesis in nine patients (53%), while patch plasty using autologous pericardium, polytetrafluoroethylene or Dacron grafts was performed in eight patients (47%). Eleven patients (65%) necessitated concomitant resections of neighboring structures. Mean length of hospital stay was 11±6 days. There was no intraoperative death. Mortality occurred in three patients (18%). Five patients (29%) developed complications. Mortality occurred commonly in elderly patients (p<0.0001). Postoperative complications were more common in patients with concomitant resections (p=0.05). Neither acute nor chronic thrombosis developed in any patients. Median survival in patients with malignant diseases was 57 months, with a oneyear and three-year probability of survival of 83% and 74%, respectively. CONCLUSION: Replacement of superior vena cava should be included in the therapeutic algorithm of selected patients with mediastinal tumors and benign diseases. Mortality rates may be higher in older patients, while the need for concomitant resections may increase morbidity rates.

Salvage thoracic surgery in patients with lung cancer: potential indications and benefits.

BACKGROUND: To investigate the feasibility and efficacy of salvage lung resection and describe the possible indications and contraindications in patients with primary lung cancer. METHODS: Thirty patients undergoing anatomical salvage lung resection were classified into three groups: GI, patients with progressive lung tumor despite definitive chemo- and/or radiotherapy; GII, patients who underwent emergency resection; and GIII, patients in whom neoadjuvant or definitive chemo- and/or radiotherapy was contraindicated because of severe comorbidities. The groups were compared based on, peri- and postoperative factors, and survival rates. RESULTS: The morbidity rate was 70%. Revision surgery was required in 23% of patients. Morbidity was affected by lower hematocrit and hemoglobin levels (P = 0.05). Mean hospital stay was 11 ± 4 days, which was longer in patients in whom complications developed (P = 0.0003). The in-hospital or 30-day mortality rate was 3%. Mean relapse-free survival and overall survivals were 14 ± 12 and 19 ± 13 months. CONCLUSION: Patients with progression of the persistent primary tumor after definitive chemo- and/or radiotherapy can undergo salvage lung resection with acceptable mortality and high morbidity rates, if the tumor is considered resectable. Other indications may be considered for salvage lung resection based on each patient's specific evaluation.

Robotic lung resections: video-assisted thoracic surgery based approach.

Advances in technology cause major developments in minimally invasive thoracic surgery practice. The expected benefits of minimally invasive pulmonary surgery are clear and mostly as follows; shorter hospital stay, fast recovery, less pain, and decreased morbidity and mortality. Robotic surgery with improved visualization and instrumental technical capabilities has become an attractive tool for surgeons who are performing lung resections. However, robotic surgery still seems far away from standardization even in the basic fundamental which is "the best approach for docking". In this article, we would like to share our experience in robotic surgery with video-assisted thoracic surgery (VATS) based or in other terms "robotic-assisted" approach, and discuss its advantages and disadvantages. We speculate that, especially at early experience, VATS based approach or "robotic-assisted approach" may provide a smooth start up with the support of the experienced table surgeon.

Robotic thymectomy-a new approach for thymus.

Advancements in modern technology bring many evolutions in minimally invasive surgery such as robot assisted approaches. Because of complete resection is so important in thymectomy operations, they became a new era for robotic surgery as a result of its superiorities (intuitive movements, tremor filtration, more degrees of manipulative freedom, motion scaling, and high-definition stereoscopic vision).

Rupture of abdominal aortic aneurysm into sigmoid colon: a case report.

Primary aorto-colic fistula is rarely reported in the literature. Although infrequently encountered, it is an important complication since it is usually fatal unless detected. Primary aorto-colic fistula is a spontaneous rupture of abdominal aortic aneurysm into the lumen of the adjacent colon loop. Here we report a case of primary aorto-colic fistula in a 54-year old male. The fistulated sigmoid colon was repaired by end-to-end anastomosis. Despite inotropic support, the patient died of sepsis and multiorgan failure on the first postoperative day.

Spinal cord ischaemia after radical pleurectomy/decortication operation for mesothelioma.

Radical pleurectomy/decortication was performed in a patient with malignant pleural mesothelioma. During the surgery, the left subclavian artery was injured, and repaired via resection and anastomosis. However, the patient was diagnosed with paraplegia following extubation. After deliberate investigations, the mechanism of injury to the critical vascular zone of the spinal cord was determined. Here, we aim to draw attention to possible similar injuries.

Lymph Node Dissection in Surgery for Lung Cancer: Comparison of Open vs. Video-Assisted vs. Robotic-Assisted Approaches.

PURPOSE: We compared open, video-assisted and robotic-assisted thoracoscopic surgical techniques in the dissection of N1 and N2-level lymph nodes during surgery for lung cancer. METHODS: This retrospective analysis is based on prospectively collected data of patients (excluding those with N2 or N3 diseases, and sleeve resections) undergoing mediastinal lymph node dissection via open (n = 96), video-assisted thoracoscopy (n = 68), and robotic-assisted thoracoscopy (n = 106). The groups are compared according to the number of lymph node stations dissected, the number of lymph nodes dissected, and the number of lymph nodes dissected by stations. RESULTS: Three techniques had similar results based on the number of the dissected N1 and N2-level lymph node stations. Robotic-assisted thoracoscopic surgery yielded significantly more lymph nodes in total (p = 0.0007), and in the number of dissected N1-level nodes (p <0.0001). All techniques yielded similar number of mediastinal lymph nodes, whereas robotic-assisted thoracic surgery (RATS) yielded more station #11 and #12 lymph nodes compared to the other groups. CONCLUSIONS: In this study, robotic-assisted thoracoscopic surgery has been shown to dissect more lymph nodes at N1 level. However, taking the open approach as standard, we could claim that both currently robotic and video-assisted techniques may provide similar number of dissected N1 and N2-level lymph node stations.

A late visceral hernia after diaphragmatic flap coverage of the bronchial stump.

A 54-year-old man presented with sudden and severe abdominal pain, and vomiting. He had underwent a right pneumonectomy with bronchial stump reinforcement using diaphragmatic muscle flap 9 years ago, due to non-small cell lung cancer after neoadjuvant chemotherapy. A right partial visceral herniation had been detected 5 years ago during the follow-up which was not present at previous visits. He had refused any surgical intervention since he had been asymptomatic. The chest computed tomography demonstrated visceral herniation. The patient underwent an urgent operation via thoracoabdominal incision to repair the herniation. This type of late catastrophic complication of diaphragmatic muscle flap reinforcement is extremely rare.

Robotic and video-assisted thoracic surgery lung segmentectomy for malignant and benign lesions.

OBJECTIVES: The experience with robotic techniques (RATS) and video-assisted thoracic surgery (VATS) in pulmonary segmentectomy is still limited. We evaluated our prospectively recorded database to compare two different minimally invasive techniques. METHODS: Between May 2007 and July 2014, a total of 99 patients underwent RATS (n = 34) and VATS (n = 65) pulmonary segmentectomies at two institutions. The median age of patients was 59 ± 15 (16-84) years, and 61% were male. Seventy-six patients were operated on for malignancy and 23 for benign diseases. RESULTS: The major morbidity and mortality rates were 24-23% and 0-1.5% for RATS and VATS (P = 0.57) and (P = 0.66), respectively. The mean console time for RATS was longer than the mean operation time for VATS [76 ± 23 (40-150) vs 65 ± 22 (30-120) min (P = 0.018)]. The mean duration of drainage was similar for RATS and VATS [3.53 ± 2.3 (1-10) days vs 3.98 ± 3.6 (1-21) (P = 0.90)], respectively. The duration of postoperative stay for RATS was 4.65 ± 1.94 (2-10) days and for VATS was 6.16 ± 4.7 (2-24) days (P = 0.39). CONCLUSIONS: Both RATS and VATS pulmonary segmentectomy operations are performed with similar morbidity and mortality rates. Although the duration of operation is longer in RATS when compared with an established VATS programme, there is a tendency towards a shorter postoperative stay.

Resection of a bronchogenic cyst in the first decade of life with robotic surgery.

The conventional surgical approach for the removal of bronchogenic cyst in children is thoracotomy. Video-assisted thoracoscopic surgery is still under debate with the concerns of incomplete removal and injury to major intrathoracic structures. In this case report, we present an 8-year old patient who was successfully treated with robotic surgery (Intuitive Surgical, Mountain View, CA, USA). Robotic technology enables precise dissection and complete resection of the thoracic bronchogenic cyst without violating the capsule and adjacent major intrathoracic structures. She was discharged on postoperative Day 2 and was active on Day 5.

Robotic lung segmentectomy for malignant and benign lesions.

OBJECTIVE: Surgical use of robots has evolved over the last 10 years. However, the academic experience with robotic lung segmentectomy remains limited. We aimed to analyze our lung segmentectomy experience with robot-assisted thoracoscopic surgery. METHODS: Prospectively recorded clinical data of 21 patients who underwent robotic lung anatomic segmentectomy with robot-assisted thoracoscopic surgery were retrospectively reviewed. All cases were done using the da Vinci System. A three incision portal technique with a 3 cm utility incision in the posterior 10(th) to 11(th) intercostal space was performed. Individual dissection, ligation and division of the hilar structures were performed. Systematic mediastinal lymph node dissection or sampling was performed in 15 patients either with primary or secondary metastatic cancers. RESULTS: Fifteen patients (75%) were operated on for malignant lung diseases. Conversion to open surgery was not necessary. Postoperative complications occurred in four patients. Mean console robotic operating time was 84±26 (range, 40-150) minutes. Mean duration of chest tube drainage and mean postoperative hospital stay were 3±2.1 (range, 1-10) and 4±1.4 (range, 2-7) days respectively. The mean number of mediastinal stations and number of dissected lymph nodes were 4.2 and 14.3 (range, 2-21) from mediastinal and 8.1 (range, 2-19) nodes from hilar and interlobar stations respectively. CONCLUSIONS: Robot-assisted thoracoscopic segmentectomy for malignant and benign lesions appears to be practical, safe, and associated with few complications and short postoperative hospitalization. Lymph node removal also appears oncologically acceptable for early lung cancer patients. Benefits in terms of postoperative pain, respiratory function, and quality of life needs a comparative, prospective series particularly with video-assisted thoracoscopic surgery.

Cyanoacrylate for wound closure in prosthetic vascular graft surgery to prevent infections through contamination.

PURPOSE: Prosthetic vascular graft infection (PVGI) still occurs at an unacceptably high rate, despite the many measures that have proven effective against infection. The major cause of PVGI is perioperative contamination, which usually occurs before a histological barrier is completed and may threaten graft viability. We assessed the efficacy of cyanoacrylate as a tissue adhesive and barrier against early contamination through the skin. METHOD: A 1 x 0.5-cm Dacron graft was placed subcutaneously under sterile conditions in 16 Sprague-Dawley rats. The skin was closed with polypropylene sutures in eight rats (group A) and with N-butyl 2-cyanoacrylate in eight rats (group B). The closed incisions were then contaminated with 75 x 10(6) cfu/ml methicillin-sensitive Staphylococcus aureus. Microbiological and histopathological assessments were done 7 days later, after the rats were killed. RESULTS: All of the graft cultures from group A (8/8) were positive for S. aureus whereas all of those from group B (0/8) were negative. This difference was significant (p < 0.001). Histological examination revealed denser inflammatory cell infiltration in group A than in group B. CONCLUSIONS: Maintaining skin integrity after closure is of the utmost importance because contamination during the first hours of the procedure may cause PVGI. Cyanoacrylate seems to be a promising molecule not only because of its bacteriostatic effects, but also because it seals the barrier effectively and immediately.