Minimally Invasive Mitral Valve Repair: From Total Endoscopic To Closed-Chest Robotic.

Minimally invasive cardiac surgery has evolved over the past few decades, thanks to advancements in technology and surgical techniques. These advancements have allowed surgeons to perform cardiac interventions through small incisions, reducing surgical trauma and improving patient outcomes1. However, despite these advancements, thoracoscopic mitral repair has not been widely adopted by the cardiac surgery community, possibly due to the lack of familiarity with video-assisted procedures1. Over the years, various minimally invasive mitral valve surgery (MIMVS) techniques have been developed to achieve comparable or better results while minimizing surgical trauma. These techniques have evolved from direct-vision procedures performed through a right thoracotomy with a rib retractor to video-directed approaches using long-shafted instruments1. Robotic surgery, introduced in the late 90s, has also played a significant role in mitral valve repair. The da Vinci system, the only robotic platform currently used for cardiac surgery, provides surgeons with enhanced dexterity and high-definition 3D visualization, allowing for precise and accurate procedure2, and is now the preferred approach for mitral repair in many programs3. The first mitral repair using the da Vinci system was performed in Europe by Carpentier and Mohr in 1998, followed by the first mitral replacement by Chitwood in the USA in 20002-4. The advantages of robotic technology allow surgeons to perform complex repair techniques such as papillary muscle repositioning and sliding leaflet plasty4. Studies have shown that robotic mitral surgery results in shorter ICU and hospital stays, better quality of life postoperatively, and improved cosmesis compared to conventional surgery5,6. In our experience, we have also observed significant benefits with robotic surgery, including reduced blood loss and the need for transfusions. This can be attributed to the closed-chest technique, which eliminates the need for a thoracotomy and rib retractor, reducing the risk of bleeding associated with these approaches7. In this article, we will compare the surgical steps of endoscopic and robotic mitral valve repair, providing detailed information on patient selection, operative techniques, and the requirements for building a successful program. By understanding the advantages and challenges of both approaches, surgeons can make informed decisions and provide the best possible care for their patients. Combined ablation and multivalvular procedures are mostly performed in few centers by minimally invasive techniques.

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.

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.

Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Cardiac surgery using a single thoracic port-current status and future directions.

Cardiac surgery is almost universally performed through a median sternotomy, an approach which is painful, unestethical, and prone to life-threatening infections. Minimally invasive cardiac surgery has tried to avoid problems associated with full sternotomy for many years. Recently, uniportal thoracic surgery was shown to be very advantageous when compared to standard thoracotomy and classical video assisted thoracic surgery (VATS). Despite very good results in lung surgery, cardiac surgery through a single thoracic port has rarely been attempted and successfully conducted. The authors present the rational, the technique, and their experience in cardiac single thoracic port surgery (CSTPS).

Use of CO2 in video assisted thoracic surgery and single-lumen endotracheal tube-a new less invasive approach.

Carbon dioxide (CO2) has been extensively used to allow laparoscopic procedures, due to its extensive advantages in obtaining a fairly innocuous pneumoperitoneum to allow visceral dissection. Its use in video assisted thoracic surgery (VATS) has seldom been described. We present our experience in more than 100 patients, operated for various thoracic pathologies, in whom we created a surgical pneumothorax to allow different surgeries to be undertaken.

Uniportal VATS Lobectomy: Subxiphoid Approach.

INTRODUCTION: Interest in uniportal video-assisted thoracic surgery (VATS) is rapidly growing worldwide because it represents the surgical approach to the lung with the least possible trauma and in recent years the subxiphoid approach has been used in the field of thoracic surgery as it is associated with lesser pain because there is no intercostal nerve damage and it provides excellent cosmetic outcomes. This technique was recently introduced for major pulmonary resections and even bilateral approaches in selected patients. METHODS: We present a case of a 66 years old male, former smoker (45 unit pack year) who had a thorax CT (computorized tomography) scan for worsening complaints of cough with sputum production. The CT scan revealed a right upper lobe nodule (16x14mm) with ground glass density and fissure retraction. The pulmonary function tests showed mild bronchial and bronchiolar obstruction. It was decided to undergo surgical treatment. The surgical approach was a subxiphoid uniportal lung resection. RESULTS: The patient was positioned in a left lateral position with 60 degrees of inclination. The surgeon and scrub nurse were located in front of the patient and the assistant in the opposite side. A 3cm midline vertical incision was made below the sterno-costal triangle. The rectus abdominis was divided and the xiphoid process was partially resected. The right pleura was opened by finger dissection. The pericardial fatty tissue was removed and a soft tissue retractor was placed. A 10- mm, 30-degrees video camera and double articulated instruments combined with several specific longer VATS instruments were used through the same subxiphoid incision.It was performed a wedge resection and after the diagnosis of adenocarcinoma in the intraoperative histological examination, the patient underwent a right upper lobectomy and complete mediastinal lymphadenectomy by the same approach.The post-operative period was uneventful, the chest tube was removed in the third postoperative day. The pain control was excellent, with a maximum of pain grade 1 in the Visual Analogue Scale.The patient was discharged in the fourth postoperative day. CONCLUSION: The subxiphoid approach is a variant of uniportal VATS approach without opening the intercostal space with its striking advantages in terms of pain control and cosmetics in selected patients. However, this technique has yet some limitations such as the control of major bleeding and the performance of a complete oncologic lymph node dissection related to its surgical complexity expected in emerging techniques. Further studies are necessary to certify the feasibility, safety and benefits of this approach.

Intracardiac leiomyomatosis presenting as an intraoperative consultation.

Intravenous leiomyomatosis (IVL) is an extremely rare variant of leiomyoma in which nodular masses of tumor grow within venous channels. Rarely, the tumor can reach the vena cava and right heart. We present a case of a 45-year-old woman, admitted with rapidly evolving exertional dyspnea. Cardiac ultrasonography revealed a "mass in the right chambers". She was submitted to right atriotomy plus tumorectomy, with intraoperative consultation requested. Grossly, the tumor was polypoid, firm, with a smooth surface. The frozen section showed a lesion composed of tortuous vessels and some areas with a fibrillar eosinophil extracellular matrix and others with spindle cells, without significant atypia, mitosis or necrosis. The diagnosis was deferred for definitive paraffin sections. In the definitive H&E and immunohistochemical stains, the case was diagnosed as an IVL and confirmed in the hysterectomy specimen. This is the first case report describing an intraoperative consultation of an intracardiac leiomyomatosis. Clinical information and pathologist awareness to this entity are essential for the correct diagnosis in frozen section.