Intercostal Catheters Reduce Long-Term Pain and Postoperative Opioid Consumption after VATS.

Background/Objectives: Pain after video-assisted thoracoscopic surgery (VATS) leads to impaired postoperative recovery, possible side effects of opioid usage, and higher rates of chronic post-surgery pain (CPSP). Nevertheless, guidelines on perioperative pain management for VATS patients are lacking. The aim of this study was to analyze the effectiveness of intercostal catheters in combination with a single shot intraoperative intercostal nerve block (SSINB) in comparison to SSINB alone with respect to opioid consumption and CPSP. Methods: Patients receiving an anatomic VATS resection between 2019 and 2022 for primary lung cancer were retrospectively analyzed. A total of 75 consecutive patients receiving an ICC and SSINB and 75 consecutive patients receiving only SSINB were included in our database. After enforcing the exclusion criteria (insufficient documentation, external follow-ups, or patients receiving opioids on a fixed schedule; n = 9) 141 patients remained for further analysis. Results: The ICC and No ICC cohort were comparable in age, gender distribution, tumor location and hospital stay. Patients in the ICC cohort showed significantly less opioid usage regarding the extent (4.48 ± 6.69 SD vs. 7.23 ± 7.55 SD mg, p = 0.023), duration (0.76 ± 0.97 SD vs. 1.26 ± 1.33 SD days, p = 0.012) and frequency (0.90 ± 1.34 SD vs. 1.45 ± 1.51 SD times, p = 0.023) in comparison to the No ICC group. During the first nine months of oncological follow-up assessments, no statistical difference was found in the rate of patients experiencing postoperative pain, although a trend towards less pain in the ICC cohort was found. One year after surgery, the ICC cohort expressed significantly less often pain (1.5 vs. 10.8%, p = 0.035). Conclusions: Placement of an ICC provides VATS patients with improved postoperative pain relief resulting in a reduced frequency of required opioid administration, less days with opioids, and a reduced total amount of opioids consumed. Furthermore, ICC patients have significantly lower rates of CPSP one year after surgery.

Sarcopenia and Mediastinal Adipose Tissue as a Prognostic Marker for Short- and Long-Term Outcomes after Primary Surgical Treatment for Lung Cancer.

Surgical resection remains the gold standard of treatment for early-stage lung cancer. Several risk models exist to predict postoperative morbidity and mortality. Psoas muscle sarcopenia has already successfully been used for morbidity prediction in lung transplantation and is not yet included in the available risk scores for pulmonary resections. We hypothesized that the skeletal muscle index and mediastinal adipose tissue might also have an impact on postoperative outcomes after primary surgery for primary lung cancer. The institutional database was queried for patients with primary lung cancer who were treated with primary lobectomy or segmentectomy between February 2009 and November 2018. In total, 311 patients were included for analysis. Patients receiving neo-/adjuvant chemotherapy or with a positive nodal status were excluded to rule out any morbidity or mortality due to (neo-)adjuvant treatment. Sarcopenia was defined as a skeletal muscle index of <34.4 cm2/m2 for women and <45.4 cm2/m2 for men. Mediastinal adipose tissue was defined with a radiodensity of -150 to -30 Hounsfield units. Sarcopenia was diagnosed in 78 (25.1%) of the 311 patients. Male patients were significantly more likely to suffer from sarcopenia (31.5% vs. 18.1%, p = 0.009). Comorbidities, lung function, tumour histology, pathologic tumour staging, mediastinal adipose tissue and age did not differ between groups with or without sarcopenia. Sarcopenic patients had a significantly longer length of stay, with 13.0 days vs. 9.5 (p = 0.003), and a higher rate of any postoperative complications (59.0% vs. 44.6%, p = 0.036). There was no difference in recurrence rate. Five-year overall survival was significantly better in the patient cohort without sarcopenia (75.6% vs. 64.5%, p = 0.044). Mediastinal adipose tissue showed no significant impact on length of stay, postoperative complications, recurrence rate, morbidity or survival. Sarcopenia, quantified with the skeletal muscle index, is shown to be a risk factor for postoperative morbidity and reduced survival in primary lung cancer. Efforts should be taken to pre-emptively screen for sarcopenia and start countermeasures (e.g., physical prehabilitation, protein-rich nutrition, etc.) during the preoperative workup phase.

Risk factors, complications and costs of prolonged air leak after video-assisted thoracoscopic surgery for primary lung cancer.

Background: Prolonged air leak (PAL) represents a common complication after lung resection. This study aims to analyze the risk factors for the development of a PAL, its impact on the postoperative outcome and to estimate additional treatment costs. Methods: A single center database was queried for all patients scheduled for video-assisted thoracoscopic surgery for primary lung cancer. In total, 957 patients between 2009 and 2021 were analyzed. Exclusion criteria was pneumonectomy. Collected data included demographics and perioperative data (e.g., duration of surgery, postoperative infections, air leak duration etc.). PAL was defined as an air leak lasting for 5 days or longer. The PAL cohort included 103 patients, the non-PAL included 854 patients. Univariate analysis and binomial logistic regression were performed. Cost calculation was performed using available data from prior publications to estimate treatment costs. Results: Male sex, chronic obstructive pulmonary disease (COPD) and low body mass index (BMI) showed to be risk factors for the development of postoperative PAL (P<0.001). Using these risk factors, a risk prediction score for PAL has been established. A subgroup analysis showed a significantly higher rate of sarcopenia in patients with PAL (P<0.001). The mean duration until removal of chest drains and length of stay (LOS) was significantly longer in the PAL cohort (14.2 vs. 4.4 days, P<0.001; 19.8 vs. 9.3 days, P<0.001). Also, the duration of the operation was longer in PAL patients (179.1 vs. 161.2 minutes, P=0.001). Patients with PAL had an elevated risk for postoperative infections [odds ratio (OR) 3.211, 31.1% vs. 12.3%, P<0.001]. As a result of a prolonged LOS, estimated treatment costs were significantly higher for PAL, ranging from 2,888.2 to 12,342.8 € depending on available cost bases compared to the non-PAL cohort, which ranged from 1,370.5 to 5,856.8 € (P<0.001). Conclusions: PAL is a frequent complication that prolongs the LOS after thoracic surgery and, according to the literature, results in elevated readmission rates, leading to excess health care costs. Risk factors for PAL are well established. Preoperative treatment of sarcopenia and dismal nutritional status might alter the risk. As measures to prevent PAL are otherwise limited, guidelines for effective management of PAL need to be established.

External validation of risk prediction scores in patients undergoing anatomic video-assisted thoracoscopic resection.

BACKGROUND: EuroLung Risk scores were established to predict postoperative morbidity and mortality in patients undergoing anatomic lung resections. We aimed to perform an external validation of the EuroLung scores, which were calculated from data of the European Society of Thoracic Surgeons database, in our video-assisted thoracoscopic surgery cohort. METHODS: All available EuroLung scores were calculated for 718 patients scheduled for anatomic video-assisted thoracoscopic surgery resections between 2009 and 2019. Morbidity and mortality according to the definitions of the EuroLung scores were analyzed in a prospectively maintained database. RESULTS: Overall observed complication rate was 10.45%. Scores showed weak individual correlation (η = 0.155-0.174). The EuroLung1 app score showed the biggest area under the receiver operative characteristic (ROC) curve with 0.660. Binary logistic regression analysis showed that predicted postoperative forced expiratory volume in 1 s was associated with increased complications in both EuroLung1 and parsimonious EuroLung1 scores. Thirty-day mortality was 0.7% (predicted 1.10-1.40%) and was associated with predicted postoperative forced expiratory volume in 1 s for both EuroLung2 and parsimonious EuroLung2 scores. The EuroLung2 (2016) showed the biggest area under the ROC curve with 0.673. Only a very weak eta correlation between predicted and observed mortality was found for both aggregate EuroLung2, EuroLung2 (2016), EuroLung2 (2019), and parsimonious EuroLung2 (2016) (η = 0.025/0.015/0.011/0.009). CONCLUSION: EuroLung scores help to estimate postoperative morbidity. However, even with the highest aggregate EuroLung scores possible only 50% suffer from postoperative morbidity. Although calibration of the scores was acceptable, discrimination between predicted and observed events was poor. Therefore, individual correlation between predicted and observed events is weak. Therefore, EuroLung scores may be best used to compare institutional quality of care to the European Society of Thoracic Surgeons database but should not be used to preclude patients from surgical treatment.

Delay to surgical treatment in lung cancer patients and its impact on survival in a video-assisted thoracoscopic lobectomy cohort.

Patient pathways from first suspicious imaging until final surgical treatment vary and in some instances cause considerable delay. This study aims to investigate the impact of this delay on survival of lung cancer patients. The institutional database was queried to identify patients with primary lung cancer who were treated with primary surgery. Time intervals were defined as date of first suspicious medical images until date of surgical treatment. All patients received PET-CT staging and tissue confirmation prior to treatment planning in a multidisciplinary tumor board. Patients with unknown date of first contact, follow-up CT-scans of pulmonary nodules, or neoadjuvant therapy were excluded. In total, 287 patients treated between 2009 and 2017 were included for further analysis. Median time between first suspicious medical imaging and surgical therapy was 62 (range 23-120) days and did not differ between male and female patients. Patients were then classified into two groups according to the duration of the medical work-up: group A up to 60 days, and group B from 61 to 120 days. Clinical T and N stages were comparable between the groups. There was no difference in overall survival between the two groups. In the subgroup of cT2 tumors (87 patients), there was a significant survival benefit for patients in group A (p = 0.043), while nodal stages, stage migration, lymphatic vessel invasion, grading and other potentially survival-influencing clinical parameters were comparable between the groups. Delay between diagnosis and treatment of lung cancer may result in dismal outcome. Efforts need to focus on improving and streamlining patient pathways to shorten the delay until surgical treatment to a minimum. Process improvement might be achieved by stringent interdisciplinary work-up and a patient-centered approach.

Intercostal Catheters for Postoperative Pain Management in VATS Reduce Opioid Consumption.

BACKGROUND: Postoperative pain after video-assisted thoracoscopic surgery (VATS) affects patients' recovery, postoperative complications, and length of stay (LOS). Despite its relevance, there are no guidelines on optimal perioperative pain management. This study aims to analyse the effects of an additional intercostal catheter (ICC) in comparison to a single shot intraoperative intercostal nerve block (SSINB). METHODS: All patients receiving an anatomic VATS resection between June 2019 and May 2020 were analysed retrospectively. The ICC cohort included 51 patients, the SSINB cohort included 44 patients. RESULTS: There was no difference in age, gender, comorbidities, or duration of surgery between cohorts. Pain scores on the first postoperative day, after chest drain removal, and highest pain score measured did not differ between groups. The overall amount of opioids (morphine equivalent: 3.034 mg vs. 7.727 mg; p = 0.002) as well as the duration of opioid usage (0.59 days vs. 1.25 days; p = 0.005) was significantly less in the ICC cohort. There was no difference in chest drain duration, postoperative complications, and postoperative LOS. CONCLUSIONS: Pain management with ICC reduces the amount of opioids and number of days with opioids patients require to achieve sufficient analgesia. In conclusion, ICC is an effective regional anaesthesia tool in postoperative pain management in minimally invasive thoracic surgery.

Nerve at risk: anatomical variations of the left recurrent laryngeal nerve and implications for thoracic surgeons.

OBJECTIVES: Recurrent laryngeal nerve (RLN) injury during thoracic surgery may result in life-threatening postoperative complications including recurrent aspiration and pneumonia. Anatomical details of the intrathoracic course are scarce. However, only an in-depth understanding of the anatomy will help reduce nerve injury. The aim of this study was to assess the anatomic variations of the intrathoracic left RLN. METHODS: Left-sided vagal nerves and RLN were dissected in 100 consecutive Caucasian cadavers during routine autopsy. Anatomical details were documented. Available demographic data were assessed for possible correlations. RESULTS: All nerves were identified during dissection. Variant courses were classified in 3 different groups according to the level at which the RLN separated from the vagal nerve: above the aortic arch, level with the aortic arch and below the aortic arch. We found 11% of RLN separating above the aortic arch and crossing the aortic arch at a considerable distance to the vagal nerve. In 48% of the RLN, the nerve split off when it was level with the aortic arch, and 41% of the RLN leave the vagal nerve in a perpendicular direction below the aortic arch. All nerves crossed the ligamentum arteriosum on the posterior side. No gender-specific differences were observed. CONCLUSIONS: Mediastinal lymph node dissection in left-sided lung cancer patients puts the RLN at risk. With more detailed anatomical knowledge about its course, it is possible to avoid risking the nerve. Visualization will help protect the nerve.

Right-Sided Approach for Segmental Resection of the Left Main Bronchus-Technical Considerations.

Carcinoids of the left main bronchus are rare tumors of the bronchial system and patients often present with dyspnea, asthma-like symptoms, and pneumonia. Gold standard for therapy of carcinoids is surgical resection, but the surgical approach for segmental resection and anastomosis of the left main bronchus is a matter of discussion. With a left-sided approach the access to the bronchus is blocked by the aortic arch and the pulmonary vein. If a right-sided approach is performed, the problem of ventilation during resection and anastomosis of the bronchus occurs. We present a surgical approach from the right side using intraoperative extracorporeal membrane oxygenation to assure oxygen supply for resection of a typical carcinoid of the left main stem bronchus, and discuss the current literature.

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.

VATS Partial Pleurectomy Versus VATS Pleural Abrasion: Significant Reduction in Pneumothorax Recurrence Rates After Pleurectomy.

INTRODUCTION: Surgical treatment of primary spontaneous pneumothorax (PSP) usually consists of bullectomy and any form of pleurodesis to reduce risk of disease recurrence. Whether pleurectomy is superior to pleural abrasion is still a matter of debate with recurrence rates especially high when performed with a video-assisted thoracoscopic (VATS) approach. Aim of this study was to compare the efficacy of the two methods in prevention of recurrence of pneumothorax in a minimally invasive setting. MATERIALS AND METHODS: Between 01/2005 and 12/2015, 107 patients younger than 40 years with PSP underwent VATS bullectomy and either partial pleurectomy or pleural abrasion. Medical records of patients were reviewed retrospectively. RESULTS: Pleural abrasion was performed in 34/107 patients, 73/107 patients underwent partial pleurectomy. There were no statistically significant differences in age, sex, body mass index or smoking history at time of surgery. There was no significant difference in major postoperative complications (p = 0.3022). Nine (8.4%) patients had a recurrence of pneumothorax during follow-up. Incidence of recurrence in those undergoing pleural abrasion was significantly higher than those undergoing apical pleurectomy (8/34 vs. 1/73, p < 0.001). Surgical technique was the only factor associated with a recurrence of PSP after surgical intervention. DISCUSSION: In our analysis, a VATS partial pleurectomy proved to be effective for prevention of recurrent PSP. Recurrence rates were low despite a minimally invasive approach and significantly lower than in the pleural abrasion group. According to these findings, VATS pleurectomy might be considered as the primary choice for surgical pleurodesis in patients with PSP.

Intraoperative complications during VATS lobectomies from conversion to minimally-invasive "trouble-shooting".

The aim of this study was to explore intraoperative complications during video-assisted thoracoscopic surgery (VATS) lobectomy. Vascular and bronchial injuries, after a robust learning curve, can be sometimes successfully managed by VATS. During a VATS lobectomy, it is necessary: to be prepared in potentially dangerous situations; to think about strategies to handle intraoperative complications and to share these strategies with your own staff. Herein we present some videos showing cases where vascular injuries led to conversion and others where a minimally-invasive trouble shooting of intraoperative complications was achieved.

Extended minimally invasive lung resections: VATS bilobectomy, bronchoplasty, and pneumonectomy.

PURPOSE: The aim of the present study was to analyze feasibility, morbidity, mortality, and oncologic outcome of extended video-assisted thoracoscopic surgery (VATS) anatomic lung resections in a single-center experience. Extended resections include bilobectomies, bronchoplasties, and pneumonectomies. METHODS: The present study is a retrospective analysis of a prospectively maintained institutional database. Between 2009 and 2014, 390 patients were scheduled for anatomical VATS resections. VATS resection was completed in 370 patients giving an overall conversion rate of 5.1 %. Extended VATS resections were performed in 29 patients (7.8 %): bilobectomy in 8, bronchoplastic resection in 15 (2 bronchial sleeve resections, 11 wedge bronchoplasties, 2 simple bronchoplasties), and pneumonectomy in 6. RESULTS: Median operative time was 217 min (117-390 min). Median chest tube duration was 4 days (range, 2-50 days). Median length of hospital stay was 9 days (6-63 days). There was no in-hospital mortality. Major complications with need for reinterventions occurred in three patients (10.3 %): one air leakage from bronchial stump after pneumonectomy, one hematothorax after completion pneumonectomy, and one chylothorax. All complications were treated with VATS procedures. Minor complications included two persistent air leaks that were treated with an additional chest drain and resolved, one urinary tract infection, one atelectasis with need for bronchoscopy, and one pleural fluid collection with the need for drainage. After a median follow-up of 26 months, no local tumor recurrence occurred. Two patients had a second lung primary cancer and four patients with advanced tumor stages had distant recurrent disease. CONCLUSIONS: With growing experience, extended VATS resections are feasible in selected cases with low perioperative morbidity and mortality.

Causes, predictors and consequences of conversion from VATS to open lung lobectomy.

BACKGROUND: To analyze causes, predictors and consequences of conversions from intended VATS lobectomy to open surgery. METHODS: This is a retrospective analysis of a prospectively maintained database. RESULTS: From 2009 until December 2012, 232 patients were scheduled for anatomical VATS resection. Conversion to open surgery was necessary in 15 (6.5 %) patients. Reasons for conversion were bleeding in six, oncologic in five and technical in four patients (adhesions after pleuritis or radiotherapy for other tumors: 3; limited space: 1). In a univariable exact logistic regression analysis, conversion rate was significantly higher in patients after induction therapy (p = 0.019). There was also a statistical trend to a higher conversion rate in patients with larger tumor size (<3 vs. ≥3 cm, p = 0.117) and during the first half of our series (p = 0.107). Conversion rate was not influenced by patient age, nodal stage (pN0 vs. pN+), body mass index, the presence of chronic obstructive pulmonary disease, lung function (FEV1) or benign disease. In a multivariable exact logistic regression, induction treatment (p = 0.013) and tumor size (p = 0.04) were independent significant risk factors for conversion. Conversion did not translate into higher overall postoperative complication rate (33.3 vs. 29.5 %), longer chest drain duration (median, 5 vs. 5 days) or in-hospital mortality (0 vs. 1 %). However, length of hospital stay was significantly longer in the conversion group (median 11 vs. 9 days, p = 0.028). CONCLUSIONS: Induction therapy was an independent risk factor for conversion to thoracotomy in this VATS lobectomy series. Following induction therapy, patients should be carefully selected for a VATS approach. Conversion to thoracotomy did not increase the postoperative rate of complications or mortality, but significantly increased length of hospital stay.

Comparative analyses of volatile organic compounds (VOCs) from patients, tumors and transformed cell lines for the validation of lung cancer-derived breath markers.

Breath analysis for the purpose of non-invasive diagnosis of lung cancer has yielded numerous candidate compounds with still questionable clinical relevance. To arrive at suitable volatile organic compounds our approach combined the analysis of different sources: isolated tumor samples compared to healthy lung tissues, and exhaled breath from lung cancer patients and healthy controls. Candidate compounds were further compared to substances previously identified in the comparison of transformed and normal lung epithelial cell lines. For human studies, a breath sampling device was developed enabling automated and CO2-controlled collection of the end-tidal air. All samples were first preconcentrated on multibed sorption tubes and analyzed with gas chromatography mass spectrometry (GC-MS). Significantly (p < 0.05) higher concentrations in all three types of cancer samples studied were observed for ethanol and n-octane. Additional metabolites (inter alia 2-methylpentane, n-hexane) significantly released by lung cancer cells were observed at higher levels in cancer lung tissues and breath samples (compared to respective healthy controls) with statistical significance (p < 0.05) only in breath samples. The results obtained confirmed the cancer-related origin of volatile metabolites, e.g. ethanol and octane that were both detected at significantly (p < 0.05) elevated concentrations in all three kinds of cancer samples studied. This work is an important step towards identification of volatile breath markers of lung cancer through the demonstration of cancer-related origin of certain volatile metabolites.

Robotic-assisted minimally invasive vs. thoracoscopic lung lobectomy: comparison of perioperative results in a learning curve setting.

PURPOSE: Minimally invasive lung lobectomy was introduced in the late 1990s. Since that time, various different approaches have been described. At our institution, two different minimally invasive approaches, a robotic and a conventional thoracoscopic one, were performed for pulmonary lobectomies. This study compares perioperative outcome of the two different techniques in a learning curve setting. METHODS: Between 2001 and 2008, 26 patients underwent lung lobectomy with a robotic-assisted thoracoscopic surgery (RATS) technique. In 2009, the minimally invasive approach was changed to a conventional video-assisted thoracoscopic surgery (VATS) technique. Perioperative results of the first 26 VATS patients were compared to the results of the robotic group. RESULTS: There were significantly more patients with clinical stage >IB in the VATS group than in the robotic-assisted group (23.1 vs. 0 %). Otherwise, demographic data were equal between the groups. Operative time was significantly longer in the robotic group (215 vs. 183 min, p = 0.0362). Median difference between preoperative hemoglobin levels and levels on postoperative day 1 was higher in the RATS group, suggesting a higher blood loss. No difference was found in conversion rate, acute phase protein levels (C-reactive protein), chest drain duration, postoperative morbidity and mortality, and length of hospital stay. Procedural costs were higher for the robotic approach (difference, 770.55 , i.e., 44.4 %). CONCLUSIONS: Shorter operative times, a lower drop of postoperative hemoglobin levels indicating less blood loss, and lower procedural costs suggest a benefit of the VATS approach over the robotic approach for minimally invasive lung lobectomy.

Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors.

BACKGROUND: Robotic surgical systems are most effective for operations in areas that are small and difficult to reach. Ideal indications for this new technology have yet to be established. The esophagus possesses attributes that are interesting for general thoracic robotic surgeons. METHODS: Robotic-assisted thoracoscopic surgery (RATS) using the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) was performed in six patients with esophageal tumors. This comprised the dissection of the intrathoracic esophagus including lymph node dissection in four patients suffering from esophageal cancer and the extirpation of a benign lesion (one leiomyoma and one foregut cyst) in the remaining two patients. RESULTS: All procedures were completed successfully with the robot. The median overall operating time was 173 (160-190) minutes in the oncologic cases and 121 minutes in the benign cases, including the robotic act of 147 (135-160) minutes and 94 minutes, respectively. There were no intraoperative complications. One patient had to undergo a redo thoracoscopy because of a persistent lymph fistula. One cancer patient died after 12 months due to tumor progression and another patient had to be stented due to local tumor recurrence 19 months postoperatively. CONCLUSIONS: This first small series of various esophageal pathologies treated by robotic-assisted thoracoscopic surgery supports the impression that the esophagus is an ideal organ for a robotic approach. The potential of the da Vinci system, especially for oncologic indications, remains to be proven in future clinical trials.

A critical comparison of robotic versus conventional laparoscopic splenectomies.

The benefit of robotic systems for general surgery is a matter of debate. We compare our initial series of robotic splenectomies with our first series of conventional laparoscopic ones. A retrospective analysis of the first six robotic versus the first six conventional laparoscopic splenectomies is presented. Patients were matched with regard to age, body-mass index, ASA score, and preoperative platelet levels. All procedures were performed by a single surgeon. Size and weight of the resected specimens were comparable in both groups. Median overall operating time was 154 (range, 115-292) min for the robotic and 127 (range, 95-174) min for the laparoscopic group. No complications occurred. There were no open conversions. The median postoperative hospital stay was 7 (robotic group) and 6 (laparoscopic group) days. Median average costs were 6927 dollars for the robotic procedure versus $4084 for the conventional laparoscopic procedure (p < 0.05). Minimally invasive splenectomies are feasible using either conventional laparoscopic techniques or the da Vinci robotic system. In this analysis, procedures performed with the da Vinci robotic system resulted in prolonged overall operative time and significantly higher procedural costs. The use of a robotic system for laparoscopic splenectomy offers, at this stage, no relevant benefit and thus is not justified.

Laparoscopic splenectomy with the da Vinci robot.

BACKGROUND: We report our first series of minimally invasive splenectomies with a robotic surgical system. METHODS: From August 2001 to October 2003, laparoscopic splenectomies with the da Vinci operating robot were performed in 7 patients (five females and two males, ages 20 to 74 years). RESULTS: Indications for splenectomy were hematologic disorders in four patients and hypersplenism in three patients. Median dimensions of the resected spleens were 140 +/- 34 mm x 80 +/- 11 mm x 50 +/- 17 mm and median weight was 307 +/- 193 g. Median total operative time was 147 +/- 58 minutes including 107 +/- 49 minutes for the robotic act. There were no intraoperative complications and no conversions to open surgery. The median postoperative hospital stay was 7 days. CONCLUSION: This first series suggests that robotic splenectomy with the da Vinci surgical system is technically feasible and safe. It provides an alternative to the conventional laparoscopic procedure. Nevertheless, justification for this new technique will require a larger prospective series and longer follow-up.