The modified Lyon's position: an alternative approach to robotic thymectomy.

The conventional supine position for robotic thymectomy may present challenges in accessing the lower thymic horns, particularly in cases requiring extensive resection of mediastinal fat. To address this issue, the authors advocate for a lateral patient position during the procedure, emphasizing optimized access to the thymic horns and improved procedural efficacy. The lateral approach involves specific trocar placements and port arrangements to minimize conflicts between instruments. This report proposes an innovative approach to robotic thymectomy for patients diagnosed with thymoma or thymic hyperplasia associated with myasthenia gravis.

Robotic enucleation of oesophageal leiomyoma technique and surgical outcomes.

INTRODUCTION: Complete enucleation of oesophageal leiomyoma is the treatment of choice, traditionally performed by open surgery. Minimally invasive thoracoscopic approaches have been proposed as an alternative to thoracotomy. Robotic surgical systems with improved dexterity, tremor filtration and stereoscopic vision are advancement over conventional thoracoscopy and may make the preservation of mucosal integrity relatively easier. We present herein our technique of robotic-assisted thoracoscopic (RATS) enucleation of oesophageal leiomyoma along with surgical outcomes and intermediate follow-up of 11 cases. MATERIALS AND METHODS: The present study retrospectively reviews patients undergoing robotic portal oesophageal leiomyomectomy from March 2012 to October 2019. The collected data were analysed for demographic details, clinical presentation, size, shape, tumour location, operating time, post-operative complications, length of hospital stay and recurrence on follow-up. RESULTS: Twelve patients underwent robotic portal oesophageal leiomyomectomy with a clinical diagnosis of oesophageal leiomyoma. Of these, 11 patients were included in the study. The average operative time was 110 min, with a mean blood loss of 26 ml. There was no conversion in this series. At a median follow-up of 44 months (range 6-78 months), all patients were symptom-free with no recurrence or diverticula. CONCLUSION: Our series demonstrates the safety and feasibility of RATS oesophageal enucleation with good short and intermediate outcomes. In our opinion, the robotic system's technical advantages are particularly beneficial for oesophageal leiomyoma enucleation.

Techniques for lung surgery: a review of robotic lobectomy.

INTRODUCTION: Robotic lobectomy is an increasingly common surgical approach for anatomic lung resection. Over the last decade, robotic lobectomy has shown to be safe, with oncologic efficacy similar to lobectomy via thoracotomy or video-assisted thoracoscopic surgery (VATS). Comparative analysis between these modalities is an active area of investigation. While initially expensive, the costs of a robotic platform decrease as the number of operations performed increases, length of stay is shortened, and postoperative morbidity is reduced. Moreover, the added cost has value which is defined over long periods of time. Areas covered: The clinical technique and optimal conduct of lobectomy is explained in granular detail for all five types of lobectomies. The advantages and disadvantages of a robotic platform are analyzed, including a review of the recent literature. Expert commentary: The number of robotic pulmonary resections performed has tripled in the past two years. Anticipated developments in robotic surgery include improvements in robotic training, continued refinement of robotic instrumentation, and additional adjunctive technologies. The overall costs of robotic surgery will decrease, in part, due to increasing competition as additional companies enter the market.

Decreasing the Preincision Time for Pulmonary Lobectomy: The Process of Lean and Value Stream Mapping.

BACKGROUND: Our objective was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process). METHODS: After meetings with our anesthesiologists, we standardized our "in the operating room-to-skin incision protocols" before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated. RESULTS: One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p ≤ 0.001 for all). A protocol for the insertion of double-lumen endotracheal tubes was established and times decreased (mean, 14 minutes to 1 minute; p = 0.001). After all changes were made, the time between operating room entry and incision decreased from a mean of 64 minutes to 37 minutes (p < 0.001). Outcomes improved, mortality decreased from 3.2% to 0.26% (p = 0.015), and major morbidity decreased from 15.2% to 5.3% (p = 0.042). CONCLUSIONS: Lean and value stream mapping can be safely applied to the clinical algorithms of high-risk patient care. We demonstrate that elimination of non-value-added steps can safely decrease preincision time without increasing patient risk in patients who undergo pulmonary lobectomy. Selected centers may be able to adopt some of these lean-driven protocols.

Retention Rate of Electromagnetic Navigation Bronchoscopic Placed Fiducial Markers for Lung Radiosurgery.

BACKGROUND: Radiosurgery is becoming an increasingly used modality for the medically inoperable early stage lung cancer patient. The optimal fiducial marker with respect to retention rate has yet to be identified. METHODS: We retrospectively reviewed our experience with electromagnetic navigational bronchoscopic fiducial marker placement in preparation for stereotactic radiosurgery. RESULTS: Forty-eight patients, treated between 2010 and January 2013, were retrospectively reviewed. All patients had a diagnosis of early stage lung cancer. Comparison of initial fiducial placement procedure data with imaging at the time of treatment was accomplished for all patients in this data set. Fiducial retention rates were as follow: VortX coil fiducials were retained in 59 of 61 (96.7%) cases; two-band fiducials were retained in 24 of 33 (72.7%) of instances; and gold seed fiducials were retained in 23 of 33 (69.7%) of cases. Retention was statistically superior when comparing the VortX coil with the two-band fiducial or the gold seed (p = 0.004 and p = 0.0001). Anatomic location by lobe was analyzed, but no statistically significant differences were observed. CONCLUSIONS: The VortX coil fiducial marker showed a statistically significant increase in retention rate compared with gold seeds or two-band fiducials. This may translate to cost savings through placing fewer markers per patient as retention is high.

Robotic lobectomy: The first Indian report.

INTRODUCTION: Even today, open lobectomy involves significant morbidity. Video-assisted thoracic surgery (VATS) lobectomy results in lesser blood loss, pain, and hospital stay compared to lobectomy by thoracotomy. Despite being an excellent procedure in expert hands, VATS lobectomy is associated with a longer learning curve because of its inherent basic limitations. The da Vinci surgical system was developed essentially to overcome these limitations. In this study, we report our initial experience with robotic pulmonary resections using the Completely Portal approach with four arms. To the best of our knowledge this is the first series of robotic lobectomy reported from India. MATERIAL AND METHODS: Data on patient characteristics, operative details, complications, and postoperative recovery were collected in a prospective manner for patients who underwent Robotic Lung resection at our institution between March 2012 and April 2014 for various indications including both benign and malignant cases. RESULTS: Between March 2012 to April 2014, a total of 13 patients were taken up for Robotic Lobectomy with a median age of 57 years. The median operative time was 210 min with a blood loss of 33 ml. R0 clearance was achieved in all patients with malignant disease. The median lymph node yield in nine patients with malignant disease was 19 (range 11-40). There was one intra-operative complication and two postoperative complications. The median hospital stay was 7 days with median duration to chest tube removal being 3 days. CONCLUSION: Robotic lobectomy is feasible and safe. It appears to be oncologically sound surgical treatment for early-stage lung cancer. Comparable benefits over VATS needs to be further evaluated by long-term studies.

The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection.

BACKGROUND: Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND). METHODS: This is a retrospective review of patients who underwent pulmonary resection with MLND. RESULTS: Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 µg subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation. CONCLUSIONS: Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.

Satisfaction and compensatory hyperhidrosis rates 5 years and longer after video-assisted thoracoscopic sympathotomy for hyperhidrosis.

OBJECTIVE: The objective of the present study was to determine the long-term fate and factors of compensatory hyperhidrosis (CH) in patients who have undergone video-assisted thoracoscopic sympathotomy for focal hyperhidrosis. METHODS: The same quality-of-life survey was administered 6 months postoperatively and then annually to all patients who underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis. A second rib (R2)/R3 sympathotomy was most commonly performed until September 2007 and then R4/R5 sympathotomy was used. RESULTS: From January 1999 until December 2012, 193 patients underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis, of whom, 173 had provided ≥1 year of postoperative survey information. No operative mortalities occurred. Of the 173 patients, 133 (77%) reported "clinically bothersome" CH. This rate had decreased to an average of 35% at 5 and 12 years postoperatively. Univariate analysis showed the CH incidence was significantly greater for the patients who had undergone R2/R3 versus R4/R5 sympathotomy (P < .001), had had multiple sites of sweating at presentation (P < .001), had used oral medication to control hyperhidrosis preoperatively (P = .022), or were female (P = .002). On multivariate analysis, only R2/R3 versus R4/R5 sympathotomy (P < .021) and multiple sites of sweating at presentation (P < .037) remained statistically significant. Twelve patients (6.2%) regretted having the operation for CH. CONCLUSIONS: Patients who undergo sympathotomy for hyperhidrosis will commonly report "clinically bothersome" compensatory hyperhidrosis. CH will more likely if R2/R3 sympathetic interruption has been performed instead of R4/R5 and in patients who present with multiple areas of sweating. The severity of clinically bothersome CH decreased during the first 3 years postoperatively.

Optimal technique for the removal of chest tubes after pulmonary resection.

OBJECTIVE: The objective is to determine the optimal manner to remove a chest tube after pulmonary resection. METHOD: This was a prospective, randomized single-institution study. Patients who underwent elective thoracotomy for pulmonary resection by 1 or 2 general thoracic surgeons were randomized to have their chest tube removed on either full inspiration or full expiration. Both patient groups performed a Valsalva maneuver during tube removal. Outcomes included the incidence of clinically nonsignificant pneumothorax (defined as a new or increased pneumothorax on the post-chest tube removal chest roentgenogram in asymptomatic patients), symptoms, delayed discharge, and the need for a new chest tube. RESULTS: Between November 2008 and June 2011, 1189 patients underwent pulmonary resection, and of these 342 met the criteria for the study. Of the 179 patients randomized to have their chest tube removed on full inspiration, 58 (32%) had a larger or new pneumothorax after chest tube removal and 5 (3%) required intervention or delayed discharge. Of the 163 patients randomized to have their chest tube removed on full expiration, 32 (19%; P = .007) had a larger or new pneumothorax after chest tube removal, and only 2 (1%) required intervention or delayed discharge (P = .78). CONCLUSIONS: Removal of chest tubes at the end of expiration leads to a lower incidence of non-clinically significant pneumothorax than at the end of inspiration. Because of these findings, this study was closed early and was thus underpowered for finding a statistically significant difference in the rare (1%-3%) clinically significant pneumothoraces.

Technical aspects and early results of robotic esophagectomy with chest anastomosis.

OBJECTIVES: Minimally invasive esophagectomy with a chest anastomosis has advantages. We present technical lessons learned and early results. METHODS: A retrospective review was conducted of minimally invasive laparoscopic and robotic Ivor Lewis esophagectomy. RESULTS: Over 10 months, 22 patients (19 men) underwent laparoscopic gastric mobilization, with robotic esophagectomy. All had the thoracic portion completed robotically and 21 had the stomach mobilized laproscopically. All had esophageal cancer and 20 received neoadjuvant chemoradiotherapy. All had R0 resection with a median of 18 lymph nodes removed and a blood loss of 40 mL. The first 6 patients underwent a stapled posterior and hand-sewn anterior anastomosis; five of these patients experienced a major morbidity, including 1 anastomotic leak and 1 leak from the gastric staple line. The last 16 patients had a 2-layered completely hand-sewn anastomosis, and there were no anastomotic leaks or major morbidities. There were no 30- or 90-day mortalities. Technical improvements included placing a loop around the esophagus in the abdomen for third arm retraction, advancing the gastric conduit into the chest using nonrobotic instruments, using 10-cm nonabsorbable interrupted sutures for the outer layer, and a running 22-cm long absorbable suture for the inner layer. CONCLUSIONS: Robotic thoracic esophagectomy using ports only is feasible, safe, and affords R0 resection with thorough thoracic lymph node dissection. It also allows the sewing of a 2-layered chest anastomosis with good early results.

Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology.

OBJECTIVE: Thoracic surgeons are performing robotic resections for anterior mediastinal tumors; however, tumors located in the posterior and especially the inferior chest can be difficult to approach robotically. The objective of this study was to evaluate the efficacy of the robot for resection of these tumors. METHODS: We performed a retrospective review of the evolution and outcomes of our surgical technique for inferior or posterior mediastinal pathology. RESULTS: During a 30-month period, 153 patients underwent robotic surgery for pathology in the mediastinum, located in the inferior or posterior mediastinum in 75 of these patients. The most common indications for surgery were posterior mediastinal mass or lymph node in 41 patients, esophageal or bronchogenic cysts in 11 patients, esophageal leiomyoma in 7 patients, and diaphragmatic elevation in 7 patients. The median tumor size was 4.4 cm, and the median length of stay was 1 day. One patient was converted to thoracotomy, but no patients were converted for bleeding. Morbidity occurred in 9 patients (12%), major in 1 patient (a delayed esophageal leak after epiphrenic diverticulectomy). There was no mortality. Technical improvements included using robotic arm 3 posteriorly for retraction, side-docking, or coming over the back of the patient for tumors inferior to the inferior pulmonary vein and for diaphragmatic plication and using the lateral decubitus position for extraction of tumors larger than 3 cm via an access port over the tenth rib above the diaphragmatic fibers. CONCLUSIONS: The robot affords safe access using a completely portal approach for resection of and surgical intervention for inferior and posterior chest pathology and for anterior tumors. Specific techniques can be used to improve the operation.

Daily chest roentgenograms are unnecessary in nonhypoxic patients who have undergone pulmonary resection by thoracotomy.

BACKGROUND: The purpose of this study is to assess the clinical benefit of performing a daily chest roentgenogram (CXR) on patients who have had a pulmonary resection. METHODS: Patients underwent thoracotomy and pulmonary resection, and all had a daily CXR. The impact the CXR had on their care was evaluated. Hypoxia was defined as a sustained decrease in oxygen saturation of 6% or greater from patient's baseline. RESULTS: Between January 2006 and December 2009, 1,037 patients met the eligibility criteria for this study. Types of resection were wedge in 282 patients, segmentectomy in 146, and lobectomy in 609. Only 20 of the 834 patients (2%) who did not have a pneumothorax on the recovery room CXR had hypoxia, compared with 42 patients (21%) who had a recovery room pneumothorax (odds ratio 10.6, 95% confidence interval: 6.1 to 18.5, p<0.001). Daily CXR changed the care of only 268 of 975 patients (27%) who never had hypoxia compared with 49 of the 62 patients (79%) who were hypoxic (odds ratio 9.2, 95% confidence interval: 4.3 to 13.7, p<0.001). Moreover, the changes in care made by the CXR in the 268 nonhypoxic patients were for small pneumothoraces, and the impact of these changes is dubious. CONCLUSIONS: Daily CXRs are not needed in the vast majority of patients who undergo elective pulmonary resection after thoracotomy. It is of little benefit for patients who do not have a pneumothorax on their recovery room CXR or for patients who do not become hypoxic.

Efficacy of endoscopic ultrasound in patients with esophageal cancer predicted to have N0 disease.

OBJECTIVE: Esophageal endoscopic ultrasound with fine needle aspiration (EUS-FNA) is a critical staging tool for patients with esophageal cancer. Previous reports suggest that it is frequently incorrect when it predicts a patient to be N0. The purpose of this study is to assess the efficacy of EUS-FNA in patients clinically staged N0. METHODS: A retrospective cohort study of patients who had a computed tomography scan, EUS-FNA and a positron emission tomography scan prior to undergoing Ivor Lewis esophagogastrectomy with abdominal and thoracic lymphadenectomy. RESULTS: From January 2002 to June 2009, 207 patients underwent Ivor Lewis esophagogastrectomy by one general thoracic surgeon. Ninety-five patients did not undergo neo-adjuvant therapy. Eighty nine of these patients had an EUS-FNA preoperatively and 82 were staged as N0. Seventy-seven (94%) were confirmed as N0 on final pathology (sensitivity 94%, accuracy 95%). Their overall 3-year Kaplan-Meier survival was 68%. Neo-adjuvant chemo-radiotherapy was given to the remaining 112 patients and 107 had a restaging EUS-FNA. Ninety of these patients were staged by EUS as N0. Seventy patients (78%) were N0 on final pathology (sensitivity 82%, accuracy 68%). There was no EUS-FNA-related procedural morbidity or mortality except for sore throat and nausea. CONCLUSION: EUS-FNA is very accurate and sensitive when it clinically stages patients with esophageal cancer as N0. In addition, it is even accurate and sensitive when restaging patients as N0 after neo-adjuvant chemo-radiotherapy. These results, which differ from previous reports, are critical for guiding treatment decisions.

General thoracic surgery is safe in patients taking clopidogrel (Plavix).

BACKGROUND: The objective of this study was to assess the safety of general thoracic surgery in patients taking antiplatelet (clopidogrel) therapy. METHODS: A prospective study was conducted of consecutive patients who underwent general thoracic surgery and who were taking clopidogrel perioperatively. They were matched using a propensity score from our prospective database of 11,768 patients. Intraoperative and postoperative outcomes were compared. RESULTS: Between January 2009 and April 2010 there were 33 patients on clopidogrel at the time of surgery and 132 controls. The most common procedures were thoracotomy with lobectomy in 11 patients (robotic in 1), video-assisted wedge resection in 6, mediastinoscopy in 4, and Ivor Lewis esophagogastrectomy in 2. Epidurals were not used. There was no intraoperative morbidity or bleeding in primary thoracotomy; however, 2 of the 4 patients who underwent redo thoracotomy had bleeding that required transfusions. None of the 8 patients receiving clopidogrel who had a coronary artery stent and underwent lobectomy had a perioperative myocardial infarction whereas 5 of the 14 control patients undergoing lobectomy who had a coronary artery stent did (P = .05). Otherwise, morbidity, mortality, and length of stay were no different. CONCLUSIONS: Patients who are receiving clopidogrel and who have a coronary artery stent placed can safely undergo general thoracic surgery. The widely held belief that surgery cannot be performed without bleeding is untrue. This new finding not only eliminates much of the preoperative dilemma posed by these patients but also may reduce their risk of a postoperative myocardial infarction. However, patients who require a redo thoracotomy may be at increased risk of bleeding.