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(BQ) Part 1 book “Operative thoracic surgery” has contents: Modern thoracic approaches - minimally invasive thoracic surgery, pectus deformities, thoracic trauma, thoracic outlet syndromes, tracheal resection, resection of posterior mediastinal lesions, right-sided pulmonary resections,… and other contents.
Operative Thoracic Surgery Operative Thoracic Surgery SIXTH EDITION Edited by Larry R Kaiser, MD, FACS The Lewis Katz Dean The Lewis Katz School of Medicine at Temple University Philadelphia, Pennsylvania, United States Sarah K Thompson, MD, PhD, FRCSC, FRACS Discipline of Surgery University of Adelaide and Royal Adelaide Hospital Adelaide, Australia Glyn G Jamieson, MS, MD, FRACS, FRCS, FACS Discipline of Surgery University of Adelaide Royal Adelaide Hospital Adelaide, Australia First published in 1956 by Butterworths Heinemann Second edition 1968 Third edition 1976 Fourth edition 1982 Fifth edition published in 2006 by Hodder Arnold, an imprint of Hodder Education CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2018 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 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Names: Kaiser, Larry R., editor | Jamieson, Glyn G., editor | Thompson, Sarah K., editor Title: Operative thoracic surgery / [edited by] Larry R Kaiser, Glyn Jamieson, Sarah K Thompson Other titles: Separated from (work): Rob & Smith’s operative surgery | Rob & Smith’s operative surgery series Description: Sixth edition | Boca Raton : CRC Press, [2016] | Series: Rob & Smith’s operative surgery series | Separated from Rob & Smith’s operative surgery 5th ed 1993-[2006] | Includes bibliographical references Identifiers: LCCN 2016042751| ISBN 9781482299571 (hardcover bundle : alk paper) | ISBN 9781482299595 (eBook VitalSource) | ISBN 9781482299588 (ebook pdf) Subjects: | MESH: Thoracic Surgical Procedures Classification: LCC RD536 | NLM WO 500 | DDC 617.5/4059 dc23 LC record available at https://lccn.loc.gov/2016042751 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com “For Lindy: who after all these years still is trying to figure out how I these books” LK “For Amelia: my most enthusiastic supporter” ST “For Elizabeth (1942-2010)” GJ Contents Contributors ix Illustrators xv Preface xvii SECTION I THORACIC SURGERY Modern thoracic approaches: minimally invasive thoracic surgery M Blair Marshall Pectus deformities Antonio Messineo and Marco Ghionzoli Thoracic trauma Scott M Moore, Frederic M Pieracci, and Gregory J Jurkovich Chest wall masses and chest wall resection Anna Maria Ciccone, Camilla Vanni, Federico Venuta, and Erino Angelo Rendina Thoracic outlet syndromes Hugh A Gelabert and Erdog˘an Atasoy 6 Tracheostomy Abbas E Abbas Tracheal resection Peter Goldstraw Mediastinoscopy and mediastinotomy Jennifer L Wilson and Eric Vallières Anterior mediastinal lesions Antonio D’Andrilli, Erino Angelo Rendina, and Federico Venuta 10 Resection of posterior mediastinal lesions Joseph B Shrager 11 Thymectomy Larry R Kaiser 12 Right-sided pulmonary resections Larry R Kaiser 13 Left-sided pulmonary resections Reza Mehran and Jean Deslauriers 14 Extrapleural pneumonectomy Yifan Zheng, William G Richards, Julianne S Barlow, Adrienne Camp, and Raphael Bueno 15 Biportal fissureless video-assisted thoracoscopic lobectomy Alessandro Brunelli 16 Robotic approach to lobectomy Benjamin Wei and Robert James Cerfolio 17 Uniportal video-assisted thoracoscopic surgery (VATS) Gaetano Rocco 18 Segmentectomy Wentao Fang, Chenxi Zhong, and Zhigang Li 19 Combined bronchial and pulmonary artery sleeve resections Abel Gómez-Caro and Laureano Molins 13 23 37 49 87 95 107 117 127 135 141 155 171 181 193 205 213 219 viii Contents 20 21 22 23 24 25 26 Superior sulcus tumors Valerie W Rusch Lung volume reduction surgery Claudio Caviezel and Walter Weder Pleural space problems Konrad Hoetzenecker and Walter Klepetko Video-assisted thoracoscopic surgery (VATS) sympathectomy Young K Hong and M Blair Marshall Lung transplantation Paula Moreno Management of postoperative chylothorax Maxim Itkin and John C Kucharczuk Outpatient thoracic surgery Laureano Molins, Juan J Fibla, and Jorge Hernández 231 239 245 259 265 279 285 SECTION II ESOPHAGEAL SURGERY 27 Endoscopy Ewen A Griffiths and Derek Alderson 28 Esophageal stents Nabil P Rizk and Sarah K Thompson 29 Esophageal anastomoses: sutured and stapled Jon Shenfine and Glyn G Jamieson 30 Use of the stomach as an esophageal substitute Arnulf H Hölscher and J Rüdiger Siewert 31 Use of the colon as an esophageal substitute Benjamin Knight and Glyn G Jamieson 32 Abdominal and right thoracic esophagectomy S Michael Griffin and Shajahan Wahed 33 Left thoracic subtotal esophagectomy Jun-Feng Liu 34 Transhiatal esophagectomy Brechtje A Grotenhuis, Bas P L Wijnhoven, and J Jan B van Lanschot 35 Thoracoscopic and laparoscopic esophagectomy B Mark Smithers, Iain Thomson, and Andrew Barbour 36 Thoracoscopic removal of benign esophageal tumors David Ian Watson 37 Perforation of the esophagus Aaron M Cheng, Douglas E Wood, and Carlos A Pellegrini 38 Laparoscopic antireflux surgery Sarah K Thompson and Glyn G Jamieson 39 Laparoscopic large hiatus hernia repair Alex Nagle, Geoffrey S Chow, and Nathaniel J Soper 40 Revisional antireflex surgery Peter G Devitt , Aravind Suppiah, and Sarah K Thompson 41 Laparoscopic cardiomyotomy for achalasia Sheraz Markar and Giovanni Zaninotto 42 Per oral endoscopic myotomy (POEM) for achalasia Amber L Shada and Lee L Swanström 43 Left thoracic approach to esophageal diverticula André Duranceau 44 Thoracoscopic management of esophageal diverticula Thomas J Watson and Christian G Peyre 45 Laparoscopic management of epiphrenic diverticula Fernando Mier and John G Hunter 295 Index 453 309 315 325 337 345 355 369 377 387 393 405 411 419 425 431 437 443 449 190 Biportal fissureless video-assisted thoracoscopic surgery lobectomy POSTOPERATIVE CARE The general principles of postoperative management apply in this setting Pain control differs between centers but most employ a combination of epidural/paravertebral pain management with patient-controlled analgesia One of the major advantages of VATS lobectomy that is promoted is postoperative pain reduction and decreased pain medication requirements Patients are encouraged to mobilize early after surgery Physiotherapy and incentive spirometry are basic requirements Chest tubes can be removed early in the absence of air leaks All necessary information is provided at bedside; hence, the routine use of several chest films and blood tests should be discouraged unless specific indications are present In case of prolonged air leak, a portable chest drainage system can be attached and the patient discharged home with follow-up visits at a nurse-led clinic OUTCOME Several case-matched analyses have confirmed the superiority of VATS lobectomy to thoracotomy in terms of postoperative morbidity and, occasionally, mortality.8,11,19–21 In particular, VATS lobectomy is associated with a reduced risk of respiratory complications and arrhythmia, and shortened hospital stay These findings have been summarized and statistically confirmed by several systematic reviews and meta-analyses.10,22–24 There remains controversy regarding the oncological validity of VATS lobectomy However, recent systematic reviews and meta-analyses have found improved or at least equivalent long-term survival rates after VATS lobectomy compared with thoracotomy.22,23,25–27 Other studies from large national or institutional registries found that a VATS resection does not compromise radicality and long-term survival compared with thoracotomy in case-matched cohorts of patients.28–31 Additionally, VATS lobectomy seems to be associated with a higher rate of completion of adjuvant chemotherapy than open lobectomy.32,33 REFERENCES Roviaro CG, Varoli F, Rebuffat C, Vergani C, D’Hoore A, Scalambra SM, Maciocco M, Grignani F Major pulmonary resections: pneumonectomies and lobectomies Ann Thorac Surg 1993 Sep; 56(3): 779–83 Kirby TJ, Rice TW Thoracoscopic lobectomy Ann Thorac Surg 1993 Sep; 56(3): 784–6 Seder CW, Salati M, Kozower BD, Wright CD, Falcoz PE, Brunelli A, Fernandez FG Variation in pulmonary resection practices between The Society of Thoracic Surgeons and the European Society of Thoracic Surgeons General Thoracic Surgery databases Ann Thorac Surg 2016 Jun; 101(6): 2077–84 Swanson SJ, Herndon JE 2nd, D’Amico TA, Demmy TL, McKenna RJ Jr, Green MR, Sugarbaker DJ Video-assisted thoracic surgery lobectomy: report of CALGB 39802: a prospective, multiinstitution feasibility study J Clin Oncol 2007 Nov; 25(31): 4993–7 Yan TD, Cao C, D’Amico TA, Demmy TL, He J, Hansen H, Swanson SJ, Walker WS; International VATS Lobectomy Consensus Group Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensus statement Eur J Cardiothorac Surg 2014 Apr; 45(4): 633–9 Decaluwe H, Petersen RH, Hansen H, Piwkowski C, Augustin F, Brunelli A, Schmid T, Papagiannopoulos K, Moons J, Gossot D; ESTS Minimally Invasive Thoracic Surgery Interest Group Major intraoperative complications during video-assisted thoracoscopic anatomical lung resections: an intentionto-treat analysis Eur J Cardiothorac Surg 2015 Oct; 48(4): 588–98 Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines Chest 2013 May; 143(5 Suppl): e166S–90S Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, Stiles BM, Port JL, D’Amico TA Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database J Thorac Cardiovasc Surg 2010 Feb; 139(2): 366–78 Paul S, Sedrakyan A, Chiu YL, Nasar A, Port JL, Lee PC, Stiles BM, Altorki NK Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database Eur J Cardiothorac Surg 2013 Apr; 43(4): 813–17 10 Cao C, Manganas C, Ang SC, Peeceeyen S, Yan TD Videoassisted thoracic surgery versus open thoracotomy for nonsmall cell lung cancer: a meta-analysis of propensity scorematched patients Interact Cardiovasc Thorac Surg 2013 Mar; 16(3): 244–9 11 Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, Harpole DH, D’Amico TA Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy J Thorac Cardiovasc Surg 2009 Aug; 138(2): 419–25 12 Berry MF, Villamizar-Ortiz NR, Tong BC, Burfeind WR Jr, Harpole DH, D’Amico TA, Onaitis MW Pulmonary function tests not predict pulmonary complications after thoracoscopic lobectomy Ann Thorac Surg 2010 Apr; 89(4): 1044–51 13 Ceppa DP, Kosinski AS, Berry MF, Tong BC, Harpole DH, Mitchell JD, D’Amico TA, Onaitis MW Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis Ann Surg 2012 Sep; 256(3): 487–93 14 Jeon JH, Kang CH, Kim HS, Seong YW, Park IK, Kim YT, Kim JH Video-assisted thoracoscopic lobectomy in non-smallcell lung cancer patients with chronic obstructive pulmonary disease is associated with lower pulmonary complications than open lobectomy: a propensity score-matched analysis Eur J Cardiothorac Surg 2014 Apr; 45(4): 640–5 References 191 15 Burt BM, Kosinski AS, Shrager JB, Onaitis MW, Weigel T Thoracoscopic lobectomy is associated with acceptable morbidity and mortality in patients with predicted postoperative forced expiratory volume in 1 second or diffusing capacity for carbon monoxide less than 40% of normal J Thorac Cardiovasc Surg 2014 Jul; 148(1): 19–28 16 Kaseda S, Aoki T, Hangai N, Shimizu K Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy Ann Thorac Surg 2000 Nov; 70(5): 1644–6 17 Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure Ann Thorac Surg 2001 Aug; 72(2): 362–5 18 Begum SS, Papagiannopoulos K, Falcoz PE, Decaluwe H, Salati M, Brunelli A Outcome after video-assisted thoracoscopic surgery and open pulmonary lobectomy in patients with low VO2 max: a case-matched analysis from the ESTS database Eur J Cardiothorac Surg 2016 Apr; 49(4): 1054–8 19 Ilonen IK, Räsänen JV, Knuuttila A, Salo JA, Sihvo EI Anatomic thoracoscopic lung resection for non-small cell lung cancer in stage I is associated with less morbidity and shorter hospitalization than thoracotomy Acta Oncol 2011 Oct; 50(7): 1126–32 20 Stephens N, Rice D, Correa A, Hoffstetter W, Mehran R, Roth J, Walsh G, Vaporciyan A, Swisher S Thoracoscopic lobectomy is associated with improved short-term and equivalent oncological outcomes compared with open lobectomy for clinical Stage I non-small-cell lung cancer: a propensitymatched analysis of 963 cases Eur J Cardiothorac Surg 2014 Oct; 46(4): 607–13 21 Falcoz PE, Puyraveau M, Thomas PA, Decaluwe H, Hürtgen M, Petersen RH, Hansen H, Brunelli A; ESTS Database Committee and ESTS Minimally Invasive Interest Group Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database Eur J Cardiothorac Surg 2016 Feb; 49(2): 602–9 22 Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy Ann Thorac Surg 2008 Dec; 86(6): 2008–16 23 Chen FF, Zhang D, Wang YL, Xiong B Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage non-small cell lung cancer: a meta-analysis Eur J Surg Oncol 2013 Sep; 39(9): 957–63 24 Cai YX, Fu XN, Xu QZ, Sun W, Zhang N Thoracoscopic lobectomy versus open lobectomy in stage I non-small cell lung cancer: a meta-analysis PLoS One 2013 Dec; 8(12): e82366 25 Yan TD, Black D, Bannon PG, McCaughan BC Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer J Clin Oncol 2009 May; 27(15): 2553–62 26 Zhang Z, Zhang Y, Feng H, Yao Z, Teng J, Wei D, Liu D Is videoassisted thoracic surgery lobectomy better than thoracotomy for early-stage non-small-cell lung cancer? A systematic review and meta-analysis Eur J Cardiothorac Surg 2013 Sep; 44(3): 407–14 27 Taioli E, Lee DS, Lesser M, Flores R Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis Eur J Cardiothorac Surg 2013 Oct; 44(4): 591–7 28 Berry MF, D’Amico TA, Onaitis MW, Kelsey CR Thoracoscopic approach to lobectomy for lung cancer does not compromise oncologic efficacy Ann Thorac Surg 2014 Jul; 98(1): 197–202 29 Cao C, Zhu ZH, Yan TD, Wang Q, Jiang G, Liu L et al Videoassisted thoracic surgery versus open thoracotomy for nonsmall-cell lung cancer: a propensity score analysis based on a multi-institutional registry Eur J Cardiothorac Surg 2013 Nov; 44(5): 849–54 30 Lee PC, Nasar A, Port JL, Paul S, Stiles B, Chiu YL, Andrews WG, Altorki NK Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy Ann Thorac Surg 2013 Sep; 96(3): 951–60 31 Hanna WC, de Valence M, Atenafu EG, Cypel M, Waddell TK, Yasufuku K, Pierre A, De Perrot M, Keshavjee S, Darling GE Is video-assisted lobectomy for non-small-cell lung cancer oncologically equivalent to open lobectomy? Eur J Cardiothorac Surg 2013 Jun; 43(6): 1121–5 32 Petersen RP, Pham D, Burfeind WR, Hanish SI, Toloza EM, Harpole DH Jr, D’Amico TA Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer Ann Thorac Surg 2007 Apr; 83(4): 1245–9 33 Zhi X, Gao W, Han B, Yang Y, Li H, Liu D, Wang C et al; China Clinical Trials Consortium VATS lobectomy facilitates the delivery of adjuvant docetaxel-carboplatin chemotherapy in patients with non-small cell lung cancer J Thorac Dis 2013 Oct; 5(5): 578–84 16 Robotic approach to lobectomy BENJAMIN WEI AND ROBERT JAMES CERFOLIO INDICATIONS/CONTRAINDICATIONS PREOPERATIVE PLANNING Robotic-assisted pulmonary lobectomy may be considered for any patient undergoing lobectomy that does not involve complex vascular or airway reconstruction, or chest wall resection The advantage of minimally invasive chest wall resection, which avoids rib spreading but still resects ribs, is controversial In our opinion and based on our considerable experience, we favor thoracotomy when chest wall resection is required Tumors larger than 7 cm (T3), tumors crossing fissures, and centrally located tumors may all be considered for robotic lobectomy with proper patient selection and increasing surgeon experience, but, in general, these factors are relative contraindications to a robotic approach However, radiologic evidence of N1 nodes, induction chemotherapy and/or radiation, calcified lymph nodes, and prior thoracic surgery are not contraindications to robotic lobectomy but a robotic approach should not be selected early in one’s learning curve The typical contraindications for lobectomy that apply to patients undergoing resection via thoracotomy would also apply to patients undergoing robotic lobectomy These include, but are not limited to, borderline lung function or medical comorbidities, multistation N2, gross N2 disease, or evidence of N3 disease Patients with apical lung tumors invading chest wall (Pancoast), tumors with extensive invasion into the mediastinum or esophagus, and contraindications to general anesthesia or single-lung ventilation are also less than ideal for robotic lobectomy In addition, small indeterminate nodules that require lung palpation for wedge resection are considered by some as a contraindication for robotic lobectomy when a completely portal technique is used, but lung palpation is possible when a robotic-assisted technique is used However, we have used navigational bronchoscopy with methylene blue tattooing of the nodules to help guide wedge resection when using a robotic approach Preoperative evaluation including pulmonary function testing should be obtained We routinely obtain stress testing to assess for myocardial ischemia, especially in patients who have had a significant smoking history Complete patient-specific staging should also be performed prior to lung resection This includes positron emission tomography–computed tomography scan in most patients and the selective use of: brain magnetic resonance imaging or computed tomography (for those who are symptomatic or who have large central adenocarcinomas), endobronchial ultrasound-guided fine needle aspiration, esophageal endoscopic ultrasound-guided fine needle aspiration for biopsy of the posterior inferior lymph nodes and adrenals, and/or mediastinoscopy depending on the tumor size and institutional experience When robotic techniques are used, special considerations for robotic proficiency are needed, as we have previously described.1 These include documented scores of 70% or higher on simulator exercises; certificate of robotic safety training and cockpit awareness; weekly access to the robot; training of the entire personnel, including the bedside assistant; and familiarity with the robotic console and the instruments, and a mandatory mastery of the pulmonary artery from both an anterior and posterior approach.2 SURGERY As with any operation, planning each stage of the procedure is crucial to ensure success This begins with operating room set-up when a robot is used The robot adds anxiety to inexperienced robotic surgeons and anesthesiologists Thus, planning of the room layout prior to the operation is critical and includes the positioning of the bedside cart, the robot, the nurses’ table, the monitors, and the patient relative to the anesthesia equipment Careful planning and communication 194 Robotic approach to lobectomy are mandatory because of the fact that the robot is driven in over the patient’s head during lobectomy, the need for two monitors, and the distance between the operating surgeon at the console and the scrub nurse and surgical assistant(s) who stand at the patient’s bedside Certain concepts specific to operating with robotic assistance should be mentioned here: ●● ●● The insertion of robotic instruments deserves special attention, as does the passing of vascular staplers around fragile structures such as the pulmonary artery and/or vein Carefully orchestrated moves and clear communication is needed between the bedside assistant and the surgeon We have developed our own communication system between the bedside assistant and the surgeon to prevent iatrogenic injuries This uses the anvil of the stapler as the hour hand of a clock and the degree of articulation is also quantified and communicated Robotic instruments should initially be inserted under direct vision during thoracic surgery Once safely positioned, instruments then can then be quickly and safely inserted or exchanged for other instruments by properly using the memory feature of the robot that automatically inserts any new instruments to a position that is exactly 1 cm proximal to its latest position However, if this feature is used, it is incumbent on the surgeon to ensure that no vital structures have moved into the path of that newly placed instrument The most common structure to so would be the lung Operating room configuration One possible universal room set-up employed for all types of robotic surgery, including pulmonary resection, is shown in Figure 16.1 Surgical Inc., Sunnyvale, California, United States) contains a microphone that amplifies the voice of the surgeon to the rest of the team The presence of a second console permits easy exchange of control between surgeon, medical student, resident, or fellow for training purposes; this second console, if used, should be located fairly close to the primary console ROBOT/BED The approach of the robot to the patient’s side should be clear of any obstacles The robot is driven over the patient’s head on a 15-degree angle to open up robotic arm 3 over their head and shoulder, as shown in Figure 16.2 In addition, monitors are positioned for a clear view by both the bedside assistants and the scrub nurse Depending on the size of the room and the arrangement of immobile structures within it, the table may need to be turned such that the patient’s head is located well away from the anesthesia console A long extension for the endotracheal tubing should be used if this is necessary As the robot is set up prior to driving it in over the patient’s head, robotic arm 3 should be placed on the robot side opposite to the side of the lobectomy thus if performing a right-sided lobectomy, robot arm should be located on the robot’s left when facing it (Figure 16.2b) ASSISTANT The assistant will be positioned on the patient’s ventral side (i.e., in front of the patient’s abdomen/chest), with a monitor opposite them SCRUB NURSE The scrub nurse will be positioned with the Mayo stand near or over the patient’s feet, as in conventional thoracotomy or video-assisted thoracoscopic surgery (VATS) CONSOLES The surgeon console should be positioned so that good communication with the team at the operating table can be established The da Vinci Surgical System console (Intuitive (a) (b) 16.1 Operating room configuration for robotic lobectomy 16.2a–b Angle of approach of robot docking for (A) right side lobectomy and (B) left side lobectomy Surgery 195 Patient positioning General anesthesia is induced and the patient is intubated with a left-sided double-lumen endotracheal tube while supine Proper placement of the double-lumen tube is facilitated greatly by the use of a flexible pediatric bronchoscope, and is critical to a smooth operation because access to the patient’s head and endotracheal tube will be limited by their positioning and the presence of the robot after docking After the double-lumen tube is secured, the patient is positioned in lateral decubitus with the operative side up Images of patient positioning are shown in Figure 16.3 An axillary roll is placed We not use an arm board but, rather, place the patient with their back at the edge of the table, leaving space in front of their face to fold their arms, taking care to expose the axilla for port placement We have used this positioning for over 17 years for our thoracotomies, but it is 16.3a–d critical when using a four-arm robotic approach, because it allows robotic arm 3 to move on a plane that is below the bed and avoid conflicts with that arm and the operative bed itself Padding should be used around the arms and head to prevent nerve damage during the case—we use large foam pads This technique is easy and quick, requires no special equipment, and is reproducible We position patients in under 10 minutes A foam pad also helps protect the back of the patient’s head from link two of robotic arm 3 Tape should be used to secure the patient’s hips and upper body above the shoulder The patient should be located with their flank (i.e., space between subcostal margin and iliac crest) directly over the break point of the bed, and the table should be flexed to increase the space between the ribs A body warmer is applied to the lower body (a) (b) (c) (d) (a) Patient positioning for robotic lobectomy, viewed from the patient’s head Foam pads for protection of pressure points of the head and arms are also shown (b) Patient positioning for robotic lobectomy, viewed from anterior to the patient The axilla is exposed widely and the space between the patient’s iliac crest and costal margin is located above the break in the bed (c) Patient positioning for robotic lobectomy, viewed from posterior to the patient The position of the axillary roll is shown (d) Patient positioning for robotic lobectomy, showing the distance between the anesthesia ventilator and the patient Long flexible tubing, used to facilitate this, is taped along the bed with the other monitoring lines to provide easier access to the posterior aspect of the patient if a thoracotomy becomes necessary 196 Robotic approach to lobectomy Port placement/Docking Sequence of port placement The ports are all inserted in the 7th intercostal space, over the top of the 8th rib, for upper/middle lobectomy, and in the 8th intercostal space, over top of the 9th rib for lower lobectomy The ports are marked as follows: robotic arm 3 (5 mm port) is located 1–2 cm lateral from the spinous process of the vertebral body, robotic arm 2 (8 mm) is 10 cm medial to robotic arm 3, the camera port (we prefer the 12 mm camera) is 9 cm medial to robotic arm 2, and robotic arm 1 (12 mm) is placed right above the diaphragm anteriorly The assistant port (12 mm) is placed as low as possible in the chest, triangulated exactly halfway in between the most anterior robotic port (which is robotic arm 1 in the right chest and robotic arm 2 in the left chest) and the camera port and then as low as possible to remain just above the diaphragm which is being pushed downward by the insufflating humidified carbon dioxide (CO2) gas (see Figure 16.4) A 5 mm port is placed first in the camera port position and CO2 insufflation initiated with a pressure of 10 mmHg We use humidified warm CO2 An intercostal nerve block with 0.25% bupivacaine with epinephrine is then performed from ribs three to eight by injecting subpleural under direct vision Then the 5 mm thoracoscope is used to help assist the placement of all of the other ports, which are all placed under direct position The camera port is placed first, robotic arm 3 is placed second, then robotic arm 2 in the right chest and robotic arm 1 in the left The 5 mm VATS camera is then moved to the port for robotic arm 2 and the two most anterior ports (robotic arm 1 in the right chest and in the left) and the access port are placed under direct vision using an exploring needle Our technique completely avoids all of the diaphragmatic fibers The 5 mm camera port is then upsized to the 12 mm camera port We use a 0-degree endoscope for the entire case to help prevent torqueing on the intercostal nerve 16.4 Port placement for right robotic lobectomy 16.5 Port placement for left robotic lobectomy Notes: C, camera port; 1, robotic arm 1; 2, robotic arm 2; 3, robotic arm 3; A, assistant port Notes: C, camera port; 1, robotic arm 1; 2, robotic arm 2; 3, robotic arm 3; A, assistant port Surgery 197 (b) (a) 16.6a View of robot docked to patient for right lobectomy 16.6b View of robot docked to patient for left lobectomy The port placement for left-sided lobectomy is a mirror image to that just outlined (see Figure 16.5) The difference is that robotic arm 3 is next to robotic arm 1, rather than robotic arm 2 The numbering is different, but the locations of the ports are the same The robot is brought in at a 15-degree angle toward the patient’s face, off the long axis of the bed (see Figure 16.6) The robotic arms are docked to the ports, maximizing the amount of space between the arms to avoid collisions Once the system is docked, the operating room table cannot be moved The three instruments used to initiate the operation are as follows: (1) left robotic arm—an 8 mm Cadiere grasper; (2) right robotic arm—an 8 mm bipolar curved thoracic dissector, and (3) robotic arm 3—a 5 mm thoracic grasper LEFT SIDE Mediastinal lymph node dissection The pleural surface is inspected prior to initiating node dissection and lobectomy to confirm that there are no metastatic lesions We perform mediastinal lymph node dissection prior to lobectomy to not only evaluate the lymph nodes but also access arterial and venous branches and the bronchus RIGHT SIDE The inferior pulmonary ligament is divided to access lymph node station 9 It is removed along with lymph node station 8 Robotic arm 3 is used to retract the lower lobe medially and anteriorly to remove lymph nodes from station 7, the subcarinal space Care is taken to control bronchial arteries Robotic arm 3 is used to retract the upper lobe inferiorly, while robotic arms and are used to dissect out stations 2R and 4R, clearing the space between the superior vena cava anteriorly, the esophagus posteriorly, and the azygos vein inferiorly Avoiding dissection too far superiorly can prevent injury to the right recurrent laryngeal nerve that courses around the subclavian artery The inferior pulmonary ligament is divided to facilitate the removal of lymph node station 9 The nodes in station 8 are then removed Station 7 is accessed in the space between the inferior pulmonary vein and lower lobe bronchus, lateral to the esophagus If still in position, the lower lobe is retracted medially/anteriorly with robotic arm 3 during this process Absence of the lower lobe facilitates dissection of level from the left One distinct advantage of the robot when compared with VATS is the dissection of the station 7 lymph node from the left chest Finally, robotic arm is used to wrap around the left upper lobe and reflect it inferiorly to allow dissection of stations and Care should be taken while working in the aortopulmonary window to avoid injury to the left recurrent laryngeal nerve Station 2L cannot typically be accessed during left-sided mediastinal lymph node dissection due to the presence of the aortic arch but the 4L node is commonly removed General concepts In general, for a right-handed surgeon, a blunt instrument such as Cadiere forceps is placed in robotic arm 2, which is always the left hand, while the right hand, which is always robotic arm 1, uses a thoracic dissector We preferentially place a vessel loop under a vessel to be stapled to help elevate it while the stapler is passed under it The stapler may be placed through one of three ports—the access port, robotic arm 1, or robotic arm 2 The current design of commercially available white or grey vascular staplers requires a 12 mm port and for the green load stapler, commonly used for the bronchus, a 15 mm port is required We prefer to remove the trocar and leave it docked to the robotic arm and then place the stapler through the skin incision We commonly use a prerolled sponge to absorb blood from the operative field, as well as to facilitate blunt dissection to improve visibility 198 Robotic approach to lobectomy Removal of lymph nodes from around bronchovascular structures should be done prior to stapling and dividing, in the interests of both ensuring an oncologically sound operation and facilitating isolation and division of structures If significant adhesions are encountered, they may be initially lysed via the assistant port using VATS techniques until safe placement of all the robotic instruments is permitted The order in which the structures are isolated and divided during lobectomy varies somewhat depending on patient anatomy What follows is a general outline of the typical conduct of the operation for each lobectomy (a) Right upper lobectomy Retraction of the right upper lobe laterally and posteriorly with robot arm 3 to expose the hilum The bifurcation between the right upper and middle lobe veins is developed by dissecting the superior pulmonary vein away from the underlying pulmonary artery The 10R lymph node between the anterior-apical segment arterial branch and the superior pulmonary vein should be removed or swept up toward the lung, thus exposing the anterior-apical segmental branch (see Figure 16.7) The superior pulmonary vein is encircled with the vessel loop and then divided The truncus branch of the pulmonary artery is then divided The right upper lobe is then reflected anteriorly to expose the bifurcation of the right main stem bronchus (see Figure 16.8) There is usually a lymph node (level 11R) here that should be dissected out to expose the bifurcation The right upper lobe bronchus is then encircled and divided (see Figure 16.9) Care must be taken to apply only minimal retraction on the specimen to avoid tearing the remaining pulmonary artery branches Next, the posterior segmental artery to the right upper lobe is exposed, the surrounding N1 nodes removed, and the artery encircled and divided (see Figure 16.10) The upper lobe is reflected again posteriorly, and the anterior aspect of the pulmonary artery is inspected to make sure that there are no arterial branches remaining If not, the fissure between the upper and middle lobes, and the upper and lower lobes, is then divided with the linear stapler This is typically done from anterior to posterior, but may be done in the reverse direction if the space between the pulmonary artery and right middle lobe is already developed During completion of the fissure, the right upper lobe should be lifted up to ensure that the specimen bronchus is included in the specimen (b) 16.7a–b Dissection of lymph node 10R between anteriorapical segment branch and right superior pulmonary vein during robotic right upper lobectomy 16.8 Anterior retraction of lung to exposure bifurcation of right main stem bronchus Surgery 199 (a) (b) (c) (d) 16.9a–d Exposure and division of right upper lobe bronchus (a) The bronchus is encircled with a vessel loop used to provide traction to allow for better visualization (b) Applying traction to the vessel loop the endoscopic stapler is passed around the bronchus (c) The stapler, having been accurately placed to encompass the entire bronchus is closed and fired (d) The stapler is removed demonstrating the stapled bronchial stump (a) 16.10a–b Exposure of right posterior segmental artery (b) 200 Robotic approach to lobectomy Right middle lobectomy Left upper lobectomy Retraction of the right middle lobe laterally and posteriorly with robot arm l helps expose the hilum The bifurcation between the right upper and middle lobe veins is developed by dissecting it off the underlying pulmonary artery The right middle lobe vein is encircled and divided The fissure between the right middle and lower lobes, if not complete, is divided from anterior to posterior Care should be taken to avoid transecting segmental arteries to the right lower lobe The right middle lobe bronchus is then isolated It will be running from left to right in the fissure Level 11 lymph nodes are dissected from around it It is encircled and divided, taking care to avoid injuring the right middle lobar artery that is located directly posterior Dissection of the fissure should continue posteriorly until the arterial branch to the superior segment of the lower lobe is identified Then the one or two right middle lobar segmental arteries are isolated and divided Stapling of middle lobe bronchus and vessels may be facilitated by passing the stapler from posterior to anterior to have a greater working distance The fissure between right middle and upper lobes is then divided Retraction of the left upper lobe laterally and posteriorly with robot arm 3 helps expose the hilum The presence of both superior and inferior pulmonary veins is confirmed, and the bifurcation between the two is dissected The lung is then reflected anteriorly with robotic arm 3 and interlobar dissection is started, going from posterior to anterior If the fissure is not complete, then it will need to be divided Reflecting the lung posteriorly again and establishing a subadventitial plane on the artery will be (a) Right lower lobectomy The inferior pulmonary ligament should be divided up to the level of the inferior pulmonary vein The bifurcation between the right superior and inferior pulmonary veins should be dissected The location of the right middle lobe vein should be positively identified to avoid inadvertent transection A subadventitial plane on the ongoing pulmonary artery should be established If the major fissure is not complete, then it should be divided The superior segmental arterial branch and the right middle lobe arterial branches are identified The superior segmental artery is isolated and divided The common trunk to right lower lobe basal segments may be taken as long as this does not compromise the middle lobe segmental artery/arteries; otherwise, dissection may have to extend further distally to ensure safe division The inferior pulmonary vein is divided The right lower lobe bronchus is isolated, taking care to visualize the right middle lobe bronchus crossing from left to right The surrounding lymph nodes, as usual, are dissected, reflected up toward the lung, and the bronchus divided If there is any question of compromising the right middle lobe bronchus, the surgeon can ask the anesthesiologist to hand-ventilate the right lung to confirm that the middle lobe expands, but the origin of the middle lobe bronchus is usually readily identified (b) 16.11a–b Isolating and dividing a lingular artery during robotic left upper lobectomy 16.12 Isolating and dividing the posterior segmental artery during robotic left upper lobectomy Surgery 201 helpful The branches to the lingula are encountered and divided in the fissure during this process (see Figure 16.11) The posterior segmental artery is also isolated and divided (see Figure 16.12) Division of the lingular artery or arteries can be done before or after division of the posterior segmental artery The superior pulmonary vein is isolated then divided (see Figure 16.13) As the superior pulmonary vein can be fairly wide, it may require that the lingular and upper division branches be transected separately Often the next structure that can be divided readily will be the left upper lobe bronchus, as opposed to the anterior and apical arterial branches to the left upper 16.13 Isolating and dividing the left superior pulmonary vein during robotic left upper lobectomy lobe The upper lobe bronchus should be encircled and divided, often passing the stapler from robotic arm 1 to avoid injuring the main pulmonary artery (see Figure 16.14) Finally, the remaining arterial branches are encircled and divided Left lower lobectomy The inferior pulmonary ligament should be divided to the level of the inferior pulmonary vein The lower lobe is then reflected posteriorly by robotic arm 3 The bifurcation of the left superior and inferior pulmonary veins should be dissected out The lung is reflected anteriorly by robotic arm 3 The superior segmental artery is identified The posterior ascending arteries to the left upper lobe are frequently visible from this view also The superior segmental artery is isolated and divided The common trunk to left lower lobe basilar segments may be taken as long as this does not compromise the middle lobar segmental artery/arteries; otherwise, dissection may have to extend further distally to ensure safe division If the fissure is not complete, this will need to be divided to expose the ongoing pulmonary artery to the lower lobe After division of the arterial branches, the lung is reflected again posteriorly The inferior pulmonary vein is divided The left lower lobe bronchus is isolated The surrounding lymph nodes, as usual, are dissected and the bronchus divided For left lower lobectomy, it may be simpler to wait until after resection is performed before dissecting within the subcarinal space for removal of level lymph nodes Specimen removal/Conclusion of operation (a) (b) 16.14a–b Isolating and dividing the left upper lobe bronchus during robotic left upper lobectomy The “drop zone” for the specimen should be well away from the pulmonary artery, which can be injured during this process if care is not taken Before the bag is inserted robotic arm 3 is used to hold the specimen The bag is inserted via the assistant port and robotic arms 1and/ or are used to ensure the bag is deployed under the trocar This ensures that the bag is opened in the right direction Robotic arm 3 then drops the specimen in the bag and it then grasps the far lip of the bag to make sure it does not spin, while robotic arms and are used to place the specimen in the bag Care is taken to make sure the arms are not inside the bag The chest is irrigated with normal saline, the presence of air leaks checked with insufflation, hemostasis is confirmed, and a 20 Fr chest tube is placed via the most anterior port which is robotic arm 1 in the right chest and robotic arm 2 in the left The robotic arms are removed under direct vision with insufflation 202 Robotic approach to lobectomy discontinued to confirm the absence of bleeding The camera port is removed The robot is undocked and pushed away from the patient’s bed The bag is removed from the body, usually after enlarging the assistant nonrobotic port posteriorly to avoid injuring the diaphram Our techniques completely avoid all of the diaphragmatic fibers The chest tube is secured with a #5 Ethibond suture The fascial layer in the 12 mm ports is closed with Vicryl suture after the break is removed from the table The skin is closed in a knotless subcuticular fashion with 3-0 Vicryl suture POSTOPERATIVE MANAGEMENT The management of patients undergoing robotic lobectomy does not differ from that of patients undergoing VATS lobectomy Our patients go directly to the standard thoracic nursing unit and not the intensive care unit (ICU) Patients generally well with patient-controlled analgesia or even oral pain medications Chest tubes are removed when any air leak resolves and at outputs of up to 450 mL/d, depending on the patient Patients are typically discharged on postoperative day or COMPLICATIONS The same complications that can occur after open or VATS lobectomy are possible following robotic lobectomy We have recently reported the incidence of chylothorax may even be slightly higher in patients undergoing robotic lobectomy, which is probably due to the increased completeness of the mediastinal lymph node dissection.3 The incidence of atrial fibrillation, pneumonia, blood loss, and pain appears less with robotic-assisted lobectomy than with lobectomy performed via thoracotomy, and similar or favorable when compared with VATS lobectomy.4 RESULTS Reported series of robotic lobectomy to date have been notable for a fairly low conversion rate, low mortality rate, and comparable morbidity to VATS approaches (see Table 16.1) With increasing experience, operating times for robotic lobectomy have been shown to decrease; at our institution, robotic lobectomies with complete mediastinal lymph node dissection can routinely be done in 1.5–2.0 hours from incision to skin closure The single comparison with VATS lobectomy published to date, by Louie et al (2012), demonstrates similar blood loss, operative time, ICU stay, and length of stay between robotic and VATS lobectomy, but did show benefits for the robotic approach in terms of duration of narcotic use and time to return to usual activities.4 Park et al reported 5-year survival rates for 310 patients with stage I non-small-cell lung cancer of ~90% following robotic lobectomy, results comparable to both VATS and open lobectomy.5,6 Our experience has been that robotic lobectomy facilitates a more thorough and complete mediastinal lymph node dissection, which we believe is associated with a greater accuracy of staging and therefore more optimal adjuvant treatment.7 CONCLUSIONS Robotic pulmonary lobectomy represents an emerging method to achieve an oncologically equivalent, minimally invasive operation that decreases perioperative risk compared with lobectomy via thoracotomy Robotic lobectomy does seem to offer some special benefits to the surgeon in terms of lymph node dissection, ergonomics, and teachability The need for highly trained team members who are familiar with both each other and the operation cannot be underestimated for robotic pulmonary lobectomy A systematic approach to both learning and executing the procedure is highly recommended Table 16.1 Results reported by series of robotic-assisted lobectomies Study Year Patients, n Conversion rate Morbidity Perioperative mortality Median LOS Other notes Cerfolio et al.7 2011 168 7.7% 27% 0% 2.0 days Park et al.5,6 2006 30 12% 26% 0% 4.5 days 2009 54 13% 20% 0% 4.5 days Shorter LOS than open lobectomy 2009 100 NS 21% 3% 4.0 days Authors note the steep learning curve Veronesi et al.8 Gharagozloo et al.9 Notes: LOS, length of stay; QOL, quality of life Decreased morbidity, improved QOL, shorter LOS than open lobectomy References 203 REFERENCES Cerfolio RJ, Bryant AS How to teach robotic pulmonary resection Semin Thorac Cardiovasc Surg 2013; 25: 76–82 Cerfolio RJ, Bryant AS, Minnich DJ Starting a robotic program in general thoracic surgery: why, how, and lessons learned Ann Thorac Surg 2011; 91: 1729–37 Bryant AS, Minnich DJ, Wei B, Cerfolio RJ The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection Ann Thorac Surg 2014 Jul; 98(1): 232–5 Louie BE, Farivar AS, Aye RW, Vallières E Early experience with robotic lung resection results in similar operative outcomes and morbidity when compared with matched video-assisted thoracoscopic surgery cases Ann Thorac Surg 2012; 93: 1598–605 Park BJ, Flores RM, VW Rusch Robotic assistance for videoassisted thoracic surgical lobectomy: technique and initial results J Thorac Cardiovasc Surg 2006; 131: 54–9 Park BJ, Melfi F, Mussi A et al Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results J Thorac Cardiovasc Surg 2012; 143: 383–9 Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ Initial consecutive experience of completely portal robotic pulmonary resection with arms J Thorac Cardiovasc Surg 2011; 142: 740–6 Veronesi G, Galetta D, Maisonneuve P et al Four-arm robotic lobectomy for the treatment of early-stage lung cancer J Thorac Cardiovasc Surg 2010; 140: 19–25 Gharagozloo F, Margolis M, Tempesta B et al Robot-assisted lobectomy for early-stage lung cancer: report of 100 consecutive cases Ann Thorac Surg 2009; 88: 380–4 ... Zhigang Li 19 Combined bronchial and pulmonary artery sleeve resections Abel Gómez-Caro and Laureano Molins 13 23 37 49 87 95 10 7 11 7 12 7 13 5 14 1 15 5 17 1 18 1 19 3 205 213 219 viii Contents 20 21 22... Index 453 309 315 325 337 345 355 369 377 387 393 405 411 419 425 4 31 437 443 449 Contributors Abbas E Abbas, MD, FACS Division of Thoracic Surgery Department of Thoracic Medicine and Surgery Temple... [2 016 ] | Series: Rob & Smith’s operative surgery series | Separated from Rob & Smith’s operative surgery 5th ed 19 93-[2006] | Includes bibliographical references Identifiers: LCCN 2 016 0427 51|