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doi:10.1510/mmcts.2004.000448Video robotic lobectomyFranca M.A. Melfi*, Marcello C. Ambrogi, Marco Lucchi, Alfredo MussiDi...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Table 1. Surgical robots ...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448                         ...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Table 3. Clinical feature...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Video 5. The robotic inst...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Video 7. The dissection o...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Video 12. This is an exam...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Table 4. Mean data ("SD) ...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448complicated especially fo...
F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448     First experiences wi...
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  1. 1. doi:10.1510/mmcts.2004.000448Video robotic lobectomyFranca M.A. Melfi*, Marcello C. Ambrogi, Marco Lucchi, Alfredo MussiDivision of Thoracic Surgery - Cardiac and Thoracic Department of Surgery, University of Pisa,Via Paradisa 2, 56124 Pisa, Italy Video-assisted thoracoscopic surgery (VATS) is beneficial to the patient but challenging for the surgeon. Recently, robots have been introduced into surgical procedures in an attempt to facilitate surgical performance. The da Vinci Robotic System (Intuitive Surgical, Inc, CA, USA) is one of these robots. It consists of a console and a surgical cart supporting three articulated robotic arms. The surgeon sits at the console where he manipulates the joystick handles while observing the operating field through binoculars that provide a three-dimen- sional image. Improved ergonomic conditions and instrument mobility at the level of distal articulation seem beneficial in thoracic procedures. After a period of technical development and training we used the robotic systems to treat patients with various thoracic diseases. We focused our efforts on the development of this technique in thoracic surgery particularly to perform video robotic lobectomy (VRL).Keywords: Robotic surgery; Thoracoscopy; Lobectomy; VATSIntroduction Historical notes The early robotic systems employed in surgery were relatively simple – programmed to handle the scopeVideo-assisted thoracic surgery (VATS) in the last dec- only or to maintain an endoscopic instrument in aade has allowed surgeons to perform an increasing fixed position during surgery w1x. These elementarynumber of operations with minimal tissue trauma, systems have given way to extremely complex andstandardization of many procedures and a progres- sophisticated robots. Human robotic surgery wassive broadening of the indications. This technique has introduced by Cadiere’s team in March 1997 w2x. Abecome widespread and is currently used in a wide thoracic procedure was performed using a voice-con-range of surgical procedures, but many major diffi- trolled robot (Zeus , MMCTSLink 30) w 3,4x and, in theculties remain. Sensory information is restricted to a same period, a different robotic device was used bytwo-dimensional image, and effectors instruments other surgical teams w5–7x.have limited manoeuvrability due to the rigid shaft axisfixed to the thorax or abdominal wall by the entry tro- At the present time, different types of robotic devicescar. Advanced engineering technology makes it pos- are used in clinical practice w8–10x (Table 1). The dasible to overcome these difficulties. Robotic surgery Vinci Robotic System (MMCTSLink 17) represents ais the most recent and advanced stage of this process complete device currently applied in the field of car-thanks to ‘micro-mechatronic’ instruments introduced diac and general surgery. Although there is a realthrough traditional trocars. difference between thoracic surgery and other disci- plines, an application in thoracic surgery seemed real-* Corresponding author: Tel.: q39-050-995211; fax: q39-050- istic. Therefore in the last years an increasing number9957239. of thoracic surgeons have used the robot device toE-mail: perform thoracic procedures some of which included 2005 European Association for Cardio-thoracic Surgery 1
  2. 2. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Table 1. Surgical robots systemsSystem DisciplineAesop EndoscopyEndoAssist EndoscopyZeus Cardiac/thoracic surgeryDa Vinci Cardiac/thoracic surgeryCyberKnife RadiosurgeryNovac 7 RadiosurgeryRobodoc OrthopedicsNeuromate NeurosurgeryVideo 1. The surgeon sits at the master console located at a dis-tance from the patient with eyes focused downwards toward theoperative field which appears as an open surgical technique and arobotic unit provides a ‘tele-presence’ within the chest for themanipulation of micro-instruments.major lung resections (video robotic lobectomy (VRL)in NSCLC-stage I patients) w11–15x.MethodCompared to conventional surgery and VATS, robot Photo 1. Motion scaling. (Reprinted with permission from Intuitivesurgery demands a new set of manual skills and eye– Surgical Inc, CA, USA.)hand coordination. The transition from traditional sur- In terms of motion, the mechanical wrists of the instruments have 6 degrees of freedom. Tip articulations mime the up/down (‘pitch’)gery to advanced totally robotic surgery is not and the side-to-side (‘yaw’) flexibility of the human wrist.immediate. Just as it was necessary to follow certainprecise organizational and didactic routes in passing The master console is connected to a surgical manip-from open surgery to minimally-invasive technique, ulator with two instrument-arms and a central arm tohere too, the same process is necessary. It is essential guide the endoscope. Two master handles at the sur-to be familiar with the device and that all members of geon’s console are manipulated by the user. The posi-the surgical team (surgeons, scrub nurses, and tech- tion and the orientation of the surgeon’s hands on thenicians) have undergone specific training. The learning handles trigger highly-sensitive motion sensors whichcurve is relatively short since the surgeons have a sol- transfer the surgeon’s movements to the tip of theid background in conventional and thoracoscopic instrument at a remote The surgical arm cart provides three degrees of free- dom (pitch, yaw, insertion). Attached to the robot armRobot-system in the operating room is the surgical instrument, the tip of which is providedThe system employed to perform video robot lobec- by a mechanical cable-driven wrist (EndoWrist ,tomy (VRL) is the da Vinci Robotic System MMCTSLink 31). This adds four more degrees of(MMCTSLink 17). freedom (internal pitch, internal yaw, rotation and grip).It is a complete robot device which comprehends a To increase precision, the system uses down-master remote console, a computer controller and a scaling from the motion of the handles to that of thethree-arms surgical manipulator with fixed remote surgical arms. In addition, unintended movementscentre kinematics connected via electrical cables and caused by human tremor are filtered by a 6-Hz motionoptic fibres (Video 1). filter (Photo 1).2
  3. 3. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448 require few accurate manoeuvres – dissection/coag- ulation – in a restricted and well-defined field: enucle- ation of condroma, excisions of mediastinal masses, thymectomies. On the contrary, during major resec- tions such as lobectomies, some manoeuvres must necessarily be performed by the assistant surgeon, given the need of a fourth arm. In fact, maintaining a correct position with appropriate tension of the lung parenchyma is a top priority for identifying and dis-Video 2. The robot’s arms are draped in special disposable nylon secting the hilum structures (vessels and bronchus),covers (for the sterile operating field) which contain the microchips as is suction, passing the sutures in the chest cavity,to connect the arms to the robotic instruments. The insertion of and appropriate positioning of the stapler. In order toelectronic microcircuit plates establishes a connection with other perform these manoeuvres the role of the assistantrobotic instruments. surgeon is mandatory, and he must always be at hand at the operating table. Like VATS, few absolute contraindications are applic- able to this surgical procedure (Table 2). During the video robotic lobectomy, a single-lung anaesthesia is achieved via a double lumen endotra- cheal tube. Patients are prepared and draped for a posterior lateral thoracotomy so that the procedure can be converted in the event of intraoperative com-Video 3. In order to avoid collisions between the mechanical arms, plications or in case a video robot lobectomy is notthe correct placement of the robot arm cart and of the trocars is possible (Video 4).essential. The trocars must be positioned at a greater distance fromeach other than they normally would be in standard thoracoscopicprocedures. Physical orientation and optimal working angles Instrumentsbetween the instruments are important issues which must beconsidered. Few robotic instruments are used during robotic lobectomy. To handle the lung parenchyma safely aTable 2. Selection criteria Cadiere forcep (MMCTSLink 32) is advisable because it is an a-traumatic instrument. In contrast, otherSize -4 cm (max diameter)Stage Clinical stage I NSCLC robotic grasps are too small to handle the lung. Dis-Anatomical features Absence of chest wall involvement section of structures is performed with a combination Absence of pleural symphysis of electrocautery and Debakey forceps (MMCTSLink Complete or near complete interlobar 32) mounted on the robotic arms. Accessory endo- fissures scopic instruments handled by an assistant surgeon at the operative site are inserted through the mini-In order to perform robotic surgery in a safe and thoracotomy (‘service entrance’) or through anstraightforward manner, it is necessary to standardize additional small incision (5 mm), when necessaryprocedures and establish operative schemes. This (Video 5).robotic device requires meticulous preparation interms of set-up of the system and its placement at Incisionsthe operating table (Video 2).The main body of the machine (robot cart) and the The location of the incisions is critical for the suc-robotic arms are placed in relation to the side of the cessful identification and dissection of the interlobarlesion. When the robotic cart has been positioned and artery – technically the most difficult aspect of videothe patient placed in the chosen position, the robotic robot lobectomy. The best positioning of the systemarms are brought into the operative field (Video 3). and of the robotic arms are established in relation to the side of the lesion in order to have an excellent, unobstructed view of the chest cavity without armOperative technique impingement and interference. However, the exactMany of the robotic procedures can be carried out by position of the operating ports is best assessed dur-a single operator. This is true for procedures which ing the operation when suitable points of entry in rela- 3
  4. 4. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Table 3. Clinical features of patients undergoing robotic lobectomyAge Preoperative Procedure Pathological Postoperative Dicharge Remarks(yr)/sex conditions findings course p.o64/F Diabetes RL lobectomy Adenocarcinoma Uneventful 5 T1N041/M Unremarkable LL lobectomy Typical carcinoid Uneventful 466/M Unremarkable LL lobectomy Typical carcinoid Sputum 6 (converted) retention70/M Prostatism/ LL lobectomy Sq. carcinoma Uneventful 5 Retained in hypertension T1N0 unit (angina)66/M Cough RL lobectomy Sq. carcinoma Sputum 6 (converted) T1N0 retention64/F Unremarkable LL lobectomy Adenocarcinoma Uneventful 4 T1N060/M Hypertension LL lobectomy Adenocarcinoma Uneventful 4 T1N161/F Unremarkable RL lobectomy Adenocarcinoma Air leaks 10 T1N061/M Unremarkable LL lobectomy Sq. carcinoma Uneventful 5 T1N069/M Hypertention LL lobectomy Adenocarcinoma Acute kidney Dead XII p.o. T1N0 failure IV p.o65/M Unremarkable LL lobectomy Sq. carcinoma Uneventful 4 T1N066/F Diabetes M lobectomy Sq. carcinoma Atrial 5 T1N1 fibrillation58/F Unremarkable LR lobectomy Adenocarcinoma Uneventful 4 T1N067/M Cough LR lobectomy Atypical carcinoid Sputum 5 T1N0 retention70/M Sigmoid colectomy M lobectomy Sq. carcinoma Sputum 6 2 years before T1N0 retention69/F Unremarkable UR lobectomy Sq. carcinoma Uneventful 5 T1N069/M Unremarkable LR lobectomy Adenocarcinoma Air leaks 6 T1N074/M Cough/hemoptysis LL lobectomy Sq. carcinoma Uneventful 4 T1N065/F Unremarkable LR lobectomy Adenocarcinoma Uneventful 4 T1N059/M Unremarkable LR lobectomy Adenocarcinoma Uneventful 5 T1N067/F Cough M lobectomy Sq. carcinoma Sputum 6 T1N0 retention71/M Unremarkable LL lobectomy Sq. carcinoma Uneventful 4 T1N060/M Hypertension LL lobectomy Adenocarcinoma Uneventful 5 T1N0 tion to the shape of each patient’s chest cavity are made. The standard layout is the following: the first port is placed at the 7th or 8th space in the mid-axillary line (for the 08 3-D scope), the other at the 6th or 7th inter- costal space in the post-axillary line (for the left robot- ic arm), a ‘service entrance’ is made at the 4th or 5th intercostal space in the anterior axillary line (where the right robot arm is placed). An additional small incisionVideo 4. The patient is placed in the lateral position with general is made (between the ‘service entrance’ and the 3-Danaesthesia and single-lung ventilation scope) for the assistant surgeon to insert conventional4
  5. 5. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Video 5. The robotic instruments currently used during the VRL areCadiere and Debakey forceps, electrocautery and micro scissors(EndoWrist , MMCTSLink 31). In addition, thoracoscopic instru-ments and a full thoracotomy instrument set is opened and kept onhand, in case of preoperative complications. Photo 3. CT scan. A computed tomogram of the chest demonstrating a speculated mass in the lower lobe of the left side. (in the anterior axillary line). It provides an easy direct access to the hilum; to insert standard endoscopic instruments when the robotic instruments are not suitable; moreover, it is wider than the posteriorVideo 6. The first incision is made at the 7th space in the mid-axillary space and facilitates later retrieval of the specimenline to verify the feasibility of the robot procedure using a standard (Photo 2).endoscopic optic. Surgical steps Video-robotic left lower lobectomy Video robotic lobectomy follows the standard surgical steps of open thoracic surgery and implies the isola- tion and resection of the vascular and bronchial hilar elements. Usually the artery is dealt with before the vein and eventually the bronchus is resected. How- ever, priorities are not strictly set. Frequently, as is the case of open thoracic surgery, due to surgical strat- egies the ligature of the vein precedes that of the artery. In some cases it is preferable to resect the bronchus before resecting the artery branch. Here below is described a robot-left lower lobectomy in a 64-year-old female. She was a non-smoker withPhoto 2. Chest incisions. small lung mass without mediastinal lymphadenopa-Incision layout during a robot left lower lobectomy. thy on CT scan, with normal bronchoscopic appear- ances, judged to have clinical stage I (positiveendoscopic instruments only when strictly necessary cytology for adenocarcinoma at needle aspiration/CT-(Video 6). guide) (Photo 3).The routine VATS exploration prior to the operationcould yield important information that would markedly Arterial phasealter the treatment strategy. Dissecting around the pulmonary vessel is basically the same as in conventional open surgery.If there is no contraindication to proceed, the mini-thoracotomy ‘service entrance’ (approximately 4 cm The Cadiere forceps and robot electrocauteryin length) is placed over the 4th or 5th intercostal space (MMCTSLink 32), connected to the robot arms, are 5
  6. 6. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Video 7. The dissection of the fissure with robotic instruments to Video 11. A double tie is advisable in all cases, even in small calibreexpose the interlobar artery. vessels to ensure a safe ligation. A resection is made between the two ligations by micro scissors (EndoWrist , MMCTSLink 31). priate traction of the lung parenchyma and helps the surgeon to position the lobes so that the hilum and the vessels can be easily accessed. If the interlobar fissure is complete or nearly complete, the incision of the visceral pleura with robotic electro- cautery or blunt dissection with a pledget mounted on the Cadiere forceps (EndoWrist , MMCTSLink 31), allows the pulmonary artery to be easily identified. InVideo 8. After dissection of the fissure, the pulmonary artery this case, the electrocautery at a low setting is usefulbranches are carefully identified and isolated. and safe (Videos 7 and 8). When the fissure is incomplete the upper lobe is retracted upward and forward, the artery appears from the posterior aspect of the lung root. The artery is then identified within the fissure by careful dissec- tion and a sling is passed between the two points of the arterial access to elevate the fused posterior fis- sure, which is divided by stapling. The same proce- dure is carried out for the resection of the anterior fissure. The mechanical stapler (Endopath ATB45, MMCTSLink 34) is used by the assistant surgeonVideo 9. A sling is passed to lift the vessels separately to obtain a through one of the other two ports (depending on thesafer ligation. alignment). Currently the apical and main-stem lower vessels are taken separately and tied with Linen 2.5 (Videos 9, 10 and 11). Instead of a double tie with Linen, conventional endo- scopic clips (MMCTSLink 35) can be used on the dis- tal part of the artery. However, this technique is not very safe because these endoscopic clips must be applied at the operating site by the assistant surgeon, who has a bi-dimensional vision and does not haveVideo 10. The vessels are taken separately and tied with Linen 2.5. sufficient coordination. On the other hand, theDue to their rough texture, linen as well as silk are ideal because available robotic clips are too small to be used forthe ligation does not come undone. pulmonary vessels. In this regard, a possible compli-introduced through the minithoracotomy and posterior cation is that the clips can lacerate the vessel duringincision for the dissection of the hilum and the fissure. the surgery or that they can slip off (Video 12).A standard endoscopic holding forceps (Babcock5BB, MMCTSLink 33) can be introduced by the assis- Vein phasetant surgeon through the service entrance or (rarely) Usually the surgical time sequence implies treatingthrough an additional incision. This provides appro- the vein as a second step. The pulmonary ligament is6
  7. 7. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Video 12. This is an example of the laceration of a pulmonary artery Video 16. The resected lobe is removed in sterile plastic bagsdue to the imprecise positioning of the clips solved by further iso- through the ‘service entrance’.lating the artery peripherally and placing additional clips. through a 4th incision, when it is made, and stitch it by using the robot Debakey forceps and a large nee- dle holder (EndoWrist , MMCTSLink 31) (Polypropyl- ene Monofilament 4/0). This is more difficult and not safe, considering that both the stapler and the clamp have to be placed by the assistant surgeon (at hand at the operating table), whose hand–eye orientation (bi-dimensional vision) is less precise compared to the surgeon who, at the console, has a different depth perception and optical resolution. Consequently poorVideo 13. The vein is cleared and separated from the lymph node, coordination between the surgeon and the assistantwhich is removed, by using electrocautery and the Cadiere forceps can jeopardize the success of the operation.(MMCTSLink 32). A blunt dissection can be useful. Bronchus phase The last step consists of isolation and resection of the lobar bronchus by using the stapler (Endopath ATB45, MMCTSLink 34), necessarily performed by the assis- tant surgeon. This is the only possible way to resect and suture the bronchus with this approach. Although the robot wrists are able to simulate even fine physiological movements, the surgeon cannotVideo 14. After isolation, a sling is passed and the vein is double make a running stitch when dealing with the bronchustied with Linen 2.5 and resected between the ligations. as the robotic instruments in current use are too small to handle such a thick structure (Video 15). Blunt dissection is particularly useful when dissecting and for sweeping tissue along the lobar bronchus peripheral to the line of intended bronchial division so that all the lobar bronchial nodes can be included in the operative specimen. The lobectomy specimen is placed in a sterile plastic bag and removed through the minithoracotomy. TheVideo 15. The bronchus is isolated and cleaned by dissection bronchial stump is then tested under water for airmanoeuvres. Here too, a sling is used to better isolate the bronchus leaks with 20 cm of positive airway pressure (Videoand to position the stapler correctly. 16).incised and the lower vein cleared from the surround- At the end of the operation all the accessible nodaling tissues and divided (Videos 13 and 14). When it is stations are systematically sampled to ensure properparticularly thick it is advisable to use a mechanical staging of the lung cancer. Currently the lymph-nodestapler, although this increases the cost. Another way samplings are made at stations that are more likelyof handling the vein is to place a vascular clamp involved for tumours originating from a particular lobe 7
  8. 8. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448Table 4. Mean data ("SD) of robotic lobectomy the lower left (ns11), the lower right (ns9), the middle lobe w3x, the upper right (ns1).Operative time (h) 3.2 ("0.6)Operative blood loss (ml) 103 ("28.1)Post-operative morphine consumption (mg/h) 0.47 ("0.1) ResultsPostoperative (VAS) pain score 1.3 ("0.7) first 24 h (mm:range 0–100) Details of patients who underwent robotic lobectomyChest tube (days) 2 ("1.4) are summarized in Table 4. In this highly selectedHospital stay (days) 5 ("1.3) group of good-risk patients no technical operative mishaps related to manoeuvres of the instrument-w16x: the right upper lobe (prevascular and retro tra- arms occurred. None of the patients had problemscheal N3 and lower paratracheal N4R), the middle related to operative bleeding. All patients tolerated thelobe (N3 and subcarinal N7), the right lower lobe (N7), procedure well and the post-operative course wasthe left upper lobe (sub-aortic N5 and para-aortic N6), satisfactory, requiring less analgesic compared tothe left lower lobe (N7). If a complete lymph node dis- conventional surgery. In two patients the proceduresection is considered necessary it should be done was converted to a minimal thoracotomy. In thesethrough a thoracotomy. Unlike VATS approach, there cases we began the lobectomies by isolating andare no limitations regarding accurate lymph-node stitching the transected lower vein with the robot.sampling, given that this is carried out at the end of However, we had to complete the operations usingthe operation when a part of the lung has been the ‘service entrance’ (enlarged by about 2 cm) dueremoved. In fact, there is no need to move the entire to hilar calcified lymph nodes, since these renderedpulmonary parenchyma in order to access all lymph- the dissecting of the pulmonary artery unsafe. Innode stations. another two patients we had air leaks. In both cases mechanical staplers were used to complete the fis-Two 24 French chest drains (through the previous sure. There was one death on the 12th p.o. day (notcamera and instrument ports) and closure of the mini- related to the surgical technique) due to pulmonarythoracotomy wound complete the operation. embolus. After an initial excellent postoperative recovery the patient had acute kidney failure on thePersonal experience 4th p.o. day which led to a worsening of the clinical conditions.Since February 2001 we have used a robotic systemto operate 85 patients with a range of thoracic dis- Chest tubes were removed in mean 2 p.o. days andeases. There were 54 men and 31 females aged 19– the patients were discharged in mean 5 postoperative71 years (mean age 61). We applied the da Vinci days.Robotic System (MMCTSLink 17) to perform various Operative time varied between 2.5 to 5 h, of which 1 hthoracic operations, ranging from the simplest pro- was used to do the self-test of the machine andcedures, such as benign tumour enucleations/ instrument set-up. This time was considerably longerexcisions, to very complex ones, such as major pul- than that for standard open surgery or VAT procedure,monary resections. but it decreased with experience so that the last cas-Video robotic lobectomies (VRL) were performed in 23 es averaged 3 h.good-risk patients selected by pre-operative investi- All patients were discharged in good condition andgations. There were 15 men and 8 females aged 41 returned to preoperative levels of physical activityto 78 years (mean age 64.4). The patients were within 10 days of the operation.referred to our Department with a pulmonary opacityon chest radiographs and normal bronchoscopic Comments and controversiesappearances. In accordance with our then normalpractice for small lesions without mediastinal lym- As far as is known, few video-assisted robotic lobec-phadenopathy on the CT scan, mediastinoscopy was tomies are performed, consequently few surgeonsnot undertaken. These patients were judged to have have experience in this field w11–16x. Currently, manyclinical stage I (NSCLC). Arterial blood gases where of the limitations of robotics surgery are related to thewithin normal limits, and pulmonary function demon- imperfections of the system. At present the greateststrated adequate pulmonary reserve to undergo a difficulties of the VRL are associated with the availableplanned lobectomy (forced expiratory volume in 1 s arm instruments, which are designed for cardiac or(FEV1) )1.5 l). Specific consent was obtained for general surgery and are not adequate for thoracic sur-attempted robotic resection. The lobes resected were gery. Consequently some procedures become more8
  9. 9. F.M.A. Melfi et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000448complicated especially for the lung major resection. bypass grafting. Heart Surg Forum 2000;3:This accounts for the extreme difficulty in performing 203–206.upper lobectomies, which can only be carried out with w4x Stephenson ER, Sankholkar S, Ducko CT,the aid of the assistant surgeon, who is in a different Damiano RJ. Robotically assisted microsurgeryergonomic position. In our experience we performed for endoscopic coronary artery bypass grafting.only one upper right lobectomy and no upper left Ann Thorac Surg 1998;66:1064–1067.lobectomy. This is because a fourth arm would have w5x Loulmet D, Carpantier A, d’Attelis N, Berrebi A,to be available to allow the surgeon to easily access Cardon C, Ponzio O. Endoscopic coronary arterythe hilum of the upper lobe and to handle the pul- bypass grafting with the aid of robotic assistedmonary parenchyma. Therefore, lower-lobe lobecto- instruments. J Thoracic Cardiovasc Surg 1999;mies, especially left lower lobectomy – also in 118:4–10.conventional thoracic surgery – are technically the w6x Falk V, Diegeler A, Walther T, Bannusch J,most straight-forward resection to carry out. Autschbach R, Mohr FW. Total endoscopic coronary artery bypass grafting. Eur J Cardio-Other limitations are system-related. At present, thoracic Surg 2000;17:38–45.blocking of the robotic arms or working against strong w7x Schurr MO, Arezzo A, Buess GF. Robotics andresistance is experienced at the console. The surgeon systems technology for advanced endoscopicdoes not receive information on the amount of force procedures: experiences in general surgery. Eur Japplied to tissue or sutures, and therefore is depend- Cardiothorac Surg 1999;16 Suppl 2:S97–105.ent on visual feedback. This is sufficient in the major- w8x LaPietra A, Grossi EA, Derivaux CC, Applebaumity of the manoeuvres, but not when it comes to RM, Hanjis CD, Ribakove GH, Galloway AC,suturing delicate structures and tying knots, or when Buttenheim PM, Steinberg BM, Culliford AT,the surgeon wants to distinguish tissue characteris- Colvin SB. Robotic-assisted instruments enhancetics. This poor tactility impairs the surgeon’s ability to minimally invasive mitral valve. Ann Thorac Surgjudge the amount of tension applied during the 2000;70:835–838.manoeuvres of suture/ligation tensioning w10x. w9x Rininsland HH. Basics of robotics and mani-Considering all these limitations, robotic procedures pulators in endoscopic surgery. Endosc Surgmay be technically feasible only in highly selected Allied Technol 1993;1:154–159.cases and in the hands of an experienced thoracic w10x Reichenspurner H, Damiano RJ, Mack M, Boehmsurgeon. Like the VAT, this new surgical technique DH, Gulbins H, Detter C, Meiser B, Ellgass R,should only be undertaken by surgeons trained in tho- Reichart B. Use of the voice-controlled andracic surgery w17x. Besides a perfect knowledge of computer-assisted surgical system ZEUS fortopographical anatomy and broad experience in con- endoscopic coronary artery bypass grafting. Jventional surgery, training in specific thoracoscopic Thorac Cardiovasc Surg 1999;118:11–16.skills is required. w11x Okada S, Tanaba Y, Yamauchi H, Sato S. Single- surgeon thoracoscopic surgery with a voice-Nonetheless, we believe that many of the current lim- controlled robot. Lancet 1998;351:1249.itations can be overcome in the near future, and that, w12x Melfi FM, Menconi GF, Mariani AM, Angeletti the da Vinci System is improved and its instru- Early experience with robotic technology forments better adapted to thoracic surgery, their appli- thoracoscopic surgery. Eur J Cardiothorac Surgcation will be extended to a wider range of operations. 2002;21:864–868. w13x Okada S, Tanaba Y, Sugawara H, Yamauchi H, Ishimori S, Satoh S. Thoracoscopic major lungReferences resection for primary lung cancer by a single surgeon with a voice-controlled robot and anw1x Osmote K, Feussner H, Ungeheurer A, Arbter K, instrument retraction system. J Thorac Cardio- Wey GQ, Siewert JR. Self-guided robotic camera vasc Surg 2000;120:414–415. control. Am J Surg 1999;177:321–324. w14x Morgan JA, Ginsburg ME, Sonett JR, Moralesw2x Cadiere GB, Himpens J, Vertruyen M, Favretti F. DLS, Kohmoto T, Gorenstein LA, Smith CR, The world’s first obesity surgery performed by a Argenziano M. Advanced thoracoscopic surgeon at a distance. Obes Surg 1999;9:206– procedures are facilited by computer-aided 209. robotic technology. Eur J Cardiothorac Surgw3x Vassiliades TA Jr, Nielsen JL. Alternative 2003;23:883–887. approaches in off-pump redo coronary artery w15x Bodner J, Wykypiel H, Wetscher G, Schmid T. 9
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