Abstract We present the case of a 74-year-old man with Stage IIa pulmonary adenocarcinoma, for which he underwent a robotic right middle lobectomy. A 4-armed, 5-port approach was used. Four intercostal ports were created above the ninth rib using the Cerfolio’s technique. The subxiphoid port was created in the midline, 5 cm down from the xiphisternum. The robot offers higher image quality, depth perception and improved articulation of the instruments, allowing for more accurate dissection and stitching. The usage of a subxiphoid utility port reduces the clashing between instruments, offers a good angle for stapling and provides a direct view of the instruments entering into the chest. Specimen removal through the subxiphoid port may reduce postoperative pain and enhance patient recovery. The use of the subxiphoid approach as a utility port for robotic surgery is promising and may be a suitable replacement for the traditional utility port. Right middle lobectomy, Robotic surgery, Subxiphoid port INTRODUCTION Robotic technology has been used increasingly as a minimally invasive approach for lung resections in thoracic surgery. The results of robotic pulmonary resections have proved that robotic technology is safe with no difference in adverse outcomes when compared with video-assisted thoracic surgery (VATS) . Recently, a rediscovered interest for the subxiphoid port in thoracic surgery is observed. The subxiphoid utility port is placed below the xiphisternum, with no incisions through intercostal spaces, minimizing neuromuscular injury. It is known that patients with intercostal incisions and rib spreading are at greater risk of severe postoperative pain, which can result in poor pulmonary re-expansion, delayed mobilization, prolonged hospitalization and chronic pain syndromes . The authors previously described the application of subxiphoid access to robotic lobectomy . CASE We present the case of a 74-year-old man, with a history of smoking, who was diagnosed with Stage IIa primary pulmonary adenocarcinoma. The patient was examined for surgical resection and underwent a robotic right middle lobectomy. A 4-armed, 5-port approach was adopted, with 2 anterior ports and 2 posterior ports for the robot arms, and a subxiphoid utility port (Video 1). All intercostal ports were created above the ninth rib using the Cerfolio’s technique . The first port was made 2 cm away from the midline, the second port was made another 10 cm away, and the third port (camera port) was created a further 10 cm away. The fourth and fifth (subxiphoid) ports were created under camera guidance. The subxiphoid port was created with a midline incision immediately below the xiphoid process. Video 1 This video demonstrates the procedure of a right middle lobectomy with a subxiphoid utility port. Intercostal and subxiphoid port placements are highlighted, as well as the division of vessels through the subxiphoid port. Finally, the extension of the subxiphoid incision to deliver the specimen is shown. Video 1 This video demonstrates the procedure of a right middle lobectomy with a subxiphoid utility port. Intercostal and subxiphoid port placements are highlighted, as well as the division of vessels through the subxiphoid port. Finally, the extension of the subxiphoid incision to deliver the specimen is shown. Close The anterior aspect of the oblique fissure was divided to allow unrestricted access to the underlying structures. The middle lobe vein, bronchus, artery and horizontal fissure were all dissected and divided using the EndoGIA tristaplers, with the aid of a yellow sling to guide the assistant in positioning the staple. The subxiphoid port was extended inferiorly in the midline, through the linea alba, avoiding fibres of the rectus abdominis, to deliver the specimen. This is important to minimize bleeding and postoperative pain. DISCUSSION Robot benefits The robot displays 3D images, which provide improved depth perception and higher quality images, when compared with 2D VATS cameras. All robotic instruments articulate in many directions of movement, which allow a wide range of manoeuvres, when compared with the linear VATS instruments. Importantly, the filtration of tremor improves precision. These factors may result in improved dissection, better stitching and, consequently, safer surgery. Some studies have shown decreased use of postoperative analgesia and opioids following robotic surgery when compared with VATS . Subxiphoid port benefits The position of the subxiphoid port enables a wider range of movement of the robot arms with less impingement and collision, as well as better access to the mediastinum. It is also in a strategic position to access hilar vessels and making it convenient for stapling and easier to control unexpected bleeding. Because of its position with respect to the camera, the port remains under direct vision and entry/exit of samples or equipment can be clearly seen. Importantly, the subxiphoid port facilitates the removal of the specimen with no rib spreading. This may result in decreased postoperative pain, enhanced recovery and reduced length of stay . Limitations Though the subxiphoid port reduces rib spreading, there are still intercostal incisions, and these have been minimal in size. There is also a small risk of developing an incisional hernia at the subxiphoid port site, probably equivalent to the risk associated with a sternotomy . This is reduced by ensuring satisfactory closure. Robotic technology is expensive and requires high maintenance and is, therefore, not widely available. It is also highly specialized, and extensive training on the robotic technology for the surgeons and the entire surgical team is required. The initial learning curve and docking set-up time result in longer operative times and prolonged single lung ventilation. However, this is an issue related to experience. Additionally, operating the instruments remotely results in the loss of tactile sensation, but this can be compensated by the high quality of visual feedback. CONCLUSION The subxiphoid approach is feasible and safe. We successfully applied the same concept in robotic lung surgery. These encouraging findings warrant further investigations, which will determine the advantage of the subxiphoid port over traditional ports. Conflict of interest: none declared. REFERENCES 1 Kent M, Wang T, Whyte R, Curran T, Flores R, Gangadharan S. Open, video-assisted thoracic surgery, and robotic lobectomy: review of a national database. Ann Thorac Surg 2014; 97: 236– 42. Google Scholar CrossRef Search ADS PubMed 2 Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin 2008; 26: 355– 67. Google Scholar CrossRef Search ADS PubMed 3 Nardini M, Migliore M, Jayakumar S, ElSaegh M, Mydin IM, Dunning J. Subxiphoid port applied to robotic pulmonary lobectomies. J Vis Surg 2017; doi:10.21037/jovs.2017.03.01. 4 Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011; 142: 740– 6. Google Scholar CrossRef Search ADS PubMed 5 Dunning J, Elsaegh M, Nardini M, Gillaspie EA, Petersen RH, Hansen HJ et al. . Microlobectomy: a novel form of endoscopic lobectomy. Innovations (Phila) 2017; 12: 247– 53. Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Interactive CardioVascular and Thoracic Surgery – Oxford University Press
Published: Jan 23, 2018
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