Introduction

Robotic thoracic operations are increasingly common and utilized for lung, esophageal, mediastinal, and chest wall resections. Robotic lobectomy and segmentectomy operative volume have now surpassed the VATS approach. Benefits of the robotic platform include improved optics and wristed articulation. Multiple studies have also indicated that risk of conversion is significantly lower with the robotic platform as compared to a VATS approach. Additionally, data indicates that when conversion occurs utilizing the robotic platform, it is typically to urgently control bleeding. Although this is an infrequent occurrence, employing an efficient, stepwise method to convert from robotic thoracoscopy to thoracotomy is paramount.

Simulating this infrequent, yet high stakes scenario, with all potential operating room (OR) personnel and stakeholders (including but not limited to the surgeon, bedside assistant, surgical technician, circulating nurse, and anesthesiologist,) is necessary to ensure a smooth conversion during an emergency setting. In doing so, potential unanticipated pitfalls may declare themselves in a controlled manner. For example, if there is anticipated delay to obtaining blood products in the hospital, then packed red blood cells should be available in the OR for cases thought to be at high-risk for conversion, or for potentially for any thoracic operation, based on the clinical scenario and logistic constraints of the practice setting. The surgeon should also recognize that scenarios other than bleeding may require conversion to thoracotomy. Anatomic constraints, space constraints, and robotic faults are known reasons for nonemergent conversion to thoracotomy that still will require a stepwise approach to conversion.

Here we submit our stepwise method of conversion from robotic-assisted thoracoscopic surgery to a thoracotomy in the emergency setting. This is a tried and tested method which our group has refined over years of real-life experience with emergency conversion as well as frequent simulation with our entire operative team. Although emergency conversion is a multidisciplinary emergency intervention, the focus of this step-by-step tutorial is on the actions undertaken by the surgeon and surgeon-assist. There are 2 key features of this conversion method. First, we emphasize that this method of conversion ensures pressure of the bleeding vessel is always controlled either by the surgeon at the robotic console or the bedside assistant. At no point is bleeding controlled by a robotic instrument without the surgeon maintaining direct control at the console, which is a potentially unreliable method to control bleeding. It can be particularly challenging to regain control with unmanned robotic arms maintaining pressure in the event that tamponade is inadvertently lost, a robotic system fault occurs, or the bedside team unintentionally jostles the robotic arm. In lieu of a robotic instrument maintaining pressure control of a bleeding vessel without the surgeon at the console, we favor a limited anterior thoracotomy in line with the eventual planned thoracotomy for the bedside assist to hold a sponge for hemostatic control. Second, we favor placement of the sponge stick through the limited anterior thoracotomy rather than the assistant port to optimize hemostatic control by the bedside assistant. In our experience, the typical assistant port during robotic thoracoscopic operations is positioned poorly for maintaining reliable pressure on a bleed. The assistant port is typically placed at the base of the diaphragm, well away from the hilum. Passing a sponge stick in this location places the fulcrum of pressure far from the area of bleeding and leads to an unacceptably high risk of losing consistent tamponade of bleeding. This conversion method allows the surgical team to always maintain direct visualization of the operative field. The details of each specific step are laid out below ( Figures 1 – 6 ).

The operative setup should be optimized for potential conversion to an open thoracotomy. The robotic console should be setup in a manner where there is direct line of site from the console surgeon to the bedside if feasible. Prior to docking the robot, the boom on the robotic arms should be maximally extended to allow for as much working room as possible at the bedside for the assistant to navigate between the patient bed and the base of the robot. The vision cart with the telestration monitor cart should be placed by the head of the patient near anesthesia. Placement of the vision cart in this location provides the most space around the scrub table and for the bedside assistant should conversion be necessary. Placement of the vision cart at the feet can cause obstruction for the scrub and bedside assistant.

Prior to prepping and draping the patient, the anticipated incision for the robotic instruments and the potential limited and full thoracotomy are marked out. The bedside assistant whether a surgical trainee, physician assistant, or registered nurse first assistant, should be credentialed, capable, and comfortable with making limited incisions for access. When converting, our team has the bedside assistant perform the limited nonrib spreading thoracotomy at the anterior aspect of the planned full thoracotomy incision. This is marked out from the outset along with the eventual full thoracotomy incision that will eventually be needed for conversion. Although the ports depicted here are a ubiquitous approach and our thoracic division’s preference for lung resections, marking of the planned mini and complete thoracotomy site is amenable to most other combinations of port site placements based on surgeon preference. Premarking minimizes the time needed for the bedside assistant to do incision planning during a high stress situation which is difficult with the docked robotic arms in place. Additionally, performing a limited thoracotomy minimizes the time from incision to placement of a sponge stick into the chest for pressure control. We have transitioned away from using the assistant port as the site of sponge stick insertion, as insertion of a sponge stick near the base of the diaphragm is not an ideal angle for proximal pressure at the hilum. Additionally, if placed through the assistant port incision, the fulcrum of the sponge stick is near the assistant, and at this angle small movements by the bedside assistant transmit to large movement at the tip of the sponge stick. A sponge stick placed at the position of the assistant port and can be extremely ineffective in control of bleeding. In contrast, the limited thoracotomy is in direct line with the hilum and allows for reliable direct pressure to the area of bleeding. The limited thoracotomy is also in line with the eventual full thoracotomy that will be needed for control of bleeding and to complete the operation. If the surgeon’s preferred port placement is such that the assistant port is positioned near the pulmonary hilum or area of injury, then use of the assistant port site for sponge stick placement is acceptable.

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