Fig. 10.1
Port placement for robotic-assisted chest wall resection with lobectomy
The pleural space is entered over the top of the seventh rib with a 5-mm port in the midaxillary line, or as anteriorly as possible, and guided by a 5-mm scope. A 5-mm VATS camera is used to ensure entry into the pleural space, and warmed carbon dioxide is insufflated to drive the diaphragm inferiorly. This incision will eventually be enlarged to allow a 12-mm port, and it will serve as robotic arm 1 (for right-sided operations). A paravertebral block is performed posteriorly with a local anesthetic and a 21-gauge needle. The needle is used to help select the ideal location for the second incision, the most posterior incision. The location chosen is two ribs below the major fissure and as far posterior in the chest as possible, just anterior to the spinal processes of the vertebral body. A small 5-mm incision is made, and a 5-mm reusable metal da Vinci trocar is placed. This will be the position for robotic arm 3. The next few incisions are carefully planned and marked on the skin before they are made. Ten centimeters anterior to the most posterior incision and along the same rib (most commonly rib 8), a third incision is planned. It is an incision for an 8-mm port, and its trocar is an 8-mm metal reusable da Vinci trocar that will be docked with robotic arm 2. A fourth incision is marked on the skin and again planned but not made 9 cm anterior to this port, along the same rib. This will eventually be used for the robotic camera. A 12-mm plastic disposable port is used for the 12-mm camera, and if the 8-mm camera is used, an 8-mm metal reusable trocar is placed. Before these 2 incisions are made, a small 21-gauge needle is used to identify the most anteriorly inferior aspect of the chest that is just above the diaphragmatic fibers. This incision will have a 15-mm port and serve as the access port. A plastic disposable trocar is used. No robotic arms are attached to the trocar that is placed in this incision. This incision is carefully planned. It is made just above the diaphragm, as anterior and inferior as possible and, importantly, to be in between the ports used for robotic arm 1 and the camera. Once these incisions have been carefully planned and their locations have been confirmed, they are made and the appropriate trocars are placed. Finally, the initial 5-mm anterior port that was made first and used to introduce the VATS camera to identify the internal landmarks is then dilated to a 12-mm double-cannulated port for robotic arm 1. The robot is driven over the patient’s shoulder on a 15° angle and attached to the four ports. In general, only three robotic instruments were used for all these operations: the Cadiere grasper, a 5-mm thoracic grasper (used exclusively through the most posterior port that is attached to robotic arm 3, which serves as a retractor of the lung), and bipolar forceps.
For rib resection, we have used the Sofamor Danek rib-cutting device. The remainder of our technique is similar to that described above for VATS chest wall resection.
10.1.6 Discussion
Developing new methods to achieve the same (or better) result that limit the amount of surgical trauma created has been the basis of many developments in minimally invasive surgery. Similarly, ways to achieve chest wall resection with or without associated lung resection have evolved as thoracoscopic and robotic techniques have become refined over the years. We previously described the use of muscle-limiting incisions that spare the extrathoracic (trapezius, rhomboid, serratus anterior) muscles during chest wall resection [6]. Although the operation described in that setting still required a thoracotomy, the application of minimally invasive techniques may permit chest wall resection without rib spreading and its attendant disadvantages such as fractured ribs left in situ, acute pain, and long-term neuralgia [7]. Berry et al. demonstrated that such resections can be done with a 100 % R0 resection rate and low likelihood of conversion, while Demmy et al. showed that VATS chest wall resection was associated with a decreased ICU stay (2 vs 6 days, p = 0.028), hospital stay (7 vs 13 days, p = 0.002), and 90-day major morbidity/mortality (53.3 % vs 87.5 %,p = 0.036) compared to chest wall resection via thoracotomy despite being performed on older patients that were more likely to be or have been smokers [2, 8]. One of the final advantages of a MICWR is that often time by leaving the overlying chest wall muscles intact the need for a prosthetic can be eliminated. The risk of the lung billowing out of the incision has to be considered if prosthetic not used. If a prosthetic is desired it can be easily sewn to the pleura inside the chest, as opposed to the ribs.
10.1.7 Conclusion
Although not yet extensively studied, the use of minimally invasive methods for assistance during chest wall resection with or without lung resection is technically feasible, associated with an acceptable safety profile in experienced hands, and may translate to decreased postoperative morbidity and pain compared to resection via rib-spreading thoracotomy.
10.2 Minimally Invasive Approach to Superior Sulcus Tumors and Tumors Involving the Chest Wall or Spine
(6)
Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
(7)
Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, 200 First Street, SW, Rochester, MN, USA
10.2.1 Preface
As thoracoscopic equipment has evolved and thoracic surgeons have become more adept and comfortable with the technology, more and more complex cases may now be completed with a minimally invasive approach. We describe herein our approach to Pancoast tumors and how to manage the lobectomy, chest wall invasion or nerve root involvement.
10.2.2 Key Words
Pancoast, minimally-invasive, chest wall invasion, nerve root, lung cancer, VATS lobectomy, minimally invasive lung surgery
10.2.3 Introduction
A minimally invasive approach to superior sulcus tumors and tumors involving chest wall is now established practice with advances in thoracoscopic equipment, improved imaging technology and increased surgeon experience. Three-dimensional models in particular have enhanced pre-operative planning have enabled surgeons to rehearse procedures, select and test instrumentation and divide task responsibilities while anticipating potential obstacles prior to the patient even entering the operative theater. A thoracoscopic approach to superior sulcus tumors provides excellent visualization throughout the procedure, and helps to reduce postoperative pain and enhance recovery as it requires no rib spreading or division of the latissimus or serratus.
We discuss herein our minimally invasive and hybrid approach to superior sulcus tumors, tumors with chest wall involvement or nerve root involvement.
10.2.4 Pre-operative Considerations
10.2.4.1 Time Out
A briefing is performed prior to bringing the patient to the room to confirm desired equipment and planned procedure. The patient is brought to the room and a critical pause is performed to confirm patient, procedure, position, administration of appropriate antibiotics and DVT prophylaxis.
10.2.4.2 Anesthesia
General endotracheal anesthesia with a double-lumen endotracheal tube is performed. Tube position is confirmed bronchoscopically and tube is secured into place.
10.2.4.3 Tubes and Lines
Foley catheter is placed. Arterial line and additional venous access is obtained.
10.2.5 Positioning
The patient is placed in the lateral decubitus position with the affected side up. An axillary roll is positioned under the patient to protect the brachial plexus. The arms are placed on either an arm board or in front of the patient. The bed is flexed to open the rib spaces. Hip and leg straps are secured. A warmer should be placed on the patient to maintain warmth during the surgery (Fig. 10.2).
Fig. 10.2
Patient is positioned in right or left lateral decubitus position. Bed is flexed, pressure points are padded and patient is secured
Patient is prepped and draped in sterile fashion.
10.2.6 Pre-operative Antibiotics
Routine prophylactic antibiotics are used.
10.2.6.1 DVT Prophylaxis
Every patient wears bilateral sequential compression devices that are placed upon arrival to the operating room, before the induction of anesthesia. Additionally, patients are administered 5,000 units of subcutaneous heparin.
10.2.6.2 Instruments
Standard VATS lobectomy instruments (Scanlan International Mayo Selection VATS Set)
Kerrison bone cutter
10.2.7 Anatomic Considerations
A Pancoast or superior sulcus tumor is defined as a lung cancer arising in the apex of the chest, involving structures of the apical chest wall. Involvement of the chest only at the level of the second rib or below does not meet criteria for involvement of the apex. Chest wall involvement may be limited to invasion of the parietal pleura or may extend deeper into periosteum or bone in the ribs, vertebral bodies, subclavian vessels or nerve roots of the brachial plexus or stellate ganglion. Pre-operative imaging studies should be performed to delineate anatomy and involvement of tumor into any vital structures [9]. MRI with contrast allows enhanced evaluation of vascular and nerve structures when there is concern of invasion. Three-dimensional printing has become an outstanding adjunctive pre-operative planning tool. Please see further information about 3-D printing later in this chapter (Fig. 10.3).
Fig. 10.3
Thoracoscopic view of the chest with the lung and apical Pancoast tumor removed. Ribs are numbered for reference. At the apex, the subclavian vein (sub v), subclavian artery (sub a), and brachial plexus with roots can be visualized. Inferiorly the hilum of the lung with the right main PA (RPA) and bronchus are appreciated. To the right is the superior vena cava (SVC) and ascending aortal. To the left is the esophagus (eso) and spine. The azygous vein (Az V) runs up along the spine then crosses superiorly to the hilum of the lung
10.2.8 Operative Approach to Superior Sulcus Tumor
10.2.8.1 Port Placement
A thoracoscopic port is placed in the seventh to eighth intercostal space in the posterior axillar line. A second port is placed in the anterior axillary line, seventh to eighth intercostal space under direct visualization. The lung and chest wall are inspected for candidacy of lobectomy. A utility incision measuring approximately 3–4 cm is placed in the fourth to fifth intercostal space anterior axillary line under direct visualization. Dissection to the chest wall should spare the serratus muscle, gently separating fibers and then disconnecting underlying intercostal muscles from the superior aspect of the fifth rib. An Alexis wound protector is used in this incision. If needed, an additional port may be placed just posteriorly to the tip of the scapula (Fig. 10.4).
Fig. 10.4
Thoracoscopic port positions for right upper lobectomy. Mirror image port sites are used for the left
For Pancoast tumors with chest wall involvement, the lobectomy may be approached as the initial portion of the procedure or the chest wall may be approached first, depending on the region of chest wall involvement. In some cases, the tumor will be affixed to the chest wall and actually assists with hilar exposure, as it retracts the lobe out of the way.
10.2.8.2 Lobectomy
The anterior mediastinal pleural surface is opened with Bovie electrocautery, paying careful attention to preserve the phrenic nerve. There is frequently a station 10 node between the RUL and RML vein branches. This node should be dissected free and send to pathology to allow for optimal exposure. The upper lobe vein is skeletonized until a curved clamp can easily pass around the RUL pulmonary vein, sparing the RML vein branches. A curved tip vascular load stapler is used to staple and divide the RUL vein after confirming separate middle vein (on the right) and lower lobe vein branches (Fig. 10.5).
Fig. 10.5
The superior pulmonary vein is skeletonized and transected. The first intra-operative photo shows blunt Kittner dissection around the pulmonary vein to the right upper lobe. The phrenic vein shown inferiorly has been carefully preserved. Prior to transecting the vein, presence of a middle lobe vein (shown in the second intra-operative photo) and lower lobe vein should be confirmed. The stapler is carefully passed around the vein and it is transected with a vascular load stapling device. We prefer to use a stapler with a tip. Staple line is shown in the third photo
Second, the truncus anterior artery is carefully skeletonized. The mediastinal pleura is opened superiorly along the border of the azygous vein on the right and away from the aortic arch on the left to facilitate adequate cephalad arterial exposure. Careful attention must be paid on the left side to avoid injuring the recurrent laryngeal nerve as it passes around the ligamentum arteriosum. Once exposed, the RUL truncus anterior may be divided with vascular load stapler. It is always important to remember to take the tension or retraction off any structure being stapled (Fig. 10.6).
Fig. 10.6
The vascular load stapling device is gently advanced posteriorly to the truncus anterior, the tip is viewed clearly past the structure, and the artery is stapled and divided. The stapler should be articulated to pass around the artery perpendicular to the direction the artery is traveling
The posterior ascending pulmonary artery branch is identified next and dissected. The artery is sometimes approached anteriorly prior to the bronchus, and other times taken after the bronchus, depending on the relative orientation. The “sump node” (level 11) which resides between the right upper lobe and the bronchus intermedius should also be removed to expose the posterior ascending artery for right upper lobectomy. The fissure may need to be partially divided to provide optimal visualization of the artery and facilitate stapling, and dividing (Fig. 10.7).
Fig. 10.7
There are times, access to the pulmonary artery is compromised by an incomplete fissure, and partial division of the horizontal fissure may facilitate dissection
The posterior ascending artery varies in size and position. The point of origin is most commonly the interlobar artery, but it may also arise from the truncus anterior. This branch typically arises individually, or may share a common trunk with the right lower lobe arterial branch. The artery should be skeletonized and divided as a separate structure, and not taken concomitant with the fissure. Depending on the size, a stapler, clip or energy device may be employed to seal the vessel prior to division (Fig. 10.8).
Fig. 10.8
Skeletonization and division of the posterior ascending artery. Depending on the size of the artery, a stapler or clip may be preferred
The left upper-lobe pulmonary artery anatomy is the most variable among lobes. Left upper lobectomy can be challenging due to variable anatomy with small vessels which can be easily injured or vary in number and caliber. Inadvertent injury or excess traction can rapidly lead to a left main pulmonary artery tear.
The bronchus to the upper lobe is dissected, carefully sweeping lymphatic tissue towards the specimen. Avoid devascularization of adjacent bronchus intermedius and the right mainstem bronchus as this compromises blood supply and impairs healing, leading to higher rates of broncho-pleural fistula formation. The bronchus is encircled, and the stapler is deployed. Anesthesia is asked to give a couple of small breaths to the lung to ensure that the lower lobe inflates. The bronchus is divided with a tissue (Green for Ethicon and Purple for Covidien) stapling device. The remaining fissure is completed with a stapling device or energy source when the fissure is thin. The specimen, if free, should be sent immediately to pathology for frozen section evaluation of margins (Fig. 10.9).
