Fig. 8.1
Da Vinci Xi surgical system (a) Surgical cart; (b) Surgeon’s console
The vision cart contains a touchscreen monitor to provide a view of the operative field to the bedside assistants and OR staff. An electrosurgical unit is integrated into the vision cart providing monopolar and bipolar energy to the various da Vinci™ Xi instruments mounted to the patient cart. The cautery is activated via the surgeon console.
The robotic instruments and endoscope are interchangeable on the patient cart arms and are inserted into the patient through 8 mm trocars. There are a variety of instrument options available for pulmonary resection. Typically, at least three instruments are used for anatomic lung resection: a forceps (Cadiere, Fenestrated Bipolar or Prograsp), an energy dissection device (Maryland bipolar, monopolar spatula, hook cautery) and a retractor (Tip up fenestrated grasper, Thoracic grasper).
8.1.2 Patient Selection and Indications
Selection criteria for robotic lung resection follow the same principles as for conventional VATS or open procedure. As with any surgical procedure, there is no substitute for sound judgment. There are no absolute contraindications for robotic lung resection per se. However, particularly during one’s early experience with the technique there are several potential relative contraindications:
Inability to maintain lung isolation
Adherent hilar nodal disease (either inflammatory or neoplastic)
Large, central lesions
Need for sleeve (bronchial or vascular) resection
Locally advanced tumors invading the chest wall or mediastinum
Pleural adhesions have been cited as a relative contraindication for a VATS approach. This is less so for robotic surgery as the visualization and the extra dexterity offered makes extensive adhesiolysis technically easier.
8.2 Surgical Technique for Robotic Pulmonary Lobectomy
8.2.1 Preparation of the Robotic System
Properly trained technical and nursing staff can set up the robotic system (cart, surgeon’s console, visual system) concurrently as the patient is being brought into the room and placed under anesthesia. Typically, the components of the system remain in dedicated rooms to minimize setup time. When using the Si system the arms are positioned on the ipsilateral side as the planned resection. This is less critical with the Xi system because of the enhanced targeting feature and ability of the arms to rotate up to 270°, and theoretically the cart may be positioned in virtually anywhere with respect to the operating table.
8.2.2 Anesthetic Consideration and Patient Positioning
The most common anesthetic approach involves general anesthesia with endotracheal intubation and lung isolation, but variations include low tidal volume ventilation with or without CO2 insufflation or intravenous anesthesia with spontaneous ventilation. Standard intraoperative monitoring includes EKG, arterial line for blood pressure monitoring and urinary catheter. We do not routinely place a thoracic epidural for robotic lung resections, instead utilizing multilevel intercostal nerve blocks, peripheral patient-controlled analgesia and liberal used of non-steroidal anti-inflammatory mediations.
The patient is positioned in the lateral decubitus position as for a posterolateral thoracotomy or any conventional VATS procedure. Adequate flexion of the operating table is essential, particularly in female patients, to maintain the scapula and iliac crest on the same horizontal plane. This maneuver also aids in opening the intercostal spaces reducing pressure on the intercostal nerve from the trocars. Prior to prepping and draping the patient, the sites for port insertion are carefully planned.
If one is employing the second (S) or third (Si) generation system, an important maneuver is to move the operating table away from the anesthesia area and to angle the foot of the operating table away from the surgical cart. The smaller the angle of approach of the cart with respect to the longitudinal axis of the patient, the more the table should be rotated. For example, if one wishes to bring the arms over the patient’s head, the table should be angled 90° from the original table position. Care must be taken to insure that sufficient length of the circuit tubing is available during this positioning, and the anesthesia team must be comfortable that there is adequate access to the patient’s airway once docking of the robotic system has taken place.
8.2.3 Port Placement
The same port strategy may be employed no matter which lung resection is planned. The first port is for introduction of the endoscope and positioned in the eighth intercostal space, posterior axillary line. It is prudent once the incision is made to digitally confirm successful entry into the chest. If CO2 insufflation is to be utilized, it may be initiated at 8–10 mmHg. Following initial exploration the remaining ports are placed in the following locations: One accessory port is placed typically in the ninth intercostal space just posterior to a vertical line from the scapula tip; a second posterior port that is useful for retraction of the lung, particularly during the posterior dissection, is placed superiorly and posterior to the ninth interspace port; the final port is placed in the fifth intercostal space in the mid-axillary line. This may be enlarged at any point in the procedure to 3–4 cm for a utility incision (Fig. 8.2). When using one of the older systems (S, Si), an important principle of port placement is to insure that each are spaced roughly 8 cm (one handbreath) apart in order to avoid extracorporeal instrument arm collisions.
Fig. 8.2
Port strategy for four-arm robotic lobectomy
8.2.4 Docking the Robot Patient Cart
Once the incisions have been made the patient cart is ready to be docked.
S or Si Systems
The instrument arms should be placed in a neutral position with the camera arm in the center and the instrument arms on either side. For four-arm procedures two instrument arms are positioned on the side of the camera arm corresponding to the side of the planned resection. The cart is then advanced from the posterior aspect of the patient with the center column and camera arm in line with the desired field of dissection. For most pulmonary resections a 45-degree angle relative to the long axis of the patient is sufficient. During the docking process it is imperative to position the cart and space the arms to avoid external instrument collisions and insure adequate range of motion of the instruments.
Once the surgical cart is in its final position relative to the patient the camera arm is secured first, and the remainder of the ports are placed under direct vision from the robotic thoracoscope. If the anterior port is a utility incision, the port is placed in the middle of the incision to allow for passage of additional non-robotic instruments. It is useful to test the range of motion of each instrument to verify there are no major conflicts (Fig. 8.3).
Fig. 8.3
Docking for da Vinci Si procedure
Xi System
Two recent innovations in the da Vinci™ Xi system have lead to substantial simplification of the docking process. First, the instrument arms have been placed on a rotating boom that can rotate 270-degrees. During docking laser cross hairs from the center of the boom allow the circulating nurse to quickly position the boom over the camera port. The cart may be positioned so the cross hairs are anywhere within 5 cm of the camera port. The port is attached to the instrument arm and the endoscope inserted. Once inserted the camera projects its own crosshairs that may be used for targeting the desired anatomic region. In the case of pulmonary resection the pulmonary hilum is centered on the endoscope view. The targeting button on the scope is then depressed, and the boom will rotate the arms automatically so that the other instrument arms are optimally positioned to maximize the range of motion of each arm and minimize internal and external arm conflicts. Second, the connection mechanism between the arm and port has been modified to allow quicker and easier connections. Third, a new patient clearance button on each arm allows maximum spacing between the arms externally while maintaining the internal range of motion of the instruments. At this point, the remaining ports are docked and instruments inserted (Fig. 8.4).
Fig. 8.4
Docking for da Vinci Xi procedure
Once the instruments are introduced and visible on the endoscope view, the surgeon moves to the console and the tableside assistant stands at the utility incision to provided assistance with retraction and suction as required. The assistant will also be required to pass and fire the staplers for division of the hilar structures and fissures as required.
8.2.5 Instrumentation
S or Si System
A forceps is most commonly controlled by one hand for grasping tissue. Several choices are available, including the Cadiere, Prograsp or Fenestrated Bipolar. The authors favor the Fenestrated Bipolar because of the option to apply bipolar cautery to small vessels when necessary. In the surgeon’s dominant hand there is typically a dissecting instrument (monopolar spatula, Maryland bipolar, monopolar hook). The authors prefer the monopolar cautery as it is blunt and can be used safely to sweep tissue as well as divide tissue with good hemostasis. The fourth arm has either a retraction instrument or suction.
Xi System
Similar instruments are utilized for the Xi System. Of note, the Cadiere forceps is not available on the Xi system. A Tip up Fenestrated Grasper is an excellent, broad-based instrument for lung retraction. This is employed through the most superior posterior port and allows for excellent retraction of the lung.
8.2.6 Posterior Hilar Dissection
In all cases of anatomic pulmonary resection it is the authors’ preference to begin with posterior hilar dissection. The lower lobe is retracted superiorly, and the inferior pulmonary ligament is divided with electrocautery. The inferior ligament and periesophageal nodes are removed. The lung is then retracted anteriorly, and the posterior pleural is divided at its interface with the lung parenchyma all the way up to the superior hilum. The hilar lymph nodes are individually removed. In the right chest this includes the interlobar “sump” nodes between the right upper lobe and the bronchus intermedius. A subcarinal lymph node dissection is performed (Fig. 8.5). It is critical, particularly on the left side, to have the tableside assistant provide aid in exposing the subcarinal space, either through lung retraction or by compressing the inferior vein (left) or pericardium (right).
Fig. 8.5
Subcarinal (level 7) node dissection from the right side
When performing lower lobectomy, during the posterior hilar dissection it is advantageous to sweep the posterior tissue distally particularly in the areas between the hilar structures and to remove the regional nodes. This will greatly facilitate subsequent isolation and division.
8.2.7 Right Upper Lobectomy
The initial posterior hilar dissection is performed with resection of the posterior hilar and subcarinal lymph nodes. Removal or partial dissection of the sump nodes with identification of the right upper lobe bronchus greatly enhances division of the bronchus either upfront or during the anterior portion of the dissection (Fig. 8.6). It is our practice to perform an anterior-to-posterior approach without dissection in the fissure. The superior hilar vessels are placed on tension by retracting the upper lobe laterally, and the pleura is incised above and below the superior vein to expose its entire extent from the takeoff of the middle lobe vein inferiorly to the course of the truncus arteriosus superiorly. Hilar nodes in these two areas should be removed both for oncologic and practice purposes. The middle lobe vein and the ongoing pulmonary artery should be identified and preserved (Fig. 8.7). Once isolated, the upper lobe vein is divided with an endovascular stapler introduced through the posterior inferior port exposing the basilar pulmonary artery and the truncus arteriosus. Of note all division of the hilar structures may be done by passage of the staplers from the posterior port. Division of the pleural reflection is continued superiorly around the hilum until the right upper lobe bronchus is reached.
Fig. 8.6
Exposure of right upper lobe bronchus
Fig. 8.7
Isolation of the right superior pulmonary vein
The hilar node adjacent to the truncus arteriosus is mobilized sufficiently to allow for isolation and division of the vessel. At this juncture the peribronchial lymph nodes and any remaining sump nodes that have not been previously excised should be removed completely. This maneuver will result in complete mobilization of the upper lobe bronchus and will clearly delineate the location of the posterior ascending artery branch. These two remaining structures may then be divided in whichever order is practically easiest. On occasion where the posterior ascending branch arises more proximal on the main pulmonary artery, it is necessary to divide this branch first (Fig. 8.8). The bronchus can be divided with a 3.5–4.8 mm stapler or cut sharply and sewn closed with a 3-0 or 4-0 absorbable suture. We perform a “fissureless” technique whereby the horizontal fissure is completely last with multiple fires of the endovascular stapler.
