INDICATIONS/CONTRAINDICATIONS

Definition

“Robotic surgery” is an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted. The term refers to the surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term would be “remote tele-presence manipulators” since the available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology enhanced device to the interaction between the surgeon and the patient in a surgical operation and assumes a certain degree of control heretofore completely reserved to the surgeon.

Indication

Robotic lobectomy is commonly performed in selected peripheral located T1 or T2 tumors and usually reserved to patients where complications are not expected. However, during these past years, robotic technology was applied also in central tumors, pneumonectomy, and in sleeve lobectomies. With regard to lymph nodes staging of NSCLC during surgical intervention, it should be as accurate as possible, however, the extent of mediastinal lymph nodes’ assessment is still a debated issue. In fact several approaches are utilized, ranging from simple visual inspection of the unopened mediastinum to an extended bilateral lymph nodes’ dissection. However, ESTS guidelines recommended systematic nodal sampling or dissection with the removal of at least six lymph nodes (UICC) from hilar and mediastinal stations to define pathologic N0.

Contraindication

The principal contraindications for the robotic approach are related to the presence of tenacious pleural adhesions, which can be expected when the medical history shows previous pleuritis, chest radiation therapy, or previous thoracic intervention. In addition, large tumors (greater than 5 to 6 cm) are contraindicated in a minimally invasive approach due to the limited maneuverability of the lesion itself in a close chest setting.

PREOPERATIVE PLANNING

Patient’s evaluation should be based on a chest x-ray, chest and upper abdomen CT scan imaging with contrast media enhancement, and positron emission tomography (PET) scan. Invasive staging procedures, such as mediastinoscopy, can be omitted in patients with stage I NSCLC and negative PET scan, while in central tumors, PET hilar N1 disease, low FDG uptake of the primary tumor and LNs ≥16 mm on CT, invasive staging remains indicated, according to ESTS guidelines. PET positive mediastinal findings should be histologically or cytologically confirmed.

Preoperative functional assessment consisted of medical history, physical examination, routine blood tests, blood gas analysis, spirometry, and cardiologic evaluation with electrocardiogram and echocardiography. Stress testing and other assessments of myocardial function were performed when indicated by the cardiologist in case of a history of coronary artery disease, suspicious symptoms, or electrocardiographic abnormality.

SURGERY

Robotic System

The robotic system consists of a master remote console, a computer controller, and a manipulator with fixed remote center kinematics connected via electrical cables and optical fibers. The master console is connected to the surgical manipulator with the camera arm and three instrumental arms. The surgeon manipulates two master handles and the movements are transmitted to the tips of the instruments, thanks to the highly sensitive motion trigger sensor. The surgical arm cart provides three degrees of freedom (pitch, yaw, and insertion), while the tips of the instruments are characterized by a mechanical cable-driven wrist (EndoWrist), providing four more degrees of freedom (internal pitch, internal yaw, rotation, and grip).

This system overcomes many of the technical obstacles found in the traditional thoracoscopic surgery.

The robotic system provides stereoscopic binocular vision allowing a depth perception and optical resolution to the surgeon.

Stable camera holders are one of the benefits of robotic system. The scope is held by the central arm, which is directly and optimally controlled by the surgeon at the console, permitting both an increased close vision for fine dissection and a panoramic vision of the whole thoracic cavity. In addition, the robotic camera holder liberates the assistant’s hands, allowing him/her to perform other functions.

Magnified video imaging up to 10 times the actual size.

Robotic instruments reproduce the human hand’s degrees of freedom, inside chest cavity (internal pitch, internal yaw, rotation, and grip).

Downscaling of surgeon’s movements, in fact the robotic system is a transducer of surgeon’s movements in more fine ones of the instrument tips.

Tremor filter: The robotic system software is able to filter up to 6 Hz of the surgeon’s hand tremor due to a transducer that is able to reproduce only the desired movements in the operative field.

Patient Positioning and Port Mapping

General anesthesia with double-lumen intubation is mandatory. The patient is positioned in a lateral decubitus position, such as for a poster lateral thoracotomy, with the operating table flexed at the scapula tip level. In case of female patients, a pillow can be positioned under the hip to have the patient’s hip and scapula leveled on the same line. The appropriate sites of the incisions are essential for the success of the procedure, and to avoid any arm impingement during the operation. For this reason a minimum distance of 6 to 8 cm from each arm is required. Generally, the first port is placed in the seventh to eighth intercostal space on the midaxillary line. In this site the camera (12 mm, 30-degree angled down scope) is positioned (called camera arm). Then, an exploration of the chest cavity is performed by the camera to have important information that could alter the programed procedure. Following, the other port incisions (8 mm) can be performed: Sixth to seventh intercostal space on the posterior axillary line (first arm), fourth to fifth intercostal space on the anterior axillary line (second arm), and in the auscultatory area (for the third arm). However, the port mapping can vary, and the best port positioning is assessed during chest cavity exploration, in relation to the fissure and to the shape of each patient’s thorax. A utility port between the camera port and the anterior robotic port can be positioned for the assistant surgeon, who has to introduce the stapler or suction. Only in some difficult cases, a service entrance, with rib spearing, can be performed. Since September 2010, we are performing a totally endoscopic procedure, without service entrance. Although, at the beginning, during the learning curve, a utility incision is recommended. Subsequently, with gained experience, it is possible to utilize a totally endoscopic technique.

Surgical Cart Positioning

After the port incisions are performed, the surgical cart can be positioned from the head of the patients. The center of the column of the surgical cart must be in line with the camera port and the longitudinal axis of the patient. This fact is mandatory to avoid impingements of the robotic arms. The layout is the same for the right and left side. Only when the patient has been placed in the chosen position and the surgical cart positioned appropriately, the ports can be fixed to the robotic arms. Thus the camera is inserted, then the instruments’ insertion in the chest cavity is accomplished under direct vision.

Instruments

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