Keywords
lung cancer treatment - robotics - minimally invasive surgery
Introduction
The surgical treatment of lung cancer patients has evolved over the years. Technological
advancements have allowed surgeons to move from open thoracotomy to video-assisted
thoracoscopic surgery (VATS) and now robot-assisted thoracoscopic surgery. The robot
has evolved to provide better visualization and improved capabilities with each upgrade
in technology. The latest version of the Da Vinci Xi provides better control during
robot-assisted lung resection compared with the Da Vinci Si robot with the ability
to control the vascular stapler. We have developed a port placement strategy that
we term “five on a dice” allows us to perform robot-assisted pneumonectomy using robotic
stapler.
Case Description
We utilized the “five on a dice” port placement and lung resection in the case of
a 59-year-old former smoker, who originally presented with hemoptysis. A chest X-ray
and a CT scan of the chest were significant for a 4.7 cm mass in left lower lobe (LLL).
The lung lesion was then further evaluated by a PET-CT that showed uptake in the mass
to 12.4 standard uptake value (SUVs) as well as a separate 1.4 cm left upper lobe
mass with an uptake of 2.7 SUVs. The patient underwent a biopsy of both lesions that
was positive for adenocarcinoma in both sites. She then underwent induction chemotherapy
with Alimta and cisplatin. After induction, she was restaged and found to have regression
of the lower lobe tumor, while the upper lobe tumor remained stable in size. There
was no lymph node involvement or metastatic disease. After a thorough workup and assessment
of postoperative predictive lung function with pulmonary function testing, a ventilation-perfusion
scan, brain MRI, and mVO2, the patient was recommended to undergo a robot-assisted pneumonectomy.
A 4-cm assistant port was placed in the fourth intercostal space in the mid-axillary
line. A soft tissue retractor with a cap was used here to allow insufflation of the
chest. The robotic camera port was placed in the seventh intercostal space just posterior
to the posterior axillary line. An anterior 12 mm port was placed in the seventh intercostal
space in the mid-axillary line and the posterior upper 8 mm port was placed in the
seventh intercostal space by the scapula. Finally, the posterior lower 12 mm port
was placed in the ninth intercostal space. This creates the “five on a dice” configuration
([Fig. 1]). The robot is docked with the boom parallel to the seventh intercostal ports.
Fig. 1 Photograph of the “five on a dice” port placement for robot-assisted left pneumonectomy.
The assistant port is in the fourth intercostal space. Robot ports of 12 mm (R) are
placed in the seventh intercostal space anteriorly and the ninth intercostal space
posteriorly. A camera (C) is placed in the 8 mm robot port in the seventh intercostal
space posterior to the posterior axillary line. The 8 mm robot port (R) is placed
by the tip of the scapula (\/).
We placed the cadiere grasper in the left arm, the tip up instrument in the right
upper port, and the bipolar dissector in the right lower port. We dissected the inferior
pulmonary ligament and the posterior hilum using the bipolar dissector. We then turned
our attention to the anterior hilum and dissected out the inferior pulmonary vein,
which we divided using a curved tip robotic vascular stapler from the anterior inferior
12 mm port ([Fig. 2A]). Next, we dissected the superior pulmonary vein and divided it using the curved
tip robotic vascular stapler from the posterior inferior 12 mm port ([Fig. 2B]). Station 10L and 9 lymph nodes were harvested using the bipolar dissector. We proceeded
by dissecting around the main bronchus, separating it away from the main pulmonary
artery. Once the dissection was complete, we passed umbilical tape around the bronchus
that allowed us to retract it away from the pulmonary artery. We then placed an Endo-GIA
tan load stapler through the anterior inferior port around the main pulmonary artery
using an introducer and divided it ([Fig. 2C]). Next, we performed flexible bronchoscopy to ensure that our staple line would
be close to the main carina. We divided the bronchus using the robotic green stapler
([Fig. 2D]) from the anterior inferior port. We then continued with dissection of station 5,
6, and 7 lymph nodes using the bipolar dissector. After ensuring no air leak was present
at the bronchial stump, we placed a 32-French chest tube and closed the incisions
in a layered fashion.
Fig. 2 Image of a stapled resection of hilar structures. The inferior pulmonary vein is
divided with the robot stapler with the vascular load from the anterior inferior port
(A); the superior pulmonary vein is divided with the robot stapler with the vascular
load from the posterior inferior port (B); the main pulmonary artery is divided with the Endo-GIA tan load from the anterior
inferior port (C); and the left main bronchus is divided with the robot stapler with a green load.
The patient tolerated the procedure well. She was transferred to the ICU for overnight
observation and to the floor the following morning. The chest tube was removed on
postoperative day 1 and she was discharged home on postoperative day 3 without any
complications.
Discussion
Several port placements have been developed to perform robot-assisted lung resection
efficiently and ergonomically. Park has adopted the typical VATS port placement to
use with the robot.[1] Drs. Cerfolio[2] and Dylewski[3] developed the complete portal port placement that takes advantage of the Da Vinci
Si robot's capabilities. Both of these strategies were developed for the Da Vinci
S/Si platform where there was no vascular stapler that could be controlled by the
surgeon. With advent of the Da Vinci Xi and its ability to control the vascular stapler,
the “five on a dice” configuration of the ports allows us to insert and use the robotic
stapler via either the left or the right inferior ports and provide improved control
of the vascular staplers during the case. This port placement and technique allow
for the successful completion of challenging cases such as pneumonectomy. Further
improvements with the Xi system are necessary to make this case less dependent on
an assistant. If there were a 60 mm robot vascular stapler, the division of the main
pulmonary artery could have been accomplished by the surgeon sitting on the robot
console. Robotic pneumonectomy is a challenging operation, but the use of the “five
on a dice” port placement and technique takes full advantage of the Da Vinci Xi's
capabilities and allows for safe and ergonomic lung resection.
