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From the Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Italy
Robotic Pulmonary Lobectomy Early Operative Experience and Preliminary Clinical Results G. F. M e n c o n i , F r a n c a M. A. M e l f i , F. Givigliano, and C. A. A n g e l e t t i Keywords: Robotic surgery - thoracoscopy - lobectomy - VAT. SchliisseIwOrter: Roboterchirurgie - Thorakoskopie - Lobektom i e - VAT.
Summary: Background: Robotic surgery represents the most advanced development of minimally invasive surgery. We are currently using a robotic system to test the applicability of this technique to standard and advanced thoracic procedures. We report our experience in five patients in whom a video robotic lobectomy (VRL) was attempted. Methods: All patients had peripheral pulmonary opacities: three of these were bronchogenic carcinoma (stage I), two were typical carcinoid lesions. Surgical access was gained via two stab incisions and one short lateral incision, which was made for specimen delivery and was used without rib separation. Results: There were no major intra-operative complications and all patients recovered uneventfully. Two procedures that began with the robotic technique were completed by a minimal thoracotomy. In each case no technical operative mishaps were caused by the manoeuvres of robotic arms. Conclusions: VRL is technically possible. This preliminary study supports the development of robotic surgery in the field of thoracic surgery. Our experience also indicates that considerable improvements are necessary to allow major procedures such as pulmonary lobectomy to be safely and expeditiously performed using the robotic approach. (Eur. Surg. 2002; 3 4 : 1 7 3 - 1 7 6
Roboter-assistierte Lobektomie Erste klinische Erfahrungen und vorliiufige Ergebnisse Zusammenfassung: Grundlagen: Die Roboterchirurgie stellt eine Weiterentwicklung der minimal-invasiven Chirurgie dar. Zur Zeit werden Robotersysteme hauptsfichlich benfitzt, um ihre Anwendung bei verschiedensten Eingriffen zu erproben und die Gerfite zu verbessem. Es wird fiber unsere Erfahrungen mit video-assistierten Roboter-Lobektomien bei ffinf Patienten berichtet. Methodik: Alle Patienten wiesen einen peripheren Rundherd auf (drei Bronchuskarzinome im Stadium I, zwei typische Karzinoide). Die chirurgischen Eingriffe erfolgten ~iber drei Trokarinzisionen und eine kurze laterale Hilfsinzision. Ergebnisse: Es gab keine gr68eren intraoperativen Komplikationen, und alle Patienten wurden nach jeweils komplikationslosen postoperativen Verlauf entlassen. Die Operationszeit betrug im Durchschnitt drei Stunden. Zweimal war ein Konvertieren zum offenen Vorgehen fiber die jeweils minimal erweiterte Hilfsinzision notwendig. In keinem Fall kam es zu einem vom Roboterarm technisch verursachten Zwischenfall.
Corresponding address: Franca Melfi, M.D., Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Via Paradisa 2, 1-56124 Pisa, Italy. Fax: ++39/50/9 95 72 39 E-mail:
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SchluBfolgerungen: Roboter-Lobektomien sind technisch m6glich. Auf Grund der yon uns gemachten Erfahrungen beffirworten wir die Weiterentwicklung der Roboterchirurgie im Rahmen der Thoraxchirurgie, um auch gr6Bere Eingriffe (z. B. Lobektomien) schneller und sicherer zu gestalten.
Introduction Video thoracoscopic surgery (VAT) in the last decade has allowed surgeons to perform an increasing number of operations with minimal tissue trauma, standardization of many procedures and a progressive broadening of the indications. There are, indeed, limitations and pitfalls in traditional thoracoscopic surgery: limited degrees of freedom, paradoxical unnatural movements, disassociation between optical and mechanical control, inability to perform high precision microsutures, two-dimensional vision. Because surgeons have to adapt their position to the location of the port, they often have to perform the operation in difficult positions (1). Robotic technology makes it possible to overcome these difficulties thanks to 'micro-mecratronic' instruments introduced through traditional trocars. These instruments, performing movements that mimic and even enhance those of the human hand, allow the surgeon to concentrate on his work, seated comfortably, even for hours. (9, 10). There are different types of robotic devices, some as simple as the voice control (4, 6) of the camera. A complete robotic system consists of three integrated components: a master console where the surgeon sits using 3-D vision and handling telemanipulators and optical controls; a surgical cart that moves the instruments into the patients, a complementary thoracoscopic tower for assistance in the operating room. After evaluation on animal models we investigated the applicability of the da Vinci TM robotic system (Intuitive Surgical, CA, USA) in clinical practice. As the majority of general thoracic surgery procedures are major operations involving the lung, we decided to examine the technical feasibility of the robotic system in major pulmonary resections. This early clinical experience forms the basis of this report.
Methods Patients Between February and December 2001, 26 patients underwent robotic thoracic surgery in our department. We have used the da Vinci TM surgical system (Intuitive Surgical, CA, USA) to perform various thoracic operations to date, ranging from simplest procedures, such as benign tumour enucleations/excisions, to very complex ones, such as pulmonary resections (Fig. 1). To evaluate the technical aspects of video robotic lobectomy (VRL), five good-risk patients were selected for a lobectomy in preoperative investigations. There were three men and two women aged 4t to 70 years (mean age 61.5 years). The patients were referred to us with a peripheral pulmonary opacity on chest radiographs and normal bronchoscopic appearances. These patients underwent a careful clinical evaluation. In accordance with our then normal practice for small peripheral lesions without mediastinal lymphadenopathy CT scan, mediastinoscopy was not undertaken. The patients with lung carcinoma were judged to have clinical stage I (NSCLC). Arterial blood gases were within n9rmal limits, and pulmonary function demonstrated adequate pulmonary reserve to undergo a planned lobectomy (forced expiratory volume in I s > 1.5 L). Specific consent was obtained for attempted robotic resection. $15.00/0
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Fig. 1.
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The da Vinci TM surgical system (Intuitive Surgical, CA, USA).
Technique We used the da Vinci TM surgical system (Intuitive Surgical, CA, USA), which consists of a master" remote console, a computer controller and a three-arm surgical manipulator with fixed remote centre kinematics. The visualization system is made up of two 3-chip cameras mounted on a three-dimensional endoscope with two separate optical channels. Independently acquired images are transmitted to a high-resolution binocular display of the operative field. The operative image magnification may be up to 10 times the actual size. In terms of motion, the mechanical wrist of the instruments has 7 degrees of freedom. Tip articulations mime the up/down ('pitch') and the side-to-side ('yaw') flexibility of the human wrist. Instrument tips in the display are electronically aligned with the instrument controllers to ensure the hand-eye orientation and natural operative feeling found in open surgery. A 6-Hz motion filter built into the system eliminated unintended movements caused by tremor. This system requires meticulous preparation. The robot's arms must be draped in special disposable nylon covers (for the sterile operating field), which contain the microchips to connect the arms to robotic instruments. The main body of the machine (robot cart) and the robotic arms are established in relation to the side of the lesion. When the robotic cart has been positioned and the patient placed in the chosen position, the robotic arms are brought into the operative field and hooked onto the optic trocar and two operative trocars. Single-lung anaesthesia was "achieved with a double lumen endotracheal tube. Patients were prepared and draped for a posterior lateral thoracotomy, so that the procedure could be converted to this in the event of intraoperative complications or if a VR lobectomy was not possible. In addition to robotic instruments, thoracoscopic instruments and a full thoracotomy instrument set was open, available at the operating table, in case of perioperative complications. Incisions: A short lateral incision (service entrance of 3 cm) was made in the fourth space, and two additional thoracoports were inserted in the 7 th and 6th--7 th at mid- and post-axillary line, respectively. The first thoracoport (12 mm) was placed for the 3-D scope and the other two ports (10 mm) were used for the placement of the right and left instrument arms and for apical and basal intercostal drain insertions at the end of the procedure. Accessory endoscopic instruments are handled by an assistant at the operative site using an additional small incision (5 mm), between the 'service entrance' and the 3-D scope. The exact position of the operating ports was, however, best assessed during the operation when suitable points of entry in relation to the shape of each patient's chest cavity were made. The 'service en-
Fig. 2. Lower left robotic lobectomy: the apical lower and mainstem lower vessels were taken separately. trance' was utilized for delivery of the specimen but it was also useful as a site for inserting a robot instrument. The location of the incisions was critical for the successful identification and dissection of the pulmonary fissures and interlobar artery, as this proved technically to be the most difficult aspect of VR lobectomy. Lobes resected were the lower right (n = 2) and the lower left (n = 3). After dissection in the fissure and exposure of the interlobar artery, the pulmonary artery branches were carefully identified and divided. If the fissure was incomplete posteriorly, the lower lobe was retracted anteriorly and the mediastinal pleura incised at the anterior border of the bronchus intermedius immediately below the upper lobe bronchus. A robotic forceps was passed through to elevate the fused posterior fissure, which was then divided, thereby fully exposing the pulmonary artery. In the right lower lobectomies the apical lower segmental artery and the main trunk were divided by stapling (Endopath TSW 35 mm vascular/thin, Ethicon). The lower lobe was retracted anteriorly (with traditional endoscopic forceps through the 'service entrance') and the pulmonary ligament incised to expose the lower vein, which was cleared of surrounding tissue and divided by stapling. The lobe was then retracted inferiorly and the anterior portion of the oblique fissure (between the middle and lower lobes) divided using electrocautery. Finally, the lower lobe bronchus was divided by stapling (Endopath ATB45 Ethicon Endo-Surgory), with care taken to preserve the middle lobe origin. In the left lower lobectomy, if the fissure was complete, the sheath of the artery was entered between the lobes so as to display the apical lower and lingular branches. When the fissure was incomplete, the upper lobe was retracted forward, the artery identified and the sheath entered from the posterior of the lung root. The artery was then identified within the fissure by careful dissection and a sling was passed between the two points of arterial access to elevate the fused posterior fissure, which was then divided by stapling. The apical lower and main-stem lower vessels were taken separately (Fig. 2). In this case, a suture ligation was used with Linen 2.5 The pulmonary ligament was incised and the lower vein cleared and divided. We gently placed a vascular clamp, and using arm instruments (DeBakey forceps and micro-forceps) we stitched (polypropylene monofilament 4/0) on the transacted lower vein. The clamp was removed when the closure was seen to be secure. The resected lobes were removed in sterile plastic bags through the 'service entrance', without a rib spreader. At the end
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Table 1.
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Clinical features of patients undergoing robotic lobectomy.
Age (yr)/sex 64/F
Preoperative conditions
Procedure
diabetes
right lower lobectomy
41/M
unremarkable
left lower lobectomy
66/M
unremarkable
left lower lobectomy (conversion)
70/M
prostatism/ hypertension
66/M
cough
Pathological findings adenocarcinoma TLN0 typical carcinoid
Postoperative course Discharge days p. o. uneventful 5 uneventful
4
typical carcinoid
sputum retention
6
left lower lobectomy
sq. carcinoma TLN0
uneventfut
5
right lower lobectomy (conversion)
sq. carcinoma TLN0
sputum retention
6
Table 2.
Remarks
retained in unit because of angina
Mean data of robotic lobectomy procedure.
Age (years) Operative time (h)
61.5 3
Operative blood loss (ml) Postoperative morphine consumption (mg/h)
80 1.00
Postoperative (VAS) pain score first 24 h (mm: range 0-100)
10
Hospital stay (day)
5.2
strong resistance is experienced at the console, but the surgeon does not receive information on the amount of force applied to tissue or sutures and therefore is dependent on visual feedback. This is sufficient in the majority of manoeuvres, but not when it comes to suturing delicate structures and tying knots, or when the surgeon wants to distinguish tissue characteristics.
Fig. 3.
Suture ligation of puhnonary artery with Linen 2.5.
of the operation, two chest tubes were inserted through the thoracoport sites, into the chest cavity.
Special technical considerations Correct placement of the robotic cart and the trocars is mandatory in order to avoid collisions between the mechanical arms and system performance: trocars must be positioned at a greater distance from each other than they normally would be in standard thoracoscopic procedures. The physical orientation and the optimal working angles between instruments, the lesion plane and the angle of the vision are important issues that must be considered. One of the most difficult aspects is the proper positioning of the trocars in the chest cavity. Currently the robotic cart is installed in the operative field, generally behind the operative site, but in some cases this must still be standardized. The best positioning of the system and the position of the robotic arms is established in relation to the side of the lesion in order to obtain an excellent, unobstructed view of the chest cavity without arm impingement and interference. Lower lobe lobectomies, especially left lower lobectomy, are technically the most straightforward resection to carry out. In the right lower lobe, as in a standard thoracotomy, it may be necessary to separately transect the superior segmental artery and bronchus so as not to compromise the middle lobe artery and bronchus. In the lower left lobe, the basilar artery, just beyond the last lingular branch, is easily transacted and legated with Linen 2.5 or sutured by stapling (Fig. 3). Both the inferior pulmonary vein and the lower bronchus lobe are exposed, dissected and divided with some difficulty due to the instruments not being tailored to grasp the lung. Currently, many of limitations of robotics surgery are related to the imperfections of the system and the lack of tactile feedback. At present, blocking of the robotic arms or working against
Results Details of patients who underwent robotic lobectomy are summarized in Table 1. In this highly select group of good-risk patients, no technical operative mishaps related to manoeuvres of the instrument arms occurred. None of the patients had problems related to operative bleeding. In two patients, the procedure was converted to a minimal thoracotomy. We began the operations with the robot technique, which allowed us to isolate and stitch on the transacted lower vein. We had to complete the operations using the 'service entrance' (enlarged by about 2 cm) due to hilar calcified lymph nodes, since these rendered the dissecting of the interlobar pulmonary artery unsafe. All patients tolerated the procedure well and the postoperative course was satisfactory, requiring fewer analgesics (Table 2). Excision was complete for all those with neoplastic disease and all bronchial stumps healed without problems. Chest tubes were removed in mean 3 postoperative days and the patients were discharged in mean 5.2 postoperative days. Operative time varied between 3 and 5 h of which 1 h was used to do the self-test of the machine and instrument set-up. This time was considerably longer than that for standard open surgery or VAT procedure, but it decreased with experience so that the last case averaged 2.5 h. All patients were discharged in good condition and returned to preoperative levels of physical activity within 10 days of the operation. Conclusions Our experience, although limited to just five cases, demonstrated the feasibility of major lung resection in good-risk patients with clinical stage I primary bronchogenic carcinomas. Robotic systems potentially offer extensive support in video thoracoscopic surgery, particularly with regard to the specific difficulties of the procedures. The basic advantages offered to the surgeon by these
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systems include the un-reversed response of the instruments, the use of scaling, the filtering of friction and tremors and the 3-D visualization, which is part of the da Vinci TM system (5, 8). These features vastly improve the dissection of the pulmonary vessels, which can be performed with greater safety and accuracy. The robot system with its joint movements allows the surgeon to use traditional open surgery techniques at the console, which are simultaneously reproduced using endosurgery movements by arm instruments at the surgical site (2, 5, 6, 7, 8). Additionally, the mechanical wrist allows for a full range of motion of the instrument tip, which facilitates dissection in remote areas in the chest cavity. At present, the areas of surgery where the robotic technique is most advantageous are those in which the procedures involve a small, deep, fixed operating field and require extreme accuracy, such as endoscopic suturing, microanastomosis, and dissection of delicate structures. Although this technology holds great promise there are still major technical hurdles that can affect the dexterity of the surgeon and add to the complexity of the procedure (3, 5). The greatest difficulties at present are associated with the available arm instruments, which are designed for cardiac or general surgery and are not adequate for thoracic surgery. Consequently some procedures became more complicated, especially for the major lung resection. In addition, the current robot manipulator system requires larger and bulkier instruments to obtain the seven degrees of freedom within the body cavity, and the system's size limits access to the patient by the surgical assistant (3, 7). Lastly, the ability to sense touch (poor tactility) is another problem that should be addressed in the future. This limitation is in part system related, because the lack of tactile feedback impairs one's abilitY to judge the amount of tension applied during the manoeuvresof suture/ligation tensioning (10, 8). With increased experience, visual clues may be sufficient to tension and tie the sutures correctly. In this preliminary experience, the operations took longer due to the setting-up of the machine and the positioning of the arm instruments. With experience, and as the machine is adapted to thoracic surgery, operative time should be reduced. To the best of our knowledge, this is the first report of robotic surgery for lobectomy procedures using a manipulator system. Although further studies on many robotic procedures are necessary to clarify the clinical feasibility and utility of our procedures, the results in this preliminary experience are encouraging. Nevertheless, like the VAT technique, this form of surgery should only be undertaken by surgeons trained in thoracic sur-
gery (11). Besides a perfect knowledge of topographical anatomy and a broad experience in conventional surgery, training in specific thoracoscopic skills is required, such as endoscopic suturing and intracorporeal knotting. We believe that robotic procedures may be technically feasible in selected cases and in the hands of an experienced thoracic surgeon. Nevertheless, due to its technical features, it is currently indicated for reconstructive surgery. As robotic systems and their ann instruments are improved and adapted to thoracic surgery, their application will be extended to a wider range of operations and operating time will be significantly reduced. In conclusion, the robotic surgery systems will give new impetus to the evolving techniques of thoracoscopic surgery. The increased dexterity and ease of manipulation offered by this system will stimulate the surgeons to continue their task of defining the future role of minimally invasive thoracic surgery.
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