Atlas of Robotic Thoracic Surgery (eBook)

Dr. Kernstine specializes in minimally invasive and robotic surgery including dozens of robotic thoracic procedures since he started his practice at UT Southwestern and more than 500 cases in the last 10 years. He is credited with performing several first robotic chest procedures and techniques, including the first published robotic oncologic esophagectomy in the world. Since the first surgery, he has become one of the highest volume robotic thoracic surgeons in the country with outstanding results. He has lectured worldwide on the different robotic chest techniques and serves as instructor internationally to surgeons and new surgical programs. As Professor and Chair of the Division of Thoracic Surgery and a leader on the lung cancer treatment team, Dr. Kernstine focuses on the surgical management of a wide spectrum of benign and malignant diseases of the chest and coordinates care with other physicians and team members throughout Simmons Cancer Center and UT Southwestern.

Preface 6
Acknowledgements 7
Contents 8
List of Editor and Contributors 11
Part I: Overview 14
1: Principles of Robotic Thoracic Surgery, Program Development and Equipment 15
1.1 Case Setup 17
1.2 Port Placement 20
1.3 General Tips 24
1.4 The Future 25
Selected References 26
2: Anesthesia for Robotic Thoracic Surgery 27
2.1 Introduction 28
2.2 Anesthesia Considerations in Robotic Thoracic Surgery 28
2.3 Robotic-Assisted Surgery and Anesthesia for Mediastinal Masses 28
2.4 Robotic-Assisted Pulmonary Lobectomy 29
2.5 Robotic-Assisted Esophageal Surgery 30
2.6 Carbon Dioxide Insufflation During Thoracoscopy 31
2.7 Anesthesia Considerations in Robotic Cardiac Surgery 32
2.8 Anesthestic Considerations in Robotic Mitral Valve Surgery 32
2.9 Robotic-Assisted Endoscopic Coronary Artery Bypass Grafting 34
2.10 Robotically Assisted Totally Endoscopic Atrial Septal Defect Repair 35
2.11 Robotic Arrhythmia Surgery and Resynchronization 35
2.12 Postoperative Pain Control in Robotic Cardiac Surgery 35
2.13 Complications of Robotic Cardiac Surgery 35
2.14 Summary 36
References 36
Part II: Anatomic Lung Resection 38
3: Robotic Lobectomy 39
3.1 Development of Robotic Lung Resection 39
3.1.1 Components of the System 40
3.1.2 Patient Selection and Indications 40
3.2 Surgical Technique for Robotic Pulmonary Lobectomy 41
3.2.1 Preparation of the Robotic System 41
3.2.2 Anesthetic Consideration and Patient Positioning 41
3.2.3 Port Placement 41
3.2.4 Docking the Robotic Cart 42
3.2.4.1 S or Si Systems 42
3.2.4.2 Xi System 42
3.2.5 Instrumentation 42
3.2.5.1 S or Si System 42
3.2.5.2 Xi System 42
3.2.6 Posterior Hilar Dissection 43
3.2.7 Right Upper Lobectomy 43
3.2.8 Lower Lobectomy 45
3.2.9 Middle Lobectomy 45
3.2.10 Left Upper Lobectomy 46
3.3 Results and Discussion 47
3.4 Summary 48
References 48
4: Robotic Lobectomy: Hilum First Technique 49
4.1 Background, Specific Indications 49
4.2 Operative Setup 50
4.3 Anesthetic Management 50
4.4 Stepwise Conduct of the Operation 51
4.4.1 Right Upper Lobectomy (Figs. 4.9, 4.10, 4.11, 4.12, and 4.13) 56
4.4.2 Right Middle Lobectomy (Figs. 4.14 and 4.15) 59
4.4.3 Right Lower Lobectomy 61
4.4.4 Left Upper Lobectomy (Figs. 4.24 and 4.25) 64
4.4.5 Left Lower Lobectomy (Figs. 4.8, 4.26, 4.27, 4.28, 4.29, 4.30, 4.31, and 4.32) 66
4.5 Tips and Pitfalls 69
4.6 Outcomes in Brief 70
Selected References 70
5: Robotic Pancoast and Chest Wall Resection 72
5.1 Anesthetic Management 73
5.2 Operative Set-Up 73
5.3 Stepwise Conduct of the Operation 74
5.4 Tips and Pitfalls 76
5.5 Postoperative Management Issues 77
5.6 Outcomes 77
References 77
Part III: Mediastinum 78
6: Robotic Anterior Mediastinal Mass/Cyst and Thymectomy 79
6.1 Background/Specific Indications 79
6.2 Operative Set-Up 80
6.3 Anesthetic Management 81
6.3.1 Preoperative Preparation 81
6.3.2 Operative Phase 81
6.4 Stepwise Conduct of the Operation 81
6.5 Postoperative Phase 86
6.6 Tips and Pitfalls 86
6.7 Brief Outcome Analysis 87
References 88
Further Reading 89
7: Robotic Anterior Mediastinal Mass Resection: Belgium 90
7.1 Neurological Aspects of Anterior Mediastinal Tumors 90
7.2 Thymectomy by Minimally Invasive Techniques 91
7.2.1 General Principles 91
7.2.2 Anesthesia 92
7.2.3 Surgical Technique 92
7.3 Outcomes 93
References 94
8: Robotic Thymectomy: China 95
8.1 Background 95
8.2 Anesthetic Technique 96
8.3 Surgical Technique 97
8.4 Outcomes 100
References 100
9: Robotic Applications to the Mediastinum 102
9.1 Operative Technique 103
9.2 Tips and Pitfalls 104
9.3 Outcomes 104
References 105
10: Difficult Mediastinal Mass Resections: Robotic Approach and Solutions—Austria 106
10.1 Background and Specific Indications 106
10.2 Surgery of the Mediastinum 107
10.3 Anesthetic Management 107
10.4 Operative Set-Up 107
10.5 Stepwise Conduct of the Operation 108
10.5.1 Extended Thymectomy 108
10.5.2 Extirpation of a Posterior Mediastinal Paravertebral Tumor (Neurinoma, Cyst, Sympathetic Chain Lesion) 109
10.5.3 Resection of a Benign Esophageal Tumor (Leiomyoma, Foregut Cyst, Esophageal Diverticulum) 109
10.5.4 Extirpation of Masses in the Aortopulmonary Window (Ectopic Parathyroids, Lymph Nodes) 112
10.5.5 Resection of an Ectopic Mediastinal Goiter 112
10.6 Tips and Pitfalls 112
10.7 Postoperative Management Issues 112
10.8 Outcomes 113
References 113
Part IV: Esophagectomy 114
11: Robotic Transhiatal Esophagectomy 115
11.1 Background and Specific Indications 115
11.2 Operative Set-Up 116
11.3 Anesthetic Management 116
11.4 Stepwise Conduct of the Operation 116
11.4.1 Upper Flexible Endoscopy 116
11.4.2 Positioning 117
11.4.3 Port Placement 117
11.4.4 Exposure of the Hiatus and Mobilization of the Stomach 118
11.4.5 Ligation of the Left Gastric Artery 118
11.4.6 Trans-Mediastinal Esophageal Dissection 118
11.4.7 Cervical Dissection 119
11.4.8 Gastric Tube Formation and Resection of the Specimen 120
11.4.9 Cervical Anastomosis 120
11.5 Tips and Pitfalls 120
11.5.1 Tips 120
11.5.2 Pitfalls 121
11.6 Outcomes 121
References 121
12: Robot-Assisted Thoracolaparoscopic Esophagectomy: The Netherlands 123
12.1 Indications 124
12.2 Preoperative Considerations 124
12.3 Anesthesia Management 125
12.3.1 Preoperative 125
12.3.2 Perioperative 125
12.3.3 Management of One-Lung Ventilation in RTE 125
12.3.4 Fluid Management 126
12.3.5 Perioperative Complications 126
12.3.6 Postoperative Care 126
12.4 Procedures 127
12.4.1 Robot-Assisted Thoracoscopic Dissection 127
12.4.1.1 Instruments 127
12.4.1.2 Positioning 127
12.4.1.3 Operative Steps 127
12.4.2 Laparoscopic Dissection 129
12.4.2.1 Instruments 129
12.4.2.2 Positioning 129
12.4.2.3 Operative Steps 129
12.5 Postoperative Care 130
12.5.1 Clinical Care 130
12.5.2 Points of Interest 130
12.5.2.1 Anastomotic Leakage 130
12.5.2.2 Chylous Leakage 130
12.5.3 Outpatient Care 131
References 131
13: Robot-Assisted Thoracoscopic Esophagectomy in the Semi-Prone Position 133
13.1 Introduction 133
13.2 Operative Technique 134
13.2.1 Set-Up of Operation Room and Anesthetic Management 134
13.2.2 Thoracoscopic Esophagectomy and Mediastinal Lymph Node Dissection 136
13.2.3 Laparoscopic Gastric Mobilization and Upper Abdominal Lymph Node Dissection 138
13.2.4 Gastric Pull-Up and Cervical Esophagogastrostomy 138
13.3 Postoperative Care 141
13.4 Outcome 141
13.5 Tips and Pitfalls 141
References 141
Additional Readings 141
14: Robotic Esophagectomy 143
14.1 Background 143
14.2 Operative Setup 144
14.3 Anesthetic Management 144
14.4 Stepwise, Conduct of the Operation 144
14.4.1 Robot-Assisted Trans-Hiatal Esophagectomy (RATE) 145
14.4.2 Robot-Assisted Ivor Lewis Esophagectomy (RILE) 148
14.4.3 Robot-Assisted Extended Lymphadenoesophagectomy (RALE) 153
14.4.4 Perioperative Management 154
14.5 Tips and Pitfalls 157
14.6 Outcomes 157
References 157
Part V: Diaphragm Procedures 158
15: Laparoscopic Robotic Diaphragmatic Plication 159
15.1 Background 159
15.2 Operative Set-Up 160
15.3 Anesthetic Management 160
15.4 Stepwise Conduct of the Operation 160
15.5 Tips and Pitfalls 162
15.6 Brief Outcomes 163
References 163
16: Robotic Diaphragmatic Mass Removal 164
16.1 Background, Specific Indications 164
16.2 Operative Set-Up 164
16.3 Anesthetic Management 164
16.4 Stepwise Conduct of the Operation 165
16.5 Tips and Pitfalls 166
Further Reading 166
17: Robotic Phrenic Nerve Pacemaker Implantation 167
17.1 Background 167
17.2 Set Up and Operation 168
17.3 Anesthetic Management 169
17.4 Tips and Pitfalls 169
17.5 Results 169
References 169
18: Robotic Pericardial Cyst/Mass Resection 171
18.1 Background, Specific Indications 171
18.2 Operative Setup 172
18.3 Specific Anesthetic Management 172
18.4 Stepwise Conduct of the Operation 172
18.4.1 Mid- to Anterior Pericardial Cyst or Mass 172
18.4.2 Posterior Pericardial Cyst or Mass 173
18.5 Tips and Pitfalls 174
18.6 Outcomes 175
References 175
19: The Surgical Treatment of Pericardial Disease: The Robotic Approach 176
19.1 Background 176
19.2 Operative Technique 177
19.2.1 Patient Position 177
19.2.2 Anesthetic Management 177
19.2.3 Port Placement 177
19.2.4 Pericardial Effusion 177
19.2.5 Subacute or Effusive Pericarditis 177
19.3 Pitfalls and Pearls 179
References 179
20: Robotic Transthoracic Thoracic Duct Ligation 180
20.1 Background, Specific Indications 180
20.2 Operative Setup 182
20.3 Anesthetic Management 183
20.4 Stepwise Conduct of the Operation 183
20.5 Tips and Pitfalls 187
20.6 Brief Outcomes Section 187
Selected References 188
21: Robotic Transthoracic Diaphragm Plication 189
21.1 Background, Specific Indications 189
21.2 Operative Setup 192
21.3 Anesthetic Management 192
21.4 Stepwise Conduct of the Operation 192
21.5 Tips and Pitfalls 195
21.6 Brief Outcomes Section 195
Selected References 197
Part VI: Hiatal Hernia Repair 198
22: Robotic Laparoscopic Modified Belsey Procedure (Gastroesophageal Valvuloplasty) for Gastroesophageal Reflux Disease 199
22.1 Background 199
22.2 The Antireflux Barrier 201
22.3 Conventional Laparoscopy Compared to Robotics 201
22.4 Robotic Laparoscopic Gastroesophageal Valvuloplasty (Fundoplication) 202
22.4.1 Posterior Crural Closure 204
22.4.2 Anterior Crural Closure 204
22.4.3 Gastroesophageal Valvuloplasty (Fundoplication) 204
22.5 Outcomes 205
22.5.1 Early (1–12 Weeks) Postoperative Results 205
22.5.2 Late Follow-Up 205
References 206
23: Robotic Fundoplication: Nissen-Rossetti 207
23.1 Background and Specific Indications 207
23.2 Operative Set-Up 208
23.2.1 Positioning and Trocar Placement 208
23.2.2 Anesthetic Management 208
23.3 Operative Procedure 208
23.3.1 Laparoscopic Exploration and Port Placement 208
23.3.2 Exposure of the Operative Field 209
23.3.3 Dissection of the Gastroesophageal Junction 209
23.3.4 Fundoplication 211
23.4 Tips and Pitfalls 212
23.4.1 Exposure of the Operative Field 212
23.4.2 Dissection of the Gastroesophageal Junction 212
23.4.3 Fundoplication 212
23.5 Outcomes 213
References 214
24: Robotic Paraesophageal “Giant” Hiatal Hernia Repair 216
24.1 Background, Specific Indications 216
24.2 Operative Setup 219
24.3 Anesthetic Management 220
24.4 Stepwise Conduct of the Operation 220
24.5 Tips and Pitfalls 225
24.6 Brief Outcomes Section 225
References 228
Selected Reading 228
Part VII: Repair of Esophageal Dysmotility 230
25: Robotic Heller Myotomy 231
25.1 Operative Technique: Robotic-Assisted Heller Myotomy 232
25.1.1 Anesthetic Management 232
25.1.1.1 Preoperative 232
25.1.1.2 Perioperative 233
25.1.2 Patient Position 233
25.1.3 Abdominal Access and Trocar Positioning 233
25.1.4 Dissection of the Lower Third of the Esophagus and Division of the Short Gastric Vessels 233
25.1.5 Heller Myotomy 234
25.1.6 Creation of the Partial Fundoplication (Dor) 235
25.2 Pearls and Pitfalls 235
References 236
26: Robotic Assisted Laparoscopic Cardiomyotomy (Heller Myotomy) in Achalasia: Austria 237
26.1 Background and Specific Indications 237
26.2 Anaesthetic Management 238
26.3 Operative Set-Up 238
26.4 Stepwise Conduct of the Operation 240
26.4.1 Exposure of the Esophageal Hiatus 240
26.4.2 Division of Esophageal Muscle Layers—Heller Myotomy 240
26.4.3 Closure of the Hiatus 241
26.4.4 Creation of the Fundic Wrap 241
26.5 Failure Management 243
26.6 Postoperative Management 243
26.7 Outcomes in our Series 243
References 245
Part VIII: Miscellaneous 246
27: Robotic-Assisted Esophageal Epiphrenic Diverticulectomy 247
27.1 Background 247
27.2 Operative Technique: Robotic-Assisted Epiphrenic Diverticulectomy 249
27.2.1 Anesthetic Management 249
27.2.1.1 Preoperative 249
27.2.1.2 Perioperative 249
27.2.2 Patient Position 249
27.2.3 Abdominal Access and Trocar Positioning 249
27.2.4 Dissection of the Lower Third of the Esophagus in the Posterior Mediastinum and Transection of the Short Gastric Vessels 250
27.2.5 Isolation of the Diverticular Pouch 250
27.2.6 Transection the Diverticular Neck 251
27.2.7 Heller Myotomy 251
27.2.8 Closure of the Esophageal Hiatus 252
27.2.9 Dor Fundoplication 252
27.3 Postoperative Care 252
27.3.1 Management of Postoperative Leaks 252
27.4 Pitfalls and Pearls 253
References 254
28: Esophageal Leiomyoma 255
References 258
29: Robotic Transthoracic Esophageal Leiomyoma Resection 259
29.1 Background 259
29.2 Operative Setup and Stepwise Conduct of the Operation 261
29.3 Tips and Pitfalls 263
29.4 Outcomes 265
Selected References 266
30: Robotic First Rib Resection: Paget-Schroetter Syndrome 267
30.1 Background, Specific Indications 267
30.2 Operative Setup 269
30.3 Anesthetic Management 269
30.4 Stepwise Conduct of the Operation 269
30.5 Tips and Pitfalls 271
30.6 Brief Outcomes Section 271
Selected References 271
Index 272