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Eur J Cardiothorac Surg 2004;25:844-851
© 2004 Elsevier Science NL

First experiences with the da VinciTM operating robot in thoracic surgery

J. Bodner, H. Wykypiel, G. Wetscher, T. Schmid*

Department of General and Transplant Surgery, University Hospital Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria

Received 9 October 2003; received in revised form 9 January 2004; accepted 4 February 2004.

* Corresponding author. Address: Department of General and Transplant Surgery, University Hospital Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. Tel.: +43-512-504-2580; fax: +43-512-504-675-948
e-mail: thomas.schmid{at}uibk.ac.at


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objectives: The da VinciTM surgical robotic system was purchased at our institution in June 2001. The aim of this trial was to evaluate the applicability of the da VinciTM operation robot for general thoracic procedures. Methods: The da VinciTM surgical system consists of a console connected to a surgical arm cart, a manipulator unit with two instrument arms and a central arm to guide the endoscope. The surgical instruments are introduced via special ports and attached to the arms of the robot. The surgeon, sitting at the console, triggers highly sensitive motion sensors that transfer the surgeon's movements to the tip of the instruments. The so-called ‘EndoWristTM technology’ offers seven degrees of movement, thus exceeding the capacity of a surgeon's hand in open surgery. We evaluated the role of the robot for several thoracic procedures such as thymectomies, fundoplications, esophageal dissections, resection of mediastinal masses and a pulmonary lobectomy. Results: A total of 10 thymectomies, 16 fundoplications, 4 esophageal dissections, 5 extirpations of benign mediastinal masses and 1 right lower lobectomy was performed with the robot. One resection of a paravertebral neurogenic tumor had to be converted due to surgical problems. A lesion to a left recurrent laryngeal nerve caused transient hoarseness after the extirpation of an ectopic parathyroid in the aortopulmonary window in one patient. The postoperative courses were uneventful and patients were discharged between postoperative days 3 and 8 (with the exception of patients who underwent dissection for esophageal cancer and the patient with conversion to an open access). Conclusions: Advanced general thoracic procedures can be performed safely with the da VinciTM robot allowing precise dissection in remote and difficult-to-reach areas. This benefit becomes evident most elegantly in thymectomies, which at our institution have become a routine procedure with the robot. The rigid anatomy of the chest seems to be an ideal condition for robotic surgery. A major limitation for robotic surgery is the lack of more appropriate instruments. This disadvantage becomes most evident in pulmonary lobectomies.

Key Words: Thoracic surgery • Robotics • da Vinci robotic system • Video-assisted thoracoscopic surgery • Fundoplication


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Video-assisted thoracoscopic surgery (VATS) has gained a broad acceptance for diagnostic and therapeutic procedures of pulmonary and non-pulmonary thoracic lesions [1,2]. It allows for good exposure of the pleural cavity, enables extensive dissection and combines the advantages of minimal invasive surgery with little tissue trauma, short recovery, less pain and improved cosmetic results [3,4]. There are, however, some limitations for this method, such as impaired vision and restricted maneuverability of the tips of the instruments [5].

To overcome these limitations, advanced technology has been introduced providing three-dimensional (3D) video imaging, automatic stable camera platforms and telemanipulated flexible effector instruments [6]. The state-of-the-art da VinciTM robotic system (Surgical Intuitive, Inc., Mountain View, CA) comprises these developments. It consists of three major components: a console for the operating surgeon, the robotic arm cart and a vision cart including optical devices for the robotic camera (Fig. 1) . So far, the da VinciTM robotic system has gained acceptance for selected surgical procedures [7–10]. However, only few reports on robotics do exist in general thoracic surgery and its impact has not yet been evaluated [11,12].



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  		Fig. 1. The da VinciTM robotic surgical system (console, vision cart, robotic arm cart).

 
We have shown for the first time that different complex thoracic procedures can be performed safely with the da Vinci robot.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1. The da VinciTM robotic system
The da VinciTM surgical system consists of a console and the surgical arm cart, a manipulator unit with two instrument arms and a central arm to guide the endoscope. By moving the camera to the operating field closer to the area of interest, vision can be improved, similar to a microscope. The surgical instruments are introduced via special ports (10 mm for the binocular robotic camera and 8 mm for the instruments) and attached to the arms of the robot. The system can downscale from the motions of the handles to that of the surgical instruments from 3:1. By elevating the robotic camera arm, the thoracic (abdominal) wall can be kept up. This ‘thoraco-lift’ (‘laparo-lift’, respectively) provides an augmentation of the entire visceral cavity. In general, robotic procedures are performed by two surgeons (surgeon on the console and the tableside surgeon).

2.2. Patients
From August 2001 to October 2003, 36 patients suffering from intrathoracic lesion (n=20, Table 1) or from a severe gastroesophageal reflux disease (GERD; n=16, Table 2) were operated on with the da VinciTM robot. Informed consent was obtained from all patients and the trial was approved by the institutional ethics committee on human research. The mean age of 20 women and 16 men was 52 (±27) years. The indication for operation was GERD in 16 (44%) patients, a mediastinal lesion in 15 (42%) patients, an esophageal carcinoma in 4 (11%) patients and a pulmonary carcinoma in 1 (3%) patient. Preoperative manometry, pH esophageal monitoring and barium studies supported the indication for partial posterior fundoplication [13]. In patients with mediastinal lesions, the thymus was involved in 10 (28%) patients, the posterior mediastinum in 3 (8%) patients, the upper anterior and middle anterior mediastinum in 1 (3%) patient each. In patients with esophageal cancer, the robot was used for dissection of the intrathoracic part of the esophagus and for lymphadenectomy only. The tumor in the lung cancer patient was UICC stage I, located in the right lower lobe. Fundoplications (n=16, 44%) were carried out in a steep reverse-Trendelenburg position. For thymectomy all but two patients were placed in an incomplete (side up at a 30° angle) left lateral decubitus position. One patient was operated on from the left side (incomplete right lateral decubitus position), after preoperative CT revealed a predominantly left positioned thymic cyst. In one very petite, adipose female patient we preoperatively decided for a bilateral access; this patient was placed in a supine position with a pillow behind the spine. For esophageal dissection patients were placed in an overwound left lateral decubitus position. Patients with a tumor in the posterior mediastinum were placed in an overwound lateral decubitus position, right or left, respectively. Complete right lateral decubitus position was used in the patients with non-thymic lesions in the upper and middle anterior mediastinum as well as in the lung cancer patient.


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  		Table 1. Patients' characteristics: robotic-VATS group

 

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  		Table 2. Patients' characteristics: robotic-fundoplication group

 
2.3. Fundoplication
Five trocars were placed through the abdominal wall (Fig. 2) . The camera in the supraumbilical positioned trocar and the instruments, inserted through the left and the right subcostal trocars were connected to the robot. The two further trocars served as auxiliary ports for better exposure. All surgical steps including dissection and creation of the fundic wrap were performed entirely with the robot using an electrocautery hook, a grasper, or a needle holder. The operation followed exactly our technique of conventional laparoscopic antireflux surgery [14].



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  		Fig. 2. Detailed description (adjustment in the OR, patient's placement, trocar positioning) of a robotic fundoplication.

 
2.4. Thymectomy
An extended thymectomy with en bloc resection of the anterior mediastinal fat tissue, following the rules of Masaoka [15] was performed thoracoscopically with the robot. The adipose tissue around the upper poles of the thymus, around both brachiocephalic veins and on the pericardium was resected meticulously. The borders of resection are the diaphragm caudally, the thyroid gland cranially, and the phrenic nerves laterally. The port for the robotic endoscope was positioned in the 6th intercostal space in the middle axillary line (Fig. 3) . The two robotic instrument ports were placed in the 3rd and in the 6th intercostal space, one handbreadth left and right of the camera trocar, respectively. An auxiliary port was positioned dorsal between the camera- and the left instrument trocar. For dissection the Cadiere forceps (Surgical Intuitive, Inc., Mountain View, CA, USA) was attached to the left arm, which was mainly used to grasp the tissue. Dissection was performed starting medially to the right phrenic nerve from caudal to cranial and was then continued to the substernal region, already opening the controlateral pleural cavity. The thymus was freed from the pericardium and dissection proceeded as far as the thymic veins. The next steps were the dissection of the right and left upper horn and the transsection of the thymic vein(s). The left thymic lobe was also dissected accurately from a right sided access.



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  		Fig. 3. Detailed description (adjustment in the OR, patient's placement, trocar positioning) of a robotic thymectomy.

 
In the patient with a non-thymic lesion in the anterior mediastinum, set up, positioning and trocar placement was identical to the thymectomy procedures.

2.5. Mass resection in the posterior mediastinum
The camera port was positioned in the anterior axillary line, the intercostal space was determined by the actual position of the tumor. The ports for the two instrument arms were placed symmetrically one handbreadth right and left of the camera trocar, respectively. Dissection was accomplished with the Cadiere forceps in the left hand and the cautery hook in right hand.

2.6. Esophageal dissection
The trocars for the robot were placed far caudally (camera trocar in the 9th intercostal space in the mid-axillary line; left robotic arm in the 9th intercostal space in the posterior-axillary line; right robotic arm in the 8th intercostal space in the anterior-axillary line; Fig. 4) . An auxiliary port for suction and retraction of the deflated lung was positioned between the left robotic arm and the camera arm and a second in the 4th intercostal space medial to the anterior axillary line. After division of the azygos vein, using vascular endostaplers, circumferential mobilization of the esophagus with surrounding lymph nodes and periesophageal tissue and fat was performed from the diaphragmatic reflection to the thoracic inlet. The robotic thoracoscopic dissection of the esophagus was part of a abdomino-cervical procedure.



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  		Fig. 4. Detailed description (adjustment in the OR, patient's placement, trocar positioning) of a robotic esophageal dissection.

 
2.7. Right lower lobectomy
A 5 cm service entrance was created in the 8th intercostal space. It was used to place the camera port at the posterior-axillary line, to insert automatic staplers and to remove the specimen at the end of the operation. The two instrument ports were both placed also in the 8th intercostal space. A 5 mm auxiliary port for additional conventional endoscopic instruments and for suction was placed ventral to the right robotic arm. The inferior pulmonary vein was cleared of surrounding tissue and divided by stapling. Dissection in the fissures was performed with the coagulation hook or with endo-staplers. The lower main-stem artery was dissected circularly with the flexible Goldfinger (J&J Ethicon Endosurgery, Cincinnati, OH). The lower apical and lower main-stem arteries were controlled separately and entirely by means of the robot. Finally, the lower lobe bronchus was divided by endo-stapling. Standard lymph node dissection was performed. The specimen was removed in an endobag without a rib spreader.

2.8. Mediastinal parathyroidectomy
The camera-port was situated in the 6th intercostal space in the anterior axillary line and the two instrument ports were placed in the 4th intercostal space one handbreadth right and left. A flexible retractor (US Surgical, Norwalk, CT) was inserted via the first auxiliary port in the mid-clavicular line of the 6th intercostal space to retract the lung. Suction was provided via a second auxiliary port, positioned in the posterior axillary line of the 6th intercostal space. Preparation started with the incision of the parietal pleura covering the aorto-pulmonary window. Caution had to be taken as not to injure the left vagus and recurrent laryngeal nerves. The tumor between the aortic arch, the pulmonary trunk artery and the trachea was cautiously excised using blunt dissection and the cautery hook. The vascular pedicle was controlled with clips (Fig. 5) .



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  		Fig. 5. Robotically resected ectopic parathyroid from the aorto-pulmonary window.

 
Follow-up of patients was identical to those being operated on conventionally with CT scan (for oncologic procedures), neurologic evaluation (myasthenia gravis) and manometry, pH esophageal monitoring and endoscopy (fundoplications).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Thirty-nine (94%) procedures were completed exclusively with the da VinciTM robotic system. In patient 13 of the fundoplication group a technical breakdown of the robotic system occurred and forced us to convert to conventional laparascopy. In one patient with a large sand-glass-like paravertebral tumor, conversion to a standard thoracotomy was necessary for surgical reasons.

The time for the set-up of the robot, the time of the surgeon working on the console (console time) and the overall operating time (first skin incision until skin closure) for each patient is depicted in Table 3.


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  		Table 3. Set-up, console and overall time for each procedure

 
There was no relevant intraoperative blood loss in any of the patients. No complications were seen in patients after fundoplications, thymectomies, esophageal dissections and extirpations of a paravertebral mediastinal mass. In the patient with the tumor in the aorto-pulmonary window, however, postoperative ENT consultation revealed an incomplete lesion of left recurrent laryngeal nerve with partial activity. Chest tubes were generally removed on postoperative day 2 (±2). The mean postoperative hospital stay of the entire group was 6 (±3) and 4 (±2) days when excluding the patients with conversions and abdomino-cervical procedures. Pathology revealed seven thymomas (six Masaoka stage I, one Masaoka stage II), one age-adequate atrophic thymic gland, one persistent thymic gland and one thymic cyst. The non-thymic-anterior mass was a lymphangioma. The paravertebral mediastinal tumors were neurogenic and benign. The tumor in the aorto-pulmonary window was a parathyroid adenoma. Two of the esophageal carcinomas were UICC stage I, two stage II. There were three squamous cell carcinomas and one adenocarcinoma (Barrett's carcinoma). The resected lung cancer was a NSCLC adenocarcinoma, UICC stage I. All tumors were resected in sano (R0).

Twenty-eight (78%) patients were followed up for 17±9 months. Following fundoplication, endoscopy did not reveal acute esophagitis or hiatal or paraesophageal herniation. Postoperative manometric data showed a significant improvement of the resting pressure and the intraabdominal length of the lower esophageal sphincter (LES). After resection of a mediastinal tumor, patients did not show any clinical or radiologic sign of recurrence (mean follow-up 7 months). The patient who suffered from an incomplete lesion of the left recurrent laryngeal nerve after mediastinal parathyroidectomy was clinically asymptomatic 8 months postoperatively. Extended thymectomy improved clinical symptoms in two of the three patients suffering from myasthenia gravis. One patient (patient 11) of the esophageal cancer group died 12 months postoperatively due to tumor progression. The other patients of this group as well as the lung cancer patient are in complete remission after a mean follow-up of 6 months.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The Innsbruck University Hospital was the first institution in Austria to purchase a da VinciTM system. At a cost of over 1 million {euro}, the initial value was relatively high. However, robotic surgery has opened new options for minimally invasive operations [16]. Hand movements in the grips of the console are naturally and intuitively transmitted to the robot's instruments. High-precision microsutures can be performed. Ergonomics for the surgeon are much better than in conventional laparoscopic surgery. Movement of the instruments allows for seven degrees of freedom and thus is even superior to a surgeon's hands in conventional surgery. Anyone who works with a robot for the first time is amazed by the rapid ability to acquire dexterity and accuracy with a very short learning curve [17].

Partial posterior fundoplication can be easily and safely performed with the da VinciTM robotic system. No complications were seen in this series and the learning curve was steep. The high quality 3D virtual operating field and the stable camera platform allow for gentle and precise dissection and suturing. The approximation of the hiatal crura and the creation of the fundic wrap was found to be easier than by conventional laparoscopy [18]. Various complex surgical maneuvers were performed in the mediastinum without problems. It is obvious that the robot offers benefit especially in operations in tiny and remote areas. A striking example is the dissection of the superior horns during thymectomy, which sometimes is cumbersome to achieve by means of conventional thoracoscopy but is relatively easy to perform with the robot. The capacity of the robot even allows for extended thymectomy from a single-sided approach which is critical for VATS [19,20]. In 4 of our 10 thymectomy patients an extended resection was mandatory, due to myasthenia gravis and potential malignancy. This was achieved by an exclusively right-sided approach with identification of the left phrenic nerve as borderline for dissection. The extent of the procedure was controlled with backtable tissue investigation of the specimens and intraoperative evaluation of the resection margins. The superior feasibility is due to the excellent movements of the robotic instruments together with the active elevation of the chest wall (thoraco-lift). In one short but obese female patient a successful one-sided approach appeared unrealistic due to anatomical limitations and therefore a bilateral approach was chosen.

The resection of masses in the posterior mediastinum is relatively simple and straight forward as long as the tumor does not involve the radices [21]. The limitation for the robotic approach (as well as for conventional VATS) is tumor size. One out of the three interventions had to be converted to an open procedure. In this patient the tumor size was 17x8 cm2, and therefore did not fulfill the requirements for resection by any kind of minimally invasive access. In the other two patients presenting smaller masses, the robotic resection was performed without any problems. Based on this experience, we have restricted the tumor size for future minimally invasive approaches to a diameter of less than 10 cm.

Another domain for the robotic procedure was the resection of an ectopic mediastinal parathyroid adenoma in the aorto-pulmonary window. Dissection within this delicate area was found to be accurate and safe at any stage of the operation. Furthermore, it is well known from open and conventional thoracoscopic surgery, that ectopic parathyroids can often be identified only by the assistance of radionuclided guidance [22,23]. The superb 3D vision, however, made it relatively easy to locate the tumor for the surgeon at the console, whereas for the surgeon at the table, looking into a conventional monitor, it was found to be difficult to identify the lesion.

The thoracoscopic dissection of the esophagus was our very first experience with the robot in thoracic surgery. The da VinciTM allowed for meticulous lymphadenectomy from the diaphragm to the thoracic inlet.

Currently, the robot's outfit is very basic and comparable to the early days of laparoscopy. The setup of the system, which includes full sterile draping, positioning of the arm cart, and attachment to the trocars is time consuming. This may be reduced through further experience of the whole team. Other limitations of robotic surgery are related to the current system's lack of tactile feedback. The surgeon does not receive information on the amount of force applied to the tissue or sutures but is dependent on visual feedback only. Special devices, such as transsection instruments with full EndoWristTM technology and different-shaped clamps need to be developed. An accessory robotic arm, which would be able to position retractors and provide suction and irrigation would definitely facilitate complex operations.

From the technical point of view, lobectomies are the most challenging operations in the field of general thoracic robotic surgery. The clearance of the pulmonary artery from its connective tissue is difficult and care has to be taken not to harm the pulmonary artery. For this purpose, more specialized robotic instruments would be needed. Moreover, the lack of curved instruments makes operating at the inner side of the thoracic wall difficult. Therefore, simple procedures, such as pleurectomies or resections of masses of the inner thoracic wall, can be accomplished much easier by conventional VATS.

The current da VinciTM system offers its specific advantages over conventional VATS especially in remote and difficult-to-reach areas. Thus, its domains are procedures within the mediastinum.


   Acknowledgments
 
The authors thank emeritus Prof. Ernst Bodner MD for his vision and endeavours which enabled the acquisition of the da VinciTM robot for the Department of Surgery, University Hospital Innsbruck.


   Footnotes
 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.


   References
Top
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 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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