The operating room technical staff sets up the robotic surgical system (surgical cart, surgeon's console, vision system) in the room (Fig. 165-1). In the beginning of the case the nursing staff power up the system, run the appropriate diagnostics, and drape the robotic arms and camera. This requires two individuals and typically takes 5 to 10 minutes for staff who are trained and are familiar with the process and occurs prior to or while the patient is undergoing induction of anesthesia and positioning.
Robotic surgical cart draped and prepared for docking.
Standard methods of general anesthesia and single-lung ventilation are employed via either double-lumen endotracheal tube placement or bronchial blocker. The patient is placed in a maximally flexed, lateral decubitus position, and single-lung ventilation is initiated. Depending on the size of the operating room, it will often be necessary to move the table away from the anesthesia machine and angle the foot of the table away from the surgical cart (Fig. 165-2). This establishes enough space to dock the robot. Care must be taken to insure that sufficient length of the circuit tubing is available during this positioning, and the anesthesia team must be comfortable that there is adequate access to the patient's airway once docking of the robotic system has taken place.
Table positioning prior to docking.
Initial Exploration and Docking of the Robot
Initial thoracic exploration is conducted with the robotic thoracoscope through a 12-mm trocar in the eighth intercostal space (ICS) just posterior to the anterior axillary line (Fig. 165-3) to verify tumor location, establish a tissue diagnosis if necessary, assess resectability and appropriateness of the robotic approach, and to place the additional incisions prior to docking. A 1-mm incision is placed posterior to the tip of the scapula in the ninth ICS just above the diaphragm. The 3- to 4-cm access incision is placed in the fourth or fifth ICS in the midaxillary line. A fourth incision may be employed posteriorly in the fifth or sixth ICS in line with the ninth ICS incision if so desired. Once the skin incisions have been made, the surgical cart is brought into position from the posterior aspect of the patient with the center column and camera arm angled over the scapula at an approximately 45-degree angle with respect to the longitudinal axis of the patient (Fig. 165-4). This allows for the field of dissection to include the hilar structures and the majority of the chest. When docking the surgical cart, it is important to avoid positioning the surgical cart too close to the patient and maintain adequate spacing between ports (handbreadth). This will eliminate instrument arm conflicts and maximize range of motion of the instruments.
Incision strategy for VATS-based robotic pulmonary resection.
Docking of the surgical card for lobectomy.
Once the surgical cart is in position the camera arm is attached first to the trocar, and the robotic thoracoscope is introduced and secured to the camera arm. The 8-mm metallic robotic trocars are introduced through each of the other incisions and attached to their respective arms. This is accomplished under direct vision both from outside the patient and from within the patient's thorax. In the case of the access incision the trocar is placed in the midpoint of the incision with room above and below to introduce additional instruments (lung retractor, suction). Care must be taken to ensure that each instrument arm has full range of motion and does not collide with one another or with the patient (Fig. 165-5).
Positioning of the instrument arm through the access incision.
Once the trocars are in place and attached to the robotic arms, the surgical instruments are introduced under direct thoracoscopic vision. A Cadiere forceps is most commonly controlled by one hand for grasping tissue, and a cutting instrument (monopolar spatula, Maryland bipolar, monopolar hook) is used in the other hand. If the fourth arm is employed, it is typically used for a lung grasper or suction irrigator. After the instruments have been introduced the operating surgeon moves to the surgeon's console. The bedside assistant stands at the anterior aspect of the patient and provides additional exposure through the access incision.
Completely Portal Robotic Lobectomy (CPRL-4)
Cerfolio et al.8 have developed a robotic incision strategy that avoids an access incision under the premise that no exposure of the intrathoracic cavity to air may have additional benefits over and above lack of rib spreading. There are four robotic arm incisions, all placed in the sixth ICS spaced 9 to 10 cm apart beginning from the midaxillary line to the paraspinal area (Fig. 165-6). In addition, there is a fifth, nonrobotic 15-mm assistant access port through which the endovascular staplers are passed. The surgical cart is then brought in over the head of the patient, with the camera view replicating the traditional thoracotomy view.
Incision strategy for a CRPL-4 approach.
Mediastinal and Hilar Lymph Node Dissection
Dissection is performed with the Cadiere forceps and the monopolar cautery spatula. Wherever possible, the entire nodal packet is removed without fracturing the nodes into fragments (Fig. 165-7). Large bronchial or lymphatic vessels can be clipped, and when indicated suspicious lymph nodes are sent for frozen section analysis to identify occult N2 disease. For a right upper lobectomy it is easier to perform the paratracheal node dissection after the specimen has been removed. Similarly, it is often advantageous to perform the subcarinal lymphadenectomy by retracting the stump of the lower lobe to elevate the mediastinum.
Right-sided interlobar hilar lymph node dissection.
If there are no contraindications to lobectomy, individual isolation of the hilar structures proceeds with dissection around the hilar vessels and bronchi performed through a combination of cautery, sharp, and blunt dissection. Complete removal and labeling, rather than sweeping of all regional nodal tissue is performed both for adequate staging and to facilitate isolation of the hilar structures. When either a vessel or the bronchus is mobilized sufficiently, the Cadiere forceps are used to isolate the structure, using the seven degrees of freedom to articulate the instruments at near right angles to do so (Fig. 165-8). Ligation and division of the named vessels and bronchus are performed with endovascular staplers introduced either through the posterior inferior or access incision. This requires temporary removal of one of the robotic trocars followed by replacement of the arm after stapler firing.
Robotic isolation of the right upper lobe superior vein.
The precise order in which the structures are divided depends on the particular lobectomy being performed and the approach (anterior vs. posterior/fissural). Therefore, the specific steps for each lobectomy will not be reviewed in detail.
Completion of the fissure is performed last, just prior to removal of the specimen. For upper lobectomy the entire fissure is divided with endoscopic staplers (Fig. 165-9); for middle and lower lobectomies the anterior portion of the fissure is often divided with electrocautery in the course of dissection of the hilar structures. The remaining posterior portion of the fissure is then completed using the endoscopic staplers.
Division of the horizontal fissure during robotic lobectomy.
The completed lobectomy specimen should be placed in a durable laparotomy sac and removed through the access incision in the case of a VATS-based incision strategy or by enlarging one of the port incisions in a completely portal approach. In the event that the primary tumor is large the access incision may have to be enlarged to remove the specimen without inadvertently fracturing the ribs.
Termination of the Procedure
Once the specimen has been removed and the systematic lymphadenectomy or sampling has been completed the surgical arms can be undocked from the trocars, and the cart can be moved away from the patient. The trocars should be removed, and a single drainage chest tube placed through the anterior inferior camera incision and positioned with the tip at the apex of the chest posteriorly. The lung should be reinflated under direct thoracoscopic vision with the robotic scope placed in the access incision. The remaining wounds are closed in a standard fashion (Fig. 165-10).
Incision closure following right robotic lobectomy.