Robot-Assisted Thoracic Procedures
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Robot-Assisted Thoracic Procedures

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Overview; Urologic Procedures; Laparoscopic Procedures; Cardiac Procedures; Thoracic Procedures

Definition

To perform thoracic surgery (a non-cardiac chest procedure), a surgeon guides small robotic arms through several tiny “keyhole” incisions, sometimes allowing for greater range of movement than a surgical hand.

Thoracic Surgery

Laparascopic Thoracic

Keyhole incisions and specialized equipment for a robot-assisted thoracic procedure.

© 2008 Nucleus Medical Art, Inc.

Parts of the Body Involved

  • Chest wall
  • Chest cavity
  • Lungs
  • Esophagus
  • Thymus gland
  • Mediastinum
  • Sympathetic nerve

Reasons for Procedure

Robot-assisted thoracic procedures are considered for surgeries that require precision and do not require open access. Performing surgery in this way can result in less scarring, reduced recovery times, less risk of infection, less blood loss, and reduction in stress response compared to more invasive procedures. If necessary, this method can be abandoned during surgery and the surgeon can take over with a more traditional laparoscopic or open surgery approach. Thoracic surgeries that have been successfully performed using robotic techniques include:

  • Thymectomy—removal of the thymus gland
  • Lobectomy—removal of a lung lobe
  • Esophagectomy—removal of the esophagus
  • Mediastinal tumor resection—removal of tumors located in the mediastinum (the part of the chest cavity that separates the lungs)
  • Sympathectomy—cauterizing a portion of the sympathetic nerve

New robot-assisted thoracic procedures are being added to this list all the time.

Risk Factors for Complications During the Procedure

A risk factor is something that increases your chance of having complications during your procedure. Risk factors for complications during robot-assisted thoracic procedures include:

What to Expect

Prior to Procedure

Depending on the reason for your surgery, your doctor may do the following:

  • Physical exam
  • Blood tests
  • Urine tests
  • Chest x-ray
  • Pulmonary function test—a test to assess the capacity of your lungs to undergo surgery
  • Upper GI series—x-ray of the esophagus, stomach, and part of the small intestines after swallowing a barium solution
  • Electrocardiogram (ECG, EKG)—a test that records the electrical currents passing through the heart muscle
  • Ultrasound—a test that uses sound waves to visualize the inside of the chest
  • CT scan—a type of x-ray that uses a computer to create images of structures inside the chest
  • MRI scan—a test that uses powerful magnets and radiowaves to create images of structures inside of the chest
  • Upper endoscopy—a lighted tube equipped with a camera used to visualize the inside of the esophagus, stomach, and part of the small intestines
  • Pre-operative plasma exchange, intravenous immunoglobulin (IVIg), or immunosuppressive therapy, if you are undergoing a thymectomy
  • Placement of a feeding tube into your small intestine in the days leading up to or on the day of surgery, if you are having an esophagectomy

  • Review your medications with the surgeon; you may need to stop taking some of them.
  • Use an enema to clear your colon, if directed to do so by your surgeon.
  • Follow a special diet, if recommended by your surgeon.
  • Take antibiotics, if prescribed by your doctor.
  • Shower the night before your procedure using antibacterial soap, if your doctor asks you.
  • Arrange to have someone drive you to and from the procedure, and for help at home after your procedure.
  • Eat a light meal the night before, and do not eat or drink anything after midnight unless told otherwise by your doctor.
  • Plan to wear comfortable clothing on the day of your procedure.

Anesthesia

General anesthesia will be used. An endotracheal tube will be placed in your windpipe to help you breathe. You may also be given spinal or epidural pain medication through a tube placed along the spinal column in your back.

Description of the Procedure

To begin a robot-assisted thoracic procedure, the surgeon cuts several small (approximately one centimeter) “keyhole” openings in the chest wall between the ribs. One or more chest tubes may be placed into the side of your chest to drain fluids and monitor air leakage. A needle may be used to inject carbon dioxide gas into the chest cavity, making it easier for the surgeon to see internal structures.

The surgeon passes a small camera (endoscope) through one of the incisions, which lights, magnifies, and projects an image of internal organs on to a video screen for the surgeon to see. The endoscope is attached to one of three or four of the surgical system’s robotic arms.

The other two or three arms hold other instruments such as dissectors, scissors, scalpels, or forceps. These instruments are able to grasp, cut, dissect, and suture structures inside the chest during the operation.

While sitting at a console several feet away from the operating table, the surgeon looks through lenses at a magnified three-dimensional image of the inside of the chest. Another surgeon stays by the patient during the procedure, where he can adjust the camera and instruments as needed.

With joystick-like hand controls and foot pedals, the surgeon at the console guides the movement of the robotic arms and surgical instruments. The robotic arms are able to perform surgical tasks with an increased range of motion than would be possible using traditional surgical techniques. In addition, the robotic arms can filter out hand tremor and translate the surgeon’s larger hand movements into smaller ones.

In procedures in which cancerous tumors or tissues are removed, the surgeon may also remove nearby lymph nodes. He or she drops these organs, tissues, and/or lymph nodes into a specimen bag and removes them through one of the openings.

After the endoscope and other instruments are removed, the surgeon closes the incisions with sutures or staples, and applies a sterile dressing.

After Procedure

If an organ, tissue, or lymph node was removed, it will be sent to a pathologist for examination. Barring any significant complications, the endotracheal tube in your windpipe will usually be removed soon after surgery, and the chest tubes will follow soon thereafter.

How Long Will It Take?

Usually 1-4 hours, but this depends on the type of procedure being done.

Will It Hurt?

General anesthesia prevents pain during surgery. Patients typically experience some pain and soreness during recovery, but receive pain medication to relieve the discomfort. You may also feel some discomfort from the gas used during the procedure. This can last up to three days.

Possible Complications

  • Bleeding in the lung cavity (hemothorax)
  • Collection of air or gases in the lung cavity (pneumothorax)
  • Collapsed lung
  • Need for a prolonged artificial respiration on a ventilator (breathing machine)
  • Damage to neighboring organs or structures
  • Infection
  • Bleeding
  • Anesthesia-related problems
  • Compensatory sweating
  • Horner’s syndrome
  • Death

Also, sometimes it becomes necessary during the procedure to abandon the robotic method and perform the surgery using traditional methods (eg, traditional endoscopic or open surgery).

Average Hospital Stay

Your stay is usually a few days to a week, but may be longer, depending on the procedure.

Postoperative Care

You will receive instructions on when and what you can eat, and how you need to restrict your activity.

After an esophagectomy, you will not be allowed to eat or drink anything for about a week after surgery. You will receive nutrition through the feeding tube in your abdomen in the days after surgery. Depending on the extent of your surgery, you may gradually progress from a liquid to a solid diet. The feeding tube is often removed about one month after surgery.

Your doctor will likely advise you to:

  • Perform deep breathing and coughing exercises soon after the surgery to expand your lungs, and prevent infection and collapse
  • Sit up and move around as soon as possible after surgery
  • Take antibiotics to prevent infection
  • Avoid certain medications
  • Resume normal activities (eg, taking daily walks) soon, to promote healing
  • Wash the incisions with mild soap and water
  • Limit certain activities, such as showering, bathing, driving, walking up stairs, lifting, and working, for a period of time

Outcome

Depending on your procedure, you should be able to resume most, if not all, regular activities within a few weeks after your surgery. Based on evidence available to date, the risks of robotic surgery appear to be less than for more traditional forms of surgery.

Benefits of robot-assisted thoracic procedures over traditional thoracic procedures may include:

  • Reduced trauma to the body
  • Reduced risk of blood transfusion
  • Shorter hospital stay
  • Faster recovery

Call Your Doctor If Any of the Following Occurs

It is essential for you to carefully monitor your own recovery once you leave the hospital. That way, you can alert your doctor to any problems immediately. Promptly notify your doctor if any of the following occur:

  • Cough or shortness of breath
  • Coughing up yellow, green, or bloody mucus
  • New chest pain
  • Signs of infection, including fever and chills
  • Redness, swelling, increasing pain, excessive bleeding, or discharge from an incision site
  • Difficulty urinating, such as pain, burning, urgency, frequency, or bleeding
  • Pain and/or swelling in your feet, calves, or legs
  • Persistent nausea, vomiting, and/or diarrhea
  • Headache, muscle aches, feeling faint or dizzy
  • Other worrisome symptoms

RESOURCES:

American College of Surgeons
http://www.facs.org/

Society of Thoracic Surgeons
http://www.sts.org/

CANADIAN RESOURCES:

The Canadian Lung Association
http://www.lung.ca/

Canadian Agency for Drugs and Technologies in Health
http://www.cadth.ca/

References:

Esophageal cancer—esophagectomy. University of Maryland Medical Center website. Available at: http://www.umm.edu/thoracic/esoph_surgery.html . Accessed July 21, 2006.

Rea F, Marulli G, Bortolotti L. Robotic video-assisted thoracoscopic thymectomy. Multimedia Manual of Cardiothoracic Surgery. Available at: http://mmcts.ctsnetjournals.org/cgi/content/full/2005/0324/mmcts.2004.000422. Accessed July 21, 2006.

Sympathectomy. New York Presbyterian Hospital website. Available at: http://www.nyp.org/health/sympathectomy.html. Accessed May 5, 2008.

Thoracic applications. Intuitive Surgical website. Available at: http://www.intuitivesurgical.com/clinical/thoracicapplications/index.aspx. Accessed July 21, 2006.

Thoracic lobectomy. New York-Presbyterian Hospital website. Available at: http://www.nyp.org/masc/lobectomy.htm. Accessed July 21, 2006.

Thymectomy. Myasthenia Gravis Foundation of America website. Available at: http://www.myasthenia.org/information/thymectomy.htm. Accessed July 21, 2006.



Last reviewed May 2008 by Rosalyn Carson-DeWitt, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

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