Page 7 - Read Online

Page 2 of 9 Durand. Mini-invasive Surg 2019;3:35 I http://dx.doi.org/10.20517/2574-1225.2019.31

INTRODUCTION
Telemanipulation surgery is a significant revolution in thoracic surgery. It allows minimizing the chest
trauma while preserving-or enhancing-the surgeon’s skills and vision, allows bimanual surgery, provides
a 3rd hand, and gives 3D magnified vision. This is of greatest interest for complex procedures that are
performed to spare the patient’s lung function. Two trends are noticed in this area: the merger of sub-
[1]
[2]
lobar resections and bronchial sleeve resections . These 2 approaches require advanced skills that can be
provided by the telemanipulator.
In this paper, we focus on the technical details of bronchial sleeve resections and report the early results of
our experience.

METHODS
We collected retrospectively all the bronchial sleeve procedures performed in our center from the
beginning of our robotic program in February 2014 to August 2019. All procedures were performed by a
single surgeon. We analyzed them as a series of cases.

Surgical technique
TM
TM
The procedures were performed with either the Da Vinci Si system or the Xi system (Intuitive Surgical
TM
TM
California). For the Si system, a 12-mm 30° camera was used. For the Xi system, an 8-mm 30° camera
was used.
Patient position and port placement
The same patient position and port placement as for any robotic anatomical lung resection and node
[3,4]
harvest were used, as described previously . This is shown in Figure 1 and summarized below.

The patient was placed on their left side with a tissue roll below their chest to avoid the hip. The patient’s
body was stabilized with a vacuum cover. The right arm was placed in front of the head on the operating
table. Neither central venous line nor arterial blood line was placed. A two-level paravertebral block and a
serratus block were performed by the anesthesiologist with ultrasound guidance before surgical incision.

First, the design of the port placement was prepared. The shape of the scapula tip and scapula line were
drawn. Then, the intercostal space (ICS) count was done from the 11th ICS from the back of the patient to
the anterior side to spot the ninth for the 15-mm port access and the 8th for the camera port at the junction
of the scapula line. The first port placed was the camera port to check the position of the other ports from
inside the chest. After insertion of the camera, the capnothorax was started under vision control, and low
pressure (5 mmHg) and medium flow (10 L/min) were applied. The other ports were placed in the following
order: the right hand, the left hand, the third hand, and the port access.

The 30° camera was inserted with vision up to place the other ports. The right-hand port was placed in the 7th
ICS, at the junction of the diaphragm and the end of the major fissure. The left-hand port was placed in the
9th or 10th ICS above the triangular ligament. The 3rd hand was placed in the 7th ICS, at least 2 fingers closer
to the spine to avoid conflict with the left hand, and at the junction of the visible muscular part of the ICS
muscle and the posterior ICS ligament. Its angle of penetration in the chest was 90°. Then, the 15-mm port
access was placed in the ninth ICS at the diaphragm insertion, as low as possible to enlarge the triangle
among it, the right hand, and the camera port. Then, the capnothorax insufflation was moved from camera
port to port access.

Instruments and procedure steps
The instruments used for the procedures and for a right-handed surgeon were as follows:
TM
- The right hand: permanent cautery spatula (Ref. 420184), needle holder SutureCut (Ref. 420296), or