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Page 12 of 19 Gharagozloo et al. Mini-invasive Surg 2020;4:48 I http://dx.doi.org/10.20517/2574-1225.2020.35

ROBOTIC SELECTIVE DORSAL SYMPATHECTOMY
One of the shortcomings of the VATS techniques stems from the fact that the instruments are introduced
through ports or small incisions which amount to holes in the chest wall. The instruments pivot at the entry
holes and can be moved in four directions. The limited mobility of conventional endoscopic instruments,
whether in the abdomen or the chest, has been referred to by some investigators as “chopstick surgery”.
The chopstick nature and the limited maneuverability of the effector instruments stems from the rigid shaft
access fixed to the thorax by the entry hole. This technical shortcoming limits the surgeon in performing
fine dissection and complex three-dimensional maneuvers. Pivoting instruments on the chest wall results
in a large radius of curvature for the tip of the instrument and makes fine dissection in deep spaces such as
the mediastinum very difficult and even dangerous.

Another shortcoming of the VATS technique is in the lack of the three-dimensional visualization. The
surgeon has to use two-dimensional information from the video monitor to create a three-dimensional
mental image. This fact requires significant experience and can prove to be a course of fatigue for the
surgeon. Most importantly, using such indirect means of judging depth perception is rarely equivalent to
binocular vision. In maneuvering the sympathetic chain away from the underlying vessels and determining
the position of the RCG, binocular vision is paramount. The use of robotic technology obviates these
difficulties. The Da Vinci robot (Intuitive Surgical) represents an ideal tool for the accurate dissection of the
sympathetic chain away from the underlying vessels and identifying the preganglionic and postganglionic
fibers to perform highly selective dorsal sympathectomy. The indispensable features of the Da Vinci robot
for performing this procedure are: (1) the EndoWrist or the cable-driven wrist at the end of the robotic
arm. The placement of the robotic arm through the VATS hole is comparable to and accomplishes the
chopstick maneuvers performed by conventional VATS instruments. However, the EndoWrist at the distal
end of the robotic arm is positioned in the confined spaces within the chest and brings 4_ more of freedom
and six additional directions of movement compared to normal VATS techniques. The EndoWrist provides
the surgeon with fine instrument maneuverability in a very confined space; (2) the Da Vinci robotic system
is designed to provide downscaling from the motion of the surgeon’s hand to that of the robotic instrument.
This is invariable in dissecting fine and fragile intrathoracic structures. Furthermore, a 60 Hz motion
filter is used to filter out any tremor in the surgeon’s hand; and (3) the binocular robotic camera provides
superb three-dimensional visualization by the nature of being mounted on the central robotic arm. It can
be manipulated by the surgeon. The surgeon’s ability to manipulate the camera and the arm recreates the
natural biologic motion of the surgeon’s head, eyes, and hands in providing optimal hand-eye coordination.

Operative technique
Room setup is depicted in Figure 8. Room setup is the same for both right- and left-sided procedures.

Anesthesia
Patients require single-lung ventilation. We prefer a left-sided double-lumen endotracheal tube to a
bronchial blocker. In our experience, bronchial blockers are prone to dislodgment during the surgical
procedure and require frequent manipulation which is difficult while the robot is in position. In addition,
selective sympathectomy requires very precise dissection and a controlled visual field without intrusion
from the inflating lung. Longer tubing is required during the robotic procedure as the anesthesiologist
will occupy a more remote position away from the patient. The patient is placed in a full lateral decubitus
position. We prefer to perform highly selective sympathectomy beginning with the most affected side,
returning after any compensatory hyperhidrosis has subsided or plateaued in severity. The table is flexed to
open the intercostal spaces and the position of the double-lumen tube is reconfirmed after final positioning.
The patient then is prepared and draped in a routine manner. The superior portion of the drape is allowed
to cover the patient’s head. After port placement, the table is unlocked and rotated 30 degrees from its
normal position to facilitate the positioning of the robot over the patient’s head.