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Ann Thorac Surg 2002;74:1235-1237
© 2002 The Society of Thoracic Surgeons

Case report

Video-assisted thoracoscopic extirpation of a posterior mediastinal mass using the da Vinci computer enhanced surgical system

Ichiro Yoshino, MD*a, Makoto Hashizume, MD, FACSb, Mitsuo Shimada, MDa, Morimasa Tomikawa, MDa, Keizo Sugimachi, MD, FACSa

a Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
b Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Accepted for publication April 30, 2002.

* Address reprint requests to Dr Yoshino, Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan
e-mail: iyoshino{at}surg2.med.kyushu-u.ac.jp


   Abstract
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 Abstract
Introduction
 Comment
 References
 
A 28-year-old woman presented a left posterior mediastinal mass surrounded by the intercostal vein, hemiazygos vein, sympathetic nerve, and descending aorta. We successfully resected the mass, that was revealed to be a bronchogenic cyst, by a totally thoracoscopic procedure using the da Vinci computer-enhanced system (Intutive Surgical, Mountain View, CA) without injuring the neighboring structures or the capsule of the mass.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
A computer-enhanced surgical system, which is now available for use, was first introduced a few years ago in the field of cardiac surgery for coronary arterial bypass grafting and mitral valve repair [1]. Recently, Mohr and colleagues reported their experience of robotic cardiac surgery in which total endoscopic coronary bypass was completed in 22 of 27 cases with 95.4% patency [2]. For general surgery, more than a thousand cases have now undergone robotic surgery using such a system, including such surgical modalities as cholecystectomy, Nissen fundoplication, tubular restoration, esophagogastroplasty, and repair of a groin hernia [3]. Recently, thoracoscopic surgery has become widely indicated for such intrathoracic diseases as pneumothorax, lung cancer and mediastinal tumors, as well as for biopsy of various lung diseases [4, 5]. As a result, general thoracic surgery is now expected to be the next field to use this robotic system. In this regard, we recently reported our findings of a successful total thoracoscopic thymectomy using this robotic system [6]. The major benefits of this system in general thoracic surgery may be its potential application in performing major oncological surgery which has not yet been well performed using total thoracoscopic procedures. However, we still need to achieve more expertise in using this novel and promising system. We herein report the findings of a successful thoracoscopic operation using the da Vinci robotic surgical system (Intutive Surgical, Mountain View, CA) for a potentially benign disease.

A 28-year-old woman was found to have a left posterior mass on a chest roentgenogram at a preemployment medical checkup. She was therefore admitted to the Second Department of Surgery, Kyushu University Hospital, Fukuoka, Japan. An oval-shaped mass measuring 2.0 cm in diameter was located in a region neighboring the descending aorta on a computed tomography (Fig 1A), and a magnetic resonance imaging revealed a cystic component (Fig 1B). A bronchogenic cyst or neurogenic tumor with necrotic change was suggested, and therefore a video-assisted thoracoscopic extirpation was considered. Our department had already successfully performed a thoracoscopic operation for thymoma with the aid of the da Vinci robotic surgical system [4]. She gave her written consent to undergo the robotic procedure and our institutional review committee also gave its permission. We therefore planned to perform a thoracoscopic operation using this robotic system. On January 18, 2001, the operation was performed. The endoscopic control system has been previously described [1, 2]. Under adequate general and epidural anesthesia, the patient was placed in a right lateral position. The patient side manipulator was situated on the left. First, the three-dimensional stereoendoscope of the da Vinci system was introduced from a trocar measuring 10 mm in diameter at the sixth intercostal space of the mid-axillary region, and thereafter the thoracic cavity was explored. There was no severe pleural adhesion nor pleural dissemination, and the cystic mass neighboring the descending aorta was observed in the posterior mediastinal region. Next, two thoracic ports were inserted through the fourth intercostal space on the mid-axillary line and the ninth intercostal space on the mid-axillary line, then two arms of the da Vinci system were attached to these two accesses while another one was attached to the port-inserted endoscope. For the left arm, which was mainly used to grasp the adjacent tissue of the tumor, DeBakey Forceps (EndoWrist; Intutive Surgical) was used; and for the right arm, which performed the dissection, Electrocautery with Hook (EndoWrist; Intutive Surgical) was mainly used. Conventional instruments for endoscopic surgery such as scissors or grasper forceps were introduced from the same access ports to be used in conjunction with the da Vinci instruments. Following a mediastinotomy, the tumor was extirpated from the posterior mediastinal fat tissue in a blunt and sharp manner. The tumor was completely resected with an adequate margin and then was placed in an Endo-pouch (Johnson & Johnson, Tokyo, Japan) without injuring any neighboring tissue (such as the intercostal vein, hemiazygos vein, sympathetic nerve, descending aorta, or the capsule of the lesion), and then was passed from the thoracic cavity through the wound at the ninth intercostal space. After irrigating the surgical field with warm saline, a 20 Fr. drainage tube was inserted through the wound of the ninth intercostal space, while the other wounds were closed. These intrathoracic procedures were completely performed by this da Vinci computer-enhanced system. The total operative time was 1 hour, and the estimated blood loss was approximately 10 g. The patient was taken to a recovery room in the surgical ward. The postoperative course was uneventful, and the thoracic drain was extubated on the 1st day. The resected specimen revealed a well-capsulated cystic mass, and was histologically diagnosed to be a bronchogenic cyst. As of March 12, 2002, the patient has had no complaints regarding either wound pain or shortness of breath.



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  		Fig 1. Imaging findings of the mediastinal mass. (A) An encapsulated solid mass measuring 2.0 cm in diameter is recognized in the left posterior mediastinum on thoracic computed tomography. (B) T2-weighted magnetic resonance imaging shows a highly intensified mass, revealing fluid collection in the lesion.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
This case is our second report of robotic surgery for a mediastinal tumor, and it may provide important information for selecting the optional patient position and access routes for the posterior mediastinum. First, the position of these three holes was restricted due to the fact that the distance between the two arms holding the instruments requires a minimum space of 15 cm, whereas the telescope might be introduced from the point on the same line where the two holes for the arms were located. Second, the precise movements of the instruments and the three-dimensional view enabled us to perform the procedures both easily and safely without any injury of the neighboring tissues by this robotic system. From the above results, the performance of other intrathoracic operations using this robotic system are considered to be appropriate. Anterior and posterior mediastinal tumors, such as noninvasive thymomas or neurogenic tumors, may be good candidates for this system since most of them show a benign nature even when a complete resection is achieved [4, 5]. In this case, conventional thoracoscopic procedures would have been very difficult and high-risk since the mass was surrounded by many important structures such as the descending aorta, sympathetic nerve, hemiazygos vein, and intercostal vein; the da Vinci enhanced operation system enabled us to perform a complete excision without injuring these structures.

A major pulmonary resection for lung cancer can also be performed using this robotic da Vinci system, although surgeons would have to achieve a high degree of expertise using this specific system (especially without a sense of touch) in which surgeons can only apply three grades of tension. Improvements in the tactile feedback of this system are expected to greatly enhance both the precision and reliability of this promising surgical system.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Chitwood R.W., Nifong L.W. Minimally invasive videoscopic mitral valve surgery: the current role of surgical robotics. J Card Surg 2000;15:61-75.[Medline]
  2. Mohr F.W., Falk V., Diegeler A., et al. Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001;121:842-853.[Abstract/Free Full Text]
  3. Hashizume M., Shimada M., Tomikawa M., et al. Initial experiences of endoscopic procedures assisted by a computer enhanced surgical system, da Vinci. Proc Int Micromach Symp 2000;6:49-52.
  4. Yim A.P.C. Video-assisted thoracoscopic management of anterior mediastinal masses. Surg Endosc 1996;112:1352-1360.
  5. Roviaro G., Rebuffat C., Varoli F., et al. Video thoracoscopic excision of mediastinal masses: indicators and technique. Ann Thorac Surg 1994;58:1679-1684.[Abstract/Free Full Text]
  6. Yoshino I., Hashizume M., Shimada M., et al. Thoracoscopic thymomectomy using the da Vinci computer enhanced surgical system. J Thorac Cardiovasc Surg 2001;122:783-784.[Free Full Text]



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