Ann Thorac Surg 2003;75:571-573
© 2003 The Society of Thoracic Surgeons
Case report
Mediastinal mass evaluation using advanced robotic techniques
Joseph J. DeRose, Jr, MD*a,
Daniel G. Swistel, MDa,
Ali Safavi, MDa,
Cliff P. Connery, MDa,
Robert C. Ashton, Jr, MDa
a Columbia University College of Physicians and Surgeons, Department of Surgery, Division of Cardiothoracic Surgery, St. Luke’s-Roosevelt Hospital Center, New York, New York, USA
Accepted for publication August 14, 2002.
* Address reprint requests to Dr DeRose, 1090 Amsterdam Ave, Suite 7A, New York, NY 10025, USA
e-mail: jjd11{at}columbia.edu
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Abstract
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The diagnosis and management of mediastinal masses frequently necessitates biopsy and surgical resection. The use of videothorascopic techniques has broadened the surgeon’s ability to evaluate and treat such tumors using a minimally invasive approach. We describe herein the use of the da Vinci Robotic Surgical System for evaluating a mediastinal mass in a young woman.
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Introduction
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The diagnostic workup of a mediastinal mass may include modalities ranging from computed tomography (CT)-guided needle biopsy to sternotomy and resection. The importance of a preoperative diagnosis can at times be paramount in selecting surgical versus nonsurgical treatment. Both open mediastinotomy and thoracoscopy have been used effectively for diagnosing and managing mediastinal pathology. We describe the use of robotic technology as a new alternative for the evaluation and biopsy of a large mediastinal mass.A 24-year-old woman presented to the clinic complaining of right shoulder pain. A chest roentgenogram revealed a significantly widened mediastinum and CT scan revealed a large mass with both cystic and solid components extending into the right side of the chest (Fig 1).
A core needle biopsy revealed numerous lymphocytes consistent with possible lymphoma although a definitive diagnosis could not be made. The patient was referred to the thoracic surgery service for a diagnostic procedure. She was taken to the operating room and after double lumen intubation she was placed in the anterolateral thoracotomy position. A scapular roll was used to elevate the right side of the chest and the table was rotated 30° left side down. The daVinci Robotic Surgical System (Intuitive Surgical, Mountainview, CA) was positioned on the patient’s left side and was used to both evaluate the thorax and biopsy the mass (Fig 2).
A 30° thoracoscope (10-mm port) directed upwards and was placed in the fifth intercostal space in the midaxillary line and the thorax was gently insufflated with CO2 at 6 mm Hg. The right arm was positioned in the third intercostal space in the anterior axillary line and the left arm was placed in the seventh intercostal space in the anterior axillary line (5-mm ports).
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Fig 1. Computed tomography scan showing a large, heterogeneous, anterior mediastinal mass extending into the right hemithorax.
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Full three dimensional visualization of the entire thorax and mediastinum were possible with this configuration. By gentle manipulation the relationship of the mass to the superior vena cava, phrenic nerve, and esophagus were easily identified. The mass was quite heterogenous and multiple biopsies were performed. All specimens were removed from the thorax with a protective bag. The use of precise electrocautery allowed for accurate hemostasis. A single chest tube was left in place for 8 hours and the patient was discharged home 18 hours postoperatively. Final pathology study confirmed the diagnosis of mediastinal diffuse B-large cell lymphoma and the patient underwent a full cycle of chemotherapy without complication.
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Comment
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The da Vinci Robotic Surgical System is composed of an advanced thoracoscope with real three-dimensional vision and two robotic arms that are controlled by a surgeon who sits at an operating console. The multiple degrees of freedom of the robotically controlled instruments simulate the human wrist. Scaling of the motion at the surgical masters allows for very accurate operative movements within small spaces and through limited ports.
The application of robotic technology has rapidly emerged in cardiac surgery [1, 2], upper abdominal surgery [3], urologic surgery [4], and thoracic surgery [5]. Mediastinal pathology is particularly suited to a robotic, minimally invasive approach for both diagnosis and treatment. Although a Chamberlain incision can be used for the biopsy of anterior mediastinal pathology this approach is limited in both visualization and access. Videothoracoscopic techniques have been used for biopsy and resection of masses in all compartments of the mediastinum [6, 7]. Thoracoscopy allows the surgeon to visualize the entire thoracic cavity as well as to delineate important relationships between the mass and surrounding anatomic structures. Robotic technology is the next step in the advancement of already established thoracoscopic techniques in the evaluation of mediastinal masses. The improved three-dimensional vision as well as the scaled wrist-like motion of the robotic arms allow for fine operative movements. Delicate dissection around vascular structures is greatly facilitated as is the ability to suture and ligate. In the case presented, the ability to perform biopsies across the length and depth of the tumor greatly aided in the pathologic diagnosis of the lesion. The ability to control large blood vessels coursing around the tumor, with techniques similar to those used in an open operation, was an added advantage of the robotic assisted approach in this case. We believe that this transpleural approach should not be used when the diagnosis of thymoma is being entertained, as the risks of drop metastases and possible pleural seeding are very high.
Patient positioning and robotic port configuration are quite different from the standard port configuration used in thoracoscopic biopsy and resection. For anterior mediastinal pathology the right anterolateral thoracotomy position with the right hemithorax elevated and the right arm tucked and padded at the side is the most versatile. This configuration is similar to the positioning used in cardiac surgery for robotic internal mammary artery harvest. The right-sided approach can be used for most lesions in the anterior mediastinum even if there is extension into the left chest (ie, thymectomy). The left sided-approach is useful for aortopulmonary window nodes, left hilar pathology, and cardiac lesions. For lesions in the posterior mediastinum the patient should be positioned in the full posterolateral thoracotomy position and the robot should be brought in from the posterior aspect of the patient. This allows the robotic arms their full range of motion to "reach back" toward the tumor. Port placement will vary depending on the location of the lesion but a 0° telescope will allow the best visualization.
Rotic surgery allows thoracoscopic mediastinal procedures to be performed safely and efficiently owing to the improved optics and dexterity of robotic technology. It is hoped that this minimally invasive approach will be applicable to a wide range of mediastinal resection techniques as experience with robotic technology develops.
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References
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- Argenziano M., Oz M.C., DeRose J.J., et al. Totally endoscopic atrial septal defect repair with robotic assistance. Heart Surg Forum 2002;5:1-4.
- Chapman W.H., Young J.A., Albrecht R.J., Kim V.B., Nifong L.W., Chitwood W.R., Jr Robotic Nissen fundoplication: alternative surgical technique for the treatment of gastroesophageal reflux disease. J Laparoendosc Adv Surg Tech 2001;11:27-30.
- Abbou C.C., Hoznek A., Salomon L., et al. Laparoscopic radical prostatectomy with a remote controlled robot. J Urol 2001;165:1964-1966.[Medline]
- Ashton RC Jr, McGinnis K, Connery CP, et al. Totally endoscopic robotic thymectomy for myasthenia gravis. Ann Thorac Surg 2003;75:569–71
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Abstract
Introduction
