Ann Thorac Surg 2003;75:1953-1955
© 2003 The Society of Thoracic Surgeons
Case report
Resection of a symptomatic pericardial cyst using the computer-enhanced Da VinciTM surgical system
Matthew D. Bacchetta, MDa,
Robert J. Korst, MDa,
Nasser K. Altorki, MDa,
Jeffrey L. Port, MDa,
O. Wayne Isom, MDa,
Charles A. Mack, MDa*
a Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
Accepted for publication November 26, 2002.
* Address reprint requests to Dr Mack, Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, M-404, 525 E 68th St, New York, NY 10021, USA
e-mail: cmack{at}med.cornell.edu
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Abstract
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Traditionally, symptomatic pericardial cysts have been treated with thoracotomy and resection. More recently, video-assisted thoracoscopic procedures for pericardial cysts have been reported. We present the case of a 43-year-old man who was suffering from a symptomatic pericardial cyst. He underwent successful resection using a computer-enhanced robotic surgical system. This case is an example of the continued extension of robotic-assisted thoracic surgery.
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Introduction
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Robotic technology using computer-enhanced surgical systems has been used in a wide range of surgical specialties including cardiac surgery, general surgery, and general thoracic surgery [1–4]. Mohr and colleagues [1] and Chitwood and Nifong [2] have demonstrated feasibility and safety of off-pump and on-pump coronary artery bypass grafting and mitral valve repair using a robotic approach. The potential advantage of this technology in general thoracic surgery is the ability to perform larger resections such as esophagectomy and pulmonary resection that are difficult to perform with a traditional video-assisted thoracic surgery (VATS) approach, as well as selected cases that require superior dexterity. We therefore present a case report of a computer-enhanced robotic resection of a symptomatic pericardial cyst.
A 43-year-old man reported several episodes of left pleuritic chest pain. He denied palpitations, syncope, or exertionally provoked symptoms. He maintained an active, athletic lifestyle, and his medical and surgical history was remarkable only for mild hypertension and slightly elevated cholesterol. A stress electrocardiogram and technetium-99m sestamibi cardiac scan revealed excellent performance with no evidence of myocardial ischemia. A chest roentgenogram showed a large opacity in the left hemithorax, and computed tomography scan revealed a 5-cm x 6-cm cystic lesion abutting the left ventricle (Fig 1).
Given the symptomatic nature of this lesion, he was referred for surgical evaluation.
The patient underwent robotic surgical resection using the da VinciTM Surgical System (Intuitive Surgical, Mountainview, CA). The patient was intubated with a double-lumen endobronchial tube and placed in the full right lateral decubitus position. Three port incisions were performed to permit maximal exposure and maneuverability of the robotic arms (Fig 2).
The robotic camera (Intuitive Surgical) was inserted first to evaluate the pleural space and guide port placement for each of the two robotic arms. The cyst was easily identified and dissected free of the pericardium using electrocautery (EndowristTM; Intuitive Surgical). No pericardial communication was identified. The phrenic nerve was easily identified and preserved without injury. After freeing the cyst from its attachments, it was placed in an endoscopic specimen bag and aspirated to facilitate its removal from the thorax. A single chest tube was inserted through the inferior port site. The total robotic dissection time was 15 minutes, and total operative time was less than 1 hour. He was extubated in the operating room. The final pathologic report revealed a pericardial cyst, which was lined with mesothelial cells. The cystic aspirate was negative for malignant cells, showing only limited inflammatory cells.
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Fig 2. The robotic camera was placed in the posterior axillary line (middle port), while the remaining two ports (left robotic arm and right robotic arm) were triangulated to facilitate exposure and robotic arm movement.
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The patient had an unremarkable postoperative course. The chest tube was removed the morning after surgery, and he was discharged from the hospital that afternoon, less than 24 hours after the completion of his surgery. Within 10 days the patient resumed a full work schedule and exercise routine including running up to 4 miles per day. Five months after the procedure, the patient reports no wound complications, shortness of breath, or pain.
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Comment
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Small, asymptomatic pericardial cysts, which usually pose no immediate threat to critical thoracic structures, may be managed nonoperatively with observation. However, large or symptomatic cysts should undergo surgical resection. Before the development of VATS, a thoracotomy was required to resect these lesions. With the advent of VATS, successful thoracoscopic resection of pericardial cysts has been reported [5]. A minimally invasive approach offers potential advantages with regard to length of hospital stay, recovery period, and morbidity relative to an open thoracotomy.
This report of robotic resection of a pericardial cyst illustrates several advantages of a computer-enhanced robotic approach over conventional VATS. First, the EndowristTM technology incorporates articulating instruments, which provide six degrees of freedom, enabling suturing and knot tying to be performed with relative ease and allowing the surgeon to be ambidextrous, whereas the standard VATS instruments only provide four degrees of freedom. In our case this facilitated the dissection of an avascular plane and ensured there was no communication with the pericardium. Second, computer technology eliminates tremor and provides scaling of motion that enhances tissue manipulation. Third, the computer-enhanced three-dimensional vision system allows direct hand-eye coordination while always maintaining orientational alignment. In our case this improved our ability to identify the phrenic nerve and other critical mediastinal structures. By performing this procedure using robotic technology, the duration of dissection was limited to 15 minutes, which is shorter than our experience using VATS.
Despite many advantages over VATS, robotic technology may have some disadvantages. Robotic technology is very expensive when compared with conventional VATS equipment, rendering it unavailable in many centers at the present time. Also, despite the major advances in dexterity and three-dimensional optics with the robotic technology, there is still the lack of tactile feedback that affects the ability to palpate tissue. Lastly, like any new technology, the setup of equipment for robotically assisted procedures may be more time-consuming than either open or VATS procedures, particularly early on in the learning curve.
Improvements in computer-enhanced robotic technology are anticipated such as newer-generation systems that are smaller, easier to set up, and more competitively priced. Further refinements such as tactile feedback, which will further enhance tissue handling, knot tying, and suturing, are anticipated. In addition, a fourth robotic arm to simulate an assistant will be necessary to perform more complex cases. The advantages of robotic pericardial cyst resection as demonstrated in this case and the anticipated improvements in robotic technology support the continued use of robotic technology in general thoracic surgery.
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References
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- Mohr F.W., Volkmar F., 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]
- Chitwood W.R., Nifong L.W. Minimally invasive videoscopic mitral valve surgery: the current role of surgical robotics. J Card Surg 2000;15:61-75.[Medline]
- Kim V.B., Chapman W.H., Albrecht R.J. Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using da Vinci. Surg Laparosc Endosc Percutan Tech 2002;12:33-40.[Medline]
- Yoshino I., Hashizume M., Shimada M., Tomikawa M., Sugimachi K. Video-assisted thoracoscopic extirpation of a posterior mediastinal mass using the da Vinci computer enhanced surgical system. Ann Thorac Surg 2002;74:1235-1237.[Abstract/Free Full Text]
- Weder W., Klotz H.P., von Segesser L., Largiader F. Thoracoscopic resection of a pericardial cyst: a case report. J Thorac Cardiovasc Surg 1994;107:313-314.[Free Full Text]
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Abstract
Introduction
