Endoscopic Robotic Atrial Myxoma Resection with an 8mm Working Port and Percutaneous Cannulation

Previous reports have demonstrated the safety and efficacy of the robotic platform in minimally invasive atrial myxoma resection (1,4). This video presents possibly the least invasive reported atrial myxoma resection and the first to utilize an endoscopic robotic approach with an 8mm working port. 

There are various technical aspects of the procedure, including the use of a small 8mm working port, cryoanesthesia for intercostal nerve blocks to reduce postoperative pain, endoballoon and percutaneous cannulation to facilitate cardiopulmonary bypass, and nonresorbable V-Loc™ sutures for left atrial and pericardial closure. 

The patient was a sixty-one-year-old male with a recent episode of self-resolving atrial fibrillation and accompanying near-syncope who had no significant comorbidities. A transthoracic echocardiogram and cardiac MRI identified a 2.6cm left atrial mass, suspected to be a myxoma, attached to the interatrial septum. 

Five 8mm ports were placed, including a camera port in the 4th/5th intercostal space just anterior to the anterior axillary line; robotic left arm, right arm, and atrial retractor ports; and an air seal working port. Three 14-gauge angiocatheters were placed through the right lateral chest wall to allow for suture exteriorization, and a 12-French peel away sheath was used to place a cardiac sump drain into the right pleural space via the Seldinger technique. 

Percutaneous cardiopulmonary bypass (CPB) was established with a 26 French femoral venous cannula with the tip in the superior vena cava and a 23 French femoral arterial cannula. The endoballoon was placed through the arterial cannula side port, and the right superior vena cava was cannulated with a 19 French drainage catheter connected to the venous side of the bypass circuit. 

A figure-of-eight suture was placed through the tendon of the right hemidiaphragm to minimize the chance of diaphragmatic injury and improve exposure. Cryoablation of the R intercostal nerves was then performed from T3 to T8, staying less than 5cm lateral to the spine, with two minutes at –60 degrees Celsius. 

The pericardium was then opened. Two CV-2 GORE-TEX® pericardial retraction sutures were placed and exteriorized through the 14-gauge angiocatheters. The heart was then arrested with the endoballoon using transesophageal echocardiogram guidance and Firefly™ fluorescence imaging. A left atriotomy was performed in Waterson’s groove, and the left atrial myxoma was then resected by shaving the endocardium from the interatrial septum at the base of the tumor stalk. The left atriotomy was closed using two nonresorbable 3-0 V-Loc™ sutures, which were started at each side and run to the middle. 

After endoballoon deflation, a ventricular pacing wire was placed and exteriorized out of the left atrial retraction port. The pericardium was reapproximated with 3-0 nonresorbable V-Loc™ sutures. The surgeon then returned to the bedside to complete decannulation and port site closure. 

References

1. Gao et al. Excision of atrial myxoma using robotic technology. J Thorac Cardiovasc Surg 2010;139(5):1282-5. doi: 10.1016/j.jtcvs.2009.09.013.
2. Schilling et al. Robotic excision of atrial myxoma. J Card Surg. 2012 Jul;27(4):423-6. doi: 10.1111/j.1540-8191.2012.01478.x.
3. Yang et al. Comparison of postoperative quality of life for patients who undergo atrial myxoma excision with robotically assisted versus conventional surgery. J Thorac Cardiovasc Surg. 2015;150(1):152-157. doi: 10.1016/j.jtcvs.2015.01.056.
4. Ribeiro et al. Robotically-Assisted Myxoma Resection: Tips and Tricks. June 2020. doi: 10.25373/ctsnet.12448781.

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