Robotic Resection of Posterior and Inferior Mediastinal Lesions: Technique and Port Placement Considerations

Robotic surgery has gained popularity among thoracic surgeons worldwide because of to its lower morbidity and shorter hospital stay compared to open thoracotomy, and similar outcomes when compared with traditional video assisted thoracic surgery (VATS) (1-5). Both robotic-assisted thoracic surgery (RATS) and VATS can be used for the resection of posterior mediastinal lesions. However, the authors believe that robotic surgery offers some advantages over VATS. 

Firstly, robotic surgery allows for optimal visualization in confined and narrow spaces, such as the posterior and lower mediastinum, which cannot be achieved with VATS. Secondly, the use of CO2 facilitates dissection and identification of structures. Additionally, robotic surgery provides three-dimensional visualization in a magnified operative field and greater articulation of robotic instruments compared to VATS.

In the case presented in the video above, the lesion was located in the left posterior and inferior mediastinum, so the patient was positioned in a right lateral decubitus position. The robot was driven parallel to the patient from the posterior and feet side (1,3). Surgeons performed a completely portal robotic resection using the four robotic arms without the assistant port. Four incisions were made: one anteriorly in the anterior axillary line, in the sixth or seventh intercostal space for portal and robotic arm four; one posteriorly in the posterior axillary line, in the same intercostal space for portal and robotic arm three; two more posteriorly, behind the tip of the scapula in the sixth or seventh intercostal space for portals and robotic arms two and one respectively. 

In this case, the sixth intercostal space was used for the two anterior ports and the seventh intercostal space for the posterior ports because of stale adherences found. The authors believe it is not necessary to use the same intercostal space for all ports and that performing the procedure efficiently and quickly is more important. Cadiere forceps were allocated in arm one, optic in the third arm, and fenestrated bipolar and Meryland bipolar forceps were installed into arms two or four depending on the need of the surgery.

After the excision of adherences, the surgeons retracted the lung anteriorly with the aid of the Cadiere forceps to expose the posterior mediastinum and identify the lesion located lateral to the aorta. A self-handmade rolled gauze was used to avoid clawing the lung. After identifying the lesion, it was separated from the main structures first, then from the lung, and then from the aorta and diaphragm. Finally, the piece was taken out with the aid of an expandable thoracoscopic bag through the most anterior incision. One 28 F chest tube was inserted in the thorax after surgery.

References

1. Limmer KK, Kernstine KH. Minimally invasive and robotic-assisted thymus resection. Thorac Surg Clin. 2011;21:69-83.
2. Shen C, Li J, Li J, Che G. Robot-assisted thoracic surgery versus video-assisted thoracic surgery for treatment of patients with thymoma: A systematic review and meta-analysis. Thorac Cancer. 2022;13(2):151-161.
3. Cerfolio RJ, Bryant AS, Minnich DJ. Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology. J Thorac Cardiovasc Surg. 2012;143(5):1138-1143. doi:10.1016/j.jtcvs.2011.12.021
4. Chen K, Zhang X, Jin R, et al. Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience. J Thorac Dis. 2020;12(2):105-113.
5. El-Akkawi AI, Eckardt J. Comparison of surgical outcomes after robotic assisted thoracic surgery, video-assisted thoracic surgery and open resection of thymoma. Mediastinum. 2021;5:11. Published 2021 Jun 25. doi:10.21037/med-20-56

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