Nicola SANTELMO

In this key lecture, Dr. Liverneaux covers the use of robots for microsurgery.

This is the case of a robotic left upper lobectomy with lymphadenectomy in a woman aged 52 who has had 9 children and who was a regular smoker (50 packs per year). She is presenting with an isolated cT1N0M0 adenocarcinoma in the left upper pulmonary lobe. PET-scan was positive for the lesion without any other pathological finding in the mediastinum or far metastasis. Histology was obtained by CT-guided transthoracic needle aspiration biopsy.
This minimally invasive technique, assisted by the da Vinci® robotic surgical system, is sure, comfortable, and efficient to perform a pulmonary lobectomy with lymphadenectomy in the early stages of lung cancer.
3D vision and the accuracy of dissection appear to be better than in conventional VATS.
As in VATS lobectomy, hospital stay is reduced to 3-4 days and postoperative pain appears to be more acceptable.

This is the case of a 52-year-old obese woman, with no prior surgical history, presenting with a 1.5cm tumor-like nodule in the right upper lobe which was demonstrated on PET-scan. The lesion demonstrated on PET-scan and staging work-up indicated a cT1N0M0 tumor. A wedge resection with extemporaneous biopsy is decided upon. An upper right lobectomy with lymphadenectomy using thoracoscopy with the help of the da Vinci® surgical robotic system.

This film presents the case of a 20-year-old woman with myasthenia gravis in whom a robot-assisted left video-thoracoscopic thymectomy was performed.
This minimally invasive procedure is particularly appropriate in case of thymic hyperplasia without thymoma and very well accepted by patients. Consequently, neurologists think about thymectomy more easily even if results in terms of myasthenia gravis improvement are similar to those obtained by sternotomy.

This is the case of a 69-year-old woman presenting with primary hyperparathyroidism and mediastinal parathyroid adenoma as demonstrated by imaging studies and 3D reconstruction.
After cervical exploration of four normal glands, a left thoracoscopy was performed with robotic assistance.
After removing some mediastinal fat, localization guided by 3D imaging studies was easy and safe.
Three days of hospital stay were necessary and biological findings were normal at discharge.

We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

Symptoms are generalized to her four arms. Anti-acetylcholine antibodies and the therapeutic test of Mestinon® (Pyridostigmine) are positive.
In recent months, her symptoms worsened with the onset of swallowing disorders.

Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia.
Thymectomy is indicated. To do so, a left thoracoscopy is performed and assisted by means of the Da Vinci™ robot.

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy, which is the standard technique. When compared to thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements, and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.

We present the case of a 78-year-old woman with a typical carcinoid tumor of the middle lobe of the lung. Bronchoscopy was carried out. A tumor lying in the deep segment of the middle lobe bronchus was identified by biopsy as a typical carcinoid tumor. We decided to perform middle lobectomy using a four-arm robotic assistance as it allows for a minimally invasive surgery.

The patient is intubated with a double lumen tracheal tube. The patient is placed in a left-sided decubitus with the right arm hanging. Anesthesiologists and mechanical ventilation need to be placed on the patient’s right side. This will provide sufficient room to approach the robot on the left side with a 30-degree angulation to the patient’s head.

The robotic procedure was uneventful and was fully carried out. Chest tube drainage was removed on postoperative day 2 and the patient was discharged on postoperative day 7.

We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.