Bronchial stump reinforcement with an azygous vein flap

Bronchial stump reinforcement has been shown to significantly reduce the incidence of bronchopleural fistulas. Various coverage techniques have been described in the literature. While the azygous vein flap is an easy, safe and effective reinforcement option for right-sided bronchial stumps, the flap is not widely adopted, with little mention in the literature, partly due to surgeons' uneasiness with the technique. In this report, we describe an easy-to-adopt approach to azygous vein bronchial reinforcement

Novel thoracoscopic approach to posterior mediastinal goiters: report of two cases

Trans-cervical resection of posterior mediastinal goiters is usually very difficult, requiring a high thoracotomy. Until recently, using conventional video-assisted thoracoscopic surgery to resect such tumors has been technically difficult and unsafe. By virtue of 3 dimensional visualization, greater dexterity, and more accurate dissection, the Da Vinci robot, for the first time, enables a completely minimally invasive approach to the posterior superior mediastinum

Pain management following robotic thoracic surgery

For robotic thoracic surgical patients, minimizing pulmonary complications is the key to decreasing morbidity. Once the pain is controlled, the morbidity associated with thoracic surgery is decreased. Consequently, control of pain is the core requirement in robotic thoracic surgical patients. Appropriate pain control depends on a multifaceted program that is based on an understanding of the pathophysiology of pain. A multifaceted pain control program after robotic surgery needs to address local and systemic pain pathways. This review outlines such a multifaceted program with the use of subpleural catheters for prolonged ambulatory infusion of local anesthetic for 10 days, nonsteroidal anti-inflammatory agents, and measured use of narcotic analgesics

Robotic selective thoracic sympathectomy for hyperhidrosis

Aim: Thoracic sympathectomy is indicated in patients with upper extremity hyperhidrosis. The success of dorsal thoracic sympathectomy is judged by the rates of relief of hyperhidrosis, recurrence, and compensatory hyperhidrosis. We studied robotic selective sympathectomy (RSS) directed at the division of the preganglionic and postganglionic rami without interruption of the sympathetic chain.Methods: During RSS, the preganglionic and postganglionic sympathetic fibers and communicating rami to intercostal nerves 2, 3, and 4 are divided. The sympathetic chain is left intact.Results: Forty-seven patients underwent RSS. RSS was performed in a staged fashion with the more symptomatic side first, followed by the contralateral side after at least four weeks. Mean operative time was 67 ± 13 min for unilateral RSS. There was no conversion to thoracotomy. The mean increase in ipsilateral palmar temperature was 1.2 ± 0.3 °C. Median hospital stay was three days (range 1-4 days). Complications included transient heart block after sympathectomy on the second side in 1/47 (2%) and transient partial Horner’s syndrome which resolved in two weeks in 1/47 (2%). There was no permanent Horner’s syndrome. Relief of hyperhidrosis was seen in 98% of patients. At a mean follow up of 28 ± 6 months, 46/47 (98%) patients were free of sustained compensatory hyperhidrosis.Conclusion: RSS is associated with excellent relief of hyperhidrosis and the lowest reported rate of compensatory hyperhidrosis

The technique of robotic lobectomy II: left sided lobes

Robotic lobectomy has been evolving over the past decade and has been shown to be an oncologically efficacious procedure. The Technique of Robotic Lobectomy I outlined the stepwise approach to robotic lobectomy of the right upper, right middle and right lower lobes. This paper outlines the stepwise technical approach to robotic lobectomy of the left upper and lower lobes. The accompanying paper, Technique of Robotic Lobectomy III: Control of Bleeding Complications, outlines a methodical technical approach for the control of catastrophic bleeding complications

Minimally invasive surgical approaches to thoracic sympathectomy for hyperhidrosis

Thoracic sympathectomy is used for the palliation of hyperhidrosis. However, significant controversies surround the optimal surgical approach and the extent of sympathectomy. The determinants of success in the surgical palliation of hyperhidrosis are the postoperative rate of anhidrosis, recurrence of symptoms, and rate of compensatory hyperhidrosis. This paper attempts to shed light on the controversies by examining the historic background, clearly defining the anatomic considerations, and outlining the various surgical approaches culminating with robotic selective dorsal thoracic sympathectomy

The technique of robotic anatomic pulmonary segmentectomy I: right sided segments

Anatomic pulmonary segmentectomy and mediastinal nodal dissection have been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall five-year survival and lung cancer-specific five-year survival following anatomic segmentectomy have been shown to be equivalent to lobectomy. Robotic surgical systems have the advantage of magnified high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. Robotics can facilitate the dissection of the broncho-vascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible technique. The Technique of Robotic Anatomic Segmentectomy Part I outlines a stepwise approach to robotic segmentectomy of S1, S2, S3, S4, S5, S6, and S7-S10 of the right lung. The Technique of Robotic Anatomic Segmentectomy Part II outlines a stepwise approach to robotic segmentectomy to the left lung

Technique of robotic lobectomy III: control of major vascular injury, the 5 “P”’s

Robotic Lobectomy has been evolving over the past decade and has been shown to be an oncologically efficacious procedure. Although robotic lobectomy is performed more frequently in centers around the world, it accounts for a small percentage of all lobectomies. One of the major causes of reluctance to adopt robotic lobectomy and segmentectomy procedures by surgeons is the fear of bleeding complications, as well as the lack of a standardized reproducible approach to these potentially catastrophic events. This paper outlines a proven strategy for control of bleeding complications during robotic lobectomy and segmentectomy procedures: the 5 “P”’s of Prevention, Preparedness, Poise, Pressure, and Proximal Control

The technique of robotic anatomic pulmonary segmentectomy II: left sided segments

Anatomic pulmonary segmentectomy and mediastinal nodal dissection has been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall 5-year survival and the lung cancer-specific 5-year survival following anatomic segmentectomy have been shown to be equivalent to that of lobectomy. Robotic surgical systems have the advantage of magnified, high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. These robotic systems can facilitate the dissection of the bronchovascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible anatomic segmentectomy technique. This is a companion paper to The Technique of Robotic Anatomic Segmentectomy I: Right Sided Segments. This paper outlines the technique of anatomic pulmonary segmentectomy for the left lung: Left Upper Lobe (LUL) Anterior Segment (S3), LUL Apicoposterior Segment (S1 + S2), LUL Lingulectomy (S4, S5), Left Lower Lobe (LLL) Superior Segmentectomy (S6), and LLL Basal Segmentectomy (S7-S10)

The technique of robotic lobectomy I: right-sided lobes

Robotic Lobectomy has been evolving over the past decade and is an oncologically efficacious procedure. Although robotic lobectomy is performed more frequently around the world, it accounts for a small percentage of all lobectomies. The major determinants for the lower level of adoption of the robotic lobectomy procedure are 1. The lack of concise step by step procedure outlines for the surgeons who are transitioning from either open or video-assisted thoracic surgical procedures to robotics, or 2. A strategy for control of catastrophic bleeding during the robotic lobectomy procedure. The Technique of Robotic Lobectomy Part I outlines a stepwise approach to robotic lobectomy for the right upper, middle, and lower lobes. Part II outlines a stepwise approach to robotic lobectomy for left upper, and lower lobes. Part III outlines a methodical technical approach for the control of catastrophic bleeding complications