Chest wall resection with robotic-assisted thoracoscopic surgery for a Pancoast tumour: a case report.

We describe a rare procedure involving near-total robotic-assisted thoracoscopic surgery resection of a right posterior Pancoast tumour. Four ports and an assistant port were used. The DaVinci X system was used. The lobectomy was performed first to allow for adequate exposure to the apex and spine. The lateral aspect of ribs 1 to 4 was resected next, and the extrathoracic space was entered. Dissection proceeded through this space superiorly up to the level of the scapula and then posteriorly towards the spine. The second to the fifth ribs were dissected off the chest wall and resected medially off the spine at the rib heads. Further postero-superior exploration revealed the tumour to be invading the transverse process of the second rib, with ill-defined margins. Because of this development, and with the support of the spinal surgeons, a small high posterior thoracotomy was performed to complete the procedure and remove the specimen en bloc. The postoperative recovery was uneventful, and the patient was discharged on post-operative day 5. The final histological report confirmed a squamous non-small-cell lung cancer (pT3N0M0) with negative margins (R0). Asymptomatic recurrence was noted near the margin of the second rib resection posteriorly 1 year postoperatively and was successfully treated with radiotherapy.

Right robotic S4 segmentectomy.

Among the various segmentectomy procedures performed for lung diseases, the right S4 segmentectomy stands out as an exceptionally rare operation. Its infrequent occurrence can be attributed to several factors, including the relatively lower incidence of pathologies necessitating isolated resection of the S4 segment of the right lung. This video tutorial showcases the robotic approach to the rare right S4 segmentectomy, guiding surgeons through the step-by-step procedures for better understanding and proficiency.

Robotic resection of anterior mediastinal masses >10 cm: a case series.

Background: Robot-assisted thoracic surgery (RATS) for intrathoracic pathology and especially for mediastinal mass resection has been increasingly accepted as an alternative method to open sternotomy and video-assisted thoracic surgery (VATS). However, the utilization of this approach for complex and advanced in size cases needs more clinical evidence. We are presenting a series of 4 patients who had resection of >10 cm mediastinal masses via RATS. Cases Description: The mean age was 76.25±10.3 years and 3 were males (75%). All masses were positron emission tomography (PET) positive, and 1 patient had positive Acetyl-cholinesterase antibodies and myasthenia gravis (MG). All patients underwent RATS resection via DaVinci® X system. The dissections were conducted with spatula and/or Maryland bipolar forceps. In 2 cases, the resection was done with bilateral docking, and in 1 case, a drain was not inserted at the end. In 1 patient, pericardial resection was necessitated. All masses were thymomas with 1 dimension measured >10 cm on pathology. All patients were discharged on day 1 or 2 postoperatively with uneventful recoveries. There was no in-hospital, 30- or 90-day mortality. All patients were found to be without issues on follow-up. Conclusions: This report shows that RATS is safe and can be offered in the management of >10 cm anterior mediastinal masses. The previous size limit of the tumor for minimally invasive and especially RATS approach of 5 cm should be challenged.

Hemiclamshell approach for left pneumonectomy.

Hemiclamshell and clamshell incisions were virtually forgotten since the introduction to cardiac surgery of median sternotomy and the exhilarating advances in minimally invasive thoracic surgery. However, in rare clinical scenarios, as in large, space-occupying lesions in thoracic cavity, the surgeon will resort to a clamshell or a hemiclamshell approach to achieve complete exposure and remove a large mass from the thoracic cavity. In this video tutorial, we demonstrate the operative steps of the hemiclamshell approach in a clinical scenario for a left pneumonectomy for T4N1M0 non-small-cell lung cancer.

Complex bronchial ruptures in blunt thoracic trauma: management and outcome.

Complex bronchial ruptures are rare. Primary surgical repair is the preferred procedure. The aim of this retrospective case series was to study the clinical presentation of these complex bronchial injuries and their management and outcomes. Patients with injuries to the trachea or those who had simple single bronchial rupture and isolated lobar and segmental injuries were excluded. Twenty-one patients were operated for bronchial rupture due to blunt chest trauma. Seven patients had complex bronchial injuries and had right bronchial tree injury (n = 3), left bronchial tree injury (n = 3), and rupture of both right and left main bronchi (n = 1). Fibreoptic bronchoscopy established the diagnosis in all patients. Postoperative complications included atelectasis in four patients (57%) and left recurrent laryngeal nerve paralysis (n = 1; 14.3%), and one patient required tracheostomy (14.3%). All patients had follow-up bronchoscopy 2 months later, which showed no stenosis or scar formation in any of the patients. We concluded that primary repair of complex bronchial injuries, with preservation of the normal functioning lung, is the preferred option as it carries favorable immediate- and long-term results.

Prosthesis-Patient Mismatch Increases Early and Late Mortality in Low Risk Aortic Valve Replacement.

The concept of prosthesis-patient mismatch (PPM) has gained much attention since first described 40 years ago. Previous studies have shown conflicting evidence regarding increased early and late morbidity and mortality with PPM after aortic valve replacement (AVR). The aim of this study was to evaluate the effects of PPM on short- and long-term mortality in low-risk patients after isolated AVR. A retrospective, single-center study involving 1707 consecutive patients ≤80 years of age with preserved left ventricular systolic function who underwent elective, primary isolated AVR operations from 2008 to 2018. Patients were stratified into 2 groups according to the presence of PPM (n = 96), defined as effective orifice area index <0.85 cm2/m2 body surface area, and no-PPM (n = 1611). The effect of PPM on mortality was evaluated with univariate and multivariate analyses. 30-day mortality was 0.8% (4.2% in PPM group vs 0.6 in no-PPM group; P = 0.005). PPM occurred more in female gender, obese and older patients. PPM was highly associated with long-term all-cause mortality (median 4 years [Q1-Q3 2-7]; HR: 1.79, 95% CI: 1.27-2.55, P = 0.002), and remained strongly and independently associated after adjustment for other risk factors (HR: 1.60, 95% CI: 1.10-2.34, P = 0.014). In propensity score-matched analysis, the adjusted mortality risk was higher in PPM group (HR: 2.03, 95% CI: 1.22-3.39, P = 0.006) compared to no-PPM group. In a single-centre observational study, PPM increased early mortality and was independently associated with long-term all-cause mortality after low-risk, primary isolated AVR operations. Strategies to avoid PPM should be explored and implemented.

Clamshell incision approach for giant teratoma.

The clamshell incision (also known as a transverse or crossbow transsternal incision) was the common approach to the heart in the early days of cardiac surgery and was occasionally also used to access mediastinal tumors or both lungs. However, with the introduction of the median sternotomy, the clamshell incision was virtually forgotten, except for cardiothoracic trauma and double lung transplant. However, in rare situations, such as in large space-occupying lesions in the mediastinum, surgeons will resort to the clamshell approach to achieve exposure and complete resection.  In this video tutorial, we demonstrate the operative steps for using the clamshell approach in one of those rare clinical scenarios. The resected mass was a giant mediastinal teratoma measuring 21 x 27 x 6 cm.

Surgical ventricular restoration.

Left ventricular restoration surgery is a procedure designed to restore or remodel the left ventricle to its normal spherical shape and size in patients with akinetic segments of the heart, secondary to either dilated cardiomyopathy or post­infarction left ventricular aneurysm.  In this video tutorial, we present the operative technique for left ventricular restoration in the case of a 61-year-old male who developed a large left ventricular aneurysm a few months after delayed presentation of an occluded left anterior descending artery and subsequent myocardial infarction.

Management of idiopathic chylopericardium in Pregnant Patient.

Idiopathic chylopericardium in pregnancy is extremely rare and poses difficulties in both decision-making and timing of surgery. A young lady who was 24-weeks pregnant presented with chylopericardium and increasing shortness of breath. Repeated nonsurgical interventions failed to resolve her pathology. She underwent thoracoscopic pericardial window formation and thoracic duct ligation, and made a satisfactory recovery.