Video-assisted thoracic surgery and robotic-assisted first-rib excision and thoracic outlet syndrome decompression.

Multiple surgical approaches have been used in the management of thoracic outlet syndrome. These approaches have traditionally been "open" approaches and have been associated with the inherent morbidities of an open approach, including a risk of injury to the neurovascular structures due to traction and trauma while resecting the first rib. In addition, there has been concern that recurrence of symptoms may be related to incomplete resection of the rib with conventional open techniques. With the advent of minimally invasive thoracic surgery, surgeons began to explore first-rib resection via a thoracoscopic approach. Unfortunately, the existing video-assisted thoracic surgery technology and equipment was not well suited to working in the apex of the chest. With the introduction and subsequent progress in robotic surgery and instrumentation, this dissection can be performed with all the advantages of robotics, but also with minimal traction and trauma to the neurovascular structures, and incorporates almost complete resection of the rib with minimal residual stump. Robotics has developed as a reliable, safe, and less invasive approach to first-rib resection, yielding excellent results while limiting the morbidity of the procedure.

Robotic selective postganglionic thoracic sympathectomy for the treatment of hyperhidrosis.

BACKGROUND: The surgical management of hyperhidrosis is controversial. Robotic surgical systems with their high-definition magnified 3-dimensional view and increased maneuverability in a confined space may facilitate the technique of selective sympathectomy (ramicotomy). We present a case series of patients undergoing selective postganglionic thoracic sympathectomy using robotic technology. METHODS: This study is a case series analysis of patients who underwent selective postganglionic thoracic sympathectomy from July 2006 to November 2011. The operation was performed on a video-assisted thoracoscopic surgery (VATS) platform. The robot was used for pleural dissection and division of the postganglionic sympathetic fibers and the communicating rami. The success of sympathectomy was assessed by intraoperative temperature measurement of the ipsilateral upper extremity, patient interviews, and scoring of the symptomatic nature of hyperhidrosis based on the Hyperhidrosis Disease Severity Scale. RESULTS: There were 110 sympathectomies performed in 55 patients (25 men, 30 women). Simultaneous bilateral sympathectomy was performed in all patients. Median age was 28 years (range, 16 to 65 years). There was no conversion to thoracotomy. Complications were minor and were seen in 5 of 55 patients (9%). There were no deaths. Median hospital stay was 1 day (range, 1 to 4 days). Of the 55 patients, 53 (96%) had sustained relief of their hyperhidrosis at a median follow-up of 24 months (range, 3 to 36 months), and compensatory sweating was seen in 4 patients (7.2%). CONCLUSIONS: Robotic thoracoscopic selective sympathectomy is an effective, feasible, and safe procedure with excellent relief of hyperhidrosis and low rates of compensatory sweating and complications.

The learning curve of robotic lobectomy.

BACKGROUND: Robotic lobectomy has been shown to be feasible, safe and oncologically efficacious. The actual learning curve of robotic lobectomy has yet to be defined. This study was designed to define the learning curve of robotic lobectomy. METHODS: We performed a retrospective review of prospectively accrued patients at our institution who underwent robotic lobectomy from January 2004 until December 2011. Six scatter graphs were constructed, comparing operative time, conversion rate, morbidity, mortality, length of stay and surgeon comfort with the number of consecutive cases. In each graph, a regression trendline was drawn and the change in the slope of the curve corresponding to the beginning of the plateau defined the learning curve. The overall learning curve was defined as mean ± SD of the sum of the individual learning curves. RESULTS: Based on operative times, mortality and surgeon comfort, the overall learning curve was 18 ± 3 cases. The learning curve based on operative times, mortality and surgeon comfort was 15, 20 and 19 cases, respectively. There was no association between the need for conversion and number of consecutive cases. There was a trend towards lower morbidity and decreased length of stay with greater experience. However, these parameters did not define a specific learning curve. CONCLUSIONS: Operative time, mortality and surgeon comfort were found to be key parameters for the learning curve of robotic lobectomy when performed by surgeons who are experienced with video-assisted thoracic surgery (VATS). The learning curve was 18 ± 3 cases.

Eating disorders in men: underdiagnosed, undertreated, and misunderstood.

This article provides a survey of eating disorders in men, highlights the dramatic rise in eating disorders, identifies issues specific to males, and suggests areas for research and intervention. This survey concludes that men with eating disorders are currently under-diagnosed, undertreated, and misunderstood by many clinicians who encounter them. Ongoing research addressing these issues is expected to result in assessment tools and treatment interventions that will advance positive outcomes for men with eating disorders.

Robotic-assisted treatment of celiac artery compression syndrome: report of a case and review of the literature.

BACKGROUND: The surgical management of celiac artery compression syndrome (CACS) is controversial. Controversies include the appropriate surgical technique, the surgical approach, and the utility of postoperative stents. The literature is reviewed, and a case of CACS is presented in which a robotic-assisted division of the median arcuate ligament (MAL) was performed. METHODS: Robotic-assisted treatment of celiac artery syndrome was carried out using six (five 1 cm and one 2 cm) abdominal incisions. The robotic device was used to expose the aorta and celiac artery and divide the median arcuate ligament. RESULTS: Postoperatively, the patient's postprandial abdominal pain subsided. On 16 month follow-up, the patient was doing well, tolerated an unrestricted diet without symptoms, and exhibited weight gain. CONCLUSION: This case is the second reported in the literature and demonstrates that the robotic approach to division of the MAL is feasible, safe, and efficacious.

Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results.

OBJECTIVE: First-rib resection is a key component of the treatment of Paget-Schroetter disease. There are many controversies regarding the management of this disease. We report a safe, effective, minimally invasive robotic transthoracic approach for resection of the first rib. METHODS: Over an 8-month period, five patients underwent robotic first-rib resection. Preoperative assessment included physical examination and bilateral venous angiography. On a thoracoscopic platform using three 2-cm incisions and one 1-cm incision, the robot was used to dissect the first rib and divide the scalene muscles. Success of the first-rib resection was assessed by postoperative venous angiography. RESULTS: There were four men and one woman. Mean age was 34.6 ± 10 years. Mean operative time was 195 ± 24.6 minutes. There were no complications and no mortality. All patients had a patent subclavian vein on the postoperative venogram and were anticoagulated with warfarin for 3 months. At a median follow-up of 12 months, all patients had an open subclavian vein for a patency rate of 100%. CONCLUSIONS: Robotic thoracoscopic first-rib resection represents a feasible minimally invasive approach to en bloc resection of the first rib. This technique minimizes the risk of neurovascular complications that are associated with conventional techniques.

Proposed pathogenesis of Paget-Schroetter disease: impingement of the subclavian vein by a congenitally malformed bony tubercle on the first rib.

AIM: To study and compare the anatomical and clinical pathology of first ribs in patients with Paget-Schroetter Disease (PSD) with first ribs in patients without the disease. METHODS: In a case-control study, normal human cadaver first ribs were compared with first ribs from patients with PSD. Ribs, intraoperative videos of transthoracic en bloc surgical resection of the first rib, and preoperative and postoperative dynamic upper extremity venograms were reviewed. RESULTS: Fifteen first ribs were from patients with PSD and seven normal first ribs were from human cadavers. In all patients (100%) with PSD there was a bony tubercle that corresponded to the area of the subclavian vein groove in the normal ribs. In all controls (100%), there was a normal subclavian groove without the presence of a tubercle. On preoperative venograms in patients with PSD, the tubercle accounted for an extrinsic protuberance that compressed the subclavian vein (100%). Intraoperatively, the abnormal bony tubercle accounted for the extrinsic compression of the subclavian vein in all (100%) patients with PSD. Venograms of the upper extremity obtained after first rib resection showed the disappearance of the extrinsic compression on the subclavian vein (100%) and a patent subclavian vein with elevation of the arm in all patients. CONCLUSIONS: A bony tubercle at the site of the subclavian vein groove in patients with PSD causes extrinsic compression of the subclavian vein at rest.

Novel thoracoscopic approach to difficult posterior mediastinal tumors.

Thoracoscopic resection is the preferred treatment of posterior mediastinal tumors. However, thoracotomy may be necessary if the tumors are large or adherent; if they are demonstrate invasion or intraspinal growth; or if they are located in the superoposterior mediastinum or posterior costodiaphragmatic angle. We describe a case of a large, adherent posterior costodiaphragmatic mediastinal mass that would have been otherwise difficult to resect thoracoscopically if it were not for the three-dimensional visualization, greater dexterity, and accurate dissection offered by the Da Vinci robot.

Post-esophagectomy pseudomembranous inflammation of the interposed colon.

BACKGROUND: Pseudomembranous colitis (PMC) usually is caused by antibiotic-related changes in colonic anaerobic microflora, leading to Clostridium difficile overgrowth and overproduction of toxins. We present the first reported case of PMC affecting the intrathoracic, interposed colon of an esophagectomy patient in the absence of inflammation of the in situ colon. METHODS: Case report and review of pertinent English-language literature. CASE REPORT: A 47 year-old male developed Clostridium difficile-related colitis after in Ivor-Lewis esophagectomy for carcinoma of the esophagus, and rendered asymptomatic after 10 days of therapy with oral vancomycin. Postoperatively, the patient developed a broncho-esophageal fistula, and was reconstructed with a two-stage colonic esophageal colonic interposition three months after the fistula was closed surgically. On postoperative day nine, the patient developed symptomatic PMC of the interposed colon segment, whereas the in situ colon was spared. Therapy with oral vancomycin for three weeks eradicated the infection. CONCLUSIONS: Pseudomembranous colitismay develop in the interposed colon after a esophageal colonic interposition, even absent inflammation of the in situ colon. Previous infection with C. difficile may have increased the risk in this patient.

Outpatient management of post-pneumonectomy and post-lobectomy empyema using the vacuum-assisted closure system.

PURPOSE: The conventional management of a post-pneumonectomy (PPE) and post-lobectomy empyema (PLE) necessitates an open window, wound packing, frequent wound debridement, and prolonged hospitalization. We studied the feasibility of outpatient therapy in this patient population using the vacuum-assisted closure (VAC) therapy system. METHODS: From September 2005 to November 2007, six patients with PPE and PLE with or without a bronchopleural fistula underwent outpatient therapy using a VAC system. After debridement and closure of the bronchial fistula, a VAC system was applied and the patient was discharged. The patient returned for debridement under anesthesia and VAC replacement every 7-10 days. Once the pleural space was cleaned, the residual space was obliterated, and the wound was closed over suction catheters. Of the six patients, two developed recurrent infection after the closure that required repeated VAC dressings and flap closures. RESULTS: The outpatient use of the VAC system in patients with PPE and PLE avoided the need for any daily painful dressing changes and significantly decreased the total length of hospitalization and the time to closure of the empyema space, and thus increased the overall patient satisfaction. CONCLUSIONS: Our results suggest that outpatient VAC therapy of PPE and PLE is feasible and beneficial.

From Jacobeaus to the da Vinci: thoracoscopic applications of the robot.

With the increasing recognition of the benefits of minimally invasive surgery, surgical technology has evolved significantly since Jacobeaus' first attempt at thoracoscopy 100 years ago. Currently, video-assisted thoracic surgery occupies a significant role in the diagnosis and treatment of benign and malignant diseases of the chest. However, the clinical application of video-assisted thoracic surgery is limited by the technical shortcomings of the approach. Although the da Vinci system (Intuitive Surgical) is not the first robotic surgical system, it has been the most successful and widely applicable. After early applications in general and urologic surgery, the da Vinci robot extended its arms into the field of thoracic surgery, broadening the applicability of minimally invasive thoracic surgery. We review the available literature on robot-assisted thoracic surgery in attempt to better define the current role of the robot in pulmonary, mediastinal, and esophageal surgeries.

Robot-assisted lobectomy for early-stage lung cancer: report of 100 consecutive cases.

BACKGROUND: Robotics can facilitate dissection during video-assisted thoracoscopic (VATS) lobectomy. This study describes a hybrid minimally invasive lobectomy procedure consisting of two phases: robotic vascular, hilar, and mediastinal dissection, and then VATS lobectomy. METHODS: Over a 54-month period, 100 consecutive patients with stage I and II (T1 or T2N0, and T1 or T2N1) lung cancer (42 men, 58 women; mean age 65 +/- 8 years) underwent robotic VATS lobectomy. RESULTS: Lobectomies were right upper (29), right middle (7), right lower (17), left upper (31), and left lower (16). Mean operating room time was 216 +/- 27 minutes. Tumor type was adenocarcinoma (57), squamous cell carcinoma (25), 7 adenosquamous carcinoma (7), bronchoalveolar (3), large cell (1), poorly differentiated (3), carcinoid (2), mucoepidermoid (1), spindle cell (1). Pathologic upstaging was noted in 17 patients (10 to stage IIB, 7 to stage IIIA). There was no emergent conversion to a thoracotomy. Median hospitalization was 4 days. Complications included atrial fibrillation (13), atelectasis (5), prolonged air leak (4), pleural effusion (3), pulmonary embolus (3), incisional bleeding (1), hydropneumothorax (1), dural leak (1), liver failure (1), pneumonia (1), respiratory failure (1), and cardiopulmonary arrest (1). There was no intraoperative death. Postoperative mortality was 3%. There were no deaths among the last 80 patients. At a median follow-up of 32 months (range, 1 to 59), 1 patient (1%) died of his cancer, 6 (6%) had distant metastases, and 2 (2%) had a second lung primary cancer. There was no local recurrence. CONCLUSIONS: Robotics are feasible for mediastinal, hilar, and pulmonary vascular dissection during VATS lobectomy.

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.

Robot-assisted thoracoscopic resection of intralobar sequestration.

In this paper, we report the first case of a robot-assisted thoracoscopic resection of intralobar sequestration. By virtue of greater dexterity and three-dimensional visualization, the da Vinci robot enables a safer, more precise dissection of sequestered tissue in the face of chronic inflammatory adhesions than conventional video-assisted thoracoscopic surgery does. Thus, in expert hands, such robotic technology is likely to result in less bleeding complications and less conversions to open surgery in cases of sequestration.

Spontaneous pneumomediastinum: diagnostic and therapeutic interventions.

OBJECTIVES: The objective of this case series is to review our experience with spontaneous pneumomediastinum, review the available literature, and refine the current clinical approach to this uncommon condition. METHODS: The case notes of all patients admitted to the George Washington University Medical Center with spontaneous pneumomediastinum from April 2005 to June 2008 were retrospectively reviewed, indentifying seventeen patients on whom various data was collected and analyzed. RESULTS: The typical patient is a young man. The commonest presenting complaint is chest pain. Odynophagia and subcutaneous emphysema are common. Leucocytosis is uncommon. The need for swallow studies, antibiotics, and prolonged hospitalization is uncommon. Most patients have no recurrences or sequelae on long-term follow-up. CONCLUSION: Spontaneous pneumomediastinum is an uncommon, self-limiting condition. Due to concerns for the integrity of the aero-digestive tract, the finding of spontaneous pneumomediastinum usually results in unnecessary radiological investigations, dietary restriction and antibiotic administration with prolonged hospitalization.

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.