Robotic resection of a superior sulcus neurogenic tumor.

Neurogenic tumors do not often occur in the superior sulcus or apex of the chest cavity. Historically, surgical approaches have been dictated by the location of the tumor and its relation to the contiguous structures such as the vertebral bodies, subclavian vessels, and chest wall. Resection is hampered by difficulties with visualization and access within a narrow working space. The shortcomings associated with the traditional surgical approaches create a potential of injury to nearby structures. We present a case of a 43-year-old woman with a superior sulcus neurogenic tumor impinging on the left subclavian vein, who underwent a successful resection without injury to nearby structures. We found that a robotic approach improved visualization of the tumor and nearby structures and increased instrument maneuverability relative to a thoracoscopic approach, along with less pain and recovery time compared with a thoracotomy. This experience suggests that robotics provides a promising alternative for excision of superior sulcus neurogenic tumors, which may reduce associated morbidity.

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.

A novel robot-assisted technique for excision of a posterior mediastinal thyroid goiter: a combined cervico-mediastinal approach.

OBJECTIVE: : Intrathoracic thyroid goiter is an uncommon condition. Most goiters are found in the superior and anterior mediastinum, which can be removed either through a cervical approach or through a combined cervicotomy and sternotomy approach. Extension of the goiter into the posterior mediastinum is even less common. Transcervival approach to thyroid goiters in the posterior mediastinum can be difficult, necessitating a thoracotomy, with its associated morbidity. METHODS: : A 69-year-old patient underwent robotic assisted minimally invasive procedure, with the daVinci surgical robotic system to excise a thyroid goiter that extended into the posterior mediastinum. The blood supply of the mediastinal portion of the goiter originated from the right internal thoracic artery. The thoracic and mediastinal portion of the goiter was approached with robot-assisted minimally invasive surgical techniques. Small incisions were used to gain access to the posterior mediastinum via the right pleural cavity, obviating the need for thoracotomy. Using precise movements of the robotic arm, the mediastinal part of the goiter was dissected off vital structures, from within the posterior mediastinum. Total thyroidectomy was then completed using the cervical approach. RESULTS: : The patient tolerated the procedure well, with minimal intraoperative blood loss. The patient was discharged home after a short hospital stay. DISCUSSION: : Robotic surgical techniques for removal of a substernal goiter and other thyroid masses with mediastinal extension, in combination with cervical incision, are effective. Robotic-assisted techniques can complement video-assisted thoracic surgical techniques and broaden the indications for minimally invasive surgery.