Robotic right lower lobectomy for a persistent large pulmonary arteriovenous malformation following repeated coil embolization.

Pulmonary arteriovenous malformations create continuous shunting of unoxygenated blood through the lungs into the systemic circulation. These malformations are asymptomatic if small, but cause serious symptoms as they grow in size. Treatment primarily consists of endovascular embolization; lobectomy is preserved for recurring or endovascularly untreatable cases. We describe a case of a 24-year-old man who was first treated with coil embolization 10 years previously, with complete symptom resolution. However, more recently he noted recurrent exercise intolerance, with shortness of breath and hypoxemia. After repeat re-embolization, a computed tomography scan noted some persistent flow. Given the patient's young age, we considered resection as a definite therapy. The patient underwent an uncomplicated robot-assisted right lower lobectomy. Afterward, his symptoms resolved completely. In selected cases, robotic lobectomy for pulmonary arteriovenous malformation is feasible and safe.

Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives.

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.