Erkan Kaba

Robotic lung segmentectomy for malignant and benign lesions

OBJECTIVE Surgical use of robots has evolved over the last 10 years. However, the academic experience with robotic lung segmentectomy remains limited. We aimed to analyze our lung segmentectomy experience with robot-assisted thoracoscopic surgery. METHODS Prospectively recorded clinical data of 21 patients who underwent robotic lung anatomic segmentectomy with robot-assisted thoracoscopic surgery were retrospectively reviewed. All cases were done using the da Vinci System. A three incision portal technique with a 3 cm utility incision in the posterior 10(th) to 11(th) intercostal space was performed. Individual dissection, ligation and division of the hilar structures were performed. Systematic mediastinal lymph node dissection or sampling was performed in 15 patients either with primary or secondary metastatic cancers. RESULTS Fifteen patients (75%) were operated on for malignant lung diseases. Conversion to open surgery was not necessary. Postoperative complications occurred in four patients. Mean console robotic operating time was 84±26 (range, 40-150) minutes. Mean duration of chest tube drainage and mean postoperative hospital stay were 3±2.1 (range, 1-10) and 4±1.4 (range, 2-7) days respectively. The mean number of mediastinal stations and number of dissected lymph nodes were 4.2 and 14.3 (range, 2-21) from mediastinal and 8.1 (range, 2-19) nodes from hilar and interlobar stations respectively. CONCLUSIONS Robot-assisted thoracoscopic segmentectomy for malignant and benign lesions appears to be practical, safe, and associated with few complications and short postoperative hospitalization. Lymph node removal also appears oncologically acceptable for early lung cancer patients. Benefits in terms of postoperative pain, respiratory function, and quality of life needs a comparative, prospective series particularly with video-assisted thoracoscopic surgery.

Robotic and video-assisted thoracic surgery lung segmentectomy for malignant and benign lesions

OBJECTIVES The experience with robotic techniques (RATS) and video-assisted thoracic surgery (VATS) in pulmonary segmentectomy is still limited. We evaluated our prospectively recorded database to compare two different minimally invasive techniques. METHODS Between May 2007 and July 2014, a total of 99 patients underwent RATS (n = 34) and VATS (n = 65) pulmonary segmentectomies at two institutions. The median age of patients was 59 ± 15 (16-84) years, and 61% were male. Seventy-six patients were operated on for malignancy and 23 for benign diseases. RESULTS The major morbidity and mortality rates were 24-23% and 0-1.5% for RATS and VATS (P = 0.57) and (P = 0.66), respectively. The mean console time for RATS was longer than the mean operation time for VATS [76 ± 23 (40-150) vs 65 ± 22 (30-120) min (P = 0.018)]. The mean duration of drainage was similar for RATS and VATS [3.53 ± 2.3 (1-10) days vs 3.98 ± 3.6 (1-21) (P = 0.90)], respectively. The duration of postoperative stay for RATS was 4.65 ± 1.94 (2-10) days and for VATS was 6.16 ± 4.7 (2-24) days (P = 0.39). CONCLUSIONS Both RATS and VATS pulmonary segmentectomy operations are performed with similar morbidity and mortality rates. Although the duration of operation is longer in RATS when compared with an established VATS programme, there is a tendency towards a shorter postoperative stay.

Resection of a bronchogenic cyst in the first decade of life with robotic surgery

The conventional surgical approach for the removal of bronchogenic cyst in children is thoracotomy. Video-assisted thoracoscopic surgery is still under debate with the concerns of incomplete removal and injury to major intrathoracic structures. In this case report, we present an 8-year old patient who was successfully treated with robotic surgery (Intuitive Surgical, Mountain View, CA, USA). Robotic technology enables precise dissection and complete resection of the thoracic bronchogenic cyst without violating the capsule and adjacent major intrathoracic structures. She was discharged on postoperative Day 2 and was active on Day 5.

What happens while learning robotic lobectomy for lung cancer

A surgeon needs to perform a sufficient number of procedures to achieve a level of proficiency. Learning curves demonstrate ongoing improvement in efficiency over the course of a surgeons carrier. When the surgeon learns the procedure, this means that he has the ability to perform that procedure safely and effectively. The instruction of the da Vinci Surgical System (Initiative Surgical, Sunnyvale, CA, USA) provoked the need for preparing surgeons for complex robotic skills. As low as 5 repetitions are enough to achieve proficiency on basic robotic skills. Robotic-assisted thoracic surgery (RATS) has a steep learning curve compared to video-assisted thoracic surgery (VATS), and it was proposed that 15 to 20 operations are required to establish a learning curve for RATS anatomical pulmonary resections. Based on several studies, one can conclude that after learning, there is a tendency to toward shorter operative times, a decrease in conversion, morbidity and mortality rates, as well as an increase in the number of resected lymph nodes. Our clinical experience on 129 patients undergoing RATS anatomic pulmonary resections over a period of 5-year demonstrated that the learning curve could be established after 14th operation, and the acquired surgical skills and developing experience let surgeon to obtain shorter operative times, operate larger tumors with more advanced stages, have an increased the number of the dissected lymph nodes.

Open surgery for posterior mediastinal neurogenic tumors

Although most of the posterior mediastinal masses are found incidentally in adults, neurogenic tumors are the most common mediastinal tumors in children. The rate of malignancy may be as high as 50% in children, whereas, neurogenic tumors are almost always benign in adults. Open surgery is indicated in large-sized tumors (>6 cm), in the presence of a previous thoracic surgery, or when the tumor is presumed to invade the spinal canal or spinal artery, or is apically located (close to the satellite ganglion, and great vessel). Level of the location, the size of the tumor and its relations to neural foramina and spinal canal are used to determine the incisions and surgical approach. Two different methods were described for these tumors with clinical or radiological signs of spinal canal involvement. These methods name are Akwari and Grillo’s technique. However, approaches depend on surgeon’s preferences and experiences. Theoretically one posterior incision is appropriate for small size tumors. When tumors are larger or multiple vertebral foramens are involved Akwari method is preferable according to our experience. Radicular pain, atelectasis, phrenic nerve palsy, and Horner’s Syndrome are among the commonest complications. For tumors with intraspinal extension, cerebrospinal fluid (CSF) leak is a frightening complication. Management and identification of these complications needs experience.

Technological innovation in video-assisted thoracic surgery

The popularity of video-assisted thoracic surgery (VATS) which increased worldwide due to the recent innovations in thoracic surgical technics, equipment, electronic devices that carry light and vision and high definition monitors. Uniportal VATS (UVATS) is disseminated widely, creating a drive to develop new techniques and instruments, including new graspers and special staplers with more angulation capacities. During the history of VATS, the classical 10 mm 0° or 30° rigid rod lens system, has been replaced by new thoracoscopes providing a variable angle technology and allowing 0° and 120° range of vision. Besides, the tip of these novel thoracoscopes can be positioned away from the operating side minimize fencing with other thoracoscopic instruments. The curved-tip stapler technology, and better designed endostaplers helped better dissection, precision of control, more secure staple lines. UVATS also contributed to the development of embryonic natural orifice transluminal endoscopic surgery. Three-dimensional VATS systems facilitated faster and more accurate grasping, suturing, and dissection of the tissues by restoring natural 3D vision and the perception of depth. Another innovation in VATS is the energy-based coagulative and tissue fusion technology which may be an alternative to endostaplers.

Nodal upstaging: effects of instrumentation and three-dimensional view in clinical stage I lung cancer

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) is defined as the presence of unsuspected pathologic hilar (pN1) or mediastinal (pN2) disease detected during the final histopathologic evaluation of surgical specimens. The prevalence of pathologic nodal upstaging is used as a quality measure for the definition of the completeness of the nodal dissection. Risk factors for nodal upstaging may be patient-related (history of tuberculosis, rheumatoid arthritis, and diabetes mellitus), or tumor-related (central tumor, higher T stage, higher SUVmax value, or adenocarcinoma). Actually, the theorical superiority of a minimally invasive resections is the lymph node dissection. Studies may suggest that, expert video-assisted thoracoscopic surgery (VATS) surgeon could do similar lymph node dissection as it is done in open. Robotic surgeons may replicate the results of lymph node dissection in the open techniques. The possible reason for this is the instrumental superiority provided by the higher technology.

Robotic thymectomy—a new approach for thymus

Advancements in modern technology bring many evolutions in minimally invasive surgery such as robot assisted approaches. Because of complete resection is so important in thymectomy operations, they became a new era for robotic surgery as a result of its superiorities (intuitive movements, tremor filtration, more degrees of manipulative freedom, motion scaling, and high-definition stereoscopic vision).

Role of Surgery in the Treatment of Masaoka Stage IVa Thymoma

PURPOSE To analyze the role of surgery in patients with Masaoka stage IVa thymoma treated with multimodality therapy. METHODS Of 191 patients undergoing surgery for thymoma in our department between January 2002 and December 2015, 39 (20.4%) had Masaoka stage IVa. Histopathological tumor type, myasthenic status of the Osserman-Genkins score, Masaoka stage at the first surgery, neoadjuvant treatment, number and type of surgeries, and survival rates were recorded. RESULTS Thymoma B2 was the most common histopathological tumor type (n = 16, 41%). Twenty-six (66.7%) patients underwent primary surgeries for Masaoka stage IVa thymoma, whereas nine (23.1%) underwent secondary surgeries and four (10.3%) underwent tertiary surgeries for pleural or pericardial recurrences. Median survival was 132 ± 25 (82-181; 95% confidence interval [CI]) months. Overall 3-, 5-, and 10-year survival rates were 93%, 93%, and 56%, respectively. CONCLUSION Surgical treatment should be considered as a completion modality to oncological therapy and has the potential to provide long-term survival of Masaoka stage IVa in patients with thymoma. The type of surgery should be determined based on the invasiveness of the lesion.

A late visceral hernia after diaphragmatic flap coverage of the bronchial stump

A 54-year-old man presented with sudden and severe abdominal pain, and vomiting. He had underwent a right pneumonectomy with bronchial stump reinforcement using diaphragmatic muscle flap 9 years ago, due to non-small cell lung cancer after neoadjuvant chemotherapy. A right partial visceral herniation had been detected 5 years ago during the follow-up which was not present at previous visits. He had refused any surgical intervention since he had been asymptomatic. The chest computed tomography demonstrated visceral herniation. The patient underwent an urgent operation via thoracoabdominal incision to repair the herniation. This type of late catastrophic complication of diaphragmatic muscle flap reinforcement is extremely rare.