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Robotic-Assisted Pulmonary
https://t.me/medicina_free
Lobectomy
QiangShu andZhengTan
7
7.1 Introduction
In 2000, Rothenberg [1] described thoracoscopic
lobectomy for children for the rst time in the
literature. In recent years, thoracoscopic lobectomy has been gradually carried out all over the
world [2]. According to literature reports, thoracoscopic assisted lobectomy still has certain limitations, such as two-dimensional plane images
seen during the solo operation, limited operation
space, and fatigue of the solo surgeon caused by
too long of an operation time [3, 4]. Da Vinci’s
robot-assisted surgical system solves these problems perfectly. In 2008, Meehan rst reported the
application of robot-assisted lobectomy, believing that this method has advantages such as more
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_7.
Q. Shu
Department of Cardiac and Thoracic Surgery,
Children’s Hospital of Zhejiang University School of
Medicine, Hangzhou, China
e-mail: shuqiang@zju.edu.cn
Z. Tan (*)
Department of Thoracic Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: tanzheng@zju.edu.cn
accurate blood vessel separation and a clearer
visual eld in 3D imaging surgery [5]. The
Children’s Hospital afliated to Zhejiang
University introduced da Vinci Xi in April 2020
performed the rst robot-assisted thoracoscopic
mediastinum tumor resection in May 2020, and
completed 115 pediatric thoracic surgeries by the
end of March 2021, including 85 pediatric
7.2 Indications
andContraindications
Robotic indications for lobectomy can be compared to the thoracoscopic indications for lobectomy. Including congenital pulmonary airway
malformation, isolated lung, lobar emphysema,
and so on. However, considering the requirements of hole spacing between robotic arms,
robotic surgery is not recommended for children
of too young age at present. According to the
experience of our center, children older than 6
months can complete the operation. However, if
the operation is to be smooth, children over 8
months are generally recommended. The larger
the relative chest space, the larger the spacing of
holes can be.
Contraindications: diffuse lesions in both
lungs. Severe cardiopulmonary failure or other
conditions requiring priority. Severe thoracic
deformity.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_7
41
42
https://t.me/medicina_free
Q. Shu and Z. Tan
7.3 Preoperative Preparation
The time of fasting and water prohibition before
operation was the same as that of routine general
anesthesia. Intraoperative one-lung ventilation is
generally recommended, and a bronchial plugging device can be used routinely to block bronchial ventilation on the diseased side by lling
the balloon. However, due to the small diameter
of children’s bronchial tubes, it is sometimes difcult to place the appropriate plugging device, or
when the blockage balloon easily slides to the
main airway after the placement of the plugging
device, resulting in obstruction of ventilation,
selective endobronchial intubation can also be
considered, and endotracheal intubation can be
directly inserted into the healthy side of the bronchus. Regardless of what method is used to
achieve single-lung ventilation, it is generally
recommended to use bronchobroscopy with
close observation of changes in airway pressure,
airway carbon dioxide waveform, and arterial
oxygen saturation (SpO2) to prevent catheter or
occluded displacement. Other preoperative preparations included the establishment of central
venous access, catheterization with invasive arterial pressure, and indwelling catheterization.
Attention should be given to sputum aspiration at
any time during the operation, and arterial blood
gas analysis should be monitored when
necessary.
7.4 Position andDocking
Healthy side decubitus position, double upper
limb exion, pillow, underarm cushion pillow to
make the torso slightly folded knife position, so
that the intercostal space is passively widened.
Due to the small space of children’s chest, the
hole position should be as low as possible to
ensure that the range of motion of the lens and
instruments can cover the whole chest, and the
auxiliary hole position should also be as low as
possible to avoid interference with the mechanical arms. Generally, the three-arm method is
adopted.
The location of the cannula varies slightly
depending on the location of the lobectomy and
is generally as follows: Into the lens aperture
generally obtained after axillary line 8 or 9 rib
poke card, put between 8 mm diameter (lower
lobe resection card can be done between the ninth
oor or a 10th rib, on the middle of the rib resection can be relatively high 1, 2) into the lens conrmation is located in the chest cavity and
external articial pneumothorax (general pressure for 6 mmHg), makes the diaphragm down
further to provide more 5 breast space. For the
left and right instrument holes, 8mm stamp cards
are usually inserted in the 6th intercostal space
between the anterior axillary line and the midclavicular line and the 8th intercostal space between
the subscapular line. Ensure that there is a sufcient distance (approximately 4–8 cm) between
the two instrument holes and the lens inlet holes,
so that each mechanical arm does not interfere
with each other during operation. It is mainly
used for intraoperative use of attractor, auxiliary
hole clamp apparatus and equipment, general
with the door to the lungs for the principle, take
the axillary midline and axillary 7 rib poke card
in 5mm clearance between the front (e.g., intraoperative use endoscopic cutting anastomat can
extend the 5mm incision and poke into 12 mm),
assistant in children with ventral auxiliary operation, each robot manipulator is in the head side of
the children (Fig.7.1).
7 Robotic-Assisted Pulmonary Lobectomy
https://t.me/medicina_free
Fig. 7.1 Conventional perforation in lobectomy. C:
observation hole, A: auxiliary hole, 2: robot arm No. 2, 3:
robot arm No. 3
7.5 Surgical Steps
The surgical area was routinely sterilized, and a
disposable sterile sheet was laid out. A poke card
was inserted into the incision at the marked
43
position and then sent into the lens. After probing
the chest cavity without extensive adhesion, CO2
was added to ensure a clear visual eld and accelerate the removal of residual gas in the lung (the
pressure was generally 6 mmHg). Two instrument arm stamp cards and auxiliary hole stamp
cards were inserted into the incision under the
guidance of endoscope. Push the bedside operation arm system (generally placed on the right
side of the child, at a 90° angle with the longitudinal axis of the child) and connect the stamp
card. The right arm was connected with a
Maryland bipolar claw, and the left arm was connected with a pericardial claw (Cadiere claw).
The surgeon performs the operation in front of
the console with a three-dimensional visual eld.
Generally, the robot uses three arms (one lens
arm and two instrument arms), makes full use of
the assistant through the auxiliary mouth to complete pulling, clamping, closing operation, etc.,
and uses fewer robot instruments to save costs.
The procedure for anatomic lobectomy was
the same as that for open lobectomy. The routine
is AVB, treating the pulmonary artery rst, then
the pulmonary veins, then the bronchi. However,
in the case of lobed dysplasia, where the artery is
difcult to expose, the pulmonary veins can be
dealt with rst, then the bronchus, and nally the
pulmonary artery. Determine the procedure
according to the specic situation. Here is an
example of anatomic excision of the lower lobe
of the left lung (Fig.7.2).
44
f
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Q. Shu and Z. Tan
a
c
e
b
d
g
Fig. 7.2 Example of anatomic excision of the lower lobe
of the left lung. (a) Dissociation of lower pulmonary ligaments; (b) dissection of the pulmonary artery; (c) ligation
of the lower pulmonary artery; (d) dissection of inferior of
the pulmonary vein; (e) ligation of inferior pulmonary
vein; (f) dissection of lower pulmonary bronchi; (g) suture
bronchial stump
7 Robotic-Assisted Pulmonary Lobectomy
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45
7.6 Technical Points and Skills
The thoracic space in pediatric patients is relatively small, which limits the placement of operating and observation ports. It may not be
possible to create a straight line arrangement of
ports, so it is important to choose the maximum
distance between ports to avoid interference
between robotic arms.
For patients with a sequestered lung, there
may be abnormal collateral blood supply. In such
cases, the operating ports on the side closer to the
spine should be placed downward as much as
possible to prevent difculties during the
procedure.
For patients with a well-vascularized sequestered lung, gentle traction should be applied to
avoid bleeding that may obstruct the view.
During dissection of the pulmonary veins,
caution should be exercised, as the vessel walls
are relatively thin, especially when separating
them from the posterior wall, to prevent damage
to the blood vessels.
For proximal segment ligation of the pulmonary artery and pulmonary vein, it is recommended to perform at least two ligations to
prevent slippage and major bleeding.
After bronchus division, it is advisable to perform continuous absorbable suture with at least
one stitch to minimize the risk of suture line
detachment and pneumothorax.
7.7 Postoperative Complications
1. Pneumothorax: if there is continuous gas
leakage from the closed thoracic drainage
tube after surgery, it can be temporarily
observed; small alveolar gas leakage can heal
by itself; if there is a continuous large amount
of gas leakage, bronchopleural stula should
be considered, and timely surgical treatment
should be performed.
2. Atelectasis, contusion caused by pull-clamp
on lung tissue during operation, and atelectasis caused by obstruction of bronchial
secretions after operation are also common.
Postoperative physical therapy can be
strengthened for children and supplemented
by atomization to help discharge sputum.
3. Bleeding: if a large amount of bright red uid
continues to be extracted from the drainage
tube, the possibility of postoperative bleeding
should be considered.
4. Residual lesions: due to the large scope of
lesions in some CPAM cases, unclear boundaries, and ease of pushing the normal lung tissue, residual lesions may occur after lung
segment or wedge resection and other lung
preservation operations [6–8]. In Stanton’s
report, 15% (9/60) of patients developed residual lesions after pulmonary segmental resection [8]. In Johnson’s report, 6.6% of patients
underwent lung preservation surgery and
underwent secondary surgical resection due to
residual lesions [6]. When performing segmentary resection or irregular resection, the
surgeon should strictly grasp the indications of
surgery, accurately judge the scope of the
lesion, clarify the involvement of the lesion,
and make a careful decision in combination
with intraoperative lesion exploration to avoid
residual lesions. When residual lesions are
found during postoperative follow-up, according to current literature reports, most authors
choose to rescease the lesions, and the specic
surgical method depends on the residual
lesions [7, 8]. With respect to the timing of
reoperation, there are few reports about it in
the literature, and Fascetti etal. believed that
for residual cases, resurgical resection should
be performed about 5 months after surgery [7].
7.8 Comparisons
withConventional
Thoracoscopic Surgery
Compared with traditional laparoscopic thoracic
surgery, the robotic surgical system has unique
advantages: (1) clear and accurate threedimensional vision. The common cavity mirror
46
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Q. Shu and Z. Tan
for two-dimensional plane vision, two-dimensional view cannot accurately position the distance, and the robot’s vision for three- dimensional
vision simulates human eyes, seeing more clearly,
more accurately positioning the distance; (2)
intelligent action: the operator of hand and wrist
action can be converted into real-time accurate
mechanical action, and action height simulation
coincides with surgery; (3) motion correction and
shake ltering function: the surgical instruments
that can turn the wrist can bend and rotate far
more than the limit of the hand. Shiver ltering
and intuitive movement allow the physician to
operate steadily and naturally; (4) remote control: the operator does not need to go on the operating table, save space, avoid crowding between
the main knife and the assistant, and avoid
obstruction of the surgical eld of view; (5) suitable for pediatric surgery: Compared with adults,
the pediatric body cavity space is small, and traditional surgical operations are limited. The
progress of endoscopic surgery has gradually
solved this problem, but there are still shortcomings in the accurate operation of localized lesions.
Fine operation in a limited space can reduce the
side injury of the operation, improve the curative
effect and minimize the pain of children [5]; (6)
reduce surgeon fatigue: compared with traditional surgery and endoscopic surgery, a good
three-dimensional eld of vision and simplied
coordination, ergonomic design of the doctor’s
operation table can minimize the fatigue and
physical injury of the doctor.
References
1. Rothenberg SS.Thoracoscopic lung resection in children. J Pediatr Surg. 2000;35:271–4.
2. Tan Z, Li JH, Liang L, etal. Thoracoscopic lobectomy
in infants and children. Chin J Thorac Cardiovasc
Surg. 2017;33:490–2.
3. Kolvenbach R, Schwierz E, Wasilljew S, etal. Total
laparoscopically and robotically assisted aortic
aneurysm surgery: a critical evaluation. J Vasc Surg.
2004;39:771–6.
4. Cook RC, Nifong LW, Enterkin JE, etal. Signicant
reduction in annuloplasty operative time with the use
of nitinol clips in robotically assisted mitral valve
repair. J Thorac Cardiovasc Surg. 2007;133:1264–7.
5. Meehan JJ, Phearman L, Sandler A.Robotic pulmonary resections in children: series report and introduction of a new robotic instrument. J Laparoendosc Adv
Surg Tech A. 2008;18:293–5.
6. Johnson SM, Grace N, Edwards MJ, et
al. Thoracoscopic segmentectomy for treatment
of congenital lung malformations. J Pediatr Surg.
2011;46:2265–9.
7. Fascetti-Leon F, Gobbi D, Pavia SV, etal. Sparinglung surgery for the treatment of congenital lung malformations. J Pediatr Surg. 2013;48:1476–80.
8. Stanton M, Njere I, Ade-Ajayi N, et al.Systematic
review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg.
2009;44:1027–33.
Robotic-Assisted Segmentectomy
https://t.me/medicina_free
QiangShu andZhengTan
8
8.1 Introduction
At present, with the widespread use of prenatal
ultrasound screening, the diagnosis rate of congenital pulmonary diseases in infants and children has greatly increased [1]. Although these
lesions rarely affect pregnancy or postnatal
growth, pediatric surgeons are now faced with
advising families on prenatal and postnatal
issues and whether to operate [1–3]. While many
of these lesions were previously diagnosed after
patients developed symptoms from infections or
other problems, most are now diagnosed before
birth, and many babies are asymptomatic. The
traditional view of surgical treatment is to
remove the entire diseased lung at diagnosis, but
some centers use a more conservative approach,
believing that these lesions do not pose longterm risks, and therefore choose to retain the
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_8.
Q. Shu
Department of Cardiac and Thoracic Surgery,
Children’s Hospital of Zhejiang University School of
Medicine, Hangzhou, China
e-mail: shuqiang@zju.edu.cn
Z. Tan (*)
Department of Thoracic Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: tanzheng@zju.edu.cn
affected lung [4, 5]. To achieve a balance
between removing diseased lung tissue and preserving as much normal lung tissue as possible,
we began to attempt anatomical segment resection in children.
With the improvement of anesthesia and thoracoscopic techniques, an increasing number of
cases have been reported in pediatric thoracoscopic anatomical lobectomy. Most surgeons
agree on the benets of thoracoscopic surgery
over traditional thoracotomy, including less pain,
shorter hospital stay, better cosmetic results, and
reduced long- term morbidity, including reduced
chest wall deformities [6–8]. However, the diseases that require lobectomy in children are
mostly benign diseases, such as congenital pulmonary airway malformation (CPAM), intralobular isolated lung, and bronchial atresia. It is
necessary to retain as much healthy lung tissue as
possible and improve postoperative lung function. However, compared with lobectomy, the
anatomical structure of the pulmonary segment is
more distal to the bronchus and blood vessels,
with more branches, and the adjacents between
pulmonary arteries and veins and bronchus are
more complex, with large individual differences
and variations, which brings great difculties to
accurate pulmonary segment resection.
Therefore, the current anatomical pulmonary
segmentectomy mainly takes the basal segment,
dorsal segment, and lingual segment of the lower
lobe of both lungs [9, 10]. The anatomy of this
kind of pulmonary segment is similar to that of
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_8
47
48
https://t.me/medicina_free
Q. Shu and Z. Tan
the fusing lung lobe, and the surgical technique is
similar to that of lobectomy or wedge resection.
Compared with thoracoscopy, the Da Vinci robot
has clearer vision and more exible operation, so
it has greater advantages in performing complex
operations.
8.2 Indications
andContraindications
Indications for robotic pulmonary segmentectomy can be compared to the indications for thoracoscopic pulmonary segmentectomy which
include congenital pulmonary airway malformation, isolated lung, lobar emphysema ,and so on.
However, considering the requirements of hole
spacing between robotic arms, robotic surgery is
not recommended for children of too young age
at present. According to the experience of our
center, children older than 6 months can complete the operation. However, if the operation is
to be smooth, children over 8months are generally recommended. The larger the relative chest
space, the larger the spacing of holes can be.
Contraindications: diffuse lesions in both
lungs. Severe cardiopulmonary failure, or other
conditions requiring priority. Severe thoracic
deformity.
8.3 Preoperative Preparation
The time of fasting and water prohibition before
operation was the same as that of routine general
anesthesia. Intraoperative one-lung ventilation is
generally recommended, and a bronchial plugging device can be used routinely to block bronchial ventilation on the diseased side by lling the
balloon. However, due to the small diameter of
children’s bronchial tubes, it is sometimes difcult to place the appropriate plugging device, or
when the blockage balloon easily slides to the
main airway after the placement of the plugging
device, resulting in obstruction of ventilation,
selective endobronchial intubation can also be
considered, and endotracheal intubation can be
directly inserted into the healthy side of the bronchus. Regardless of what method is used to
achieve single-lung ventilation, it is generally recommended to use bronchobroscopy with close
observation of changes in airway pressure, airway
carbon dioxide waveform, and arterial oxygen
saturation (SpO2) to prevent catheter or occluded
displacement. Other preoperative preparations
included the establishment of central venous
access, catheterization with invasive arterial pressure, and indwelling catheterization. Attention
should be given to sputum aspiration at any time
during the operation, and arterial blood gas analysis should be monitored when necessary.
8.4 Position andDocking
Healthy side decubitus position, double upper
limb exion, pillow, underarm cushion pillow to
make the torso slightly folded knife position, so
that the intercostal space is passively widened.
Due to the small space of children’s chest, the
hole position should be as low as possible to
ensure that the range of motion of the lens and
instruments can cover the whole chest, and the
auxiliary hole position should also be as low as
possible to avoid interference with the mechanical
arms. Generally, the three-arm method is adopted.
The location of the cannula varies slightly
depending on the location of the lobectomy and
is generally as follows: Into the lens aperture
generally obtained after axillary line 8 or 9 rib
poke card, put between 8 mm diameter (lower
lobe resection card can be done between the ninth
oor and a tenth rib, on the middle of the rib
resection can be relatively high 1, 2) into the lens
conrmation is located in the chest cavity and
external articial pneumothorax (general pressure for 6 mmHg), makes the diaphragm down
further to provide more 5 breast space. For the
left and right instrument holes, 8mm stamp cards
are usually inserted in the sixth intercostal space
between the anterior axillary line and the midclavicular line and the eighth intercostal space
between the subscapular line. Ensure that there is
a sufcient distance (approximately 4–8 cm)
between the two instrument holes and the lens
inlet holes, so that each mechanical arm does not
interfere with each other during operation. It is
mainly used for intraoperative use of attractor,
cd
8 Robotic-Assisted Segmentectomy
https://t.me/medicina_free
49
a
Fig. 8.1 3D reconstruction to determine the lung segment occupied by the lesion (a-d)
auxiliary hole clamp apparatus and equipment,
general with the door to the lungs for the principle, take the axillary midline and axillary 7 rib
poke card in 5mm clearance between the front
(e.g., intraoperative use endoscopic cutting anastomat can extend the 5mm incision and poke into
12mm), assistant in children with ventral auxiliary operation, each robot manipulator is in the
head side of the children (Fig.8.1).
b
tion arm system (generally placed on the right
side of the child, at a 90° angle with the longitudinal axis of the child) and connect the stamp
card. The right arm was connected with a
Maryland bipolar claw, and the left arm was connected with a pericardial claw (Cadiere’s claw).
The surgeon performs the operation in front of
the console with a three-dimensional visual eld.
Generally, the robot uses three arms (one lens
arm and two instrument arms), makes full use of
the assistant through the auxiliary mouth to com-
8.5 Surgical Steps
plete pulling, clamping, closing operation, etc.,
and uses fewer robot instruments to save costs.
The surgical area was routinely sterilized, and a
disposable sterile sheet was laid out. A poke card
was inserted into the incision at the marked position and then sent into the lens. After probing the
chest cavity without extensive adhesion, CO2 was
added to ensure a clear visual eld and accelerate
the removal of residual gas in the lung (the pressure was generally 6 mmHg). Two instrument
arm stamp cards and auxiliary hole stamp cards
were inserted into the incision under the guidance of the endoscope. Push the bedside opera-
According to the anatomical marks displayed
in preoperative 3D-CTBA images, the vessels
and bronchus of the target segment were dissected in order from shallow to deep (Fig.8.2).
Small branches of pulmonary arteries and veins
can be cut off by electrocoagulation or ultrasonic
knife, and large branches can be cut off by ultrasonic knife after medium hemlock clamp. The
bronchus of the pulmonary segment was cut off
with a large Hem lock clamp and then cut off
with an ultrasound knife or a linear cutting
50
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Q. Shu and Z. Tan
a
c
b
d
e
Fig. 8.2 Dissection of the vessels and bronchus of the
target segment. (a, b) According to the 3D reconstructed
arterial images, the target segment arteries were determined by intraoperative comparison; (c, d) according to
f
the 3D reconstructed vein image, the target vein was
determined during the operation; (e, f) according to 3D
reconstructed bronchial images, the target segment bronchus was resected by intraoperative comparison
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