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468
A. A. Jonsson and M. E. Halkos
Outcomes
Robotic intracardiac surgery can be performed with excellent safety and efcacy.
Our technique has a less than 1% mortality and stroke rate, and at 6years freedom
from recurrent 2+ or greater MR was 85%, with only 3.9% of patients requiring
reoperation for mitral repair failure [16]. Other experienced centers have published
similar results [17, 18]. The safety of robotic mitral surgery is comparable to other
approaches including thoracotomy and sternotomy and is associated with shorter
length of stay and lower hospital readmissions [1].
Robotic Aortic Valve Replacement
One of the newest applications in robotic cardiac surgery is robotic aortic valve
replacement. Although not yet widely performed, initial results from this technique
are encouraging with less than 1% mortality and stroke rates [19]. Aortic valve
replacement can be performed in conjunction with mitral valve procedures, ablations, and transaortic septal myectomy (Fig.32.7).
Fig. 32.7 Mitral valve
before and after repair.
This patient had posterior
leaet prolapse which was
treated with neocords and
annuloplasty
32 Robotic-Assisted Cardiac Surgery
469
Conclusion
As demand grows for less invasive procedures, we must ensure that we can meet
this demand without compromising short- or long-term patient outcomes. Robotic
technology is a crucial tool for allowing surgeons to perform gold standard interventions through smaller incisions with minimal morbidity. Despite the slow early
adoption in cardiac surgery, robotic cardiac surgical procedures are now routinely
performed in many centers across North America and around the world.
References
1. Mori M, Parsons N, Krane M, Guy TS, Grossi EA, Dearani JA, Habib RH, Badhwar V,
Geirsson A.Robotic mitral valve repair for degenerative mitral regurgitation. Ann Thorac
Surg. 2024;117(1):96–104.
2. Whellan DJ, McCarey MM, Taylor BS, etal. Trends in robotic-assisted coronary artery bypass
grafts: a study of the society of thoracic surgeons adult cardiac surgery database, 2006 to 2012.
Ann Thorac Surg. 2016;102:140–6.
3. Jonsson A, Binongo J, Patel P, Wang Y, Garner V, Mitchell-Cooks D, Halkos ME.Mastering
the learning curve for robotic-assisted coronary artery bypass surgery. Ann Thorac Surg.
2023;115(5):1118–25.
4. Edwards J, Binongo J, Mullin B, Wei J, Ghelani K, Kumarasamy M, Hanson P, Duggan M,
Shoffstall J, Halkos M.Intensive care unit bypass for robotic-assisted single-vessel coronary
artery bypass grafting. Ann Thorac Surg. 2023;115:511.
5. Mohr FW, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, et al. Computerenhanced “robotic” cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg.
2001;121(5):842–53.
6. Argenziano M, Katz M, Bonatti J, Srivastava S, Murphy D, Poirier R, etal. Results of the
prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass
grafting. Ann Thorac Surg. 2006;81(5):1666–75.
7. Bonaros N, Schachner T, Lehr E, Koer M, Wiedemann D, Hong P, etal. Five hundred cases
of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety.
Ann Thorac Surg. 2013;95(3):803–12.
8. Bonatti J, Schachner T, Bonaros N, Öhlinger A, Danzmayr M, Jonetzko P, etal. Technical
challenges in totally endoscopic robotic coronary artery bypass grafting. J Thorac Cardiovasc
Surg. 2006;131(1):146–53.
9. Bonaros N, Schachner T, Wiedemann D, Oehlinger A, Ruetzler E, Feuchtner G, etal. Quality
of life improvement after robotically assisted coronary artery bypass grafting. Cardiology.
2009;114(1):59–66.
10. Harskamp RE, Williams JB, Halkos ME, Lopes RD, Tijssen JGP, Ferguson TB, et al.
Meta- analysis of minimally invasive coronary artery bypass versus drug-eluting stents
for isolated left anterior descending coronary artery disease. J Thorac Cardiovasc Surg.
2014;148(5):1837–42.
11. Kayatta MO, Halkos ME, Puskas JD.Hybrid coronary revascularization for the treatment of
multivessel coronary artery disease. Ann Cardiothorac Surg. 2018;7(4):500–5.
12. Halkos ME, Vassiliades TA, Douglas JS, Morris DC, Rab ST, Liberman HA, etal. Hybrid
coronary revascularization versus off-pump coronary artery bypass grafting for the treatment
of multivessel coronary artery disease. Ann Thorac Surg. 2011;92(5):1695–701.
13. Gao C, Yang M, Wu Y, Wang G, Xiao C, Liu H, etal. Hybrid coronary revascularization by
endoscopic robotic coronary artery bypass grafting on beating heart and stent placement. Ann
Thorac Surg. 2009;87(3):737–41.
14. Murphy DA, Jonsson AA, Halkos ME.Endoscopic robotic mitral valve surgery in patients
with previous sternotomy cardiac surgery. Innovations (Phila). 2022;17(4):297–303. 14
470
15. Murphy DA, Moss E, Miller J, Halkos ME.Repeat robotic endoscopic mitral valve operation:
a safe and effective strategy. Ann Thorac Surg. 2018;105(6):1704–9.
16. Murphy DA, Moss E, Binongo J, Miller JS, Macheers SK, Sarin EL, Herzog AM, Thourani
VH, Guyton RA, Halkos ME.The expanding role of endoscopic robotics in mitral valve surgery: 1,257 consecutive procedures. Ann Thorac Surg. 2015;100(5):1675–81.
17. Ramzy D, Trento A, Cheng W, De Robertis MA, Mirocha J, Ruzza A, Kass RM.Three hundred robotic-assisted mitral valve repairs: the Cedars-Sinai experience. J Thorac Cardiovasc
Surg. 2014;147(1):228–35.
18. Mihaljevic T, Jarrett CM, Gillinov AM, Williams SJ, DeVilliers PA, Stewart WJ, Svensson
LG, Sabik JF 3rd, Blackstone EH.Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized. J Thorac Cardiovasc Surg. 2011;141(1):72–80. e1–4
19. Badhwar V, Pereda D, Khaliel FH, Poffo R, Darehzereshki A, Mehaffey JH, Yan TD,
Melnitchouk S, Geirsson A, Arghami A, Navia JL, Raikar GV, Weber AC, Ramzy D, Černý Š,
Vojáček J, Smith RL, Bonatti J, Thourani VH, Wei LM.Outcomes following initial multicenter
experience with robotic aortic valve replacement: dening a path forward. J Thorac Cardiovasc
Surg. 2024;S0022-5223(24):00078–3.
A. A. Jonsson and M. E. Halkos
Mediastinal Procedures
33
BrittneyWilliams andManuSancheti
Introduction
Historically, resection of mediastinal pathology has required invasive surgical
approaches via sternotomy, posterolateral thoracotomy, or anterolateral thoracotomy with or without transverse sternotomy (clamshell). Since the early 1990s, minimally invasive techniques have transformed mediastinal surgery, allowing for
smaller incisions, shorter hospital stays, improved postoperative pain, and comparable oncologic outcomes when applicable [1, 2]. Video-assisted thoracoscopic surgery (VATS) has been utilized for various mediastinal pathologies including
thymectomy for myasthenia gravis, thymoma and thymic carcinoma, germ cell
tumors, neurogenic tumors, mediastinal cysts, lymphoma, and ectopic parathyroid
and thyroid tissue [3].
Given the limited working space within the mediastinum and close proximity to
great vessels, robotic-assisted thoracoscopic surgery has allowed for several advantages to navigation and dissection of the mediastinum. The benets of robotics as
compared to VATS include articulating instruments, three-dimensional visualization, scaling down of operative movements, and lack of tremor. Disadvantages
include lack of tactile sensation, higher costs, initial learning curve, and lack of
standardized approaches to robotic mediastinal procedures.
In this chapter, approaches to robotic mediastinal procedures are detailed, specically categorized into three anatomical sections, the anterior, middle, and posterior mediastinum. The mediastinum is bounded laterally by the pleura, superiorly
by the thoracic inlet, posteriorly by the thoracic spine, and inferiorly by the diaphragm. Within these boundaries, the mediastinum is further divided into anterior,
middle, and posterior compartments. The anterior mediastinum is located between
B. Williams · M. Sancheti (*)
Emory University School of Medicine, Atlanta, GA, USA
e-mail: manu.suraj.sancheti@emory.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_33
471
472
the sternum and anterior border of the pericardium. The middle mediastinum lies
between the anterior and posterior borders of the pericardium. The posterior mediastinum is the space between the posterior border of the pericardium and the anterior longitudinal ligament of the thoracic spine.
B. Williams and M. Sancheti
Preoperative Evaluation andPatient Selection
Preoperative evaluation for robotic mediastinal procedures is generally the same as
open cases with several caveats. A thorough history and physical examination
should be performed, particularly including history of prior chest surgeries that may
indicate higher risk of conversion to an open procedure. Computed tomography
(CT) with intravenous (IV) contrast is essential in evaluation of mediastinal lesions
and their proximity to the great vessels and other important mediastinal structures
as well as for planning port placement. Additional cross-sectional imaging can be
useful in some circumstances, such as magnetic resonance imaging (MRI) in evaluating for local invasion and positron emission tomography (PET) for assessment of
metastatic disease in malignant mediastinal pathologies. Histopathologic conrmation via percutaneous, transbronchial, or endoscopic biopsy can also be useful in
cases where clinical, laboratory, or radiographic ndings are inconclusive.
Pulmonary function testing is recommended as poor pulmonary function may not
allow for single-lung ventilation.
Patient selection plays a key role in successful completion of a robotic approach
to mediastinal surgery as certain patient factors and past medical and surgery history can be prohibitive. In terms of patient factors, body habitus may preclude minimally invasive access to the anterior mediastinum. History of pleural space
infections, malignancy, or prior instrumentation can result in chest wall adhesions
that may require conversion to an open procedure. Inability to safely discern the
appropriate anatomy for dissection is another common reason for conversion, which
can be related to decreased working space from inability to tolerate carbon dioxide
insufation or single-lung ventilation. Other reasons for conversion to open include
close proximity or involvement of vital mediastinal structures. The latter causes for
conversion are largely avoided with appropriate preoperative workup.
General Port Placement andRobotic
Positioning Considerations
Port placement and robotic positioning is a key aspect of successful mediastinal
robotic operations. Positioning will vary depending on use of either the da Vinci Si
or Xi surgical system (Intuitive Surgical, Sunnyvale, CA). In this chapter, the
described approach will be based on use of the da Vinci Xi surgical system. In general, the camera port should be placed 10–20cm away from the target anatomy.
33 Mediastinal Procedures
473
Ports should be placed 6–10cm apart (ideally 8cm) to decrease conict between
the robotic arms. Preoperative imaging studies are key in determining appropriate
port placement especially for masses in the middle mediastinum and posterior
mediastinum where variability in tumor location is more common. Patient cart positioning will vary based on operating room layout.
Approach toAnterior Mediastinal Pathology
Anterior mediastinal pathologies for which robotic surgery has been utilized include
thymus for myasthenia gravis, thymoma, lymphoma/lymph node excisional biopsy,
germ cell tumors, and ectopic parathyroid and thyroid tissue. Specic preoperative
consideration may be necessary for anterior mediastinal pathology. Myasthenia gravis patients have increased risks for general anesthesia requiring preoperative preparation with pyridostigmine, intravenous immune globulin (IVIG), or plasmapheresis.
IVIG should be given 2weeks prior to planned resection. Potential anestheticrelated issues include resistance to depolarizing paralytic agents, cholinergic crisis
for neuromuscular blocking reversal agents, increased risks of aspiration, increased
risks of respiratory failure, and continued requirements for intubation and ventilator
use postoperatively. If the differential for the anterior mediastinal mass includes
thymoma, screening for symptoms related to myasthenia gravis should be completed to direct further preoperative laboratory investigation to avoid potential
anesthesia- related complications.
Indications forRobotic Anterior Mediastinal Mass Resection
Cross-sectional imaging, CT and/or MRI, is required to evaluate the association of
an anterior mediastinal mass with its surrounding mediastinal structures to determine resectability of the lesion. In the case of a thymoma, complete resection is
required for adequate treatment due to risk of recurrence. Therefore, Masaoka stage
I tumors, enclosed within the thymic capsule, have been deemed acceptable for
minimally invasive techniques [4]. Some data does suggest that minimally invasive
resections of Masaoka stage I–III thymomas have equivalent rates of margin of
positivity and similar 5-year survival, but longer-term follow-up is needed given the
indolent nature of thymoma [5]. Robotic resections for anterior mediastinal germ
cell tumors are indicated for mature teratomas and dermoid cysts. Seminomatous
and non-seminomatous tumors are treated primarily with radiation and chemotherapy, respectively. If a mass persists after initial treatment, further medical treatment
may be indicated or surgical resection if tumor markers AFP and beta-HCG are
negative and remaining mass does not involve mediastinal structures. Excision of
enlarged anterior mediastinal lymph nodes may also be appropriate for diagnosis of
lymphoma or staging for other malignancies.
474
bc
B. Williams and M. Sancheti
Fig. 33.1 Computed
tomography scan for an
anterior mediastinal mass.
Red arrows point to the
anterior mediastinal mass.
(a) Axial, (b) coronal, (c)
sagittal. Anterior
mediastinal mass does not
appear to involve
surrounding mediastinal
structures and appears to
be encapsulated by thymus
and surrounding thymic fat
a
Anterior Mediastinal Mass Example Case Scenario
A 67-year-old man undergoing workup for unintentional weight loss is found to
have an incidental anterior mediastinal mass surrounded by thymus and thymic fat
on CT (Fig. 33.1). He has no symptoms concerning for myasthenia gravis.
Differential diagnosis included thymic hyperplasia, thymic carcinoma, thymoma,
and lymphoma. The patient elected to undergo resection of the anterior mediastinal mass.
Surgical equipment used:
da Vinci Xi robotic system
da Vinci 0-degree camera
Long bipolar grasper
EndoWrist® Clip applier—small and large
EndoWrist® Cadiere forceps
Vessel sealer extend
8mm instrument cannula × 3 (including one Optiview)
12mm AirSeal trocar
5mm Optiview trocar (optional)
5mm 30-degree thoracoscope
Endo Catch bag
Kittner roll gauze sponges
33 Mediastinal Procedures
475
Patient Positioning andPort Placement
Anterior mediastinal masses may be approached from either the right or the left side
of the chest. In our example, a right-sided approach was used. A double-lumen
endotracheal tube is inserted. The patient is placed in supine position with a jellyroll, beanbag, or rolled sheet along the posterior midclavicular line to elevate the
operative side. The arms are tucked with the arm on the operative side allowed to sit
slightly below the OR table to allow more space for the robotic arms. The patient’s
entire chest is prepped and draped to allow access to the contralateral side if needed.
The right pleural space is accessed with an 8mm Optiview trocar along the anterior axillary line at the midpoint of the sternum (typically the fth intercostal space).
The layers of the chest wall should be visualized during insertion to allow for safe
entry into the pleural space (Fig.33.2). After insufation to 8mmHg, two additional
8mm ports are inserted under direct visualization along the anterior axillary line,
port #1in the third intercostal space and port #2in the seventh intercostal space
(Fig.33.3). Port #1 can sometimes require bariatric length to clear the underlying
arm. Finally, a 12mm AirSeal is inserted in the midclavicular line as low as possible
just above the diaphragm.
The robot is then driven into operative eld from the contralateral side and perpendicular to the patient centered on the camera trocar. The ports are then secured
into the robotic arms with the remote center of the three robotic ports just within the
intercostal muscle of the chest wall. The 8mm 0-degree da Vinci camera is passed
into the center camera port. Under direct visualization, the Cadiere forceps are
placed into the port #1 followed by the long bipolar grasper (or robotic vessel sealer)
into port #2.
Anterior Mediastinal Mass Excision Operative Steps
The phrenic nerve is rst identied along the pericardium, as this nerve must be
preserved and denes the posterior border of the dissection. If unable to be visualized at any point in the operation, a 5mm port can be placed on the contralateral
side to allow the assistant to aid in visualization with a 30-degree thoracoscope. We
use the long bipolar grasper to initiate the dissection of the mediastinal pleura just
anterior to the phrenic nerve running along the superior vena cava (Fig.33.4). The
Kittner roll gauzes are inserted into the thoracic cavity through the access port to
assist with absorbing minor bleeding and assist with retraction. The dissection of
the mediastinal pleura is extended caudad to the inferior pole of the thymic tissue
above the diaphragm denoting the right-sided inferior border of dissection. The
mediastinal pleural incision is then extended cephalad to the innominate vein
(Fig.33.5). Care must be taken as the dissection nears the innominate vein, as clips
may be necessary to divide vein branches to the thymus. Thymic tissue underneath
the innominate is dissected free. The thymic tissues are dissected off the pericardium posteriorly to the mediastinal pleura on the left side which is incised at the
same level as on the right side. The anterior dissection is started just medial to the
476
B. Williams and M. Sancheti
Fig. 33.2 Thoracic cavity
entry using 5mm Optiview
trocar with 5mm
thoracoscope. (a)
Subcutaneous fat layer, (b)
muscle layer, (c) lung
parenchyma visualized
a
b
c
internal mammary vessels (Fig.33.6). Arterial branches may need to be clipped and
divided supplying the thymus. The right-sided superior pole of the thymus is then
dissected free using caudad and posterior traction (Fig.33.7). A clip is usually necessary at the superior aspect of the pole to control bleeding. The dissection is then
carried over to the left superior pole, which is similarly dissected away from the
inferior neck (Fig. 33.8). The dissection is then carried over to the mediastinal
pleura on the anterior aspect of the dissection along the sternum. The left pleural
33 Mediastinal Procedures
477
AAL
MAL
PAL
Camera
1
st
1
nd
2
rd
3
th
4
th
5
th
6
Assistant
th
7
2
th
th
8
9
Fig. 33.3 Port placement for robotic anterior mediastinal mass resection. AAL (anterior axillary
line), MAL (midaxillary line), PAL (posterior axillary line). Port sites are labeled blue for camera
port, yellow for robotic port 1, green for robotic port 2
Fig. 33.4 Initial
dissection plane for
anterior mediastinal mass
resection. The phrenic
nerve and SVC (superior
vena cava) are identied.
The cephalad and caudad
directions are denoted for
orientation
space is entered anteriorly taking care not to injury the left internal mammary artery.
The thymus is retracted over to the right side and the left lobe of the thymus is dissected free (Fig.33.9). An Endo Catch bag is inserted through the 12mm AirSeal
port and the specimen is removed from the pleural cavity. The robotic instruments
are then retracted and the robot disengaged from the ports. A 24 Fr chest tube is