Subcostal robotic-assisted pulmonary resection: Left lingular segmentectomy

Abstract

Central MessageSubcostal robotic-assisted pulmonary resection is feasible for left lingular segmentectomy while preserving the intercostal spaces. There is continued interest in finding an optimal approach for thoracic surgery. The intercostal space has been accepted as the standard route for video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS). However, the intercostal approach causes postoperative chronic pain and related complications due to intercostal nerve injury. To overcome the shortcomings of the intercostal approach, the subcostal VATS has been proposed.1Chiu C.-H. Chao Y.-K. Liu Y.-H. Subxiphoid approach for video-assisted thoracoscopic surgery: an update.J Thorac Dis. 2018; 10: S1662-S1665Crossref PubMed Scopus (14) Google Scholar However, the long distance from the costal arch to the hilum and the interference from the hip and abdomen make this procedure difficult. Therefore, we introduced the subcostal RATS, which is less technically demanding than subcostal VATS while maintaining the advantages of the subcostal route. We performed the subcostal RATS left lingular segmentectomy for pulmonary arteriovenous malformation. The patient was intubated with a double-lumen endotracheal tube and placed in a right lateral decubitus position. We try to minimize the interference of the patient's hip and abdomen with the robotic arms by placing a pillow under the flank and arching the patient's back downward (Figure E1). The requirement for informed consent was waived because of the retrospective study design (institutional review board number and date of approval: B-2206-763-102, June 3, 2022). A 4-cm long working port was made where the subcostal arch and the midclavicular line meet. The subcutaneous tissue and oblique muscles were incised until the transverse abdominalis fascia was visible. The pleura was accessed by tunneling below the costal cartilages and above the diaphragm using mosquito forceps. To protect the diaphragm during surgery, we sutured the cut edge of the diaphragmatic parietal pleura to the transverse abdominalis fascia preemptively and applied a wound protector (Figure 1, A and B). Subcostal 12-mm and 8-mm ports were created. Each port was kept 4 cm apart. The first and second arms were docked to ports placed on either end of the working port. The sump suction was placed within the working port. The remaining arms were docked to the 12-mm and 8-mm ports, respectively (Figure 2). The lingular segmental artery and vein were divided. The segmental bronchus was cut open and later stapled. The intersegmental plane was divided under the guidance of Firefly (Intuitive) (Video 1). A 24-F chest tube was inserted through a 12-mm port. The proximal end of an oblique muscle, the cut edge of the diaphragmatic parietal pleura, and the distal end of an oblique muscle were sutured together, and the rest of the wound was closed (Figure 1, C).Figure 2Port access and their use for subcostal robotic surgery for left lingular segmentectomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The VATS has revolutionized the management of lung cancer treatment.2Sihoe A.D. Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery.Respirology. 2020; 25: 49-60Crossref PubMed Scopus (28) Google Scholar The intercostal VATS has been refined over decades and established as the standard for thoracic surgery. RATS has been introduced for thoracic surgery recently, but it shares the same problem caused by intercostal space usage. Subcostal VATS has recently been proposed to overcome the limitation of intercostal usage.1Chiu C.-H. Chao Y.-K. Liu Y.-H. Subxiphoid approach for video-assisted thoracoscopic surgery: an update.J Thorac Dis. 2018; 10: S1662-S1665Crossref PubMed Scopus (14) Google Scholar However, the subcostal VATS is challenging to perform and unsafe for the following reasons: Most VATS instruments are rigid and unable to be angulated, and the distance from th