Robot-assisted resection of a dumbbell-shaped intradural tumor in the prone position

Abstract

Central MessageRobot-assisted approach of a dumbbell-shaped intradural tumor in the prone position is useful and presents many practical advantages. Robot-assisted approach of a dumbbell-shaped intradural tumor in the prone position is useful and presents many practical advantages. The resection of Eden type 2 or 3 dumbbell-shaped tumors has traditionally been performed by a combination of prone laminectomy and lateral video-assisted thoracic surgery (VATS).1Li X.K. Cong Z.Z. Xu Y. Zhou H. Wu W.-J. Wang G.-M. et al.Clinical efficacy of robot-assisted thoracoscopic surgery for posterior mediastinal neurogenic tumors.J Thorac Dis. 2020; 12: 3065-3072Crossref PubMed Scopus (8) Google Scholar Okazaki and colleagues2Okazaki M. Takigawa T. Suzawa K. Toyooka S. Robot-assisted intrathoracic procedure for dumbbell tumour in the prone position.Interact Cardiovasc Thorac Surg. 2021; 33: 643-645Crossref PubMed Scopus (5) Google Scholar reported the usefulness of robot-assisted intrathoracic procedure for the resection of epidural dumbbell-shaped dorsal spine tumors, with the patient in the prone position and without need for repositioning. Here, we were performed a robot-assisted thoracoscopic surgery (RATS) for an Eden type 2 schwannoma with intradural extension. In this article, we report on the various innovations we have made to resect dumbbell-shaped tumor extending into the dura mater using a posterior approach and RATS, with the patient in the prone position and without repositioning. Institutional review board approval was not required, and the patient provided informed written consent. The patient, a 65-year-old woman with no remarkable history, was diagnosed with a schwannoma on computed tomography–guided biopsy 13 years ago. The tumor grew gradually and computed tomography of the chest showed a well-defined 4-cm tumor bordering the 10th/11th intercostal space. Part of the tumor extended into the spinal canal, with apparent enlargement of the intervertebral foramen (Figure 1, A and B). Magnetic resonance imaging showed the tumor extending into the dura mater and compressing the spinal cord from the right side (Figure 1, C and D). After general anesthesia was administered, the patient was placed in the prone position (Figure 2, A). The dura was incised dorsally to expose the tumor, and the nerve roots contiguous to the tumor were separated within the dura. The tumor was dissected at the level of the intervertebral foramen, and the transverse process and ribs were not resected. The wound was temporarily protected with gauze to terminate the dorsal laminectomy but to allow additional bone resection from the dorsal side if needed for thoracic manipulation. An 8-mm port was placed above the posterior axillary line between the fourth, sixth, and eighth intercostals, and a 12-mm assist port was placed and da Vinci Xi surgical system (Intuitive Surgical) was rolled in, above the midaxillary line in the seventh intercostal space. The fenestrated bipolar forceps was manipulated using the first arm of the robot, and the permanent cautery hook forceps was manipulated by the third arm. The operation up to the visual field and pleural incision around the tumor was performed with CO2 insufflated at a pressure of 8 mm Hg. Owing to the dural incision, subsequent operative activities were performed without CO2 insufflation to prevent pneumoencephalopathy. The visual field narrowed following CO2 insufflation arrest; however, no complications arose during the robotic-assistance phase of the procedure (Figure 2, B-D, Video 1). The total operative time was 6 hours, 19 minutes, and the console time was 30 minutes. The total blood loss volume was 135 mL, with minimal loss from the thoracic part (5 mL). The tumor was resected in 2 pieces, 1 piece amputated via laminectomy and 1 piece via robotic thoracic approach. After tumor resection, the intervertebral foramen was double-sealed from the dorsal and thoracic sides with fibrin glue and polyglycolic acid