Emergency rollout and conversion procedures during the three-arm robotic open-thoracotomy-view approach

Abstract

Objectives: To conduct robotic lung resections (RLRs) with views similar to those in open-thoracotomy surgery (OTS), we adopted a vertical port placement and confronting upside-down monitor setting: the robotic open-thoracotomy-view approach (OTVA). We herein discuss the procedures for emergency rollout and conversion from the robotic OTVA to OTS or video-assisted thoracoscopic surgery (VATS).

Methods: We retrospectively reviewed the cases of 88 patients who underwent RLR with three-arm OTVA using the da Vinci Xi Surgical System between February 2019 and July 2021. Robotic ports were vertically placed along the axillary line, and 2 confronting monitors and 2 assistants were positioned on each side of the patient. Three possible conversions were prepared: (i) emergency thoracotomy using an incision along the ribs in a critical situation, (ii) cool conversion using vertical incision thoracotomy in a calmer condition and (iii) conversion to confronting VATS. All staff involved in the surgery repeatedly rehearsed the emergency rollout in practice.

Results: No emergent or cool conversion to OTS occurred. Two patients (2.3%) experienced confronting VATS conversions. One patient underwent an urgent conversion for a moderate haemorrhage from a pulmonary artery branch during left upper lobectomy in the introduction phase. Another patient underwent a calmer conversion during an extended RS6 + S10a segmentectomy, where staples could not be inserted appropriately due to lung lacerations. In all patients, postoperative courses were uneventful.

Conclusions: The OTVA setting is a possible option for RLRs. This report describes the emergent rollout and subsequent conversion procedures for this method.

Keywords: Confronting monitors; Emergency rollout and conversion procedures; Open-thoracotomy-view approach; Robotic lung resection; Vertical port placement.

Figure 1:

Vertical port placements (top), positions of the robotic arms, 2 assistants and confronting monitors (middle), and possible conversion procedures (bottom) for right-side and left-side surgeries. The lines and numbers drawn on the patient’s body indicate the location of the ribs. The green circles indicate the incision size and intercostal space where each port is placed. Arrows show the roll-in/out directions of the patient cart. The conversion types are as follows: emergency thoracotomy with an incision along the ribs in critical situations (red); cool conversion to vertical muscle-sparing/splitting thoracotomy or axillary incision in calmer conditions (blue); and conversion to confronting video-assisted thoracoscopic surgery by adding a scope port (yellow). The settings for the upper lobes are shown. For middle and lower lobes, the port locations are caudally moved, as described in the text.

Figure 2:

The flow and each staff member’s roles and actions during an emergency rollout for robotic open-thoracotomy-view approach with confronting upside-down monitor settings at our institution. This flowchart was translated to English from the original Japanese version. OTS: open-thoracotomy surgery; VATS: video-assisted thoracoscopic surgery.