Robotic-assisted costectomy using a Gigli saw for fibrous dysplasia

Abstract

Background: Fibrous dysplasia (FD) is the most common benign tumor of the ribs, with surgical resection being the preferred treatment modality for rib FD, leading to enhanced quality of life and favorable outcomes. The complexity of surgical intervention varies depending on the location of costal FD, presenting challenges for both open surgical and thoracoscopic approaches. In this study, we present a novel technique for three-port robotic-assisted costectomy utilizing a Gigli saw, detailing our initial findings and outcomes.

Methods: We reviewed five patients with benign rib tumors who underwent three-port robotic-assisted rib resection using a Gigli saw between May 2021 and December 2022. Data on patient characteristics, relevant short-term surgical outcomes and clinical long-term treatment effects were collected.

Results: The surgery was successful in all five patients without any need for an additional port and emergency conversion to open surgery. Median operative time was 76.8 min (range, 73-116 min), and the median intraoperative blood loss volumes was 75 ml (range, 40- 105 mL). On average, chest tubes were removed 1.2 days postoperatively (range, 1-2 days), with a mean drainage volume of 93 ml on postoperative day 1 (range, 70-135 ml). Patients were discharged between the 2nd and 4th postoperative day. During 1-year follow-up period, no recurrence was observed in either patient.

Conclusions: The utilization of a three-port robotic-assisted costectomy in conjunction with a Gigli saw represents a viable, secure, and efficient approach for treating isolated benign rib lesions. Our aim is to provide clinical guidance on this technique and promote its broader application.

Keywords: Fibrous dysplasia; Gigli saw; Rib resection; Robot-assisted costectomy.

Fig. 1

Preoperative imaging examinations and 3D images of some patients. (A) Chest radiography shows a lesion in the right chest wall. (B) Chest CT revealed a fusiform lesion with ground-glass centre of the lateral aspect of the right 4th rib. (C, D) 3D reconstructions show two lesions of FD in the right 4th rib and the right 5th rib respectively. (E) Bone scan shows increased activity in the right 5th rib. (F) PET-CT shows a benign costal lesion of the post aspect of the left 4th rib in a patient with breast cancer. (G, H) 3D images reconstructed with Mimics Mecdical 21.0 software. Exact three-dimensional relationships of the rib tumor, upper and lower ribs, blood vessels, spines and pulmonary tissues. Grey: normal ribs and spines; Purple: pulmonary tissues; Blue: scapulas and clavicles; Yellow: rib tumor region

Fig. 2

Intraoperative pictures and important steps of robotic-assisted costectomy in a patient with fibrous dysplasia. (A) The incisions and port placement of RATS. Port 1 is equipped with a maryland bipolar forceps (surgeon left hand); The table surgeon and the camera port share the same incision as port 2; Port 3 is equipped with a permanent cautery hook (surgeon right hand). (B) The parietal pleural over the lesion border of the rib is opened. (C) The Maryland bipolar forceps and the cautery hook cooperate with each other to create a tunnel behind the target rib for placing the Gigli saw. (D) Two robotic instruments hold the Gigli saw for cutting the rib