Interactive Cardiovascular and Thoracic Surgery 2:262-264(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Computer-enhanced thoracoscopic thymectomy with the Zeus telemanipulation surgical system
Marius Bermana,b,*,
Alon Stamlera,b,
Bernardo A. Vidnea,b and
Milton Sautea,b
a Department of Cardiothoracic Surgery, Rabin Medical Center, 49100 Petah Tikva, Israel
b Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Received October 26, 2002;
received in revised form January 28, 2003;
accepted February 26, 2003
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* Corresponding author. Tel.: +972-3-9376-701/13; fax: +972-3-9240-762
mariusb{at}clalit.org.il
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Abstract
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Recent years have witnessed important progress in the use of minimally invasive robotic-enhanced surgical systems in cardiac and general thoracic interventions. We report the first-ever successful use of the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA) for the excision of an anterior mediastinal mass. Proper positioning of the thoracic ports for the robotic arms to permit a wide range of movement, is the key to the application of the system for intrathoracic cage operations. Other advantages of the system include three-dimensional voice controlled imaging, low-heat surgical field, and good exposure of the structures.
Key Words: Thymectomy; Robotic surgery; Computer-enhanced surgery
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1. Introduction
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Great progress has recently been made in the development of minimally invasive robotically enhanced surgical systems. Encouraging reports have been published on their use in complete coronary surgery [1–3], atrial septal defect closure [4], interruption of patent ductus arteriosus [5] and mitral valve surgery [6]. These findings, combined with the well-established knowledge on video-assisted thoracoscopic surgery [7], makes thoracic intervention the next expected field of application. In the present work we describe the first successful removal of a thymus using the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA).
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2. Case report
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A 71-year-old man with stable myasthenia gravis of 1 year's duration being maintained on Mestinon (pyridostigmine bromide) 180 mg per day, in addition to a history of ischemic heart disease with hypertension, myocardial infarction and percutaneous transluminal coronary angioplasty and stenting of the left anterior descending artery, was found to have a well-demarcated 2-cm solid mass in the anterior mediastinum on periodic follow-up with thoracic computed tomography (CT) (Fig. 1). The mass had not appeared on the CT scan performed 6 months earlier. Due to the good demarcation of the mass, which was highly suspected to be of thymic origin, the patient was scheduled for thoracoscopic surgery with the robotic system. Senior staff members in our department had already acquired experience elsewhere in coronary surgery with the Zeus system. The operation was performed on June 16, 2002.
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Fig. 1 Computed tomographic imaging of the mediastinal mass. An encapsulated solid mass of 2 cm diameter is recognized in the anterior mediastinum.
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Under general anesthesia with a double-lumen tube and high epidural catheter, the patient was placed in an oblique left lateral decubitus position. The right lung was collapsed by the anesthetist, and the first port for the three-dimensional AESOP video-camera was placed at the fifth intercostal space, along the right anterior axillary line. Neither adhesions nor pleural dissemination was observed. We could see the thymus tissue at the anterior mediastinum. Two more ports for the arms of the Zeus were placed as in standard endoscopic thymectomy, over the third and seventh ribs, along the right mid-axillary line. Endograsp and a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) were connected to both arms of the robot. The mediastinal pleura were opened, and the thymus was removed from phrenic to phrenic nerves (Fig. 2). The left pleura was opened for confirmation. The gland was extracted from the thoracic cavity through an endo-pouch via the lower intercostal incision. The area of the thymus was marked with clips. A single chest drain was introduced through the camera port, and the incision was closed as usual. The patient was extubated at the end of the operation, the chest drain was removed on the first postoperative day, and the patient was discharged on the 3rd day. No frozen sections were obtained during the operation. The definitive histopathology analysis revealed normal thymus tissue.
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Fig. 2 Intrathoracic view during surgery. Dissection of the tumor from phrenic to phrenic nerves using the Endograsp and Harmonic Scalpel.
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3. Comments
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To the best of our knowledge, this is the first report of thymectomy using the Zeus robotically enhanced surgical technique. Yoshino et al. [8] reported a similar case using the da Vinci robot. Developed over 2 years ago, the Zeus system is been equipped with an integrated Micro Wrist Interface which provides the dexterity of open procedures in a minimally invasive surgical environment. Zeus translates the surgeon's hand movements and then scales them into precise micro-movements at the operative site. The system can also integrate third-party tools, such as the Harmonic Scalpel and all range of graspers and holders used in laparoscopic surgery.
Application requires a short period of adaptation and a study curve. We believe knowledge of port placement is the key to success of the Zeus system for intrathoracic cage surgery. Allowing a distance of about 8 cm between the ports permits a wide range of movement and good exposure of the structures. In addition, the Harmonic Scalpel has several advantages: (1) surgery can be done in a low-heat environment and almost smokeless field [9], with easy hemostasis and minimal instrument transfer owing to the hook-shaped tip of the scalpel [10]. Furthermore, the unit does not rely on the flow of electrical current through the patient [11], which directly minimizes the risks of improper grounding or arcing. Patient safety is also greater because the surgeons are working near central vascular catheters [11] or pacemaker wires. No spark is created by the unit [11].
The technology for suturing and ligation with robotic enhanced systems already exists, and may be safely performed in the anterior mediastinum, by both systems. This issue still presents a major difficulty. However, the experience acquired in cardiac surgery (coronary artery bypass grafting and valve surgery) will open new horizons. The major problem is the lack of space although deflation of the lung in the port-placement side considerably facilitates surgery. In this case, there was no need for suturing and ligation.
In conclusion, the Zeus system seems to serve as a good and reliable tool for cardiac intervention. We expect that further engineering advances will increase the possibilities of robot-assisted surgery in mediastinal and lung diseases, benefiting both patient and surgeon.
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Appendix A.
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Disclaimer
Neither the authors, nor the publisher nor the European Association for Cardiothoracic Surgery warrant that the data files are free of defects, or that the documentation is accurate. Neither the authors, nor the publisher nor the European Association for Cardiothoracic Surgery are liable for any damage of whatever kind sustained through downloading and/or using the files. By downloading and/or using the files, the reader, acting as user of an electronic publication, agrees to the above terms and conditions.
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Acknowledgements
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We thank Gloria Ginzach for her editorial assistance.
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References
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Abstract
1. Introduction