Robot-Assisted Thoracic Procedures

Risk Factors for Complications During the Procedure A risk factor is something that increases your chance of having complications during your procedure. Risk factors for complications during robot-assisted thoracic procedures include: Pre-existing heart or lung conditionAdvanced ageObesitySmokingDiabetesExcessive alcohol intake What to Expect Prior to Procedure Depending on the reason for your surgery, your doctor may do the following: Physical examBlood testsUrine testsChest x-rayPulmonary function testa test to assess the capacity of your lungs to undergo surgery Upper GI seriesx-ray of the esophagus, stomach, and part of the small intestines after swallowing a barium solution Electrocardiogram (ECG, EKG)a test that records the electrical currents passing through the heart muscle Ultrasounda test that uses sound waves to visualize the inside of the chest CT scana type of x-ray that uses a computer to create images of structures inside the chest MRI scana test that uses powerful magnets and radiowaves to create images of structures inside of the chest Upper endoscopya lighted tube equipped with a camera used to visualize the inside of the esophagus, stomach, and part of the small intestinesPre-operative plasma exchange, intravenous immunoglobulin (IVIg), or immunosuppressive therapy, if you are undergoing a thymectomyPlacement of a feeding tube into your small intestine in the days leading up to or on the day of surgery, if you are having an esophagectomyReview your medications with the surgeon; you may need to stop taking some of them.Use an enema to clear your colon, if directed to do so by your surgeon.Follow a special diet, if recommended by your surgeon.Take antibiotics, if prescribed by your doctor.Shower the night before your procedure using antibacterial soap, if your doctor asks you.Arrange to have someone drive you to and from the procedure, and for help at home after your procedure.Eat a light meal the night before, and do not eat or drink anything after midnight unless told otherwise by your doctor.Plan to wear comfortable clothing on the day of your procedure. AnesthesiaGeneral anesthesia will be used. An endotracheal tube will be placed in your windpipe to help you breathe. You may also be given spinal or epidural pain medication through a tube placed along the spinal column in your back.

Description of the ProcedureTo begin a robot-assisted thoracic procedure, the surgeon cuts several small (approximately one centimeter) keyhole openings in the chest wall between the ribs. One or more chest tubes may be placed into the side of your chest to drain fluids and monitor air leakage. A needle may be used to inject carbon dioxide gas into the chest cavity, making it easier for the surgeon to see internal structures.The surgeon passes a small camera (endoscope) through one of the incisions, which lights, magnifies, and projects an image of internal organs on to a video screen for the surgeon to see. The endoscope is attached to one of three or four of the surgical systems robotic arms.The other two or three arms hold other instruments such as dissectors, scissors, scalpels, or forceps. These instruments are able to grasp, cut, dissect, and suture structures inside the chest during the operation.While sitting at a console several feet away from the operating table, the surgeon looks through lenses at a magnified three-dimensional image of the inside of the chest. Another surgeon stays by the patient during the procedure, where he can adjust the camera and instruments as needed.With joystick-like hand controls and foot pedals, the surgeon at the console guides the movement of the robotic arms and surgical instruments. The robotic arms are able to perform surgical tasks with an increased range of motion than would be possible using traditional surgical techniques. In addition, the robotic arms can filter out hand tremor and translate the surgeons larger hand movements into smaller ones.

In procedures in which cancerous tumors or tissues are removed, the surgeon may also remove nearby lymph nodes. He or she drops these organs, tissues, and/or lymph nodes into a specimen bag and removes them through one of the openings.After the endoscope and other instruments are removed, the surgeon closes the incisions with sutures or staples, and applies a sterile dressing. After ProcedureIf an organ, tissue, or lymph node was removed, it will be sent to a pathologist for examination. Barring any significant complications, the endotracheal tube in your windpipe will usually be removed soon after surgery, and the chest tubes will follow soon thereafter. How Long Will It Take?Usually 1-4 hours, but this depends on the type of procedure being done. Will It Hurt?General anesthesia prevents pain during surgery. Patients typically experience some pain and soreness during recovery, but receive pain medication to relieve the discomfort. You may also feel some discomfort from the gas used during the procedure. This can last up to three days. Possible ComplicationsBleeding in the lung cavity (hemothorax)Collection of air or gases in the lung cavity (pneumothorax)Collapsed lungNeed for a prolonged artificial respiration on a ventilator (breathing machine)Damage to neighboring organs or structuresInfectionBleedingAnesthesia-related problems Compensatory sweating Horners syndromeDeathAlso, sometimes it becomes necessary during the procedure to abandon the robotic method and perform the surgery using traditional methods (eg, traditional endoscopic or open surgery).

Average Hospital StayYour stay is usually a few days to a week, but may be longer, depending on the procedure. Postoperative CareYou will receive instructions on when and what you can eat, and how you need to restrict your activity.After an esophagectomy, you will not be allowed to eat or drink anything for about a week after surgery. You will receive nutrition through the feeding tube in your abdomen in the days after surgery. Depending on the extent of your surgery, you may gradually progress from a liquid to a solid diet. The feeding tube is often removed about one month after surgery. Your doctor will likely advise you to: Perform deep breathing and coughing exercises soon after the surgery to expand your lungs, and prevent infection and collapseSit up and move around as soon as possible after surgeryTake antibiotics to prevent infectionAvoid certain medicationsResume normal activities (eg, taking daily walks) soon, to promote healingWash the incisions with mild soap and waterLimit certain activities, such as showering, bathing, driving, walking up stairs, lifting, and working, for a period of time OutcomeDepending on your procedure, you should be able to resume most, if not all, regular activities within a few weeks after your surgery. Based on evidence available to date, the risks of robotic surgery appear to be less than for more traditional forms of surgery.

Benefits of robot-assisted thoracic procedures over traditional thoracic procedures may include: Reduced trauma to the bodyReduced risk of blood transfusionShorter hospital stayFaster recovery Call Your Doctor If Any of the Following Occurs It is essential for you to carefully monitor your own recovery once you leave the hospital. That way, you can alert your doctor to any problems immediately. Promptly notify your doctor if any of the following occur: Cough or shortness of breathCoughing up yellow, green, or bloody mucusNew chest painSigns of infection, including fever and chillsRedness, swelling, increasing pain, excessive bleeding, or discharge from an incision siteDifficulty urinating, such as pain, burning, urgency, frequency, or bleedingPain and/or swelling in your feet, calves, or legsPersistent nausea, vomiting, and/or diarrheaHeadache, muscle aches, feeling faint or dizzyOther worrisome symptoms RESOURCES: American College of Surgeonshttp://www.facs.org/ Society of Thoracic Surgeonshttp://www.sts.org/ CANADIAN RESOURCES: The Canadian Lung Associationhttp://www.lung.ca/ Canadian Agency for Drugs and Technologies in Healthhttp://www.cadth.ca/ References: Esophageal canceresophagectomy. University of Maryland Medical Center website. Available at: http://www.umm.edu/thoracic/esoph_surgery.html . Accessed July 21, 2006.

Rea F, Marulli G, Bortolotti L. Robotic video-assisted thoracoscopic thymectomy. Multimedia Manual of Cardiothoracic Surgery. Available at: http://mmcts.ctsnetjournals.org/cgi/content/full/2005/0324/mmcts.2004.000422. Accessed July 21, 2006. Sympathectomy. New York Presbyterian Hospital website. Available at: http://www.nyp.org/health/sympathectomy.html. Accessed May 5, 2008. Thoracic applications. Intuitive Surgical website. Available at: http://www.intuitivesurgical.com/clinical/thoracicapplications/index.aspx. Accessed July 21, 2006. Thoracic lobectomy. New York-Presbyterian Hospital website. Available at: http://www.nyp.org/masc/lobectomy.htm. Accessed July 21, 2006. Thymectomy. Myasthenia Gravis Foundation of America website. Available at: http://www.myasthenia.org/information/thymectomy.htm. Accessed July 21, 2006. Last reviewed May 2008 by Rosalyn Carson-DeWitt, MDPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.