From the Guidelines
Robotic-assisted thoracoscopic decortication is a complex procedure that requires meticulous attention to detail and adherence to a standardized protocol to minimize morbidity and mortality, and improve quality of life. The procedure begins with patient positioning in lateral decubitus with the affected side up, followed by general anesthesia with single-lung ventilation using a double-lumen endotracheal tube 1.
Key Operative Steps
- Port placement typically includes three to four robotic ports: a camera port (8-12mm) usually at the 7th or 8th intercostal space at the mid-axillary line, and two to three instrument ports (8mm) positioned triangularly around the camera port.
- After docking the robot, the surgeon first identifies and frees adhesions between the lung and chest wall using blunt and sharp dissection.
- The fibrinous peel is then carefully grasped and separated from the visceral pleura using robotic instruments like Maryland forceps and curved scissors, working methodically from apex to base.
- Meticulous dissection is essential to avoid lung parenchymal injury, as highlighted in a systematic review and procedure-specific postoperative pain management recommendations for video-assisted thoracoscopic surgery 1.
Post-Operative Care
- Once decortication is complete, the surgeon ensures full lung expansion, performs thorough irrigation with warm saline, and places chest tubes (typically 28-32 French) under direct vision.
- The robot is undocked, ports are removed, and incisions are closed in layers.
- Post-operatively, chest tubes remain until drainage is minimal (<150mL/day) and air leaks resolve.
- The choice of surgical approach, including robotic-assisted thoracoscopic decortication, may impact postoperative complication rates and length of stay, as discussed in guidelines on enhanced recovery after pulmonary lobectomy 1 and a consensus conference on lung cancer 1.
Recommendations
- The robotic approach offers enhanced visualization and instrument dexterity compared to conventional VATS, allowing for more precise dissection in the confined pleural space, and is preferred for its potential to reduce morbidity and improve quality of life.
- A systematic review and meta-analysis of comparative studies on surgical approaches for early-stage non-small-cell lung cancer found similar results with no differences in in-hospital pulmonary outcomes or mortality between open, VATS, and robotic surgery 1.
From the Research
Operative Steps for Robotic Assisted Thoracoscopic Decortication
The provided studies do not directly outline the operative steps for robotic assisted thoracoscopic decortication. However, we can gather information on the general approach to thoracoscopic decortication and the benefits of minimally invasive surgery.
Benefits of Minimally Invasive Surgery
- Reduced operative time and postoperative hospital stay compared to open thoracotomy 2, 3, 4
- Lower rate of postoperative complications, such as atelectasis, prolonged air leak, and sepsis 2, 3
- Less blood loss and shorter chest tube duration 4
- Improved operative safety with fewer conversions for uncontrolled bleeding 5
Thoracoscopic Decortication
- Can be performed using video-assisted thoracic surgery (VATS) or uniportal VATS (U-VATS) 2, 3, 4
- Involves the removal of the restrictive "peel" or cortex to allow the lung to expand and fill the thoracic cavity 6
- Can be used to treat benign and malignant pleural effusions, as well as empyema and hemothorax 2, 3, 4, 6
Robotic Assisted Thoracoscopic Surgery
- Has been shown to have similar perioperative outcomes to VATS, even in the learning period 5
- May offer more operative safety with fewer conversions for uncontrolled bleeding 5
- Can be used for lung lobectomy and other thoracic procedures, but its role in decortication is not well defined in the provided studies 5