Nonintubated Robotic-assisted Thoracic Surgery for Tracheal/Airway Resection and Reconstruction: Technique Description and Preliminary Results.

OBJECTIVE: We aim to report a novel surgical technique that RATS combined with nonintubated spontaneous ventilation to perform tracheal/airway surgery. SUMMARY OF BACKGROUND DATA: Our team has demonstrated video-assisted transthoracic surgery can be used for thoracic tracheal diseases with satisfactory outcomes. Our team has also demonstrated that tracheal/airway resection and reconstruction under spontaneous ventilation can improve the anastomosis and operating time. Recently, RATS emerged as an available alternative minimally invasive approach for lung cancer, with lower perioperative mortality and conversion rate to open.
METHODS: Five patients fulfilling the criteria for nonintubated approach underwent RATS tracheal/airway surgery. Patient 1 has a tumor in the thoracic trachea; patient 2 had involving secondary carina; patient 3 had involving trachea carina, and patient 4 had involving left main bronchus. Patient 5 had involving mid-tracheal.
RESULTS: All patients had an uneventful procedure. The total operative time ranged from 5 hours 5 minutes to 9 hours 55 minutes. The postoperative hospital stays ranged from 4 days to 14 days. Fiber-optic bronchoscopy performed 1 month after the procedure showed good anastomotic healing with no stricture.
CONCLUSION: This is the first report on RATS use in tracheal/airway surgery, in combination with nonintubation spontaneous ventilation. In selected patients, this novel combined approach is feasible and safe. A patient can potentially benefit from the combined advantages of both techniques. More cases and longer-term data are required to establish its role in tracheal/airway surgery.

Tracheal/airway surgery is traditionally performed via an open approach.[1,2] Our team has demonstrated video-assisted transthoracic surgery (VATS) can be used for thoracic tracheal diseases with satisfactory outcomes.[3] Furthermore, our team has demonstrated that without muscle relaxant and tracheal intubation, tracheal/airway resection and reconstruction under spontaneous ventilation is also feasible and can improve the anastomosis and operating time.[4,5] Recently, robotic-assisted thoracoscopic surgery (RATS) emerged as an available alternative minimally invasive approach for lung cancer, with lower perioperative mortality and conversion rate to open.[6] However, RATS is rarely reported in the treatment of malignant tracheal tumors. In the current study, we report a novel technique of tracheal tumor resection and trachea reconstruction treated by RATS under nonintubated spontaneous ventilation.

CASE PRESENTATION

Five patients fulfilling the criteria for nonintubated surgery were selected for this novel approach. The 5 patients’ average age is 42 years old (range 33 years old–59 years old). Patient 1 has a tumor in the thoracic trachea, causing a significant obstruction (Fig. 1A). Other tumor locations (Fig. 1B) were at the left secondary carina (patient 2), trachea carina (patient 3), left main bronchus (patient 4), mid-tracheal (patient 5). One patient (patient 3) underwent neoadjuvant targeted immunotherapy, using albumin-bound paclitaxel 400 mg D1 plus carboplatin 200 mg D2 plus sintilimab 200 mg D1 [q4w; 2 cycles].

FIGURE 1

Preoperative imagines and surgical pictures. A, Preoperational CT image (patient 1); a 1.3 cm tumor located in the thoracic trachea causing a significant obstruction. B, A drawing of the tracheobronchial tree with all tumors located, Patient 1 has a tumor in the thoracic trachea. Others tumor location was at the left secondary carina (patient 2), trachea carina (patient 3), left main bronchus (patient 4), and mid-tracheal (patient 5). C, Second carinal reconstruction surgical approach (patient 2); the patient was placed in a right lateral decubitus position. The robotic thoracoscope port (1 cm) was made in the sixth intercostal space in the anterior axillary line. The main operation port (3 cm) was placed in the fourth intercostal space on the midaxillary line; the auxiliary operation port (1 cm) was made in the seventh intercostal space posterior axillary line. D, Full exposure of tumor site trachea (patient 3); the tumor was excised with a clearance margin of at least 0.5 cm from the tumor. E, Suturing the trachea and reconstruction carinal (patient 3); the airway was anastomosed using a continuous prolene suture. F, Suturing the posterior wall of the trachea and reconstructed carinal (patient 3). CT indicates computerized tomography; LMB, left main bronchus; RMB, right main bronchus.

ANESTHESIA MANAGEMENT

The anesthesia protocol for nonintubated spontaneous ventilation was described in detail elsewhere.[5] Briefly, vital signs and bispectral index was monitored from beginning to the end of the anesthesia. Patients were anesthetized using intravenous anesthesia (Propofol + Remifentanil + Sufential) and allowed to breathe spontaneously. No muscle relaxant was used. A laryngeal mask was used for assisting airway management.

SURGERY PROCESS AND OUTCOME

Depending on the tumor location, the patient was positioned either left or right lateral decubitus position; the 3-arms Da Vinci robotic surgical system was docked at 45-degree angle to the patient. Ports for the robotic arm were placed, as shown in Figure 1C. Bronchoscopy and fluoroscope were used to assist the localization of the tumor during the operation. The tumor was then excised with a clearance margin of 0.5 cm (patient 2, 4, 5) or 1 cm (patient 1, 3) from the tumor (Fig. 1D). After intraoperative frozen sections showed tumor invasion of the trachea resection margin is negative. The trachea was then anastomosed using a continuous PROLENE 2-0 suture, and the bronchus was using PROLENE 3-0 suture, followed by 3 MONOCRYL 4-0 intermittent suture for reinforcement (Fig. 1E and F) to avoid the risk of the continuing suture. The chest was closed with 1 chest drainage after confirming no bleeding and air leak.

The total preparation of the robotic system and operative time ranged from 5 hours 5 minutes to 9 hours 55 minutes, and the total blood loss ranges from 10 mL to 50 mL. Two patients’ postoperative pathology showed mucoepidermoid carcinoma; the rest showed lymphoepithelioma-like carcinoma, adenoid cystic carcinoma, and squamous cell carcinoma, respectively. The average size of the tumor is 1.2 cm (range 0.9 cm–4.3 cm). The postoperative hospital stays ranged from 4 days to 14 days. All patients have no complications 1 month after the operation, and fiberoptic bronchoscopy reexamination showed good anastomotic healing and no anastomotic stenosis.

DISCUSSION

Franca et al[7] first described their experience using the Da Vinci robotic system for thoracic surgery in 2002. Since then, the application of robotic surgical techniques has become increasingly widespread. We reported the initial experience on robotic surgery for nonintubated tracheal/airway resection and reconstruction, which has shown that this new surgical technique is feasible and can be performed safely within a reasonable time, comparing with the traditional VATS approach.

We have previously reported the technical benefits of nonintubated VATS in airway surgery over traditional endotracheal intubation VATS: it simplified airway surgery without the interference of endotracheal tube, reduces the unstable SpO2 during surgery, allows better surgical filed and airway anastomosis, thus reduces postoperative complications, and shorter hospital stay.[4] These benefits were also maintained during the RATS approach and potentially could enhance the benefit of RATS. It avoids the time loss associated with the repositioning of the robotic console during cross-field ventilation.

With the robotic arm's extra maneuverability, we found that the anastomosis suturing was relatively easier in RATS than the VATS approach under a similar nonintubation setting. Three-dimensional visualization also enhances the procedure's accuracy compared with VATS, compared with the routine 2-dimensional display. Prolene continuing suturing technique was applied, which was used in our previous report tracheal/airway series with good results,[3] based on lung and trachea transplantation experiences.[8,9] If interrupted sutures were used in the context of RATS, the robotic arm would need to be withdrawn frequently to reload the suture, thus increasing operating time.

When compared with the nonintubated VATS approach, several points need to be considered. Intraoperative mediastinal swing can be a life-threatening problem during surgery. This risk can be minimized by selecting the appropriate patients [male body mass index (BMI) <25, female BMI <23], satisfied vagus nerve block and tacit cooperation between surgeons and anesthesiologists. However, with increased experience, the restriction of BMI can be relaxed to 30.[10] In addition, suppose a drop in oxygenation does not improve with continuous positive airway pressure or high-frequency jet ventilation. In that case, it may be more difficult to intubate the patient because of the robot console. Besides, 2 assistants were required during nonintubated RATS tracheal surgery, 1 assist the surgeon, and the other helps to clean the surgical field with a suction.

In conclusion, robotic-assisted thoracic surgery for tracheal/carinal/airway surgery under nonintubated spontaneous ventilation is feasible in carefully selected patients at the preliminary practice. However, more data is needed to establish its future role in this field.