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Complications during robotic-assisted thoracic surgery are rare.
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Awareness of potential complications is essential for a robotic thoracic surgeon.
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If a complication occurs, first, stabilize the patient and assess the situation.
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If the complication cannot be managed with robotic assistance, convert to a thoracotomy/sternotomy for definitive repair.
Management of Complications in Robotic Thoracic Surgery
Section snippets
Key points
Background
Intraoperative complications are a potential during any surgical procedure. However, the stakes are higher in thoracic surgery compared with other surgical fields, as thoracic procedures generally take place in a small, fixed volume area, in close proximity to the pulmonary vasculature, tracheobronchial tree, great vessels, and heart. This unique setting creates an environment for possible catastrophic complications. Given the sparse literature and the similarity between robotic-assisted
Prevalence
The incidence of intraoperative complications in robotic-assisted thoracic surgery is low. Reported conversion rates from minimally invasive thoracic surgery to thoracotomy range from 1.6% to 9.0%, but most series do not differentiate emergent conversion (ie, for a catastrophic complication) from elective conversion (ie, difficult anatomy or need for more complex vascular or bronchial reconstruction).10, 11, 12, 13, 14, 15 A retrospective review of 1304 patients who underwent robotic-assisted
Pulmonary Arterial Injury
The most feared intraoperative complication during thoracic surgery is an injury to the pulmonary artery. The published incidence of pulmonary artery injury during robotic anatomic resection varies from 0.5% to 2.6%8,11, 12, 13, 14, 15; this is not statistically different than the incidence of pulmonary artery injury during video-assisted thoracoscopic surgery (1%–2.9%).9,16,17 The right and left upper lobes were cited as the most common location for pulmonary artery injury during
Great vessel injury
The superior vena cava, azygous vein, innominate vein, and thoracic aorta all reside in the thoracic cavity and, therefore, are at risk of injury during robotic-assisted thoracic surgery. Injuries to the superior vena cava, azygous vein, and innominate vein are reported during robotic-assisted thoracic surgery series, but a reasonable incidence for each is not well established. No published accounts of thoracic aortic injury during robotic-assisted thoracic surgery could be identified, although
Thoracic duct injury
The thoracic duct is commonly injured during robotic-assisted thoracic surgery and usually occurs with extensive dissection during lymphadenectomy or esophageal mobilization. The most common site of injury is in the subcarinal space, as the thoracic duct’s location moves from the right chest (between the aorta, azygous vein, and vertebral bodies) and crosses to ascend toward its eventual destination, the angle of the left internal jugular vein and the left subclavian vein.
If a thoracic duct
Erroneous transection
Unintended division of structures in the pulmonary hilum is a rare complication that is most often described in the setting of abnormal or distorted anatomy. The largest published minimally invasive thoracic surgery series to include data regarding accidental transection of structures demonstrated a 0.3% incidence rate (9 out of 3076 cases), and risk factors included previous thoracic operations, prior chemotherapy, and prior radiation therapy.8 Inadvertent transections have been reported of
Tracheobronchial injury
Tracheobronchial injury during robotic-assisted thoracic surgery is uncommon. In the literature, the most common cause of injury to the uninvolved airway, proximal trachea, or contralateral mainstem bronchus is a tear in the ipsilateral or contralateral mainstem bronchus during placement or manipulation of the double lumen endotracheal tube. However, although rare, intraoperative injuries to the tracheobronchial tree have been reported during subcarinal lymphadenectomy, stapling of the lower
Esophageal, diaphragmatic, or abdominal organ injury
Esophageal, diaphragmatic, and abdominal organ injuries during robotic-assisted thoracic surgery are rare. During subcarinal and inferior pulmonary ligament lymphadenectomy, the esophagus can become injured secondary to electrothermal injury or sharp laceration. Injury to the esophagus from the stapler tip has also been reported. Management of an esophageal injury depends on the extent of the injury and the experience of the surgeon. It can range from robotic-assisted simple suture repair to
Effects of carbon dioxide insufflation
A unique aspect of robotic-assisted thoracic surgery, as compared with video-assisted thoracoscopic surgery, is the use of carbon dioxide insufflation. Several complications, including carbon dioxide embolus, decreased venous return, severe bradycardia, progressive arterial hypoxia, and acid-base disorders can arise from the use of carbon dioxide insufflation. These complications can occur rapidly (ie, embolus, decreased venous return, and severe bradycardia) and therefore require quick
Additional complications
Published series have detailed several highly unusual or uncommon complications that are rarely reported but should be familiar to experienced thoracic surgeons. These complications include airway kinking, massive parenchymal air leak, and lobar torsion. Overall, the management of these complications is not standardized, but instead, is based on each surgeon’s individual judgment.
Summary
Complications during robotic-assisted thoracic surgery are rare but have the potential to result in significant morbidity and mortality for patients if not managed properly. In the event of a complication, the safety of the patient should remain top priority. Robotic surgeons and their operating room teams should routinely review plans for complication management. This preparation should include the use of mock scenarios, including steps for hemorrhage control and conversion to thoracotomy.
Clinics care points
Pulmonary arterial injury is the most common reported complication during robotic-assisted thoracic surgery, and incidence may not be affected by surgeon experience. Pulmonary vascular injuries during robotic-assisted thoracic surgery may be more common in patients with larger tumors (ie, >5 cm) or who have received neoadjuvant chemotherapy and/or radiation. The incidence of erroneous transection of thoracic structures may be more common when patients have had previous thoracic surgery or
Disclosure
Dr M.D. Stanley has nothing to disclose. Dr M.S. Sancheti discloses a financial relationship with Intuitive Surgical.
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