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LETTERS TO EDITOR
Year : 2017  |  Volume : 18  |  Issue : 1  |  Page : 30-32
 

Perioperative management lessons learned from the robot-assisted thymectomy project


1 Institute of Critical Care and Anaesthesiology, Gurgaon, Haryana, India
2 Department of Minimally Invasive Thoracic Surgery, Medanta the Medicity, Gurgaon, Haryana, India

Date of Web Publication27-Jun-2017

Correspondence Address:
Jyotirmoy Das
Aero View Heights, Plot 3B, Sector 22, Dwarka, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_4_17

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How to cite this article:
Deka S, Das J, Khanna S, Mehta Y, Khan AZ. Perioperative management lessons learned from the robot-assisted thymectomy project. Indian Anaesth Forum 2017;18:30-2

How to cite this URL:
Deka S, Das J, Khanna S, Mehta Y, Khan AZ. Perioperative management lessons learned from the robot-assisted thymectomy project. Indian Anaesth Forum [serial online] 2017 [cited 2019 Oct 22];18:30-2. Available from: http://www.theiaforum.org/text.asp?2017/18/1/30/208966


Sir,

Certain surgical techniques have inherent risks associated with procedures. For example, risk of embolic stroke during carotid endarterectomy, glottis edema during robotic pelvic surgery, bone cement implantation syndrome in knee arthroplasty, or facial nerve injury during parotidectomy. As perioperative physicians, we often have to strike a balance between the complications of the surgical technique and smooth conduct of the desired surgical procedure. The anesthesiologist is often caught in the dilemma of whether to stop the surgery when patient is at risk or to continue with the prior explained risk consent when no other technique or approach is feasible. The question then comes – what is the alternative?

Robot-assisted thymectomy is one such procedure where the robotic approach is very helpful because of its three-dimensional magnified vision quality, dexterity, and range of movement. In addition, robotic technique has the advantage of minimally invasive approach with the capability of extensive mediastinal dissection [1] inside the narrow superior mediastinum. However, the problem arises with the traditional approach of robotic port placement. In the conventional approach of robotic thymectomy, the anesthetized patient is kept in supine position with the right arm abducted [Figure 1]. The robot docks from the left side of the patient with the surgical ports at the anterior axillary line on the right side.[2] The drawback with this approach is the very high risk of brachial plexus injury [3],[4] and mechanical compression of the upper limb by the robotic arms. We tried various methods to reduce this risk by the use of bean bags and lowering the arm at the shoulder joint a little bit. However, the risk of perioperative injury still remains very high. Moreover, bean bags may not always be available. Recently, our surgeons tried a different approach to access the thymus. The trachea was intubated with a left-sided double lumen tube as per protocol. The patient was kept supine with both arms abducted at <90°. A bolster was used below the scapula to raise the upper chest. This position allows access to the thoracic cavity from both sides or by sternotomy if needed. The surgeons docked the robot from the head end and robotic instruments went through a subxiphoid port toward the superior mediastinum [Figure 2] and [Figure 3]. With a little help of capnothorax (pressure 6–8 cm H2O), they could access the thymus very easily and the surgery was done uneventfully in 3 h. Extraction of the specimen was done through one of the ports. Since the robotic arms were far away from the upper limbs, compression injury or risk of brachial plexus injury was eliminated.
Figure 1: Conventional approach in robotic thymectomy

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Figure 2: Subxiphoid approach in robotic thymectomy

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Figure 3: Final position of the surgical robot after docking

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One-lung ventilation can cause harmful effects in both the collapsed as well as the ventilated lungs.[5] The resulting lung injury ranges from atelectasis, surfactant dysfunction, and volutrauma to acute lung injury. Another major advantage with this technique was that it actually does not need lung isolation. In the traditional axillary approach, lung isolation is required for surgical access to the thymus. Being a midline approach, this new technique could be performed with two-lung ventilation. If necessary, a low tidal volume, high respiratory rate, and permissive hypercarbia can be tried before switching to one-lung ventilation as the final step of surgical assistance. We used permissive hypercarbia with low tidal volume during half the duration of surgery. Maximum PaCO2 recorded was 55 mmHg. Researchers have proved that the harmful effects of one-lung ventilation are duration dependent [5] and we think that the short duration of lung isolation, if really needed in this technique, will be quite helpful in reducing the extent of lung injury.

It will be inappropriate to conclude by a single case report that the new subxiphoid technique is better than the conventional axillary approach. As anesthesiologists, it will not be prudent to comment on the technique as choosing the technique is under the surgeon's domain. However, through this article, we would like to highlight the importance of innovation and to evolve new techniques to improve the perioperative outcome. We hope a large-scale comparative evaluation using both the approaches in terms of the concerns highlighted above will be of great value in this regard.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rueckert J, Swierzy M, Badakhshi H, Meisel A, Ismail M. Robotic-assisted thymectomy: Surgical procedure and results. Thorac Cardiovasc Surg 2015;63:194-200.  Back to cited text no. 1
[PUBMED]    
2.
Deen S, Farivar AS, Louie BE. Thoracic techniques: Robotic thymectomy for thymoma. Indian J Surg Oncol 2013;4:132-7.  Back to cited text no. 2
    
3.
Pandey R, Elakkumanan LB, Garg R, Jyoti B, Mukund C, Chandralekha, et al. Brachial plexus injury after robotic-assisted thoracoscopic thymectomy. J Cardiothorac Vasc Anesth 2009;23:584-6.  Back to cited text no. 3
    
4.
Campos J. Anesthesia for robotic thoracic surgery. In: Slinger P, editor. Principles and Practice of Anesthesia for Thoracic Surgery. New York:© Springer Science+Business Media, LLC; 2011. p. 445.  Back to cited text no. 4
    
5.
Lohser J, Slinger P. Lung injury after one-lung ventilation: A review of the pathophysiologic mechanisms affecting the ventilated and the collapsed lung. Anesth Analg 2015;121:302-18.  Back to cited text no. 5
    


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