Robot-assisted single lung transplantation

Abstract

To the Editor: Currently, lung transplantations are typically performed via a transverse thoracosternotomy or a sternotomy for double lung transplantation, or a posteriolateral thoracosternotomy for single lung transplantation. However, these extremely invasive approaches may contribute to early post-operative pain, delay wound healing, and cause chronic post-thoracotomy neuralgia, which can affect patient's quality of life.[1,2] Of interest, several minimally invasive surgical methods for lung transplantation were reported.[3,4] Furthermore, robotic surgical systems are now widely used in the field of thoracic surgery. Herein, we reported a case of performing robot-assisted right single lung transplantation for a patient with end-stage chronic obstructive pulmonary disease (COPD). A 59-year-old male recipient (weight, 52 kg; height, 170 cm) with end-stage COPD underwent bilateral pulmonary bullae resection via open approaches ten years ago [Figure 1A]. The pre-operative lung function of the recipient showed a forced expiratory volume in 1 s of 0.27 L, a forced vital capacity of 0.52 L, and a vital capacity of 1.20 L. Blood gas test showed a pH of 7.35, a partial pressure of oxygen of 88.1 mmHg, a partial pressure of carbon dioxide of 50.8 mmHg, a concentration of HCO3− of 26.1 mmol/L, and an oxygen saturation of 97.6% (fraction of inspired oxygen of 41%). Transthoracic echocardiogram showed an ejection fraction of 60% and a pulmonary artery systolic pressure of 30 mmHg. After waiting for 69 days, a matched donated lung was found from a 40-year-old male who developed cerebral hemorrhage, with a weight of 65 kg, a height of 170 cm, and an oxygen index of 450 mmHg. With full consent and an allocation process, the graft lung was procured and transported to our hospital.Figure 1: (A) Pre-operative chest computed tomography of the recipient. (B) The pulmonary artery was cut by robotic scissors. (C) The right main bronchus was cut by robotic scissors. (D) End-to-end half-continuous anastomosis for the bronchus. (E) Anastomosis for the pulmonary artery. (F) Anastomosis for the left atrium. (G) The skin incision was closed with an intradermal suture. (H) Post-operative chest computed tomography of the recipient.The recipient was placed in the lateral decubitus position and administered general anesthesia with a left-sided double-lumen endotracheal intubation. A robot system (Si da Vinci Robotic System, Intuitive Surgical, Inc., Mountain View, CA, USA) was positioned into the operating field over the patient's head. An 8.0-cm utility incision was made in the sixth intercostal space, and a silicon rubber wound protector was used. Four port incisions (1.0 cm each) were then made. The first port, which was located on the midaxillary line in the seventh intercostal space, was used for the robotic camera. The second port, which was located on the midclavicular line in the fifth intercostal space, was used for the right robotic arm with the robotic hook cautery, scissors, and needle holder being positioned. The third port was made on the scapular line in the ninth intercostal space for the left arm and robotic long forceps. The fourth port was made on the midaxillary line in the fourth intercostal space for the vascular block clamps. Extensive pleural adhesions were encountered in the right thoracic cavity. These were carefully managed, and blood infiltrations from the chest wall were carefully treated one by one. Next, the pulmonary veins were prepared and freed from the pericardium. The right upper and lower pulmonary veins were cut sequentially using a stapler (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA). The right pulmonary artery was then prepared and clamped using a vascular block clamp through the fourth port. The anterior apical branch of the right pulmonary artery was cut using the stapler. The right pulmonary artery was divided by the hot scissors distal to the anterior apical branch [Figure 1B]. Finally, the right main bro