Telemicrosurgery: robot-assisted microsurgery

This video demonstrates a left upper lobectomy for the management of a proximal cT2N2M0 lung tumor. It is usually considered a contraindication of minimally invasive surgery. Our aim is to show the feasibility and the safety of the procedure. Robotic surgery will allow for more minimally invasive indications.
The tumor lies proximally to the left trunk of the pulmonary artery which could be a contraindication to a minimally invasive surgery. A CT-scan combined with a 3D reconstruction helps to rule out the existence of pulmonary artery invasion. Hilar adenopathies as well as adenopathies of the aortopulmonary window present a hypermetabolism on PET-scan. No neoadjuvant chemotherapy is performed since a R0 surgery is potentially feasible immediately and can be associated with a full lymphadenectomy.
This video presents our technique of robotically assisted left upper lobectomy combined with a lymph node dissection. We have attempted to standardize our lung resection technique using 6 areas of dissection to gain in efficacy and save time. The first operative step is to free the triangular ligament and to sample potential lymph nodes (station No. 9). A hilar lymphadenectomy (lymph node station No. 10) is then performed using a posterior approach first followed by a subcarinal approach (lymph node #7, by skeletonizing the pulmonary artery and the left main bronchus. The third step of the procedure is to dissect the fissure to skeletonize the pulmonary artery and its lingular branches as well as branches of the posterior fissure, dissection of lymph node stations No. 11 is performed simultaneously. The elements of the hilum are then approached using an anterior approach. The superior pulmonary vein is dissected. The roof of the hilum is then freed. The left upper bronchus is divided last. Dissection of lymph node station No. 5 completes the procedure with preservation of the left recurrent nerve
Abbreviation:
CPRL-3: complete portal robotic lobectomy using 3 arms

This video demonstrates the case of a 28-year-old female patient who underwent a robotic cholecystectomy for symptomatic calculous gallbladder. The patient had no past medical or surgical history. In October 2018, the patient presented with an acute mild pancreatitis which had a favorable evolution under medical treatment. Blood tests showed cytolysis without cholestasis. Bili-MRI showed a calculous gallbladder with no signs of complication and no biliary tract dilatation. A cholecystectomy was then indicated. Preoperative work-up did not show anything abnormal.

In this lecture, Doctor Alex Mottrie shows the current indications of urological robotic procedures, and presents the Guidelines on Renal Cell Carcinoma, the techniques of partial nephrectomy, tumor enucleation and renorrhaphy. He presents his experience and his results in a series of 62 patients.

As the technique and the indications of robotic video-assisted lung resections have evolved, surgeons have had to face numerous pitfalls. One in particular is the vascular tear, which urge the operator to convert to thoracotomy. The decision as to when and how to convert to thoracotomy is always difficult to make. This video illustrates a complex case of robotic right upper lobectomy which required thoracotomy for controlled bleeding.
This is the case of a 47-year-old woman with a past medical history of severe chronic obstructive pulmonary disease, active smoking, alcoholic liver cirrhosis, but no history of tuberculosis. She presented with a 3-month history of a right upper lobar mass detected on chest X-ray which evolved despite antibiotic treatment. Work-up including a PET-scan evoked a suspicion of malignancy.

While finishing the lobectomy, we had to face a difficult dissection of the posterior part of the oblique fissure with a tricky control of the dorsal artery. Trying to open the fissure with the endostapler, we tore the arterial branch and applied an immediate control by means of a double Cadiere grasper. When bleeding was finally controlled, we decided to convert for safety reasons. We proceeded without undocking the last robotic arm, clamping the artery until control was achieved using thoracotomy instruments. It allowed us to manage this situation with no rush and stress.
There are two types of bleeding: controlled and uncontrolled. In our experience of RATS lobectomy and by reviewing our complications, we feel that there are several advantages to this technique: first, small instruments make small injuries which can be controlled by robotic instrument. Secondly, passive locking of the robotic arm provides sufficient time for the surgical team to prepare conversion.

In this lecture, Dr. Katz presents the evolution of robotic surgery and its application in morbidly obese patients. Dr. Katz’s technique is also outlined.

In this key lecture, Dr. Keith Kim addresses the next steps in robotics.

In this key lecture, Dr. Parra-Davila focuses on robotic transanal TME (taTME).

A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.

In this key lecture, Dr. Laurent Brunaud compares robotic bypass with laparoscopic bypass.

This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.