Subcostal Specimen Removal in Completely Portal Robotic Lobectomy
April 19th, 2024
This protocol describes the removal of lung specimens following a completely portal robotic lobectomy. Determining the optimal location for specimen extraction is a pertinent question, as both intercostal and subcostal routes can serve as potential extraction paths following robotic or video-thoracoscopic lobectomy. We choose subcostal lung specimen removal over intercostal removal.
Following robotic lobectomy. Our study highlights the viability of subcostal trans-diaphragmatic specimen removal as a newly introduced alternative method. CPRL is the latest, most recent development in robotic lobectomy.
The da Vinci Robotic Surgical Instrument is used for minimal invasive robotic surgery. A major experimental challenge is removing specimen through the trans-diaphragm. The subcostal specimen removal is a feasible, safe specimen removal method.
It causes less pain than intercostal removal technique, Also, smaller incision, easier stapling through subcostal access port are additional advantages. To begin, place the patient in the lateral decubitus position and tilt the operating table by 10 to 20 degrees and reverse Trendelenburg by 5 to 10 degrees. Then drape the arm, axilla, and chest of the patient.
Make a first port incision in the chest through the seventh and eighth mid axillary intercostal space. Dissect the cutaneous and subcutaneous tissue, then enter the thoracic cavity and place the camera port. Insert the thoracic camera port.
Induce pneumothorax with heated carbon dioxide insufflation into the thoracic cavity. With the camera visualization as a guide, open three more ports in the seventh to eighth intercostal space. Next, make a 15 millimeter incision in the anterior end of the 11th rib as a service port.
With a cautery pen, dissect the subcutaneous tissue. Use the robotic camera to bluntly dissect the inferior and posterior aspects of the 10th rib to reach the diaphragm. Next, use a curved clamp to separate the diaphragm from the adjacent chest wall and divide the diaphragm from its attachment to the 10th rib.
Then use an endoscopic grasper through the posterior axillary port as a guide and insert the subcostal access port without damaging the peritoneum. Place the robot at the posterior side of the patient. Dock the robot after opening the ports.
Direct a pair of bipolar curved forceps through the anterior axillary port. Then pass a prograsper through the posterior axillary port. Next, pass a tip-up grasper through the paravertebral port.
Now, perform pneumolysis and explore the pleural cavity. Remove the adhesions between the parietal pleura and pulmonary parenchyma. Next, perform the hilar and mediastinal lymph node dissection.
Following this, dissect the inferior pulmonary ligament. With an endoscopic vascular stapler. staple the arteries supplying the lobe to be resected.
Staple the vein that will drain the lobe to be resected. Use an endoscopic bronchial stapler to staple the bronchi of the lobe before completing the lobectomy. For the removal of the subcostal specimen, extend the subcostal service port from 15 millimeters to three centimeters long.
Use a single arm specimen extractor to remove the specimen trans-diaphragmatically via the subcostal port. Close the diaphragm with non-absorbable sutures endoscopically. For closing the ports, first, insert a size-24 French chest tube through the camera port.
Inflate the lung under visualization, ensuring that the chest tube is not malposed. Suture the subcostal port with absorbable sutures. Then, stitch the remaining thoracic ports with absorbable sutures.
Overview
This protocol describes a novel method for lung specimen removal following robotic lobectomy, emphasizing the advantages of subcostal access over intercostal routes. The study demonstrates the feasibility and safety of this technique, which minimizes patient discomfort.
Key Study Components
Area of Science
- Robotic surgery
- Thoracic surgery
- Minimally invasive techniques
Background
- Robotic lobectomy is a recent advancement in thoracic surgery.
- Specimen removal techniques are critical for surgical outcomes.
- Subcostal access may reduce pain and improve recovery.
- Understanding the anatomical considerations is essential for safe procedures.
Purpose of Study
- To evaluate the effectiveness of subcostal trans-diaphragmatic specimen removal.
- To compare subcostal and intercostal removal techniques.
- To enhance surgical outcomes and patient comfort.
Methods Used
- Positioning the patient in lateral decubitus with specific table tilts.
- Creating multiple ports for robotic instruments and camera access.
- Performing pneumolysis and lymph node dissection.
- Utilizing a single arm specimen extractor for trans-diaphragmatic removal.
Main Results
- Subcostal removal is a safe and effective method.
- It results in less postoperative pain compared to intercostal removal.
- Smaller incisions facilitate easier stapling and closure.
- The technique was successfully implemented in the study.
Conclusions
- Subcostal access is a viable alternative for lung specimen removal.
- This method may improve patient recovery and surgical efficiency.
- Further studies could validate these findings across larger populations.
Frequently Asked Questions
Executive Industry Relevance
Innovations in minimally invasive robotic lobectomy, such as subcostal trans-diaphragmatic specimen removal, address procedural pain and complication risks associated with traditional intercostal extraction. This advancement enhances surgical workflow efficiency and patient recovery, directly impacting perioperative outcomes in thoracic oncology. Adoption of such techniques can inform enterprise-level decisions on surgical platform investments and procedural standardization.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise evaluation of surgical access routes for tissue procurement in translational research.
- Supports development of less invasive specimen retrieval protocols for downstream molecular analyses.
- Facilitates biological de-risking by minimizing tissue trauma during sample collection.
Screening & Assay Development
- Improves quality and integrity of resected specimens for biomarker and histopathological assays.
- Standardizes specimen handling, reducing variability in sample acquisition for multi-site studies.
- Enhances reproducibility of tissue-based screening workflows by minimizing procedural artifacts.
Translational & Preclinical Research
- Aligns surgical specimen collection with requirements for disease-relevant model development.
- Supports continuity from surgical innovation to preclinical validation of diagnostic or therapeutic targets.
- Reduces confounding variables in translational studies by limiting post-surgical complications.
Pipeline & Workflow Integration
This subcostal specimen removal technique integrates into the surgical-to-biomarker pipeline, supporting tissue acquisition for discovery, screening, and translational research phases.
- Discovery Biology: Provides high-quality, minimally traumatized tissue for hypothesis-driven studies.
- Screening: Ensures consistent sample quality for assay development and validation.
- Analytics: Enables reliable quantitative and qualitative readouts from resected specimens.
- Translational Research: Facilitates alignment of surgical and preclinical workflows for biomarker continuity.
- Enterprise Reuse: Establishes a reproducible, scalable protocol for specimen extraction across thoracic surgical programs.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in tissue-based analyses by reducing procedural variability.
- Operational Value: Streamlines surgical workflows and minimizes post-operative complications.
- Strategic Value: Supports data quality and integrity for go/no-go decisions in translational pipelines.
- Portfolio Impact: Enables risk-adjusted prioritization of surgical and biomarker-driven research initiatives.
Implementation Considerations
- Requires expertise in robotic thoracic surgery and familiarity with subcostal access techniques.
- Demands access to advanced robotic surgical platforms and specimen extraction tools.
- Necessitates cross-team standardization for specimen handling and post-surgical care.
- May require adaptation for different patient anatomies or disease presentations.
- Potential limitations include learning curve and procedural adaptation for broader clinical teams.
