Robotic Surgery of the Mediastinum: A Review

Abstract

Background: The mediastinum is a complex anatomical region which contains many vital structures. Many aspects of mediastinal surgery, like that for other anatomic regions, have evolved from a maximally invasive approach involving a median sternotomy, anterior mediastinotomy, mediastinoscopy or thoracotomy, to a minimally invasive video-assisted approach. Robotic surgery is presently the most advanced form of minimally invasive surgery. Methods: We reviewed our experience with a robotic approach to mediastinal pathology. In addition, an extensive search was conducted using PubMed, in order to extract references for the application of robotics to surgical conditions of the mediastinum. Results: The first robotic procedure by our group was a mediastinal procedure in 2003. In the past eighteen years, 203 patients have undergone robotic surgery for mediastinal pathology. There were 119 procedures for the Anterior Mediastinum, 33 procedures for the Middle Mediastinum, and 51 procedures for the Posterior Mediastinum. 78 patients underwent robotic thymectomy using a left-sided approach. 43/78 (55%) patients underwent radical thymectomy for Myasthenia Gravis. Thymoma was histologically identified in 32% of patients with Myasthenia Gravis. In patients with thymoma, there was no tumor recurrence. In patients with Myasthenia Gravis, the overall improvement rate after robotic radical complete thymectomy was 91% (39/43). Following robotic surgery for the mediastinal disease, the median hospitalization was 3 days, major complications occurred in 0.9% of patients and there was no mortality. Conclusion: With the advent of robotic surgery, many of the current surgical approaches to diseases of the mediastinum will likely be replaced over time by robotic surgery. When applied to the mediastinum, robotics has a number of benefits when compared to conventional Video-Assisted Thoracic Surgery (VATS) including three-dimensional visualization, magnification of the operative field, precise instrument movement, and improved dexterity. Much of the mediastinal disease encountered in an adult is benign, making it especially suited to a minimally invasive approach. With the use of the robot, a complete anatomical and oncological procedure can be performed through a number of small incisions or ports, while at the same time providing the patient with minimally invasive benefits including shorter hospitalizations, quicker returns to preoperative activity, less pain, less inflammatory response and better cosmesis. The excellent range of motion of the robotic instruments makes them particularly suitable to maneuver around the vital structures and the rigid axial skeleton encountered in various compartments of the mediastinum, and for reaching those “distant” areas of the mediastinum that are difficult to explore and dissect with conventional Video-Assisted Thoracic Surgery (VATS).