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In Barcelona, a team of thoracic surgeons announces that they have performed the world’s first lung transplant assisted by a robot surgeon without opening the patient’s chest. A feat much less invasive than traditional surgery.
For the first time ever, a lung has been transplanted using a minimally invasive technique that involves the use of robotic surgery. The news comes to us from the Vall d’Hebron University Hospital, in Barcelona. Additionally, a new access route has been created through which diseased lungs can be removed and new lungs can be inserted.
An 8 cm incision and the expert work of a robot
Professionals from the Thoracic Surgery and Lung Transplant Department performed the procedure through the lower part of the sternum, on a 65-year-old man in need of a lung transplant for pulmonary fibrosis.
As explained in the statement released by the hospital, surgeons manually made an eight-centimeter incision in the skin below the xiphoid and above the diaphragm. In the open hole, they placed a soft tissue retractor: a simple plastic tool that is used to keep the incision open and clean during surgery to remove diseased lungs and insert new ones. “It differs from the incision made between two ribs, which is common in transplants, which is not elastic” say the surgeons.
From there, the operation is 100% robotic: four arms of the Da Vinci robot are inserted through four small holes (measuring 8 to 12 millimeters wide) made in different parts of the thorax. The thoracic surgeon sits at the console and moves the robot arms by delicate means of four different control levers: one lever moves an arm that separates the heart from the lung, so it does not interfere with removal or insertion lungs ; two arms carry surgical tools, such as scalpels and forceps; and the fourth arm incorporates a camera that allows the surgeon to have a 3D view of the inside of the body. After the patient’s lung was separated from the heart by the robotic arms, the diseased lung was removed through the subxiphoid opening. The new lung was then inserted through the same incision and reattached to the body by the robotic arms.
An approach considered less aggressive at the key
“The main problem with opening the thorax in lung transplant procedures is that it is a very aggressive approach which leads to a very delicate postoperative period”, explains Dr. Albert Jauregui, head of the Thoracic Surgery and Lung Transplant Service at the Vall d’Hebron University Hospital. In some cases, an infection eventually occurs and the wound does not close properly (when both lungs are transplanted, the incision is about 30 centimeters long and goes from one side of the chest to the other).
When the wound does not close due to the presence of an infection, it is necessary to operate again to control the infection. “This new surgical technique allows us to cut a small section of skin, fat and muscle, leaving a wound that closes easily. Not only is it much safer than the traditional method, but for this first patient it was virtually painless. This is a historic step that we believe will improve the lives of thousands of patients”.
For his part, the first transplant patient, Xavier Llobet Ordóñez, 65, confirms the benefit: “The pain is zero. It’s zero pain!”he told the Catalan press.
“An undeniable progress, but the multidisciplinary approach remains the priority”
If the announcement effect of such surgery by a robot with several arms (the famous Da Vinci surgical robot) is impressive, for Charles Al Zreibi, thoracic and cardiovascular surgeon contacted by Doctissimo, this should not cause loss the priority of such an intervention.
“Any effort to reduce surgical aggression will reduce the risk of postoperative complications and improve outcomes, but severe respiratory failure is a pathology with a reserved prognosis. Lung transplantation is an intervention with a high risk of complications and the prognosis of transplanted patients is essentially linked to the tolerance of the graft by the immune system. Thus, I am skeptical about the contribution of robotic surgery.”
Moreover, according to him, robotic surgery is not suitable for all patients.
“One of the frequent reasons for conversion to open surgery is the existence of pleuropulmonary adhesions, secondary physiological reactions to diseases that lead patients to transplant and make any minimally invasive intervention impossible. Although not all patients present in this situation, this situation is very frequently encountered.”
However, minimally invasive approaches are strongly recommended in thoracic surgery to reduce postoperative morbidity and mortality “but the real revolution is the modification of perioperative management with programs such as accelerated rehabilitation after surgery (RAAC) which consists, among other things, in limiting fasting, better physical preparation before and after surgery, early mobilization of the patient, better perioperative analgesia…” tempers our expert. These measures do not seem revolutionary, but they have a much greater effect than the access road.
“All this to say that robotic surgery is undeniable progress in surgery, particularly thoracic surgery, but we must not forget that the pathologies treated are severe and depend on several factors, in particular the expertise of the multidisciplinary team that takes care of these patients.”