The Operating Theatre Journal - Journal - Page 17
Last year, this American hospital used robotic
surgery for the first time as part of a lung
transplant when suturing the new lung to the
patient’s airway and great vessels. However,
the rest of the operation was performed
in the traditional way and the lung was
introduced through the ribs, as is customary.
“We at Vall d’Hebron had been thinking
for some time about how we could make
this very aggressive surgery less invasive.
However, we were always faced with the
same problem: we couldn’t work out a route
to remove the diseased lung and insert the
new one”, explained Dr Albert Jauregui.
He added “finally, Dr Iñigo Royo Crespo, a
specialist in the Thoracic Surgery and Lung
Transplants Department, came up with
the idea of exploring an access route used
to operate on lung cancer and the thymus
known as subxiphoid surgery.
The xiphoid is a small cartilaginous extension
of the lower part of the sternum. Surgeons
manually made an eight-centimetre 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 serves to keep the incision open and
clean during the operation to remove the
diseased lungs and insert the new ones.
The skin here is very elastic, so the eight
centimetres are sufficient for the lungs to
pass through. This differs from the incision
made between two ribs, that is common
in transplants, which is not elastic. From
that point onwards, the operation was 100%
robotic: four arms of the Da Vinci robot were
inserted through four small holes (measuring
8 to 12 millimetres wide) made in different
parts of the thorax.
The thoracic surgeon sits at the console and
moves the robot’s arms by means of four
different control levers: one lever moves
an arm that delicately separates the heart
from the lung, so that it doesn’t hinder the
removal or insertion of the lungs; two arms
carry the 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 (remember
that, until now, lung transplants were
carried out by opening up the thorax so
that the surgeon could see everything with
the naked eye). The Da Vinci robot enables
high-precision surgical interventions, as it
offers excellent visibility and greater freedom
of movement. Minimal, precise, and less
invasive incisions can be made by means
of this technology, which removes the risk
factors of trembling, involuntary movements
of surgeons and postural fatigue in long
operations.
Once 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 attached to
the body by the robotic arms. This is how the
first fully robotic lung transplant was carried
out at the Vall d’Hebron University Hospital,
which could mark a real turning point in the
history of lung transplants.
Lung transplants: a multidisciplinary task
A key speciality in all surgical operations
is anaesthesia. As explained by Dr Maribel
Rochera, head of the Anaesthesia,
Resuscitation and Pain Management
Department, these specialists “monitor the
patient’s condition at all times, keeping them
in the best possible condition throughout the
operation.
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Issue 392
As this is a pioneering technique, we
needed to combine our experience in both
traditional transplants and robotic thoracic
surgery, which involved a lot of teamwork”.
Carme Vallès, supervisor of the Transplant
Coordination Nursing Department, stated
“this technique was completely new for
all of us. However, we in the Nursing
Department had been preparing for this
moment for some time”. With this milestone,
“the intensification of nursing care in the
surgical process and the importance of the
selection of the surgical nurse, perfusionist
and anaesthetist to carry out the robotic
operation is clear: a challenge that has
been a success thanks to teamwork and
professional consensus”.
When transplant patients leave the
operating theatre they are always referred
to the Intensive Care Unit, as this is where
they receive the most appropriate care
after such a complex operation. The first
robotic lung transplant patient followed the
same procedure. Dr Judit Sacanell, a lung
transplant specialist in the Intensive Medicine
Department, explained how “the role of the
Intensive Medicine Department is key in the
immediate postoperative period of transplant
patients and the treatment of possible
post-operation complications. We hope that
this new technique will allow us to reduce
the number of complications related to this
type of surgical approach”. Finally, Dr Carles
Bravo, medical director of the Hospital’s lung
transplant programme, stated that “thanks to
this important milestone, the lung transplant
programme enters a new stage of minimally
invasive surgery which offers multiple
advantages for the lung transplant patient,
which will improve the results of the lung
transplant programme”.
May
2023
17