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.
