Faculty Bibliography

BACKGROUND:Robotic Ivor-Lewis esophagectomy is increasingly adopted due to its minimally invasive approach and favorable outcomes. Anastomotic leak remains the most serious complication after esophagectomy, with reported rates of 5-18%. We describe a reinforced, stapled, single-layer, thoracic anastomosis which has resulted in no leaks in 50 consecutive patients. METHODS:We performed a retrospective review of consecutive patients who underwent robotic Ivor-Lewis esophagectomy by a two-surgeon team. RESULTS:From January 2022 to February 2026, 50 patients were included with a median age of 70 years. Indications for surgery were malignancy in 47 patients, most commonly adenocarcinoma (85.1%) and benign disease in 3 patients. Median operative time was 237 min, median actual blood loss was 35 mL and median lymph node yield was 20. R0 resection was achieved in all 47 malignant cases. Complete pathologic response (pCR) was observed in 13 out of 38 patients that received neoadjuvant therapy (34.2%). There were no conversions, and median LOS was 4 days. No anastomotic leaks were detected clinically, radiographically, or biochemically and there was no 30- or 90-day mortality. At a median follow-up of 26.8 months, 1- and 2-year overall survival rates were 88.2 and 84.6%, respectively. CONCLUSIONS:This technique, when properly executed, is reproducible, safe, and can afford R0 resection and thorough thoracic lymph node dissection, with promising results. Prospective, multicenter studies are needed to compare this approach to alternative anastomotic techniques.

BACKGROUND/UNASSIGNED:Previous studies report a 20% conversion to open thoracotomy and 25% major morbidity rate for minimally invasive thoracic surgery following neoadjuvant chemotherapy or immunotherapy. METHODS/UNASSIGNED:This retrospective review includes a consecutive (non-selected) series of patients from two surgeons who underwent robotic resection after neoadjuvant therapy for non-small cell lung cancer. RESULTS/UNASSIGNED:From January 2018 to October 2024, 150 patients (51% male) underwent surgery following systemic therapy. The median age was 67 years. Preoperatively, 92% received chemotherapy, 65% immunotherapy, and 27% radiation. Median time from therapy to surgery was 6 weeks. The most common tumor type was stage IIIA adenocarcinoma (25%). Median operative time was 152 min, and median blood loss was 20 mL. There were no unplanned conversions to open thoracotomy or from lobectomy to pneumonectomy. Median length of stay was 1 day; 28% had chest tube removed on the day of surgery. Twenty-one patients experienced Clavien-Dindo grade III complications (primarily atrial fibrillation and effusion). There were no 30-day mortalities and two 90-day mortalities. Median follow-up was 19 months, with a median postoperative survival of 513 days. CONCLUSION/UNASSIGNED:Robotic lobectomy and pneumonectomy can be safely performed after neoadjuvant therapy, with conversion rates <1% and minimal 30- and 90-day mortality. Key technical factors include intra-pericardial control of the pulmonary artery, division of the lobar airway prior to pulmonary artery dissection, and performing surgery within 6 weeks of completing neoadjuvant therapy.

BACKGROUND/UNASSIGNED:Spray cryotherapy (SCT) has been used as a bronchoscopic tool within the large airways for over a decade. SCT is unique in its non-contact method of flash freezing (up to -196 ℃) tissue versus a contact cryoprobe (up to -50 ℃). Techniques for venting nitrogen gas formed from liquid nitrogen during SCT are essential for safe use. Prospective data on SCT in bronchoscopy are lacking. The objective of this study was to evaluate the safety, dosimetry, and clinical outcomes of the trūFreeze SCT system in a prospective multicenter registry of patients with benign and malignant central airway disease. METHODS/UNASSIGNED:This was a prospective observational registry of patients undergoing SCT enrolled at 4 participating institutions for up to 5-year follow-up (2013-2021). Data focusing on patient safety, diseases treated, dosimetry and selected efficacy measures were collected in a standardized electronic report form and central database. RESULTS/UNASSIGNED:A total of 64 patients (47 with malignant disease and 17 with benign disease) were enrolled in the registry. A total of 114 SCT procedures were performed and 472 SCT freeze/thaw cycles delivered. The median observed follow-up for the malignant cohort was 520 days [interquartile range (IQR), 153-1,818 days]. The median observed follow-up for the benign cohort was 1,803 days (IQR, 1,769-1,832 days). Malignant disease included 14 different cancer types. Subglottic stenosis was the most common benign disease treated and only 3 patients needed more than 2 serial SCT treatments. SCT was used to treat endobronchial bleeding in 30% of cases, with complete success reported in 91%. Adverse events included one death which was unrelated to SCT and one small asymptomatic pneumothorax which did not require a chest tube. CONCLUSIONS/UNASSIGNED:SCT can be safely used within the central airways, adding the unique capability of delivering flash-freezing temperatures to tissue. This approach shows potential utility in treatment strategies for a wide range of benign and malignant conditions, though further controlled studies would better define these roles.

Surgical approaches to lung cancer resection are rapidly evolving, particularly for early-stage lung cancer. Advances in chest CT technology and increasing use of CT in patient care have led to detection of smaller nodules, many with ground-glass attenuation that do not require lobectomy for resection. Lung-sparing and minimally invasive techniques have been shown to result in improved patient outcomes compared with those of traditional open thoracotomy and are noninferior in terms of cancer recurrence. As more patients undergo these surgeries, it is important for radiologists to be aware of useful information for surgeons before the operation. It is helpful for radiologists to understand the indications for lung-sparing surgery and have a basic understanding of the techniques involved in video-assisted and robotic thoracic operations. Identification of the location and morphology of the tumor, as well as the pulmonary vasculature that feeds and drains the segment of lung containing the tumor is important. Also, the presence of emphysema, pulmonary fibrosis, and incomplete fissures is useful information. In addition, chest imaging is also progressing, with improvements in multiplanar reformations and three-dimensional imaging allowing for more detailed and accurate image-based localization of tumors and visualization of anatomy. Nodule localization for surgery plays an even larger role given the limited ability to palpate nodules during surgery with minimally invasive surgery approaches. Methods can involve imaging and in vivo localization, with transthoracic and bronchoscopic methods used to label a nodule. Finally, radiologists should be aware of postoperative complications and their imaging characteristics, such as suture line granulomas and bronchopleural fistulas. Supplemental material is available for this article. ^©RSNA, 2025.

OBJECTIVE:To confirm feasibility and safety of the Da Vinci Single-Port (SP) System to perform pulmonary lobectomy procedures utilizing a subcostal, uniportal approach. METHODS:We performed a prospective, multicenter, single arm, clinical study evaluating performance and safety of the da Vinci SP Surgical System for pulmonary lobectomy. RESULTS:Nineteen subjects (benign, n=1; malignant, n=18) were enrolled at six academic medical centers in the United States and underwent robotic-assisted SP subcostal lobectomy. All SP lobectomy procedures were completed without conversion to multiport thoracoscopic/robotic or open approaches. No intraoperative adverse events or unanticipated adverse device effects were observed; 13 postoperative adverse events (AEs) commonly experienced after lobectomy were reported, 4 of which were Clavien-Dindo grade III. Rate of complete (R0) resection was 100%. The median (interquartile (IQR)) number nodal stations sampled was 6.5 (6.0-8.0) with a median of 17.5 (7.0-34.0) nodes resected per patient. CONCLUSIONS:Robotic SP subcostal lobectomy is feasible and is associated with acceptable perioperative and oncologic quality outcomes. Additional clinical experience and research is necessary to determine whether this alternative single incision approach has clinical benefit compared to standard transthoracic, multiport robotic lobectomy.

BACKGROUND:Sternotomy is the traditional approach for thymectomy. However, over the last 2 decades minimally invasive surgical approaches (multiport thoracoscopic and robotic-assisted surgery) have proven feasible, offering similar survival, lower morbidity and shorter length of stay. Single-port (SP), subxiphoid thymectomy potentially offers less pain and allows bilateral visualization of the mediastinum. METHODS:A prospective, multicenter, single-arm clinical study was conducted to evaluate the performance and safety of the da Vinci SP Surgical System for thymectomy via a subxiphoid incision. Primary performance endpoints included ability to achieve R0 resection and completion of the procedure without conversion. The primary safety endpoint was all adverse events (AEs) up to 30-days postoperatively. RESULTS:Thirteen subjects (benign, n=6; malignant, n=7) were enrolled at six centers in the United States. All SP thymectomy procedures were completed via a small (mean 3.8cm) subxiphoid incision without conversion to other minimally invasive or open approaches. For malignant cases rate of complete resection was 100%. No study subjects experienced any intraoperative or serious AEs. No unanticipated adverse device effects were reported. CONCLUSIONS:Thymectomy using the da Vinci SP Surgical System via a subxiphoid approach is feasible and there are no early indications of safety or procedural concerns. Larger clinical studies are warranted to further evaluate the relative benefits and limitations of the SP System compared to multiport robotic thymectomy.

The conventional supine position for robotic thymectomy may present challenges in accessing the lower thymic horns, particularly in cases requiring extensive resection of mediastinal fat. To address this issue, the authors advocate for a lateral patient position during the procedure, emphasizing optimized access to the thymic horns and improved procedural efficacy. The lateral approach involves specific trocar placements and port arrangements to minimize conflicts between instruments. This report proposes an innovative approach to robotic thymectomy for patients diagnosed with thymoma or thymic hyperplasia associated with myasthenia gravis.