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OBJECTIVE: Robotic Video Assisted Thoracic Surgery (RVATS) is increasing for lung resections. While improved visualization and instrument dexterity are potentially advantageous compared to standard thoracoscopy, our initial experience suggests complications associated with systematic lymph node dissection during these procedures, specifically recurrent laryngeal nerve injury (RLNI) and chylothorax, may be significant.
METHODS: Consecutive patients undergoing RVATS anatomic lung resections for suspected or confirmed cancer performed during the study period and with a complication of RLNI or chylothorax were identified and reviewed from a prospectively maintained database. Complications were graded according to the Common Terminology Criteria for Adverse Events v. 3.0 (CTCAE).
RESULTS: From July 28, 2010 to December 20, 2013, 251 patients underwent RVATS segmentectomy, lobectomy, or bilobectomy with MLND. 11 patients (4.4%) experienced MLND related complications and comprised the study group. There were 6 cases (2.4%) of RLNI and 6 cases (2.4%) of chylothorax. Case-specific data are presented in Table I. The majority of cases (81.8%) were right sided resections, and median lymph node counts in right station IV and station VII were 9 (range 1-23) and 5.5 (1-10), respectively. 74.5% of cases were performed for early stage I and II lung cancers. Complications requiring procedural intervention (Grade 3) included 4 cases of RLNI undergoing percutaneous vocal cord medialization and 3 cases of chylothorax undergoing image guided thoracic duct embolization or maceration. No operative interventions were required and there was no operative mortality.
CONCLUSIONS: Chylothorax and RLNI are rare complications with reported occurrence rates of 1.7% and 1.0%, respectively, after systematic MLND during open or VATS pulmonary resections.¹ RVATS MLND during anatomic lung resections may be associated with increased rates of chylothorax and RLNI, notwithstanding improved magnification and dexterity. Further prospective studies are warranted to understand potential technical advantages and pitfalls of RVATS MLND and allow adjustment of surgical technique accordingly.
1. Allen MS et al. Ann Thorac Surg. 2006 Mar;81(3):1013-9

Data summary of patients with RVATS MLND associated complications.

Case#	Complications(s)	Procedure Laterality	MLND Station(s)	LN Count(s)	Operation	Stage	CTCAE
1 2 3	L RLN L RLN Chylothorax	Right Left Left	IV, VII V, VII V, VII	NR, 6 2, 8 2, 5	Bilobectomy Lobectomy Lobectomy	IIIA IA IV	3 3 3
4	R RLN	Right	IV, VII	9, 4	Segmentectomy	IA	1
5	Chylothorax	Right	IV, VII	1, 1	Lobectomy	IB	2
6	Chylothorax	Right	VII	9	Lobectomy	Benign	2
7	Chylothorax	Right	VII	NR	Lobectomy	IA	3
8	RLN	Right	IV, VII	7, NR	Lobectomy	IB	1
9	R RLN	Right	IV, VII	23, 3	Bilobectomy	IA	3
10	R RLN Chylothorax	Right	IV, VII	19, 10	Lobectomy	IIA	3
11	Chylothorax	Right	IV, VII	NR, NR	Lobectomy	IIA	3