Adjusting To Cardiac Bleeding Encountered During Robot Assisted Video Assisted Thoracoscopic Surgery (VATS) Thymectomy
Kyle W. Riggs1, Lawrence Glassman1, Dishen Lin2, David B. Meyer1, Paul C. Lee1, David Zeltsman1.
1Northwell Health, New Hyde Park, NY, USA, 2Hofstra Northwell School of Medicine, Hempstead, NY, USA.
OBJECTIVE: One of the significant challenges in robotic surgery is the absence of haptic (force and tactile) feedback and the altered field of vision. We present a case of injury to the right ventrical (RV) during robotic assisted VATS thymectomy for thymoma.
METHODS: The patient was positioned with her left side elevated 30° for a left chest approach. The first incision (camera port) was made in the fifth intercostal space in the anterior axillary line. The two “operative” ports were made in the anterior axillary line in the third intercostal space and in the sixth intercostal space in the mid-clavicular line. During initial mobilization of the thymus, significant dark bleeding was noted from the mediastinum. The left spatula tip was in view of the camera, but the arm of the instrument had caused blunt injury to the heart out of view which was initially undetected. It was successfully tamponaded with a sponge stick and median sternotomy was performed. A 2 cm laceration and a separate 1 cm laceration were found on the RV free wall immediately adjacent to, and heading under the left anterior descending (LAD) coronary artery.
RESULTS: Beating heart-cardiopulmonary bypass was instituted. The RV free wall laceration was repaired with a series of pledgetted sutures brought from the left ventricle, under the LAD, to the right margin of the laceration. Open thymectomy was completed without further complications. The patient had an uneventful post-operative course and was discharged home on post-operative day five with normal biventricular function.
CONCLUSIONS: The loss of haptic feedback allows injuries such as this to develop unnoticed until a visual or hemodynamic cue draws the surgeon’s attention. Successful recognition of devastating and potentially lethal complications depends on constant vigilance for injuries out of view. Successful management continues to require the availability of the full spectrum of cardiothoracic surgical interventions, such as cardiopulmonary bypass in this case. With improvement in hepatic feedback being developed in future robot versions, this injury could have been completely avoided.
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