Robotic lung transplant combined with newly developed access route

Surgeons at Vall d’Hebron University Hospital in Spain have achieved a double milestone in the field of lung transplantion. 
For the first time, a lung has been transplanted using a minimally invasive technique (robotically-assisted) whilst also developing a new access route through which diseased lungs can be removed and the new lungs can be inserted. The new access route, which requires just an 8cm incision, was made in the lower part of the sternum, just above the diaphragm. This means it is no longer necessary to make a large opening by separating the ribs and opening up the thorax, which was the standard option until now. 
This pioneering procedure, which was performed on a 65-year-old man requiring a lung transplant due to pulmonary fibrosis, was carried out as part of a multidisciplinary intervention involving professionals from the hospital’s Thoracic Surgery and Lung Transplants Department, the Anaesthesia, Resuscitation and Pain Management Department, the Cardiac Surgery Department and the Transplant Nursing Department.
"We are proud to present a pioneering technique carried out by the Catalan Health-Care System that contributes to the clinical improvement of all patients internationally," said Manel Balcells, Minister of Health of Catalonia. 
“We present a new technique in lung surgery that represents an international and global advance. 
“We do it together with Xavier, the first patient transplanted with robotic surgery and with a new, less invasive access route that allows a faster recovery.” 
Dr Albert Jauregui, Head of the Thoracic Surgery and Lung Transplants Department at Vall d’Hebron University Hospital said: “The main problem with opening up the thorax in lung transplant procedures is that it is a very aggressive approach which leads to a very delicate post-operative period.”
In any transplant procedure, in order to prevent rejection of the new organ, medication must be administered that depresses the patient’s immune system for the rest of their life. 
This means that the risk of post-operative infection is always very high. 
When both lungs are transplanted, the incision is about 30 centimetres-long, running from one side of the chest to the other. In the presence of infection this large wound may fail to heal and on occasion require surgical debridement. 
Dr Albert Jauregui said: “This novel surgical technique allows us to cut a small section of skin, fat and muscle, leaving a wound that closes easily. 
“Not only is this much safer than the traditional method, but for this first patient it has been virtually painless. 
“This is a historic milestone which we believe will improve the lives of thousands of patients.”
The professionals at Vall d’Hebron University Hospital’s Thoracic Surgery and Lung Transplants Department had been planning to introduce robotic surgery to lung transplants for some time. 
This innovation had only been used once before, although in a less ambitious procedure, at the Cedars-Sinai Hospital in Los Angeles, USA. 
Last year, the American hospital used robotic surgery for the first time as part of a lung transplant when suturing the new lung to the patient’s existing airways 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. 
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 per cent 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. 
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.
Dr Maribel Rochera, head of the Anaesthesia, Resuscitation and Pain Management Department, said: “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.”
Carme added 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.”
Dr Judit Sacanell, a lung transplant specialist in the Intensive Medicine Department, said: “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, said: “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.”
In Catalonia, lung transplants are carried out exclusively at the Vall d'Hebron University Hospital for both children and adults. Since the programme began, more than 1,556 lung transplants have been carried out at Vall d'Hebron.