A 65-year-old man who needed a lung transplant urgently suffering from pulmonary fibrosis, he has just become the first patient to undergo a single lung transplant (a single donor lung) with robotic technology. The intervention –the first of its kind– was carried out in the Vall d’Hebron University Hospital of Barcelona with the Da Vinci robot.
The technique used has avoided conventional surgerywhich is very invasive because it requires a large incision to separate the ribs and open the thorax. This means a higher risk of complications and pain and a slower recovery for the patient. In 1990, this medical center was a national pioneer in successfully performing a lung transplant and has now managed to perform, for the first time in the world, a fully robotic lung transplant.
The patient underwent surgery on February 28 and was discharged more than a week ago, so there are already positive data on his recovery. This surgical intervention constitutes a milestone in lung transplantation and will allow the majority of transplant patients to avoid the invasive technique. Vall d’Hebron is the hospital in which the most lung transplants are performed each year, around 100, compared to a measure of 40 that are carried out among the seven that have a specific program for it.
Albert Jáuregui, head of the Thoracic Surgery and Lung Transplant Service at Vall d’Hebron University Hospital, explained in statements to Diario Médico that “The more interventions, the better results; and ours are exceptional”. In recent years, he explains, he has greatly improved the donation – “Spain is a luxury in this.” Despite this, surgery has hardly changed since the 1990s and, he says, “we didn’t quite understand why so many years later we continue to offer such delicate patients such aggressive surgery.”
Using robotic surgery to treat lung cancer in transplants
Robotic surgery is already used around the world to treat lung cancer, which has improved patient survival and recovery. “We wondered why we used the robotics in patients with lung tumor And for those who need a transplant, who have a very poor quality of life, we had to open their chests like the hood of a car. The conventional technique works well, but the patients are in a lot of pain and have a hard time recovering”, continues Jáuregui.
In the case of kidney transplantation, an organ much smaller than the lung, robotic surgery had also already been implemented. However, Jáuregui explains that they did not know where to extract the damaged lung and introduce the healthy one. When Vall d’Hebron specialists learned a year ago that surgeons at the Cedars-Sinai Hospital in Los Angeles (USA) had performed the first robotic lung transplant, they thought they had anticipated it.
After contacting them, they discovered that the operation was similar to the traditional one and that they had made “the same cut between the ribs and used the robot only at a specific moment of the intervention (when suturing the new lung in the airway and in the large vessels), but not in all. In other words, it was still the same: opening the thorax, which is exactly what we did not want to continue doing.
How robotic lung transplantation is performed
Iñigo Royo Crespo, a specialist from the Vall d’Hebron Thoracic Surgery and Lung Transplant Service who now practices in Zaragoza (at the Miguel Servet University Hospital/Lozano Blesa Clinical University Hospital), “had the idea of exploring an access route that is used to operate on lung and thymus cancer: subxiphoid surgery”.
They began to test the technique with plastic lungs and, later, with sheep, as it was the “animal lung model most similar to humans,” says Jáuregui. This allowed them to verify that their idea worked and they then requested authorization from the National Transplant Organization (ONT) and the Catalan Transplant Organization (Ocatt) to select the patients who could benefit, an option they welcomed with joy because traditional surgery of lung transplantation is very aggressive and “they have a lot of fear of pain”.
The surgeons manually performed a eight centimeter incision in the skin at the bottom of the sternum—below the xiphoid, a small cartilaginous extension—just above the diaphragm, and placed a soft tissue retractor—a plastic device that keeps the incision open and clean during the operation—into the opening to allow take out and put in the lungs.
Four arms of the Da Vinci robot were then inserted through four small holes (8 to 12 millimeters wide) located in different parts of the thorax, and the thoracic surgeon sat at the console to operate the arms using four control levers: one lever moves one arm that separates the heart from the lung very carefully so that it does not interfere with the exit and entry process of the lungs; two arms that carry surgical tools such as scalpels and tweezers, and the last arm that contains a camera that allows the surgeon to have a three-dimensional view of the inside of the body. After separating the diseased lung from the heart with the robotic arms, it is extracted through the subxiphoid opening, through which the new lung is also inserted, which is attached to the body using the robotic arms.
The goal of the Vall d’Hebron team is to operate on more patients in this way, as well as prepare to perform the first double lung transplant with it, but they also want to publicize the method and their intention is to present it at the XX Congress of the Spanish Society of Laparoscopic and Robotic Surgery, which will be held in Bilbao this week, between April 20 and 21.