The Vall d'Hebron has put into practice an innovation of global reach. The specialists at the Barcelona hospital have carried out the first fully robotic lung transplant in the world and have also created a new access route to remove damaged organs and introduce new lungs.
More precision, less risk, a much less complicated postoperative period. There will be a before and after in lung transplantation since the pioneering surgery performed on a 65-year-old man who required a new lung due to pulmonary fibrosis. The patient, a 65-year-old man, participated this morning in the presentation of the new and revolutionary technique.
The Minister of Health, Manel Balcells, the Vall d'Hebron staff and the different services involved have explained to the world the most significant progress since the first lung graft was performed in Spain in 1990. Last year, 415 were performed, a quarter of which (107) were performed at Vall d'Hebron, the most experienced center and the one that has been pursuing the introduction of robotic surgery for years.
The specialists from the Thoracic Surgery and Lung Transplant Service accessed the cavity through the lower part of the sternum, through an 8-centimeter incision just above the diaphragm. The traditional system, the only one available up to now, consists of a large horizontal opening of 30 centimeters in the thorax to handle the organs to be extracted and implanted between the ribs.
"The big problem with opening the thorax is that it is a very aggressive approach with a very delicate postoperative period," explains Albert Jauregui, head of the Lung Transplant service. In this sense, the immunosuppressive medication that the patient must receive for life to avoid rejection of the new organs increases the risk of postoperative infection. And if an infection occurs in the large 30-centimeter wound, it is necessary to operate again to control it.
Much less aggressive, "the new technique allows us to cut only a small section of skin, fat and muscle, a wound that heals easily, much safer and in this first patient has caused practically no pain", explains Jauregui. “This is a historic milestone that we believe will improve the lives of thousands of patients,” he concludes.
The Vall d'Hebron has worked for a long time to reduce the aggressiveness of lung transplantation, but it always ended up running into the lack of an alternative way to extract and introduce the organs. It was Dr. Iñigo Royo who came up with the idea of exploring subxiphoid surgery, an access route that has been used for a few years to operate on lung cancer (subxiphoid resection for the tumor in its initial stages) and the thymus gland.
The xiphoid is the cartilage found at the lower end of the sternum. A manual 8-centimetre incision in the skin below the xiphoid and above the diaphragm, with a retractor to maintain the orifice, was sufficient for passage of the lungs.
From then on, the intervention was completely robotic, with four arms of the Da Vinci robot introduced into the thorax and controlled by the surgeon from a console. A lever guides the arm that separates the heart from the lung so that it does not make it difficult to maneuver in and out of the lungs. Two other arms handle surgical tools such as scalpels and forceps. The last arm incorporates a camera that allows the surgeon to see the inside of the body in 3D through monitors in a clear way.
The robot allows for minimal, less invasive and precise incisions, suppresses the tremor or involuntary movements of surgeons, as well as their postural fatigue.
Once separated from the heart, the diseased lung was extracted through the subxiphoid wound and the new one was inserted through the same incision, sewn to the body by means of robotic limbs.
"A before and after in the history of lung transplants", celebrates the Vall d'Hebron. The only precedent that comes close to this milestone takes us to the United States, to the Cedars-Sinai hospital in Los Angeles. Last year, robotic surgery was used for the first time in this center in a final phase of the procedure, when the new lung was sutured to the airway and the great vessels. The rest of the operation, including the insertion of the organ between the ribs, was carried out in the traditional manner.
Proof of the success and validity of the new technique is that the patient's stay in the intensive care unit has been reduced compared to conventional operations and he has overcome the postoperative period with pain relievers, without the need for opioids." We hope with this new technique to reduce the number of complications related to the type of surgical approach”, says Judit Sacanell, from the Intensive Medicine service.
