Double world milestone for Vall d'Hebron. The hospital has become the first to transplant a lung using robotic surgery and, furthermore, to do so without opening the thorax, a very aggressive approach with a very delicate post-operative period, finding a new access point at the bottom of the sternum to remove diseased organs and introduce substitutes. The intervention was performed on a 65-year-old man who needed a lung transplant due to pulmonary fibrosis. "This is a historic milestone that we believe will improve the lives of thousands of patients," says Dr. Albert Jauregui, head of the Thoracic Surgery and Lung Transplant Service.
This case has been the first in which a multidisciplinary team of professionals has started and finished a surgery of these characteristics solely by endoscopy. The approach followed by Vall d'Hebron only has one precedent in the United States, at Cedars-Sinai Hospital in Los Angeles. Last year, this center used robotic surgery in part of the transplant, at the moment of suturing the new lung in the recipient, but not throughout the entire process, which was done traditionally and by introducing the organ by making a large cut in the chest and breaking the ribs.
"At Vall d'Hebron, we had been thinking for a long time about how we could make this very aggressive surgery less invasive, but we always encountered the same problem: we couldn't find where we could remove the diseased lung and introduce the new one," explains Dr. Albert Jauregui. The solution was proposed by the specialist from the hospital's Thoracic Surgery and Lung Transplant Service, Dr. Iñigo Royo Crespo, who thought of trying through the xiphoid, the cartilage at the end of the sternum. This is an access route already explored for operating on lung cancer and the thymus, an organ where T cells or lymphocytes, essential for the immune system, mature.
In the operation, the surgeons made an eight-centimeter incision below the xiphoid and above the diaphragm so that they could pass the lung. "We have devised a completely new technique so that we didn't have to open the patient's chest or sternum as if it were the hood of a car," Jauregui remarks. Once the small cut was made, the intervention became 100% robotic, managing four Da Vinci robot arms from the console, introduced through four small holes in the chest, less invasive than those of the traditional system. Precision is also gained, eliminating the tremor of the surgeons and postural fatigue in long interventions.
Thanks to the elasticity of the skin, a large cut was not necessary for the transplant, unlike the one usually made between the two ribs, 30 centimeters when both lungs are transplanted, from side to side of the chest. "This new surgical technique allows us to cut only a small section of skin, fat, and muscles, a wound that heals easily, much safer and that in this first patient has practically not produced pain," says Jauregui.
Furthermore, in every transplant, patients must be given a lifelong treatment that depresses the immune system to prevent rejection of the new organ. If an infection occurs, the wound does not close well and surgery must be performed again to control the infection. In the case of recipients of a healthy lung, these are people with chronic respiratory insufficiencies, so a simple action like going to the bathroom can be exhausting and such an aggressive surgery always entails negative consequences. This time, not only have postoperative complications been reduced, but the patient has had little pain and the days of hospitalization have been decreased.
"Thanks to this milestone, the lung transplant program enters a new stage of minimally invasive surgery with multiple advantages for the lung transplant recipient and, therefore, will improve outcomes," remarks the medical director of the program, Dr. Carles Bravo. Vall d'Hebron does not contemplate generalizing the use of this innovative technique for all lung transplants it performs and will select the most suitable patients. They do plan to expand the system outside the hospital and estimate that the first transplant of two lungs can be performed in the coming months.