Robotic Thoracic Surgery:

The thoracic robotic program at St. Luke’s-Roosevelt Hospital is one of the most established in the country. We are considered experts at performing robotic lung resection including robotic lobectomy, robotic thymectomy, robotic excision of mediastinal cysts and tumors, robotic excision of duplication and foregut cysts, robotic Heller myotomy, robotic excision of esophageal leiomyoma, and robotic-assisted esophageal operations including esophagectomy and repair of paraesophageal hernia. In addition, we are the first group to perform robotic reversal of thoracic sympathectomy performed for hyperhidrosis.

Robotic Lobectomy:

Use of the da Vinci robot to perform lobectomy provides all the oncologic benefits of an open operation, but with significant advantages by using a completely minimally invasive approach. We are one of the few surgeons in the country that perfom a completely port access lobectomy. The wristed articulation provided by the robotic instruments allows precise and very fine dissection with complete removal of all thoracic lymph nodes. The largest incision is approximately 15 mm to 20 mm in size used for extraction of the lobe at the end of the procedure. We offer robotic lobectomy for most of our patients needing lobectomy for lung cancer and other conditions. The typical hospital stay ranges from two to three days with significantly reduced pain in the postoperative period and early return to normal activity. We have presented our robotic series showing our excellent outcomes at both national and international meetings.

Robotic Right Upper Lobectomy
Robotic Right Lower Lobectomy

Patients not eligible for VATS, such as those with a large tumor near the central blood vessels and airways would undergo an open lobectomy.

VATS:

Most of our thoracic surgical operations are now performed with VATS rather than open thoracotomy. The VATS technique utilizes two or three 1-cm incisions which allow for the use of a thoracoscope (camera) as well as surgical instruments to perform an operation within the chest. This is a truly minimally invasive operation that allows for significantly decreased pain, a deceased hospital stay, and significantly improved recovery time. Patients are also allowed to have much smaller scars with VATS compared to open surgery.

Tracheo-bronchial Tumor Resection and Tracheal/Esophageal Stents:

Management of advanced esophageal and lung cancers can be a technical challenge. 20-30% of patients with lung cancer will present with central airway obstruction. This is a significant cause of morbidity and early mortality, with patients suffering from extreme shortness of breath, hemoptysis (coughing up blood), post-obstructive pneumonia, sepsis and an early death. Further, both a debilitated patient as well as superimposed infection precludes this group of patients from receiving chemotherapy and radiation therapy. Endobronchial airway stenting usually leads to immediate relief of symptoms with minimal post-operative complications. Several clinical trials are underway to study the effects of stenting in conjunction with chemo and/or radiation therapy in improving the quality of life as well as survival in patients with advanced lung cancer. Similarly advanced inoperable esophageal cancers can present with obstruction that makes it difficult to swallow food. Esophageal cancers may also lead to fistulous connection between the esophagus and airway, leading to continuous aspiration, mediastinitis and pneumonia. Esophageal stenting dramatically improves the quality of life in selected patients, with restoration of natural alimentation that enables the patients to swallow soft food and liquids. Our advanced airway program is the busiest in Manhattan, and we are frequently referred the most complex cases, with excellent results.

Robotic Thymectomy:

Thymectomy is an operation to remove the thymus gland and is performed for thymic tumors or for myasthenia gravis. Myasthenia gravis is an autoimmune condition that is characterized by weakness of the voluntary muscles of the body. Thymectomy for myasthenia gravis leads to a significant remission of disease in more than 80% of patients. Using the da Vinci robot, we are able to perform a complete thymectomy for myasthenia gravis and also for removal of mediastinal tumors especially tumors less than 5 cm to 6 cm in size. The da Vinci robot provides excellent visualization of the anterior mediastinum and articulating instruments allow for safe and precise dissection. Most patients require only an overnight stay in the hospital.

Robotic Thymectomy

Robotic excision of duplication and foregut cysts:

Cysts can arise from either the esophagus or from the trachea. Most of these cysts are benign, but they do compress adjacent structures and produce symptoms. Due to the propensity to enlarge and get infected, surgical excision is often recommended for most patients. The da Vinci robot allows for precise and meticulous dissection of the cysts of important mediastinal structures allowing for complete and safe excision. Most patients just need an overnight stay in the hospital with rapid recovery to normal function.

VATS Treatment of Spontanous Pnemothorax:

A spontaneous pneumothorax, or the sudden collapse of a single lung, may occur without any trauma or injury. The pneumothorax results from the rupture of a blister on the lung, which allows air to leak out. When this condition occurs in an individual without prior history of lung disease, it is known as primary spontaneous pneumothorax. This is most commonly seen in tall, thin individuals between the ages of 17-40 who have a predisposition to spontaneous pneumothorax. The anatomy of their lungs in addition to the large volume of air they hold makes it more likely that a small blister --a bleb -- will burst on the upper part of the lung. The lung collapse is unpredictable, as it may occur during physical activity or simply at rest. When the pneumothorax is due to an underlying lung condition such as emphysema, it is known as a secondary spontaneous pneumothorax. In this, the emphysematous blebs are larger and known as bullae. In both primary and secondary spontaneous pneumothorax, surgery is done with a VATS approach. The bleb or bullae is removed, and the lung is made to adhere to the chest wall in order to prevent future pneumothoraces using mechanical pleurodesis. Talc pleurodesis is used only for a failed primary procedure. This surgical technique almost always prevents recurrence of pneumothorax, whereas non surgical management shows a 30-50% recurrence rate.

Endoscopic Thoracic Sympathectomy:

Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive procedure that is more than 97% effective in curing severe palmar hyperhidrosis. Hyperhidrosis – meaning excessive sweating – can be present in patients with sympathetic hyperactivity. Patients afflicted with this disorder can exhibit severe sweating of the hands, underarms and feet, which can be so debilitating that it can affect job performance and a patient’s social well being. Severe focal hyperhidrosis may affect as much as 3% of the population and appears to be genetically related. This sweating is not part of the body’s normal temperature regulation. Unfortunately in patients with a severe case, topical ointments and treatments with iontophoresis devices are unlikely to be effective. Botulinum toxin infections may be effective in some patients especially those with axillary sweat. However the duration of effect is limited and repeat treatments are the norm. In selected patients, especially those with severe palmar sweat or combinations of other areas with palmar sweat, ETS is the preferred method of treatment. The surgery is usually performed with 2 pencil sized incisions in the axillae and entails an overnight stay. Our surgeons are skilled in the procedure and have outstanding results with a minimum of complications. Compensatory sweating in other parts of the body can occur so careful consultation by an experienced team familiar with other treatment options is of paramount importance for patients afflicted with this disorder.

Treatment of Malignant Pleural Effusion:

A pleural effusion is a collection of fluid in the chest cavity around the lungs, due to a variety of reasons. A malignant pleural effusion is when fluid collects in the chest due to an underlying cancer. The presence of an effusion represents metastasis of the primary cancer to involve either the lung itself or the pleura, the inner lining of the chest wall and is a poor prognostic sign. This fluid can compress the lung tissue, resulting in shortness of breath that often requires oxygen therapy. Treatment of this condition involves insertion of a tube to drain the fluid, which typically relieves the symptoms; however, recurrence of these effusions is extremely high with drainage alone. Definitive treatment involves an operation where 2-3 small incisions are made in the side of the chest and a fiber optic camera (thoracoscope) is inserted. The chest is inspected for signs of abnormal growths either on the lung or on the inner surface of the chest well. The fluid is drained, all loculations broken up and talc powder is instilled in the chest. This causes an inflammatory reaction which scars the lung against the chest wall, preventing the re-accumulation of fluid. This operation is approximately 75% successful in preventing recurrence of the fluid collection, but does not treat the underling malignancy. Another good option in patients with trapped lung (lungs that do not expand due to severe cancer or scar tissue involvement) is placement of a pleurex catheter.

Endobronchial Ultrasound (“EBUS”):

EBUS is a procedure that aids in the diagnosis and staging of cancers of the chest. The management of lung and other thoracic cancers depends heavily on the extent of disease, which is based on the involvement of lymph nodes in the center of the chest (the mediastinum). Historically, evaluation of these lymph nodes required an invasive surgical procedure called mediastinoscopy, which entails an incision in the neck and dissection of the lymph nodes off the major vascular and airway structures. In selected cases, mediastinoscopy has been replaced, at least as an initial diagnostic test, by EBUS. EBUS involves passing a long, thin flexible camera called a bronchoscope into the airway under light anesthesia. The airway is visualized and extensively inspected for any abnormalities. Suspicious lymph nodes previously identified on CT scan are located using an ultrasound probe built into the bronchoscope. A thin needle is passed out of the bronchoscope, through the wall of the airway and into the lymph node and a biopsy is taken. Depending on the results of the biopsy, mediastinoscopy may be avoided, but it may still be necessary if the EBUS biopsy is non-diagnostic. Some lymph nodes are difficult to reach using EBUS, and a similar procedure with the probe in the esophagus instead of the airway, called endoscopic ultrasound or EUS, may also be necessary.

Esophagectomy and Minimally Invasive Esophageal Surgery:

Esophagectomy is surgical removal of all or part of the esophagus and is typically undertaken for esophageal cancer. Once the esophagus has been removed, reconstruction after esophagectomy is performed by making stomach into a tube and re-anastomosing it to the esophagus either in the neck or the right upper chest. We perform esophagectomy in a minimally invasive fashion using a combination of laparoscopy as well as thoracoscopy/robotic surgery. We are able to perform minimally invasive esophagotomy even after neoadjuvant chemotherapy and radiation for advanced esophageal cancer. Our outcomes for esophagectomy are amongst the best in the country according to the national STS database.

Totally Endoscopic Ivor Lewis Esophagectomy

Robotic Heller Myotomy for Achalasia:

Achalasia is a rare motility disorder of the smooth muscles of the esophagus that is characterized by failure of the lower esophageal sphincter to relax and absence of normal motility within the esophageal wall. Once diagnosis is made by barium swallow and manometry, surgery is recommended which provides permanent relief in over 80% of patients. We use the da Vinci robot to divide the muscles of the lower esophagus. The high definition, magnification, and precision provided by the da Vinci robot makes this an excellent operation to be performed with robotic assistance. Most patients have a one-day hospital course and are discharged on a clear liquid diet for a week before resumption of a normal diet.

Robotic Myotomy for Achalasia

Minimally Invasive Para-Esophageal Hernia Repair:

Para-esophageal hernia occurs when a portion of the stomach prolapses up into the chest through the esophageal hiatus alongside the esophagus, while the gastro-esophageal junction remains in its normal location. Serious complications can occur with this type of hernia. When symptomatic, they can cause chest pain, difficulty swallowing, abdominal pain, indigestion, nausea, vomiting and retching. Serious complications include incarceration and strangulation, which can be life threatening. Incarceration results when hernia is stuck and non-reducible, while strangulation results from a lack of blood supply, leading to the death of tissues involved. Surgery is aimed at reducing the hernial sac, with closure of the abnormally wide esophageal hiatus. Immediate surgical intervention is required if strangulation develops and carries a high morbidity and mortality. Most elective cases can be repaired in a minimally invasive fashion, using advanced laparoscopy techniques collaborating with our minimally invasive team.

Minimally Invasive Hiatal Hernia Repair:

A hiatal hernia occurs when a portion of the stomach prolapses through the widened diaphragmatic esophageal hiatus (opening). This type of hernia is commonly associated with gastro-esophageal reflux disease also known as GERD, due to widening of the lower esophageal sphincter (LES). Hiatal hernias are themselves asymptomatic, however, in a minority of patients, hiatal hernias can predispose to increased acid reflux or worsen existing reflux. Hiatal hernia with uncontrolled GERD may be responsible for intermittent bleeding from associated esophagitis, erosions or a discrete esophageal ulcer, leading to iron-deficiency anemia. Barrett's esophagus is also associated with this condition. Surgery is indicated in a minority of patients with complications of GERD despite aggressive treatment with acid suppressing medications and involves a laparoscopic Nissen fundoplication.

Pectus Excavatum Repair:

Pectus excavatum is a rare deformity of the sternum and ribs, where the cartilages that attach the ribs to the sternum are deformed. Patients complain of shortness of breath on exertion or chest pain. We offer these patients a comprehensive assessment and evaluation for the need for surgical correction and are one of the few centers in Manhattan that offer repair for this condition.

Treatment of Empyema:

Empyema is a collection of fluid within the pleural cavity (membranous covering of the lung). It usually occurs due to the extension of pneumonia in the adjacent lung segment or lobe. It starts out as a clear serous effusion which later becomes infected and thick in consistency. With free flowing fluid, chest tube drainage along with antibiotic coverage provides optimum resolution, however with thickening and formation of loculations, chest tube drainage becomes inadequate and surgical drainage, usually VATS is required for complete drainage. If drainage is delayed, VATS may not achieve complete decortication (removal of the infected peel covering the lung) and a conventional open thoracic surgical procedure with decortication is required. VATS drainage is a highly successful procedure with cure rates above 90-95%.

Minimally Invasive Thoracic Dissectomy:

Degenerative disc disease is one of the most common causes of disc herniation, which can be painful and disabling due to impingement on the nerve roots. Thoracic disc herniation occurs less frequently than lumbar and cervical disk herniation. Often thoracic disc herniations fail to respond to conservative treatment like heat, physiotherapy and pain medications. In these cases, the definitive treatment is surgical removal of part of the herniated disc, which can be performed through minimally invasive endoscopic techniques using VATS.