Satisfactory outcome with robotic-assisted chest wall resection and reconstruction: a case report

Introduction

Background

Fibrous dysplasia (FD) of the ribs is a rare benign bone disorder, occurring in approximately 1 in 30,000 to 100,000 individuals in the general population. It is characterized by the replacement of normal bone with fibrous tissue, leading to abnormal growths or lesions, with the ribs being among the more common locations in the chest. FD typically presents during adolescence or early adulthood and is often discovered incidentally through imaging conducted for unrelated conditions. Most cases of rib FD are asymptomatic and do not require intervention unless the lesions result in symptoms such as pain, deformity, or, in rare cases, pathologic fractures (1). However, surgical resection may be warranted if there is suspicion of malignancy, significant symptoms, or large lesions that compromise structural integrity (2).

The surgical management of chest wall tumors and rib lesions presents significant challenges, particularly in balancing effective resection with the preservation of structural integrity and minimizing postoperative morbidity. Traditionally, open thoracotomy has been the standard approach for these procedures. However, it is associated with considerable trauma, prolonged recovery times, and higher rates of complications. In recent years, minimally invasive surgical techniques, particularly robot-assisted thoracoscopic surgery (RATS), have emerged as viable alternatives, offering several potential benefits (3,4).

Rationale and knowledge gap

RATS provides superior visualization and precision through three-dimensional imaging and articulating instruments, enabling meticulous dissection and reconstruction, even in anatomically complex regions (5). Despite its increasing use, reports on the application of RATS for chest wall resection and reconstruction remain relatively scarce, particularly in cases involving rib resection and subsequent repair using mesh (6).

Chest wall resections often require the removal of rib segments to achieve clear margins, which can compromise the stability and function of the thoracic cage. Reconstructing the resultant defect is crucial to prevent complications such as flail chest, respiratory dysfunction, and paradoxical movement (7). The use of synthetic meshes in reconstructive surgery is well-documented, providing robust support and facilitating tissue integration (8).

Objective

This case report aims to contribute to the growing body of evidence by detailing the successful resection of a rib segment and repair of the chest wall defect using mesh via a RATS approach. We discuss the perioperative management, surgical technique, and postoperative outcomes, emphasizing the advantages of RATS in minimizing patient morbidity and enhancing recovery. This case is presented in accordance with the CARE reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-20/rc).

Case presentation

A 35-year-old woman presented with an incidental finding of an expansive lesion on the left 4th rib. She denied any exposure to carcinogens and had an unremarkable medical history, with no previous surgeries or pathologies. In July 2023, thoracic magnetic resonance imaging (MRI) revealed a 67 mm × 17 mm left pleural lesion with heterogeneous contrast enhancement. A subsequent chest computed tomography (CT) confirmed an expansive alteration of the 4th rib, characterized by significant enhancement, cortical thinning, and focal interruption, but without periosteal reaction (Figure 1). The lesion extended over more than 50% of the rib arc length (>10 cm) but showed no infiltration into adjacent muscles or lung parenchyma. Surgical treatment was recommended after specialist consultation. Laboratory tests, pulmonary function tests, and echocardiogram were unremarkable.

Figure 1 Axial (A,B) and sagittal (C) thorax contrast-enhanced CT reconstructions showing the expansive alteration of the fourth rib. The red arrows point the rib lesion. CT, computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. The patient provided explicit consent by signing a specialized agreement, permitting the retrospective review of her medical records for scientific research purposes. A copy of the written consent is available for review by the editorial office of this journal.

Surgical procedure

The robotic procedure is demonstrated in Video 1. After double-lumen intubation, the patient was positioned in the right lateral decubitus position. The 8-mm, 30° camera port was inserted in the mid-axillary line at the eighth intercostal space, while two 8-mm robot arms were placed in the fourth intercostal space along the anterior axillary line and in the eighth intercostal space just below the scapula tip (Figure 2). The da Vinci Surgical System (DVSS) (Intuitive Surgical, Sunnyvale, CA, USA), fourth generation (Xi), was brought in from the left side of the patient. Upon introducing the camera, the lesion appeared as an intrathoracic bulge, with no evidence of infiltration into the parietal pleura or surrounding intercostal muscles. The parietal pleura was opened 2 cm away from both ends of the tumor using a monopolar hook. The intercostal muscles were detached along the superior and inferior margins of the rib throughout the entire course of the lesion. The periosteum at both ends was cauterized and peeled off the rib. Using an endoscopic costotome, the anterior end of the rib segment was sectioned first. Traction on the lesion was maintained using a fenestrated bipolar forceps. The outer surface of the rib was then freed in an anteroposterior direction from the external muscular fascia using the monopolar hook, extending to the posterior end of the lesion. The rib segment was subsequently sectioned posteriorly with the costotome, and the rib segment containing the lesion was removed after enlarging the thoracic access to 3 cm at the fourth intercostal space.

Figure 2 Patient in right lateral decubitus position. The 8-mm 30° camera port [1] was placed in the mid-axillary line in the eighth intercostal space, one 8-mm robot arm was placed in the eight intercostal space just below the tip of the scapula [2], and one 8-mm in the fourth intercostal space at the anterior axillary line [3].

The chest wall defect was repaired using a 15 cm × 10 cm Optimized Composite Mesh Parietex™ by Covidien™, which was trimmed to half its width to fit the defect. The mesh was secured using two continuous sutures with STRATAFIX™ Knotless Tissue Control Devices 2-0, along the long side of the mesh in a postero-anterior direction, starting from the superior margin of the thoracic defect. The sutures were secured with endoscopic hem-o-lock clips. At the end of the suturing process, the mesh was covered with a biodegradable synthetic adhesive (Glubran^®2 by GEM™).

After saline lavage and ensuring hemostasis, a 30-Fr chest tube was inserted through the camera port. The surgery lasted 120 minutes, with a total intraoperative blood loss of 150 mL. The specimen measured 16 cm in length and 5 cm at its widest diameter (Figure 3).

Figure 3 Surgical specimen of 16 cm in length, 5 cm in widest diameter, with clear visualization of the rib structure and surrounding tissue.

Histological analysis confirmed a fibroblastic/myofibroblastic lesion with medium-low cellular density, consistent with FD (p16+; β-catenin+). The anterior margin was pathology-free for 3.5 cm, while the posterior margin was clear for 1.6 cm.

The postoperative course was uneventful. The highest Visual Analogue Score (VAS) for pain was 3/10 in the immediate postoperative period, localized at the posterior periscapular surgical site, and it was effectively managed with medication. The pain management included intravenous analgesia on the first postoperative day with paracetamol 100 mL three times a day and ketorolac 30 mg twice a day. This was followed by oral therapy with paracetamol 1 g three times a day and ketorolac as needed. The patient began rehabilitative physiotherapy on the first postoperative day, achieving full mobilization. The chest tube was removed on the third postoperative day, with no recorded air leaks. She was discharged on the fourth postoperative day, with a VAS of 1/10. Oral pain medication was discontinued within 2 weeks of discharge.

At the latest follow-up in August 2024, the patient reported no persistent pain at the surgical site, denied any respiratory difficulties, and had not developed a lung hernia. The patient expressed high satisfaction with the procedure, both from a functional perspective—reporting no impediments to daily activities—and with the speed of her recovery, allowing her to resume all preoperative activities without restrictions.

Figure 4A,4B show the postoperative and 6-month follow-up (January 2024) chest X-rays.

Figure 4 Post-operative (A) and 6 months after surgery (B) chest X-ray with the red arrow indicating the chest wall defect.

Discussion

Key findings

We described a case of a 35-year-old asymptomatic woman who was incidentally found to have an expansive lesion on her left 4th rib. Imaging revealed a 67 mm × 17 mm pleural lesion with significant rib involvement but no infiltration of surrounding tissues. After consultation, robotic surgical resection was performed. The chest wall defect was repaired using a composite mesh, and the postoperative course was uneventful. Histological analysis confirmed FD. Pain was managed effectively with intravenous and oral analgesia, and the patient was discharged on the fourth postoperative day. At her last follow-up, she was asymptomatic and had resumed all preoperative activities.

The traditional approach for the resection of large rib tumors is a lateral or posterolateral thoracotomy (9). Several video-assisted thoracoscopic surgery (VATS) approaches for rib resection and reconstruction have been introduced for the resection of upper rib lesions (from the first to the third rib) to provide better visualization of vascular and nerve structures, which thoracotomy cannot offer (10). However, the VATS approach remains technically challenging due to the need for precise hand-eye coordination and the difficulty in performing sutures, which can lead to prolonged surgical times (11,12). In contrast, RATS, with its high-definition three-dimensional vision, enhanced instrument articulation, and tremor filtration, makes this procedure easier to perform, particularly the reconstructive aspect. This could result in a shorter learning curve for minimally invasive procedures. Additionally, this approach has been associated with a low risk of perioperative morbidity, reduced postoperative pain, and a shorter hospital stay.

Strengths and limitations

RATS rib resection and chest wall reconstruction enabled the performance of a procedure that, until now, has predominantly been carried out using the open technique, but through a minimally invasive approach. This resulted in controlled postoperative pain and reduced intraoperative bleeding. Moreover, the patient was able to mobilize on the first day, as pain did not hinder rehabilitation exercises. Since this is the first case performed to our knowledge, it is not yet possible to draw definitive conclusions about the advantages of the procedure compared to other techniques. This surgical procedure does present some technical limitations. Regarding the tumor, the technique could be complicated by tumors that infiltrate the overlying muscle layer or those with a free margin that is not easily identifiable visually and requires palpatory confirmation. Additionally, the procedure may be difficult to perform if the rib lesion has a protruding or pedunculated shape within the thoracic cavity, or if its size does not allow for removal of the rib segment through a thoracoscopic surgical access. In such cases, enlarging the surgical incision and performing rib retraction would negate the attempt to complete the procedure in a fully minimally invasive manner. This procedure might also be discouraged in patients with fibrothorax, as narrow intercostal spaces could increase the risk of vascular and/or nerve damage to the ribs above and below during rib margin resection with the hook. This could raise the likelihood of hemorrhage or chronic intercostal pain.

Comparison with similar researches

To date, few studies have reported rib resections using RATS. Most describe resections of the first rib, typically in patients with thoracic outlet syndrome (13), or the second rib (14,15).

In the study by Liu et al. (16), a 17-cm lesion of the second rib was resected using a triportal RATS approach, which is similar to the one described in our study. However, we did not use CO₂ insufflation, and in Liu’s case, a pneumatic surgical drill with a blunt tip was used to transect the rib anteriorly and posteriorly, which generated significant heat, controlled by continuous irrigation with saline solution. In our case, the use of an endoscopic rib cutter avoided the need for additional surgical ports and prevented excessive heat generation by energy devices. Operative times in our case were nearly identical to those in Liu’s study (120 and 135 minutes, respectively); however, Liu’s case did not include chest wall reconstruction.

Explanations of findings

To our knowledge, this is the first reported case of robotic chest wall reconstruction with mesh after rib segment resection. A systematic search of the literature in the MEDLINE, PubMed Central, and EMBASE databases was conducted to identify any previously reported cases, and no results were found. The repair was necessary due to the extensive resection and the location of the lesion, to prevent lung herniation and respiratory issues. Robotic mesh placement was straightforward, facilitated by 3D visualization, tremor filtration, and enhanced instrument articulation, which made suturing easier than with VATS. The RATS approach resulted in low perioperative morbidity, reduced postoperative pain, and a short hospital stay, due to the absence of a thoracotomy incision, muscle preservation, and avoidance of rib spreading. Early mobilization and a shorter hospital stay contributed to the patient’s high level of satisfaction. Additionally, the use of an endoscopic costotome to cut the rib minimized potential heat damage to the intercostal nerve, reducing the risk of chronic pain.

Implications and actions needed

Costal resection and chest wall repair using the minimally invasive RATS technique offer a valid alternative to the open or VATS approaches for the treatment of chest wall lesions. Compared to the open approach, the advantages lie in its less invasive nature, resulting in reduced post-operative pain, a smoother post-operative course without complications, and a shorter hospital stay. In comparison to VATS, the benefits stem from greater feasibility and simplicity made possible by 3D visualization, tremor elimination, and enhanced instrument articulation. These features make the RATS approach accessible even to less experienced surgeons, allowing for a rapid learning curve. The surgical technique, as described, did not present significant challenges during its execution. The main difficulty was the gradual separation of the anterior rib stump during the dissection of the rib along its length, in order to adequately expose the overlying muscle plane. This was achieved using fenestrated bipolar forceps, though care must be taken to avoid abrupt movements that could lead to excessive traction and potential damage to the muscle or intercostal neurovascular bundle.

Additional surgical cases and comparative studies are required to demonstrate the actual non-inferiority or superiority of this method compared to other approaches (open or minimally invasive). In particular, further studies are necessary to investigate whether this technique can reduce the incidence of lung herniation at the prosthetic site, as well as the development of chronic pain and/or dysesthesia at the rib resection site. Moreover, it would be valuable to evaluate whether this minimally invasive approach, which avoids a cutaneous and muscular incision at the rib defect, may also reduce the incidence of infection at the site of the implanted prosthesis.

Conclusions

Our technique can be easily replicated and applied in all cases where chest wall reconstruction with mesh is required following resection. This procedure ensures intraoperative safety, with optimal short-term results as well as excellent long-term outcomes, providing strong chest wall stability. The simplicity of suturing with the robotic technique may facilitate a rapid learning curve.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-20/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-20/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-20/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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