The precision of robot-assisted surgery has now become a life-saving option for tracheobronchomalacia (TBM) patients in Alabama. "It's going to extend the candidacy for this operation to more people," says Benjamin Wei, MD, the thoracic surgeon who performed the first robotic-assisted tracheobronchoplasty in the state.
Generally, the complicated surgery excludes patients because of the pulmonary access and pain. But Wei recently performed the robotic-assisted tracheobronchoplasty on an 80-year-old woman who was able to leave the hospital three days after the surgery.
A progressive, debilitating disease, TBM collapses the airway on itself due to weakened tissue and its abnormal shape. The surgical treatment for this rare disease often involves placing stents inside the airways as support. "But the stents can be irritating to the tissue, which can form mucus or scar tissue," Wei says. "This can end up requiring an additional surgery in which surgeons may need to exchange the stents. If the stents get clogged, it's a life-threatening emergency."
A tracheobronchoplasty (TBP), however, shores up the outside of the diminishing structures. "We put in mesh to re-shape the trachea and bronchia and plicate the redundant area so there is not as much floppiness and redundancy that is outside the airway," Wei says. "It's a more permanent solution that has arguably fewer side effects. There is less chance of infection and no structures inside the airways to stimulate scar tissue or mucus formation."
But a TBP is a complex surgery. The traditional approach requires a six to eight inch incision and a metal retractor to pull the ribs apart to gain access to the chest. "The trachea is in the center of the human body. To finely suture something in this big cavity is like working in a deep ravine," Wei says. "Everything becomes difficult because of where the trachea is."
The robotic approach simplifies the process. "I can bring the camera right up to a couple of inches away from what I'm looking at," Wei says. "And the tools can come from pretty much any angle, and they're wristed so it's like a tiny hand in the center of the cavity. It's a lot easier--better mobility, better control, and better visualization."
That simplicity shortens the surgery. Instead of the long incision with the traditional approach, the robotic-assisted approach results in just five small incisions across the chest that are used as ports for the robotic arms. These smaller incisions decrease the time needed for the surgery. "The robot makes a five-hour surgery four hours instead," Wei says. "Because it takes a good 45 minutes just to close the incision from the open surgery."
The robot's better visualization also means more compact tools for the surgeon. For example, instead of using a needle driver that is eight to 10 centimeters long, Wei uses a driver that is only one to two centimeters.
Besides the arm for the camera, the robot utilizes four other arms to hold tools, all controlled by the surgeon through a console. "We put our eyes into a head piece to see what's going on and use our feet and fingers to control the arms. We're fully in control of the robot at all times," says Wei, who is one of only about a dozen surgeons who perform the TBD in the nation. "The robot makes a painful, long procedure a lot shorter and a lot easier and, I'd argue, somewhat more precise. Patients can return home as soon as a day later and usually no more than three days. Under the open surgery approach, that stay extends to five to seven days.
They also return to daily activities within a month versus double or triple that using the traditional approach primarily because of potential complications from the large incision and the sutures holding the ribs. "They're much less able to move and use their upper body, so they're less mobile and have more issues with pain," Wei says.
Wei says the rare procedure may become more common as physicians become aware of tracheobronchomalacia. Underdiagnosed, the condition is often disguised as COPD or asthma. "It's not something that we learn about in training in any specialty and it's not common," Wei says, adding that diagnosis relies on examining the airways from the inside.
"If someone has breathing problems much worse than you would expect based on their COPD or emphysema or asthma, than have them diagnosed by a thoracic surgeon," Wei says. "Even pulmonologists may need more awareness of this condition so we can optimize the therapies that these patients get."