Our First 31 Robotic Tracheobronchoplasties for Excessive Central Airway Collapse at a High Volume Complex Airway Center

Purpose: We began transitioning to the robotic platform for airway surgery in highly selected patients in 2020. Herein, we will report our early experience, outcomes, and lessons learned in transitioning from open thoracotomy to a robotic tracheobronchoplasty approach (rTBP) in our first 31 consecutive patients.

Methods: We queried a prospectively maintained database of all consecutive rTBP operations performed from February 2020 to May 2023 at Beth Israel Deaconess Medical Center (Boston, Massachusetts). Highly selected operative candidates with severe symptomatic excessive central airway collapse (ECAC) underwent surgical stabilization of their airway by 2 experienced airway surgeons who individually determined the operative approach (robotic or thoracotomy). Polypropylene mesh was customized based on dimensions measured from the patient's airway computed tomography scan preoperatively. The mesh was used to stabilize and remodel the posterior wall of the airway using carefully placed interrupted partial thickness permanent sutures that anchor the mesh to the cartilage laterally and plicate the posterior membrane of the intrathoracic trachea, right mainstem bronchus, bronchus intermedius and left mainstem bronchus when indicated. Intermittent apnea and double lumen tube manipulation was used to facilitate suture placement when necessary. Patient demographics, comorbidities, operative case times, and complications were retrospectively reviewed.

Results: A total of 31 patients underwent rTBP during the study period. The majority were female (68%), the median age was 54, and the most common comorbidity was asthma (n=23, 78%). Median operative time was 8.25 hours (range 5.7-13 hours). There were 3 intraoperative complications (10%): a left mainstem bronchus airway injury requiring conversion to thoracotomy for repair, cardiac arrest for hypercarbia requiring chest compressions, and inadvertent extubation during the surgery by anesthesia that required emergent reintubation. Postoperatively, almost half of the patients (n=14, 45%) experienced at least 1 complication. However, only 3 patients (10%) experienced a major post operative complication (Clavien Dindo ≥IIIb) and all of these were respiratory in nature. Two patients required reintubation after surgery due to respiratory failure and pneumonia and one patient was unable to be weaned from the ventilator due to pneumonia and underwent tracheostomy and gastrostomy feeding tube placement post operative day 9. There were no intraoperative or post operative mortalities. The median ICU length of stay was 1 day (range 0-22 days) and hospital stay was 5 days (range 2-48 days). The majority of patients were discharged directly home after surgery (n=26, 84%).

Conclusion: We have observed acceptable complication rates in our first consecutive rTBPs with a trend towards lower respiratory complications as compared to thoracotomy. As data accumulates, a propensity score matched analysis could provide us with a more direct comparison to determine how the robotic platform compares to the open approach.

Identify the source of the funding for this research project: None