Dr. Pedro Catarino, still fairly new to the Smidt Heart Institute, joined his colleagues in an operating room in fall 2021. He was there to observe one of the most skilled teams in the world perform a minimally invasive heart valve procedure. As a 3D camera moved into place to guide the robot that would assist with replacing the valve, it offered him a magnificent and familiar view.

"We were watching them set up the mitral valve surgery, and we thought, wow! This is almost the exact view we get when we're doing lung transplants," says Dr. Catarino, director of aortic surgery at the Smidt Heart Institute and an expert in cardio-thoracic transplantation. "It occurred to us that we could use this technology to augment our minimally invasive lung transplant approach."

This observation led to a collaboration with heart surgeons and resulted in the first robotic-assisted lung transplant earlier this year. This is one of several advances in recent years that has made lung surgery more accessible to those who need it.

"Lung transplant is a quality of life procedure above all else. If we can improve a patient's quality of life by giving them a minimally invasive procedure, then that's an important step forward."

Patients suffering with lung failure tend to be frail, and for some, a traditional lung transplant might be more than their bodies could withstand. New techniques in lung transplantation using smaller incisions allow transplant to be a potentially lifesaving option for more people.

"Lung transplant is a quality of life procedure above all else," says Dr. Dominick Megna, surgical director of the Lung Transplant Program. "If we can improve a patient's quality of life by giving them a minimally invasive procedure, then that's an important step forward."

From clam shell to credit card

Traditionally, a lung transplant is performed using a 20- to 24-inch incision across the breastbone from armpit to armpit, sometimes called a "clam shell" incision. The sternum is broken across the middle to access the lungs and a patient is put on a heart-lung machine during the surgery.

Minimally invasive (non-robotic) lung transplant surgery uses incisions under the nipple of 3-inches or less—about the length of the short side of a credit card. The incision allows for enough space for a patient's deflated lung to be removed, and their new lung to be inserted and reinflated within the body. Specialized instruments and custom clamps are used to perform the operation, as the incisions are too small for a surgeon's hand.

The minimally invasive technique reduces scarring and eliminates the need to break the sternum. It also cuts the average time taken to perform the procedure from six hours to under an hour, eliminating the need for a heart-lung machine.

"By definition, a transplant is maximally invasive," Dr. Megna says. "I think when a patient knows that they're having a surgery that's going to be a little bit easier, it puts them at greater ease mentally, which is also important to their recovery."

The minimally invasive technique was developed in Germany, and Dr. Catarino was part of a team pioneering the procedure in England. The team at Cedars-Sinai performed perhaps the first minimally invasive double lung transplant in the United States in 2021, further demonstrating the benefit of the approach to patients.

Read: Cedars-Sinai's First Minimally Invasive Double Lung Transplant

Robotically assisted lung transplants

The next advance in lung transplantation is using robotic devices to assist with the procedure. The Smidt Heart Institute team performed the first-ever robotically assisted lung transplant in early 2022. Dr. Megna and Dr. Catarino worked with Dr. Dominic Emerson, associate surgical director of Heart Transplant and Mechanical Circulatory Support, to develop the procedure.

The robotic procedure adds two tiny "porthole" incisions on either side of the body to make way for a camera and robotic instruments. Those instruments allow for more precise movements and manipulation. Minimizing movement inside the body also reduces the amount of pain a patient will experience post-surgery and speeds recovery times.

After Dr. Catarino watched the valve replacement, he worked with Dr. Megna and Dr. Emerson to develop the idea further.

"We work closely, and we discuss these sorts of problems," Dr. Catarino says. "It's one of the great enjoyments of our jobs to figure out how to do things differently and make them better for our patients. We all made suggestions that moved it from a good idea to being in the realm of possibility and then to a reality."

They started off by testing the idea using a box and suturing some gloves together then moving on to more sophisticated models.

So far, they've used the robotic technique only with single-lung transplants and limited them to the right side of the body—to match the comfortable view of the mitral valve surgeries.

"We can, of course, do the same thing on the left side, and we will," Dr. Catarino says. "In the future, we believe this will become the standard in centers all over the country."

Read: Faces of Cedars-Sinai: Cardiac Surgeon Dr. Pedro Catarino

 

A beautiful view

Another benefit of the robotic technique is the introduction of a high-definition camera. It allows surgeons to see the blood vessels and airways more clearly than ever before. This view also helps solve a longstanding challenge.

Minimally invasive lung transplants have become more common in the last two years, but the technique can be difficult to teach.

"When you do the transplant through a small incision, often only one surgeon can see what's going on, and it's quite difficult to train others," Dr. Catarino says. "With the robot, everyone can see exactly what's happening."

With more surgeons trained on the procedure, it will be available to more patients. Beyond developing and perfecting the techniques that lead to better outcomes in lung transplant patients, the team also wants these advances to become widely available.

"We already see that our patients recover faster with these new approaches," Dr. Megna says. "It helps us bring those who need lung transplants closer to getting back to all the things they enjoy in their lives."