Pulmonary Resection in the 21st Century

The interest in robotic thoracic surgery continues to increase. Preliminary reports suggest that there are certain advantages to a robotic approach, in comparison with a video-assisted technique. These include easier operations in the mediastinum, such as a thymectomy or a resection of an esophageal leiomyoma. The robot provides better instruments and a better view of the operative field: 3-dimensional rather than 2-dimensional; ×10 magnification rather than ×2 or ×3; and less fogging, therefore less camera manipulation. Most surgeons who have earnestly tried to learn both video-assisted thoracic surgery (VATS) and robotic techniques agree that the robot provides clear advantages for mediastinal and esophageal operations. However, no prospective randomized trials support the contention that these “advantages” lead to improved outcomes. Even the several advantages that robotics offers to pulmonary resection remain controversial.

We believe that these advantages for lung surgery include better dissection of enlarged or metastatic N1 lymph nodes off the pulmonary artery, more precise and thorough N2 lymph node dissection, and less operative blood loss. Others have argued (but we are not yet convinced) that the robot is less painful than VATS and leads to fewer conversions. Clearly, the operative technique of robotic lobectomy mimics that of open surgery more closely than does the VATS technique.

To date, the largest completely portal robotic lobectomy series with 4 arms (CPRL-4) is our series reported in 2011.¹ Of 168 patients with non-small cell lung cancer who underwent robotic pulmonary resection, 106 had a lobectomy. We matched those 106 patients with 318 propensity-matched patients who underwent lobectomy via nerve- and rib-sparing thoracotomy.¹ In that study, 16 of the 106 patients had a completely portal robotic segmentectomy-4 (CPRS-4) as well. The results showed some of the advantages described above.

Since then, we have made several technical changes. These include starting with the marks on the skin for the 4th robotic arm posterior; placing a vessel loop around the artery, vein, bronchus, and fissures to help guide the stapler; removing the tumor above the diaphragm; and using carbon dioxide insufflation. The results of CPRL-4 after these technical modifications show a trend toward the reduction of median operative times and the reduction of conversion rates.

Although the advantages of robotics are controversial, the disadvantages are mostly agreed upon. These include the cost, the lack of consistent platform availability, the lack of tactile feedback, the fact that several countries cannot afford any robot (certainly not one for thoracic surgery), the need for the bedside assistant to fire the stapler on pulmonary vessels, and the lack of standardized credentials and training programs for the surgeons and technical assistants. Many of these issues apply to any new or emerging technology.

Recently, in connection with our service on an international committee, we submitted a proposal on robotic surgery nomenclature.² In accordance with that proposal, a “completely portal operation” is an operation in which only ports are used (that is, incisions no larger than the trocars placed in them); moreover, air in the pleural space or chest cavity does not communicate with ambient air in the operating room, carbon dioxide is insufflated in the chest, and the portal incisions are not enlarged at any time during the operation, save for the removal of a specimen that is contained in a bag.^* The number of robotic arms used during the operation is preceded by a hyphen after the type of operation. Thus, we prefer a CPRL-4 and Dylewski has used a CPRL-3 approach for several years with outstanding results.

Robotic operations (unlike completely portal operations) make utility incisions and are defined as “robotic-assisted procedures.” A utility incision is a chest incision that might or might not have trocars or robotic arms placed through it; that does allow communication between the pleural space and the ambient air in the operating room; that is less than 5 cm in length; that does not spread the ribs; and that uses carbon dioxide insufflation selectively. Each has its advantages and disadvantages.

Once the politics has been eliminated, the reality is that the robot enables a more sophisticated and precise operation than does VATS, and is the next step in the evolution of minimally invasive surgery.