Letter From the Guest Editor: Advances in Robotic Thoracic Surgery

For CTSNet’s first General Thoracic Guest Editor Series, Advances in Robotic Thoracic Surgery, we asked Dr David Rice of the University of Texas MD Anderson Cancer Center to bring together videos from experts focused on this increasingly important approach within general thoracic surgery.

Dear Reader,

With any new technology, there is a latent period between inception and acceptance. This was true for video-assisted thoracoscopic surgery (VATS) lobectomy, which was pretty much ignored by thoracic surgeons until almost 15 years after its initial debut. Now, of course, VATS lobectomy is commonplace, accounting for 50% of lobectomies in The Society of Thoracic Surgeons National Database, and residents cannot hope to land their first job without being able to competently perform it. So it is with robotic-assisted lobectomy (RAL). Though initially described in 2003, RAL is now gaining significant traction among general thoracic surgeons. It is estimated that approximately 15 - 20% of lobectomies are now being performed robotically, a rate of adoption that is currently faster than for VATS lobectomy.

What can account for this? The reasons are several. First, there is general acceptance that minimally invasive lobectomy decreases postoperative morbidity, is less painful, and leads to earlier recovery compared to thoracotomy. Second, and perhaps more important, is that the added dexterity, precision, and enhanced visualization of the robotic platform extends the limits of what can be performed minimally invasively compared to VATS for most surgeons. It is for this reason that many previously die-hard VATS surgeons have now wholly migrated to the surgical robot. This is not to say that sleeve resection, complex bronchoplasty, or atypical segmentectomy cannot be performed by skilled VATS surgeons—they can and are. Rather, these procedures become much easier to do with the robot. Additionally, surgeons who did not learn VATS lobectomy during residency often find it easier to learn robotic surgery because of the wristed instruments, stereoscopic vision, and similarity to how dissection and manipulation of tissue is done during an open case. Therefore, the robotic platform may provide an avenue for non-VATS surgeons to perform minimally invasive lung surgery. Lastly, I believe a major factor that has led to increased adoption of the surgical robot is one of autonomy, particularly in the case of the da Vinci Xi platform, which enables robotic stapling. The surgeon controls camera, retraction, dissection, even suctioning, relying on a bedside assistant only for instrument placement and specimen extraction. The entire procedure is in the hands of the surgeon.

The videos presented here highlight the many attributes of the surgical robot for performing complex pulmonary resection. The viewer will observe how wristed instrumentation facilitates sutured reconstruction of a divided bronchus, how bipolar dissection allows for meticulous and safe dissection of small pulmonary artery branches during atypical segmentectomy, and how the surgeon can control stapling of tissue completely from the robotic console. Many of these videos have been compiled by some of the pioneers of robotic general thoracic surgery, and they include a multitude of technical pearls that even advanced robotic surgeons will find useful. What do you do when the tumor extends too close to the secondary carina to divide it with a stapler? How do you approach a patient with known hilar nodal metastases? How do you identify the correct segmental anatomy and define the intersegmental plane of the A2 segment? And, what if the patient needs a pneumonectomy? The answers to these and many other complex clinical scenarios will be addressed in these videos, which I hope will enrich the viewer’s understanding of this increasingly important technology.

Sincerely,

Dr David Rice

Robotic Left Lower Lobectomy With Primary Bronchial Closure and Pleural Flap Coverage for Proximal Carcinoid
by Richard Lazzaro, Byron Patton

Robotic Left Upper Lobe Posterior Segmentectomy Using ICG and Navigational Bronchoscopy
by Travis Geraci, Robert Cerfolio

Robotic XI Four-Arm Total Port Video-Assisted Left Pneumonectomy
by Mark Dylewski

Robotic-Assisted Left Upper Lobectomy in Non-Small Cell Lung Cancer With N1 Disease
by Luis Herrera

Robotic Right Upper Lobe Sleeve Lobectomy
by Vittorio Aprile, Carmelina Zirafa, Ilenia Cavaliere, Gaetano Romano, Sara Ricciardi, Federico Davini, Franca Melfi

Robotic Anterior Basilar Segmentectomy
by Bernard Park

Right Main Bronchus Sleeve Resection
by Marco Nardini, Joel Dunning, Marcello Migliore, Robert Cerfolio

Robotic-Assisted Left Upper Lobe Anterior (S3) Segmentectomy
by David Rice