Tips and Tricks for Robotic Versius Left Lower Lobectomy

The current treatment strategy for non-small cell lung cancer depends on clinical staging. Surgical resection is generally considered the treatment of choice in patients with stage I or II disease (1).

Minimally invasive techniques are the standard of care today. Video assisted thoracoscopic surgery (VATS) has been established as a safe and favorable approach for the resection of pulmonary neoplasms when compared to the traditional open thoracotomy (2). Recently, robotic assisted thoracic surgery (RATS) has been increasingly used worldwide as a new surgical approach to lung cancer. RATS can provide 3D high definition visualization over the operative field and improves the precision of manipulations and angulation of the surgical instruments (3,4). 

A recent meta-analysis by Zhang et al. revealed that RATS is a feasible and safe alternative to VATS, with low thirty-day mortality and similar morbidity for early stage lung cancer (5). Usually, RATS is performed with the Da Vinci surgical system, but the Versius system has been increasingly used. Recently, the first lobectomy with the Versius system in Latin America was completed (6).

The Patient

This video presents the case of a seventy-year-old woman with diabetes, hypertension (HTA), and chronic obstructive pulmonary disease (COPD) with a history of cough. A chest computed tomography (CT) demonstrated an irregular 24 mm nodule in the inferior lobe of the left lung.

A PET scan demonstrated a hypermetabolic left lower lobe mass and hilar lymphadenopathy. An endobronchial ultrasound guided transbronchial fine needle aspiration (stations 4L, 4R, 7, 11RI,11RS, 11L) was negative. A brain magnetic resonance image (MRI) was negative for metastatic disease. A pulmonary function test showed FEV1 of 76 percent, DLCO of 15.07 (66 percent of predicted), and VO2 max of 88 percent.

Postoperatively, the patient did well without complications. Final pathology revealed invasive adenocarcinoma T2a N0 M0 (Stage IB) with zero of fifteen lymph nodes with cancer.

Tips and Tricks

In terms of implementation, the Versius training program requires a team of at least two surgeons and a scrub nurse to complete theoretical modules, dry lab, and cadaver lab training before implementation. Coordinating this can be logistically challenging. 

The lessons after using the console for thoracic surgery include preferring a C-shape for the arms whenever possible, leveling the lowest robot joint with the trocar sites by elevating the platform, spacing out the robots to avoid clashes, and switching to a 30-degree down vision only after placing all the trocars. 

The trocar placement is similar if not the same as for a VATS case, which allows the surgeon to switch to this approach if it becomes impossible to make progress using the robot. This versatility is not uniform to the Da Vinci since the port placement philosophy in this platform is entirely different. 

Another difference between Da Vinci and this platform is that the hot Maryland used for the dissection does not use much force when fully closed. This is advantageous for mobilizing delicate tissue since it is gentle but can be problematic when needing a firm grasp. The trocars in Versius are also smaller than Da Vinci, mostly 5 mm in size. 

The surgical assistant in the Versius console is more critical than the assistant in the Da Vinci platform, mainly to troubleshoot clashes and because of the increased use of the assistant port for creating exposure. Having a surgical representative for first cases is also essential since it makes alarm control more manageable and they can oversee the cables that connect the robots. 

Lastly, the Versius allows the surgeon to operate standing up, which is quite ergonomic and comfortable for some surgeons. It also allows a more panoramic oversight of the operating room since the company recommends that the operating console face the patient. 

Conclusions

This video presents one of the first robotic lobectomies in Latin America using the Versius platform. This surgery is undoubtedly possible based on this case and preliminary experience utilizing this robot. The platform maintains most traditional thoracic robotic benefits, such as enhanced vision, increased lymphadenectomy, decreased blood loss, and possibly less pain, yet requires a different training and learning curve than other conventional platforms. 

References

1. Hoy H, Lynch T, Beck M. Surgical Treatment of Lung Cancer. Crit Care Nurs Clin North Am. 2019;31(3):303-313. doi:10.1016/j.cnc.2019.05.002
2. Wahi JE, Ajabshir N, Williams R, Bustamante H, Safdie FM. Robotic-assisted lobectomy for malignant lung tumors. J Minim Access Surg. 2022;18(3):415-419. doi:10.4103/jmas.jmas_266_21
3. Zhang J, Feng Q, Huang Y, Ouyang L, Luo F. Updated Evaluation of Robotic- and Video-Assisted Thoracoscopic Lobectomy or Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis. Front Oncol. 2022;12:853530. Published 2022 Apr 12. doi:10.3389/fonc.2022.853530
4. Ahn S, Jeong JY, Kim HW, Ahn JH, Noh G, Park SS. Robotic lobectomy for lung cancer: initial experience of a single institution in Korea. Ann Cardiothorac Surg. 2019;8(2):226-232. doi:10.21037/acs.2019.02.08
5. Liang H, Liang W, Zhao L, et al. Robotic Versus Video-assisted Lobectomy/Segmentectomy for Lung Cancer: A Meta-analysis. Ann Surg. 2018;268(2):254-259. doi:10.1097/SLA.0000000000002346
6. Dunning, Joel; Pilla, Eduardo; Theresa, Maria (2022): The First Versius Lobectomy in the Americas. CTSNet, Inc. Media. https://doi.org/10.25373/ctsnet.21760457.v1

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