Approaches and outcomes of Robotic-Assisted Thoracic Surgery (RATS) for lung cancer: a narrative review

Postoperative arrhythmias in geriatric lung cancer patients undergoing thoracoscopic surgery: an exploration of prevalence and influencing factors

BACKGROUND

Arrhythmias are a frequent complication in the postoperative period following surgical procedures. This study aims to investigate the incidence and contributing factors of arrhythmias in elderly patients with lung cancer who have undergone thoracoscopic surgery, thereby providing scientific evidence to support clinical treatment and nursing care.

METHODS

This retrospective cohort study included elderly patients diagnosed with lung cancer who underwent treatment at our hospital between June 1, 2022, and October 31, 2024. Patients were categorized into two groups based on the development of postoperative arrhythmias following thoracoscopic surgery: the arrhythmia group and the non-arrhythmia group. A comparative analysis of the clinical data was conducted between these two groups.

RESULTS

A total of 208 patients were enrolled, with an incidence of postoperative arrhythmias of 19.71% (41/208). Logistic regression analysis identified age ≥ 70 years (OR = 2.586, 95% CI: 1.805-3.221), hypertension (OR = 2.761, 95% CI: 2.103-3.588), history of smoking (OR = 2.070, 95% CI: 1.741-2.446), TNM stage II (OR = 3.181, 95% CI: 2.842-3.690), postoperative pulmonary infection (OR = 2.122, 95% CI: 1.836-2.690), and postoperative constipation (OR = 2.495, 95% CI: 1.988-3.072) as independent risk factors for postoperative arrhythmias (all p < 0.05).

CONCLUSION

The incidence of postoperative arrhythmias in elderly patients with lung cancer following thoracoscopic surgery is relatively high. Targeted interventions addressing the identified risk factors are essential to mitigate the risk of postoperative arrhythmias.

Re-do robot-assisted salvage lobectomy after esophagectomy with gastric pull-up reconstruction: a case report

BACKGROUND

Robot-assisted Thoracic Surgery (RATS) is well-established for complex minimally invasive thoracic surgery. Despite the available literature, robotics for complex advanced NSCLC for re-do surgery remains underexplored.

CASE PRESENTATION

We present a 55-year-old female who underwent esophagectomy with gastric pull-up reconstruction for squamous cell carcinoma (SCC) of the esophagus (cT3N2M0, stage IIIB) after neo-adjuvant concurrent chemoradiation therapy (ypT2N1 stage IIB disease). Six years later, computed tomography (CT) scan showed stage IA Thyroid Transcription Factor-1 (TTF-1) positive adenocarcinoma in the left upper lobe treated by stereotactic radiotherapy. Two years later, a SCC of the right upper lobe (RUL) was found (Fig. 1). Although locoregional therapy was preferred Pembrolizumab® was initiated with curative intent as the tumor demonstrated a high Programmed Death-Ligand 1 (PD-L1) expression. Follow-up CT-scan showed no biological response. Salvage lobectomy was proposed, and patient consent obtained. As demonstrated in the video, RATS provided great exposure to the adhesions, vascularization of the neo-oesophagus and maximal dexterity in difficult spaces.

CONCLUSIONS

This case demonstrates the value of RATS in complex re-do thoracic surgery after immunotherapy and previous thoracotomy.

Treatment of lung diseases via nanoparticles and nanorobots: Are these viable alternatives to overcome current treatments?

Challenges

Respiratory diseases remain challenging to treat, with current efforts primarily focused on managing symptoms rather than maintaining overall lung health. Traditional treatment methods, such as oral or parenteral administration of antiviral, antibacterial, and anti-inflammatory drugs, face limitations. These include difficulty in delivering therapeutic agents to pathogens residing deep in the airways and the risk of severe side effects due to high systemic drug concentrations. The growing threat of drug-resistant pathogens further complicates infection management.

Advancements

The lung's large surface area offers an attractive target for inhalation-based drug delivery. Nanoparticles (NP) enable uniform and sustained drug distribution across the alveolar network, overcoming challenges posed by complex lung anatomy. Recent breakthroughs in nanorobots (NR) have demonstrated precise navigation through biological environments, delivering therapies directly to affected lung areas with enhanced accuracy. Nanotechnology has also shown promise in treating lung cancer, with nanoparticles engineered to overcome biological barriers, improve drug solubility, and enable controlled drug release.

Future scope

This review explores the progress of NP and NR in addressing challenges in pulmonary drug delivery. These innovations allow targeted delivery of nucleic acids, drugs, or peptides to the pulmonary epithelium with unprecedented accuracy, offering significant potential for improving therapeutic effectiveness in respiratory disorders.

Implementation of a robotic-assisted thoracic surgery program for anatomical lung resections, a single surgeon's experience

Background

Robotic-assisted thoracic surgery (RATS) for pulmonary resections has been reported to be a safe and feasible method with similar outcomes to those of video-assisted thoracic surgery (VATS). In 2021 our department launched a RATS program. The aims of this study are to evaluate the initial results and learning curve of a series of RATS procedures performed by a single surgeon experienced in uniportal video-assisted thoracic surgery (uVATS) during an initial period of access to the robotic platform limited to two cases per week.

Methods

A retrospective study including consecutive RATS and uVATS lobectomies performed by a single surgeon from November 2021 to September 2023 at Sahlgrenska University Hospital. Endpoints were days with chest tube (CT), length of stay (LOS) and intraoperative learning curve as reflected in the duration of procedures.

Results

A total of 82 RATS and 60 uVATS consecutive lobectomies were included. Preoperative demographics were similar in the RATS and uVATS groups. Preoperative assessment of tumour size from computed tomography scans were larger in the uVATS group than in the RATS group [25 (18.00-39.00) vs. 18 (14.00-28.25) mm, P=0.002], but clinical tumour-node-metastasis (TNM) stage were similar between groups (P=0.23). Days with CT was significantly shorter for RATS than uVATS [1.00 (1.00-1.00) vs. 1.00 (1.00-3.75)]; P=0.01]. LOS in the RATS group was 2 [2.00-3.00] vs. 2 [2.00-5.00] days in the uVATS group (P=0.07). Operation time (OP time) was longer in the RATS group [136.00 (114.50-152.25) vs. 100 (84.25-120.00) minutes in the uVATS group; P<0.001]. After RATS case number 44 no further reduction in OP time was recorded.

Conclusions

RATS is a feasible method for lobectomy and can be efficiently introduced as a standard surgical approach even with limited access to the robotic surgical platform, with a learning curve of approximately 44 cases.

Comparison of midazolam and dexmedetomidine combined with thoracic paravertebral block in hemodynamics, inflammation and stress response, and cognitive function in elderly lung cancer patients

OBJECTIVE

This study aimed to compare the clinical outcomes of midazolam and dexmedetomidine combined with ropivacaine-induced thoracic paravertebral nerve block (TPVB) in radical lung cancer surgery.

METHODS

To retrospectively analyze the clinical data of elderly patients who underwent thoracoscopic radical lung cancer surgery from March 2020 to February 2023 in our hospital. All patients underwent a single two-site method of TPVB at the levels of T4 and T7 under ultrasound guidance. The patients were divided into midazolam group (0.25 % ropivacaine + 0.1 mg/kg midazolam) and dexmedetomidine group (0.25 % ropivacaine + 0.8 μg/kg dexmedetomidine) according to the application of sedative drugs, with 78 cases in each group. Ramsay sedation score, mean arterial pressure (MAP), heart rate (HR), electroencephalographic bispectral index (BIS), and blood oxygen saturation (SpO2), as well as the serum levels of C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), epinephrine (E), cortisol (Cor), and norepinephrine (NE) were recorded at 6, 12, 24, 36 and 48 h postoperatively, respectively. The patients' cognitive function was assessed using the Brief Mental State Evaluation Scale (MMSE) at 1 d preoperatively, 1 d postoperatively, and 7 d postoperatively.

RESULTS

The amount of intraoperative sufentanil in the dexmedetomidine group was lower than that in the midazolam group (P < 0.05). The rate of atropine use was higher in the dexmedetomidine group than that in the midazolam group (P < 0.05). There was no significant difference in the occurrence of overall intraoperative adverse reactions (P > 0.05), but the incidence of respiratory depression in the dexmedetomidine group was significantly lower than that in the midazolam group, and the incidence of bradycardia in the dexmedetomidine group was significantly higher than that in the midazolam group (P < 0.05). At T0 ∼ T4, BIS and MAP showed a decreasing trend in both groups. 12, 24, 36 and 48 h postoperatively, the Ramsay sedation score was higher in the dexmedetomidine group than in the midazolam group (P < 0.05). At 36 and 48 h postoperatively, the serum Cor, E, NE, CRP, TNF-α, and IL-6 levels were lower in the dexmedetomidine group than in the midazolam group (P < 0.05). Compared with the preoperative 1d, the MMSE scores were significantly lower in both groups on one day postoperative, while the MMSE scores were significantly higher at postoperative day 7 than on postoperative day 1 (P < 0.05). At postoperative day 1, the MMSE score was significantly higher in the dexmedetomidine group than in the midazolam group (P < 0.05). The difference in the incidence of adverse events within 72 h postoperatively between the two groups was not statistically significant (3.95 % vs. 1.28 %, χ2 = 0.284, P = 0.594).

CONCLUSION

Dexmedetomidine compounded with ropivacaine-induced ultrasound-guided thoracic paravertebral nerve block is superior to midazolam for sedation, anti-inflammation, and anti-stress in elderly lung cancer patients.

Robotic Versus Sternotomy, Thoracotomy and Video-Thoracoscopy Approaches for Thymoma Resection: A Comparative Analysis of Short-Term Results

OBJECTIVE. The optimal surgical approach for thymoma resection is still an object of debate. The increasing experience in robotic-assisted thoracic surgery (RATS) has led to the progressive affirmation of this technique as a valid alternative to Sternotomy, Thoracotomy and Video-Assisted Thoracic Surgery (VATS) in this setting. The present study aims to compare the post-operative and short-term results of RATS Thymectomy for thymoma with those of other main surgical approaches (sternotomy, thoracotomy and VATS) from a high-volume single center. METHODS. Between May 2021 and September 2023, 40 consecutive patients underwent RATS Thymectomy for stage I to limited-stage III thymoma in our center. Three homogenous groups of patients who received thymoma resection through main alternative approaches (sternotomy, thoracotomy, VATS) over the last 5 years, were identified in order to perform a comparative analysis. Data including surgery duration, associated resections, conversion rate, overall morbidity, tumor size, radicality of resection, post-operative pain, length of hospital stay and cosmetic results were retrospectively collected and compared between the RATS and each control group. RESULTS. Mean tumor size was higher in the sternotomy group, but not significantly. The mean operative time of RATS interventions was significantly lower than that of sternotomy and VATS. It was significantly shorter compared to thoracotomy if excluding docking-undocking time. A higher rate of associated adjacent structures resection was reported in the sternotomy group (p = 0.005). Conversion rate was significantly higher in the VATS group (p = 0.026) compared to RATS. Post-operative pain at 24 and 48 h was significantly lower in the RATS group compared to the others. Improved cosmetics results were reported after RATS compared to sternotomy (p = 0.0001) and thoracotomy (p = 0.001) groups, with a trend towards better results compared to VATS (p = 0.05). Length of hospital stay was shorter in the RATS group with a significant difference vs. the sternotomy group (p < 0.001). CONCLUSIONS. These results from a single center confirm the safety and efficacy of RATS for the treatment of limited stage thymoma. An advantage in terms of operative outcomes, post-operative pain, cosmetic results and hospital stay was observed if compared to the alternative approaches. The short-term oncologic outcome was excellent based on the high complete resection rate of the tumor.

Early Experience of Uniportal Robotic-Assisted Anatomic Resection in Lung Cancer Patients: Is it Safe and Feasible for Direct Transition From Uniportal Video Thoracoscopic-Assisted Surgery to Uniportal Robotic-Assisted Surgery?

BACKGROUND

Lung cancer remains a leading cause of mortality worldwide, with surgery being a primary treatment option for early-stage cases. Minimally invasive surgery has gained attention due to its potential benefits. Uniportal robotic-assisted thoracic surgery (RATS) is emerging as a viable option for treating lung cancer patients.

METHODS

In this retrospective study, conducted from August 2023 to December 2023, we assessed the feasibility of Uniportal robotic-assisted thoracic surgery (URATS) in 15 patients with 16 lung cancers. The perioperative and 30-day short-term outcome results were collected.

RESULTS

Perioperative outcomes, including length of hospital stay and postoperative complications, were evaluated. No perioperative or 30-day mortality was observed, and there were no cases requiring conversion to multiport RATS or thoracotomy.

CONCLUSION

Our findings suggest that URATS can be successfully performed in lung cancer patients, provided the surgical team possesses excellent communication skills and extensive training in Uniport video-assisted thoracoscopic surgery and comprehensive RATS techniques.

Learning curve of consolers and bedside surgeons fused robotic-assisted thoracoscopic segmentectomy: insights from the initial 100 cases

PURPOSE

This study examined the learning curve of segmentectomy using the "fused surgery" approach.

METHODS

We retrospectively collected data from 100 patients who underwent segmentectomy via fused robot-assisted thoracoscopy at our institution between September 2020 and February 2024. The learning curve was evaluated using the cumulative sum of the operative times in all cases and was analyzed separately for simple and complex segmentectomies.

RESULTS

After applying the cumulative sum method to all cases, we obtained a graph of the operative time that showed three well-differentiated phases: phase 1 (n = 23), the initial learning phase; phase 2 (n = 28), the increased competence phase; and phase 3 (n = 49), the highest skill phase. Comparing phases 1 and 2 with phase 3, we found significant differences in operative time (P < 0.001); however, no significant differences were observed in bleeding or rate of postoperative complications. We observed a significant reduction in operative time after 25 simple segmentectomies and 22 complex segmentectomies.

CONCLUSIONS

The data suggested that the inflection point of the learning curve was achieved in 51 cases. Complex segmentectomy requires the same cases to achieve the same level of competence as simple segmentectomy.

Risk factors for conversion from minimally invasive surgery to thoracotomy in patients with lung cancer: outcomes from a pooled analysis

The purpose of this study is to explore the risk factors for conversion from minimally invasive surgery to thoracotomy in patients with lung cancer through meta-analytic approach, and provide a better evidence-based basis for clinicians to perform surgery. We conducted a comprehensive search across databases including PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant English-language studies published up to February 2024. The pooled effect estimate was calculated using the odds ratio (OR) and a 95% confidence interval (CI). We also conducted sensitivity, subgroup, and publication bias tests. Meta-analysis was performed by using stata18MP software. The study was registered with PROSPERO(ID: CRD42024524790). We included a total of 8 studies. We discovered that gender (OR: 1.58; 95% CI: 1.23-2.03; P < 0.001), chronic obstructive pulmonary disease (COPD) (OR: 1.13; 95% CI: 1.04-1.23; P = 0.005), location of the tumor (OR: 1.21; 95% CI: 1.12-1.31; P < 0.001) were all linked to an increased risk of conversion. Additionally, the type of surgery (OR: 0.14; 95% CI: 0.05-0.39; P < 0.001) was associated with a reduced risk of conversion. Nevertheless, age, smoking, and obesity showed no association with the risk of conversion. The current meta-analysis suggests that the male gender, COPD, upper lobe tumor location, and the video-assisted approach are risk factors for conversion from minimally invasive surgery to thoracotomy in patients with lung cancer. More high-quality studies are required to validate the above results due to the limited number and types of studies included.

Surgical management of thymic tumors: a narrative review with focus on robotic-assisted surgery

Background and Objective

Thymic epithelial tumors, including thymomas and thymic carcinomas, represent the most common mediastinal tumors and account for up to 50% of all anterior mediastinal tumors. For early stages of these thymic tumors, complete resection of the entire thymus is the recommended treatment. The transition from open surgery to video-assisted thoracoscopic surgery (VATS) and recently to robotic-assisted thoracic surgery (RATS) has fundamentally altered the treatment of thymic tumors. While RATS has been widely implemented due to its many advantages including good visualization with magnification and three-dimensional vision, improved maneuverability and precise instrument control, different techniques have been described. This narrative review focuses on the main approaches and outcomes of RATS thymectomy. It compares the technical, perioperative and clinical outcomes of RATS thymectomy, in particular, with VATS and open thymectomy.

Methods

A non-systematic review for full text studies written in the English language was conducted using the PubMed search engine and literature was summarized.

Key Content and Findings

We present an overview of robotic-assisted resection for thymomas and review the main approaches and outcomes of RATS thymectomy. Critical points of the RATS approach, including surgical specifics and pitfalls, are presented. Technical advantages and disadvantages of each technique are discussed. The perioperative and clinical outcomes of RATS thymectomy are compared, where possible, to those for VATS and open thymectomy. Currently, retrospective analyses demonstrate comparable or even more favorable outcomes following a RATS approach in comparison to VATS and open approaches in terms of operating time, conversion rates, intraoperative complications, completeness of resection and mortality. Certain analyses also report better outcomes for patients undergoing RATS thymectomy in terms of blood loss, postoperative complications, duration of pleural drainage and length of hospital stay compared to VATS and open thymectomy.

Conclusions

Overall, RATS has shown promising results and could become the preferred technique for resection of thymic tumors. It shows good outcomes compared to VATS and open thymectomy in the current literature. However, especially for extended tumors with the need for extended resection and reconstruction, open thymectomy remains a valuable approach.

Trends and Disparities in Robotic Surgery Utilization for Non-Small Cell Lung Cancer

INTRODUCTION

Robotic surgery has become an increasingly utilized approach for resectable lung cancer. However, availability may be limited for certain patient populations, underscoring inequity in access to innovative surgical techniques. We hypothesize that there is an association between social determinants of health and robotic surgery utilization for resectable non-small cell lung cancer (NSCLC).

METHODS

We queried the National Cancer Database (2010-2019) for patients with clinical stage I-III NSCLC who underwent resection, stratifying the cohort based on surgical technique. Multivariable logistic regression analysis was performed to identify associations between sociodemographic and clinicopathologic factors and the robotic approach.

RESULTS

Among the 226,455 clinical stage I-III NSCLC patients identified, 34,059 (15%) received robotic resections, 78,039 (34.5%) underwent thoracoscopic resections, and 114,357 (50.5%) had open resections. Robotic surgery utilization increased from 3.1% in 2010 to 34% in 2019 (P < 0.001). Despite this, after adjusting by clinical stage, extent of resection, site of tumor, and receipt of neoadjuvant therapy, multivariable analysis revealed various sociodemographic and treatment facility factors that were associated with underutilization of this approach: lack of insurance (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.73-0.93), lower income brackets (aOR 0.93, 95% CI 0.91-0.96), provincial settings (urban aOR 0.79, 95% CI 0.76-0.82; rural aOR 0.57, 95% CI 0.51-0.64), and treatment at community centers (comprehensive community cancer programs aOR 0.73, 95% CI 0.70-0.75; community cancer programs aOR 0.51, 95% CI 0.47-0.55).

CONCLUSIONS

This study suggests that disparities in determinants of health influence accessibility to robotic surgery for resectable NSCLC. Identification of these gaps is crucial to target vulnerable sectors of the population in promoting equality and uniformity in surgical treatment.

Robotic surgery: bibliometric analysis, continental distribution, and co-words analysis from 2001 to 2023

The project aimed to conduct an up-to-date and comprehensive bibliometric analysis of robotic surgery to provide a detailed and holistic understanding of the field. Three strategies were employed in the data analysis i.e. search terms were explored in (A) the title, abstract, and keywords and (B) only in the title of the documents. In 3rd part we analyzed the top 100 most cited papers. Vosviewer and R Studio were utilized for detailed bibliometric and network analyses. Strategy one identified 38,469 publications, and strategy two identified 6451 publications from 2001 to 2023. The top authors, universities, countries, sponsors, and sources based on the number of publications were identified for both strategies. The top 100 most cited papers were analyzed, providing the annual number of publications and various citation metrics. Top authors (by number of publications, total citations, h-index, g-index, and m-index), universities, and countries within these highly cited papers, along with their co-authorship networks and dynamics, were examined. Co-words analysis of the top 100 most cited papers revealed the primary focus of these documents across 25 categories. This comprehensive bibliometric analysis of robotic surgery highlighted significant contributions and collaborations in the field, emphasizing the importance of global and collaborative efforts in advancing robotic surgery research.

Implementation of the Versius robotic surgical system for thoracic surgery: first clinical evaluation of feasibility and performance

OBJECTIVES

The aim of this study is to demonstrate the ability of the Versius surgical system to successfully and safely complete a range of thoracic procedures aligned with Stage 2a (Development) of the Idea, Development, Exploration, Assessment and Long-term follow-up framework for surgical innovation.

METHODS

This prospective study included the first 30 consecutive patients who underwent robotic surgery with Versius by 2 surgeons without prior robotic experience between 1 April 2023 and 30 December 2023 [25 lung resections (wedge, segmentectomy and lobectomy) and 5 thymectomies]. There were no specific predetermined selection criteria for each case. The primary outcome was safe completion of the procedure without unplanned conversion. Secondary outcomes included intraoperative and postoperative complications, intraoperative device-related outcomes and pathology results.

RESULTS

Twenty-eight (93.3%) cases were completed without conversion. Both conversions were to thoracoscopy, one due to a 'console alarm' and the other due to pulmonary artery bleeding. In lung resections, median console time was 103 (90-129) min. Five (20%) patients experienced postoperative complications, most frequent was persistent air leak (16%). Median length-of-stay was 3 (2-4) days. Neither readmissions nor mortality was observed. In thymectomies, no intraoperative or postoperative complications, readmissions, reinterventions or mortality were observed. Median console time was 77 (75-89) min and median length of stay was 1 (1-1) day.

CONCLUSIONS

This phase 2a IDEAL-D study confirms lung resections and thymectomies are feasible with the use of Versius system, laying the foundation for larger phase 2b and 3 clinical studies within the IDEAL-D framework.

Factors affecting the short-term outcomes of robotic-assisted thoracoscopic surgery for lung cancer

PURPOSE

Robotic-assisted thoracoscopic surgery (RATS) is a relatively new approach to lung cancer surgery. To promote the development of RATS procedures, we investigated the factors related to short-term postoperative outcomes.

METHODS

We analyzed the records of patients who underwent RATS lobectomy for primary lung cancer at our institution between June, 2018 and January, 2023. The primary outcome was operative time, and the estimated value of surgery-related factors was calculated by linear regression analysis. The secondary outcome was surgical morbidity and the risk was assessed by logistic regression analysis.

RESULTS

The study cohort comprised 238 patients. Left upper lobectomy had the longest mean operative time, followed by right upper lobectomy. Postoperative complications occurred in 13.0% of the patients. Multivariate analysis revealed that upper lobectomy, the number of staples used for interlobular fissures, and the number of cases experienced by the surgeon were significantly associated with a longer operative time. The only significant risk factor for postoperative complications was heavy smoking.

CONCLUSION

Patients with well-lobulated middle or lower lobe lung cancer who are not heavy smokers are recommended for the introductory period of RATS lobectomy. Improving the procedures for upper lobectomy and dividing incomplete interlobular fissures will promote the further development of RATS.

Commentary: A New Frontier: Exploring Novel Articulating Hand-Held Instruments in Video-Assisted Thoracoscopic Surgery

See Article page 329.

Systematic review of robotic video-assisted thoracoscopic surgery total pneumonectomy for lung cancer

Introduction

This systematic review aims to provide a comprehensive evaluation of the literature on robotic video-assisted thoracoscopic surgery (VATS) pneumonectomy.

Aim

To evaluate its effectiveness and safety in treating various lung diseases.

Methods

A thorough search of electronic databases was conducted, and 25 studies encompassing 1,650 patients were included in the review.

Results

The review found that robotic VATS pneumonectomy surgery is a safe and effective alternative to traditional open surgery for the treatment of various lung diseases, particularly early-stage lung cancer. The surgery is associated with shorter hospitalizations, less blood loss, and less postoperative pain when compared to traditional open surgery.

Conclusions

However, long-term survival outcomes were not significantly different between robotic and open surgery. The review also highlights the need for further studies to determine the optimal use of robotic VATS pneumonectomy surgery in different clinical scenarios and to determine whether the benefits of this technique outweigh the costs. Overall, this systematic review suggests that robotic VATS pneumonectomy surgery is a safe and effective technique that can be used as an alternative to traditional open surgery.

Is RATS Superior to VATS in Thoracic Autonomic Nervous System Surgery?

Technological development in the field of robotics has meant that, in recent years, more and more thoracic surgery departments have adopted this type of approach at the expense of VATS, and today robotic surgery boasts numerous applications in malignant and benign thoracic pathology. Because autonomic nervous system surgery is a high-precision surgery, it is conceivable that the application of RATS could lead to improved outcomes and reduced side effects, but its feasibility has not yet been thoroughly studied. This review identified three main areas of application: (1) standard thoracic sympathectomy, (2) selective procedures, and (3) nerve reconstruction. Regarding standard sympathectomy and its usual areas of application, such as the management of hyperhidrosis and some cardiac and vascular conditions, the use of RATS is almost anecdotal. Instead, its impact can be decisive if we consider selective techniques such as ramicotomy, optimizing selective surgery of the communicating gray branches, which appears to reduce the incidence of compensatory sweating only when performed with the utmost care. Regarding sympathetic nerve reconstruction, there are several studies, although not conclusive, that point to it as a possible solution to reverse surgical nerve interruption. In conclusion, the characteristics of RATS might make it preferable to other techniques and, particularly, VATS, but to date, the data in the literature are too weak to draw any evidence.

Tackling complex thoracic surgical operations with robotic solutions: a narrative review

Background and Objective

The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions.

Methods

Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria.

Key Content and Findings

The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates.

Conclusions

The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.

Console and bedside surgeon fused robot-assisted thoracic surgery

In the last decade, even thoracic surgery has seen an increase in the use of robotic surgical systems, and robot-assisted thoracic surgery (RATS) is considered one of the main issues. While RATS is associated with solo manipulative freedom and high-definition optical systems, several disadvantages, such as the lack of tactile sensation and difficult learning curves for the whole team, have been raised. Therefore, to overcome these issues, we developed a 'fusion surgery' approach combining a robotic procedure with manual maneuvers, where the table surgeon retracts the lung and staples the pulmonary vasculature and bronchus. Herein, we introduce our 'fusion surgery' procedure and elaborate on its advantage from technical and educational perspectives.

Uniportal Robotic Lung Resection Techniques

Uniportal video-assisted thoracic surgical (U-VATS) and telerobotic techniques have become widely adopted strategies for lung resection and represent a natural progression born of advancing technologic innovation and decades of expanding clinical experience. Combining the best that each approach offers may be the next logical step in the evolution of minimally invasive thoracic surgery. Two parallel efforts are underway: one that combines the traditional U-VATS incision with a multi-arm telerobotic platform and one that utilizes a new single-arm device. Feasibility and refinement of surgical technique will need to be achieved before any conclusions about efficacy can be drawn.

Predictors of Long-Term Survival of Thoracoscopic Lobectomy for Stage IA Non-Small Cell Lung Cancer: A Large Retrospective Cohort Study

The standard of care for patients with early-stage non-small cell lung cancer (NSCLC) is anatomical lung resection with lymphadenectomy. This multicenter, retrospective, cohort study aimed to identify predictors of 5-year survival in patients after thoracoscopic lobectomy for stage IA NSCLC. The study included 1249 patients who underwent thoracoscopic lobectomy for stage IA NSCLC between 17 April 2007, and December 28, 2016. The 5-year survival rate equaled 77.7%. In the multivariate analysis, higher age (OR, 1.025, 95% CI: 1.002 to 1.048; p = 0.032), male sex (OR, 1.410, 95% CI: 1.109 to 1.793; p = 0.005), chronic obstructive pulmonary disease (OR, 1.346, 95% CI: 1.005 to 1.803; p = 0.046), prolonged postoperative air leak (OR, 2.060, 95% CI: 1.424 to 2.980; p < 0.001) and higher pathological stage (OR, 1.271, 95% CI: 1.048 to 1.541; p = 0.015) were related to the increased risk of death within 5 years after surgery. Lobe-specific mediastinal lymph node dissection (OR, 0.725, 95% CI: 0.548 to 0.959; p = 0.024) was related to the decreased risk of death within 5 years after surgery. These findings provide valuable insights for clinical practice and may contribute to improving the quality of treatment of early-stage NSCLC.