Uniportal Robotic-Assisted Thoracic Surgery for Lung Resections

Single-port robotic subcostal major pulmonary resection using the single-port robotic system

BACKGROUND

The da Vinci single-port system (SPS) (Intuitive Surgical, Sunnyvale, CA, USA) was designed for single-port (SP) surgery. Although we have reported our clinical outcomes using the SPS for a simple procedure in general thoracic surgery, major pulmonary resection had been performed only in cadaveric experiments to date. This study evaluated the feasibility of SP subcostal robotic major pulmonary resection using the SPS. Here, we present our initial clinical experience of SP subcostal robotic major pulmonary resection at our institution.

METHODS

Twenty-five patients with lung cancer underwent SP major subcostal pulmonary resection using the SPS between March and November 2022. Patient characteristics, intraoperative and perioperative outcomes were assessed. Questionnaires were used to evaluate patient satisfaction with the cosmetic results and quality of life through face-to-face or telephone interviews on postoperative day 30.

RESULTS

All patients underwent major pulmonary resection with complete radical resection (R0). Nineteen patients underwent lobectomy, whereas six patients underwent segmentectomy. The mean docking time and total operative time were 4.16 ± 1.19 min (range, 2.3-7.8 min) and 197.6 ± 55.33 min (range, 130-313 min), respectively. No patients underwent conversion to open thoracotomy. One patient required an additional assistant port due to severe pleural adhesions.

CONCLUSIONS

SP subcostal robotic major pulmonary resection using the SPS is feasible and safe. With the continuous development of robotic technology and surgical techniques, we believe that more complex general thoracic surgeries will be performed in the future using SPS.

Case Report: Uniportal robot-assisted thoracoscopic double-sleeve lobectomy after neoadjuvant immunotherapy

Minimally invasive thoracic surgery, including video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery, has been proven to have an advantage over open thoracotomy with less pain, fewer postoperative complications, faster discharge, and better tolerance among elderly patients. We introduce a uniportal robot-assisted thoracoscopic double-sleeve lobectomy performed on a patient following neoadjuvant immunotherapy. Specialized instruments like customized trocars with a reduced diameter, bulldog clamps, and double-needle sutures were utilized to facilitate the maneuverability through the single incision. This technique integrates the merits of multiport robot-assisted thoracic surgery with uniportal video-assisted thoracoscopic surgery.

What's new in thoracic oncology

Many changes have occurred in the field of thoracic surgery over the last several years. In this review, we will discuss new diagnostic techniques for lung cancer, innovations in surgery, and major updates on latest treatment options including immunotherapy. All these have significantly started to change our approach toward the management of lung cancer and have great potential to improve the lives of our patients afflicted with this disease.

Outside the Cage Subcostal RATS Lobectomy: Technical Aspects and Results of the First Series of a Novel Approach to Pulmonary Lobectomy

OBJECTIVE

The goal of minimally invasive surgery is to reduce trauma to patients and improve their postoperative outcomes. In this context, the utilization of robot-assisted thoracic surgery (RATS) in the treatment of lung cancer has increased worldwide. The feasibility of single-incision major pulmonary resections by RATS was recently reported, with the objective of minimizing the surgical trauma of the traditional multiportal RATS approach. However, both techniques require intercostal incisions, potentially causing immediate and chronic pain resulting from intercostal nerve injury. To reduce postoperative pain resulting from intercostal approaches, we developed a nonintercostal, outside the thoracic cage (OTC) approach for RATS lobectomy, avoiding intercostal instrumentation. This report aims to describe the results of the first reported series of OTC subcostal RATS lobectomies.

METHODS

Retrospective analysis of a series of the first consecutive patients operated on using the novel OTC subcostal RATS lobectomy technique.

RESULTS

Between August and December 2022, a total of 10 consecutive cases were analyzed. The median age was 63 (55 to 84) years, the mean body mass index was 29 (24 to 45) kg/m2, and the median American Society of Anesthesiologists score was III (II to IV). No serious adverse events were observed, and there was no conversion of the surgical technique. The mean operative time was 132.6 (98 to 223) min. The median length of stay was 2 days. No pain-related complications, readmissions, or 30-day mortality were observed.

CONCLUSIONS

This series demonstrates that OTC RATS lobectomy is feasible and safe. A phase I clinical trial is currently underway to prospectively assess the safety of the technique as well as its clinical relevance.

Uniportal robotic assisted surgery for anatomical lung resection-First German experience

BACKGROUND

Uniportal robotic-assisted thoracic surgery (uRATS) has emerged as a promising technique with potential advantages over multiportal approaches. This study aims to evaluate our initial outcomes of uRATS.

MATERIAL AND METHODS

Five patients underwent anatomic lung resections with systematic nodal dissection through a uniportal robotic approach by one surgeon. The results were compared to the results of the first five uniportal video-assisted thoracic surgery (uVATS) anatomical resections performed by the same surgeon.

RESULTS

No adverse events occurred during the uRATS-procedures. Comparable surgical outcomes were observed between uRATS and uVATS, including hospital stays, complication rates, and blood loss. The average procedural time was slightly but non-significantly longer in the uRATS-group. Average pain-scores were lower in the uRATS group. One patient in each group experienced major postoperative complications, with one case of in-hospital mortality in the uRATS-group.

CONCLUSION

The outcomes of uRATS/uVATS were comparable, highlighting the potential and the feasibility of this technique. Prospective studies comparing the learning curves, complication rate and hospital-stay are required in order to justify the superiority of robotics over uVATS.

Minimally Invasive Surgery in Non-Small Cell Lung Cancer: Where Do We Stand?

In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.

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.

A real-world experience of transition to robotic-assisted thoracic surgery (RATS) for lung resections

Objective

We report our experience of transition to robotic-assisted thoracic surgery (RATS) for lung resections with the da Vinci Xi surgical system, exposing short-term results.

Materials and methods

This is a single-center, retrospective analysis of RATS lung resections performed between April 2021 and September 2022 during our new robotic program. The surgical approach evolved over time, starting from a four-arm approach with four incisions. Alternative RATS approaches were subsequently evaluated, such as uniportal and biportal.

Results

During a 17-month period, 29 lung resections were performed. Of them, 16 were lobectomies, 7 were segmentectomies, and 6 were wedge resections. The most common indication for anatomical lung resection was non-small cell lung cancer. A uniportal approach was used for two simple segmentectomies and a biportal RATS was performed in five lobectomies and two segmentectomies. A mean number of 8.1 lymph nodes and a mean of 2.6 N2 and 1.9 N1 stations were resected during surgery, and no nodal upstaging was observed. Negative resection margins were 100%. There were two (7%) conversions, one to open surgery and one to video-assisted thoracic surgery (VATS). Eight (28%) patients experienced complications with no 30-day mortality.

Discussion

High-ergonomic and high-quality views were immediately observed. After some procedures, we abandoned uniportal RATS because of the possibility of arm collisions and the necessity of a VATS-skilled surgeon at the operating table.

Conclusion

RATS for lung resections was safe and effective, and from the surgeon's standpoint, several practical advantages over VATS were observed. Further analysis on outcomes will help better understand the value of this technology.

Port Placement Variations for Robotic Lung Resection: Focusing on Their History, Conventional Look-Up-View and Horizontal Open-Thoracotomy-View Techniques, and More

This is a narrative review that summarizes the variations in approaches and port placements used for performing robotic lung resections on the da Vinci Surgical Platforms. Currently, the four-arm, look-up-view method, in which the intrathoracic cranial side is viewed from the caudal side, is considered the mainstream approach worldwide. Several variations were devised from this conventional technique, including the so-called horizontal open-thoracotomy-view techniques in which the intrathoracic craniocaudal axis is aligned with the horizontal direction of the console monitor, and fewer port and incision techniques. In September 2022, 166 reports were surveyed using a PubMed English literature search, and this review finally included 30 reports describing the approaches. We categorized the variations into four-phase groups considering advent histories: (I) early era, three-arm technique with utility incisions; (II) four-arm, total port technique without robotic staplers; (III) four-arm technique using robotic staplers; (IV) maximizing the functional features of the Xi, significant alterations in viewing directions, and reducing ports, including the ultimate uniport technique. To comprehensibly visualize these variations for practical use, we created elaborate illustrations based on the literature. The familiarity of thoracic surgeons with the variations and characteristics allows them to choose the optimal procedure that best suits each patient and their preferences.

Simulation in thoracic surgery-A mini review of a vital educational tool to maximize peri-operative care and minimize complications

Thoracic surgery is an increasingly expanding field, and the addition of national screening programs has resulted in increasing operative numbers and complexity. Thoracic surgery overall has an approximately 2% mortality and 20% morbidity with common specific complications including persistent air leak, pneumothorax, and fistulas. The nature of the surgery results in complications being unique to thoracic surgery and often very junior members of the surgical team feel underprepared to deal with these complications after very little exposure during their medical school and general surgical rotations. Throughout medicine, simulation is being increasingly used as a method to teach the management of complicated, rare, or significant risk occurrences and has shown significant benefits in learner confidence and outcomes. In this mini review we explain the learning theory and benefits of simulation learning. We also discuss the current state of simulation in thoracic surgery and its potential future in aiding complication management and patient safety.

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

Robotic-Assisted Thoracic Surgery (RATS) is considered one of the main issues of present thoracic surgery. RATS is a minimally invasive surgical technique allowing enhanced view, accurate and complex movements, and high ergonomics for the surgeon. Despite these advantages, its application in lung procedures has been limited, mainly by its costs. Since now many different approaches have been proposed and the experience in RATS for lungs ranges from wedge resection to pneumonectomy and is mainly related to lung cancer. The present narrative review explores main approaches and outcomes of RATS lobectomy for lung cancer. A non-systematic review of literature was conducted using the PubMed search engine. An overview of lung robotic surgery is given, and main approaches of robotic lobectomy for lung cancer are exposed. Initial experiences of biportal and uniportal RATS are also described. So far, retrospective analysis reported satisfactory robotic operative outcomes, and comparison with VATS might suggest a more accurate lymphadenectomy. Some Authors might even suggest better perioperative outcomes too. From an oncological standpoint, no definitive prospective study has yet been published but several retrospective analyses report oncological outcomes comparable to those of VATS and open surgery. Literature suggests that RATS for lung procedures is safe and effective and should be considered as a valid additional surgical option.

Early experience with uniportal robotic thoracic surgery lobectomy

Background

Invasiveness is considered one of the cornerstones of every field of surgery, and video-assisted thoracoscopic (VATS) approaches are now routinely used worldwide to perform pulmonary resections. Recently, robotic-assisted thoracic surgery (RATS) has become the preferred technique in many centers; it is routinely performed using three or four ports with at least one service incision, contrasting with the real concept of invasiveness, especially when compared to uniportal VATS (U-VATS). Hereby, we present our early experience with uniportal RATS (U-RATS) pulmonary resections for early-stage lung cancer. Technical details of surgical steps are accurately described and commented on.

Results

Twenty-four consecutive patients with lung cancer underwent U-RATS anatomical pulmonary resections at our institute. All procedures were completed with the uniportal approach. The mean operative time was 210 min (range 120–350); in the last 10 cases, the operative time was significantly reduced (180 min) compared to the first 10 cases (232 min) (p < 0.02), showing a very fast learning curve. The postoperative pain score was comparable to that for U-VATS and was constantly low.

Conclusions

U-RATS is a safe and feasible technique, combining the advantages of U-VATS with the well-known advantages of robotic surgery.