Robotic-assisted thoracoscopic sleeve lobectomy for locally advanced lung cancer

Comparison of robot-assisted and video-assisted thoracic sleeve lobectomy in non-small cell lung cancer: insights from a high-volume center

Background

Although minimally invasive sleeve lobectomy (SL) preserves lung function, it is a complex and demanding thoracic surgical technique. This study aimed to evaluate perioperative and long-term outcomes of robot-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) in patients with non-small cell lung cancer (NSCLC) undergoing SL, and explore the safety and feasibility of robot-assisted SL in patients following neoadjuvant therapy.

Methods

A retrospective analysis was performed on a cohort of patients diagnosed with NSCLC who underwent minimally invasive SL at a high-volume center between December 2019 and February 2023. Demographic characteristics, perioperative outcomes, and survival rates were compared between the RATS and VATS groups.

Results

The study enrolled 347 patients with NSCLC, 78 (22.5%) patients received RATS and 269 (77.5%) patients received VATS. In the overall cohort, the RATS group was associated with a greater number of dissected lymph nodes (18.0 vs. 16.0; P=0.048) and a lower conversion rate (6.4% vs. 18.2%; P=0.01) than the VATS group. The overall median follow-up for the entire cohort was 34 [interquartile range (IQR), 26-42] months, with 30 (IQR, 26-38) months in the RATS group and 35 (IQR, 25-44) months in the VATS group. The Kaplan-Meier survival curves showed no significant difference in overall survival and progression-free survival (P=0.68 and P=0.98, respectively) between the groups.

Conclusions

Robot-assisted SL shows comparable results to VATS group for perioperative and long-term tumor prognosis. For patients who have received neoadjuvant therapy, robot-assisted SL is a safe and feasible option.

Adoption of the Robotic Platform across Thoracic Surgeries

With the paradigm shift in minimally invasive surgery from the video-assisted thoracoscopic platform to the robotic platform, thoracic surgeons are applying the new technology through various commonly practiced thoracic surgeries, striving to improve patient outcomes and reduce morbidity and mortality. This review will discuss the updates in lung resections, lung transplantation, mediastinal surgeries with a focus on thymic resection, rib resection, tracheal resection, tracheobronchoplasty, diaphragm plication, esophagectomy, and paraesophageal hernia repair. The transition from open surgery to video-assisted thoracoscopic surgery (VATS) to now robotic video-assisted thoracic surgery (RVATS) allows complex surgeries to be completed through smaller and smaller incisions with better visualization through high-definition images and finer mobilization, accomplishing what might be unresectable before, permitting shorter hospital stay, minimizing healing time, and encompassing broader surgical candidacy. Moreover, better patient outcomes are not only achieved through what the lead surgeon could carry out during surgeries but also through the training of the next generation via accessible live video feedback and recordings. Though larger volume randomized controlled studies are pending to compare the outcomes of VATS to RVATS surgeries, published studies show non-inferiority data from RVATS performances. With progressive enhancement, such as overcoming the lack of haptic feedback, and future incorporation of artificial intelligence (AI), the robotic platform will likely be a cost-effective route once surgeons overcome the initial learning curve.

Automated 3D Segmentation of the Aorta and Pulmonary Artery on Non-Contrast-Enhanced Chest Computed Tomography Images in Lung Cancer Patients

Pulmonary hypertension should be preoperatively evaluated for optimal surgical planning to reduce surgical risk in lung cancer patients. Preoperative measurement of vascular diameter in computed tomography (CT) images is a noninvasive prediction method for pulmonary hypertension. However, the current estimation method, 2D manual arterial diameter measurement, may yield inaccurate results owing to low tissue contrast in non-contrast-enhanced CT (NECT). Furthermore, it provides an incomplete evaluation by measuring only the diameter of the arteries rather than the volume. To provide a more complete and accurate estimation, this study proposed a novel two-stage deep learning (DL) model for 3D aortic and pulmonary artery segmentation in NECT. In the first stage, a DL model was constructed to enhance the contrast of NECT; in the second stage, two DL models then applied the enhanced images for aorta and pulmonary artery segmentation. Overall, 179 patients were divided into contrast enhancement model (n = 59), segmentation model (n = 120), and testing (n = 20) groups. The performance of the proposed model was evaluated using Dice similarity coefficient (DSC). The proposed model could achieve 0.97 ± 0.007 and 0.93 ± 0.002 DSC for aortic and pulmonary artery segmentation, respectively. The proposed model may provide 3D diameter information of the arteries before surgery, facilitating the estimation of pulmonary hypertension and supporting preoperative surgical method selection based on the predicted surgical risks.

Early Outcomes of Robotic Versus Video-Assisted Thoracoscopic Anatomical Resection for Lung Cancer

Background

We compared the safety and effectiveness of robotic anatomical resection and video-assisted thoracoscopic surgery (VATS).

Methods

A retrospective analysis was conducted of the records of 4,283 patients, in whom an attempt was made to perform minimally invasive anatomical resection for lung cancer at Seoul National University Hospital from January 2011 to July 2020. Of these patients, 138 underwent robotic surgery and 4,145 underwent VATS. Perioperative outcomes were compared after propensity score matching including age, sex, height, weight, pulmonary function, smoking status, performance status, comorbidities, type of resection, combined bronchoplasty/angioplasty, tumor size, clinical T/N category, histology, and neoadjuvant treatment.

Results

In total, 137 well-balanced pairs were obtained. There were no cases of 30-day mortality in the entire cohort. Conversion to thoracotomy was required more frequently in the VATS group (VATS 6.6% vs. robotic 0.7%, p=0.008). The complete resection rate (VATS 97.8% vs. robotic 98.5%, p=1.000) and postoperative complication rate (VATS 17.5% vs. robotic 19.0%, p=0.874) were not significantly different between the 2 groups. The robotic group showed a slightly shorter hospital stay (VATS 5.8±3.9 days vs. robotic 5.0±3.6 days, p=0.052). N2 nodal upstaging (cN0/pN2) was more common in the robotic group than the VATS group, but without statistical significance (VATS 4% vs. robotic 12%, p=0.077).

Conclusion

Robotic anatomical resection in lung cancer showed comparable early outcomes when compared to VATS. In particular, robotic resection presented a lower conversion-to-thoracotomy rate. Furthermore, a robotic approach might improve lymph node harvesting in the N2 station.

Comparison of Sleeve Lobectomy for Lung Cancer Using Mini-Thoracotomy and an Optimized Robot-Assisted Technique

Objective: To evaluate the clinical significance of an optimized approach to improve surgical field visualization and simplify anastomosis techniques using robotic-assisted sleeve lobectomy for lung or bronchial carcinoma. Method: A total of 26 consecutive patients who underwent sleeve lobectomy between January 2017 and April 2020 were enrolled in the study. The cohort included 11 cases of robotic-assisted surgery (RAS group) and 15 cases of mini-thoracotomy (MT group). RAS was performed via an exclusive optimized approach utilizing the "3 to 4-6 to 8/9" four-port technique. Retrieved demographical and clinical data included operation time, anastomosis time, blood loss, chest drainage time and volume, postoperative pain scores, complications, white blood cell (WBC) levels, and duration of hospital stay and follow-up. Results: No cases of perioperative death were recorded. Compared to MT group, the RAS group had a similar anastomosis time (30.82  ±  6.08 vs 33.20  ±  7.73 min, respectively, p > 0.05) and shorter operation time (189.73  ±  36.41 vs 225.33  ±  38.19 min, respectively, p < 0.05). The RAS group had lower pain scores (4.23  ±  0.26 vs 4.91  ±  0.51, p < 0.05), lower levels of WBC (p < 0.05), and no anastomotic complications postoperatively. The RAS and MT groups demonstrated a successful bronchus reconstruction with low risk of angulation (1/11 vs 1/15, p > 0.05) and satisfactory disease-free survival (eight cases, 72.73% and 12 cases, 80%, respectively). Conclusion: The optimized approach to RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes. Further study with a large sample size and evaluation of long-term survival are warranted. Key points: (i) we present a novel, convenient, and efficient approach for robotic-assisted sleeve lobectomy, ie, "3 to 4-6 to 8/9" four-port technique. The optimized approach for RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes; (ii) details for the "3 to 4-6 to 8/9" four-port method: the assistant port was located at the fourth intercostal space. The 1-cm camera port was inserted at the sixth intercostal space in the posterior axillary line. The 0.5-cm da Vinci ports of the instrument arms were placed at the third intercostal space in the anterior axillary line and the eighth or ninth intercostal space in the posterior axillary line. The patient cart was inserted from the back of the patient's head and shoulders at 75° to the longitudinal line.

Simulation training for lobectomy: a review of current literature and future directions†

With growing work-time restrictions and public expectations, the Halstedian educational model of 'see one, do one, teach one' is unfit for the modern training of thoracic residents. With the cardiothoracic surgical workforce set to decline by 50% over the next 10 years, new models are desperately needed to help trainees bypass the early error-prone phase of the lobectomy learning curve. In this review, we detail the development and validation of numerous simulators designed to teach trainees an array of skills ranging from basic technical skills to more complex non-technical skills. Given the recent increases in minimally invasive lobectomies, we critique both open and thoracoscopic simulators. We elucidate that whilst there are a growing number of thoracic simulators of varying fidelity available, fundamentally, there is currently a significant lack of well-designed trials validating various simulators for teaching lobectomy despite an awareness of their potential to improve surgical education. Furthermore, there is a void in the simulation training of non-technical skills within thoracic surgery. Encouragingly, there is a definite awareness of the ability of simulation to aid with the training of future thoracic surgical trainees.

An antiquated contraindication for minimally invasive lung surgery: No place to staple the bronchus

Background

This study aims to evaluate the feasibility and outcomes of lobectomy operations without using a stapler for bronchial closure.

Methods

Between December 2014 and August 2018, a total of 108 patients (72 males, 36 females; mean age 62.1±9.8 years; range, 19 to 83 years) with primary lung cancer who underwent lobar resection with robot-assisted thoracoscopic surgery were included in this study. Primary bronchial closure (n=7) and sleeve anastomosis (n=9) were performed in some cases. These 16 patients were compared with other lobectomy cases (n=92) who had bronchial stapling for bronchial closure.

Results

There was no statistically significant difference in the mean duration of operation, amount of intraoperative bleeding, length of postoperative stay in the hospital, and morbidity and readmission rates between the two groups (p=0.3, p=0.5, p=0.06, p=0.4, and p=0.63, respectively). No bronchial fistula developed in any of the patients.

Conclusion

Primary bronchial closure and sleeve anastomosis can be safely performed with robot-assisted thoracoscopic surgery without conversion to thoracotomy, or a larger assistance incision with a similar success rate of the stapled bronchus.

Successful Sleeve Resection as a Marker for Proficiency for Robotic Pulmonary Resection

BACKGROUND

 Robot technology is a revolutionary technique to overcome limitations of minimal invasive surgery. The proficiency level varies from study to study. We considered the first sleeve lobectomy as a benchmark procedure to evaluate the proficiency level.

METHODS

 We retrospectively analyzed 197 patients who underwent robot-assisted thoracoscopic surgery (RATS) for primary lung cancer between December 2011 and May 2018. Patients were divided into two groups based on undergoing surgery earlier period (EP) or later period (LP) than the first sleeve lobectomy by RATS (May 25, 2015). The preoperative, operative, and short- and long-term postoperative outcomes were compared. Seven-year survival was also compared between two periods for T1N0 and T2N0 diseases.

RESULTS

 Preoperative features were similar. The mean operative time was 166.8 ± 55.1 and 142.4 ± 43.9 minutes in EP and LP, respectively (p = 0.005). The mean number of dissected lymph nodes in LP was also significantly higher than that in EP (24.4 ± 9.4 vs. 20.8 ± 10.4, p = 0.035). The complication rate was significantly lower in LP (29/86 vs. 25/111, p = 0.048). The extended resection (ER) rate was significantly higher in LP (p = 0.023). The 7-year survival was comparable in EP and LP in both patients with T1N0 and T2N0 (p = 0.28 and p = 0.11, respectively).

CONCLUSION

 Perioperative outcomes, such as duration of surgery, number of dissected lymph nodes, complications, and ERs are favorable in patients who underwent surgeries after the first sleeve resection. The first sleeve lobectomy may be considered as the benchmark procedure for the proficiency level in RATS.

The evolution of robotic thoracic surgery

Robotic surgery has the features to represent the future of surgery, considering the rapid evolution of its technology and the resulting in the surgical field. In the last years, the robotic technique in thoracic surgery has progressively become widespread in the word, particularly for the treatment of the mediastinal and pulmonary lesions. The development of technology in the robotic system has been associated with the improvement of intraoperative and postoperative results. Due to the satisfying results and increasing experience and confidence with the robotic technique, surgeons are consequently enlarging the surgical indication, moving to increasingly challenging cases. Thoracic robotic surgery is being affirmed as a safe technique also for those complex cases, which in the past were considered a matter solely for open surgery. In fact, robotic surgery is increasingly associated with positive surgical results and guarantees less traumatism and a fast recovery to the patients. These positive results have resulted from the evolution of the technique, which has developed in parallel with the evolution of the technology, exploiting to its best the latest features of the robotic system. These features, such as the fluorescence-detection tool or the robotic stapler, have been aiding the surgeon to maximise the safety and feasibility of the application of the robotic technique to thoracic surgery.

Robotic sleeve resection for pulmonary disease

Background

Few studies have described robotic sleeve resection with pulmonary resection. Here, we report the successful implementation of a completely portal robotic sleeve resection with or without pulmonary resection using a modified suture mode.

Methods

In total, 339 patients underwent curative robotic pulmonary surgery at Ruijin Hospital between May 2015 and September 2017. Three of these patients underwent robotic sleeve resection (right upper lobe, one; left upper lobe, one; and lingular segmental bronchus, one). Five port incisions were utilized, and a simple continuous running suture combined with two interrupted sutures of the membranous and cartilaginous junction portion was preferred for the anastomosis.

Results

The postoperative course was uneventful for two patients with squamous cell carcinoma. The lingular segmental bronchus patient without pulmonary resection (a salivary gland tumor) underwent short-term atelectasis. The median operation time was 155 (range 132–230) minutes. The median anastomosis time was 25 (range 23–32) minutes. The median length of postoperative hospital stay was 7 (range 6–10) days. There was no mortality or conversion to thoracotomy for any of the patients. All patients were followed for 3–6 months, and there is no tumour recurrence.

Conclusions

Our limited experience suggested that robotic sleeve resection for pulmonary disease with or without pulmonary resection may be safe and effective. The anastomosis time can be shortened with more robotic surgery experiences and the modified suture mode.

Robotic sleeve lobectomy with four arms for lung cancer centrally located in the right lower lobe: a case report

Sleeve lobectomy can preserve healthy lung parenchyma in centrally located lung cancer surgery. Video-assisted thoracoscopic surgery (VATS) lobectomy has been shown to have better results for postoperative complications than thoracotomy lobectomy. However, its limitations in visualization of operative field and handling of instruments restrain surgeons performing sleeve lobectomy. Robotic surgery has several advantages, including magnified 3-dimensional vision and angulation of the robot arm that can provide better circumstances for sleeve lobectomy than VATS. However, robotic sleeve lobectomy has been rarely reported. Here, we describe our experience of performing robotic sleeve lobectomy using four arms for lung cancer centrally located in the right lower lobe.

Initial Results of Robotic Surgery for Primary Lung Cancer: Feasibility, Safety and Learning Curve

BACKGROUND

At the end of 2016, robot-assisted thoracoscopic surgery (RATS) was still not covered by Japanese national health insurance. Therefore, few institutions in Japan perform RATS and even fewer have reported procedures as they occurred earlier. So, we decided to focus on the initial results of RATS for primary lung cancer.

METHODS

We retrospectively reviewed 44 patients who underwent RATS for primary lung cancer from January 2011 to August 2016. After mastering the initial procedure, we introduced a completely portal robotic pulmonary resection procedure using a carbon dioxide insufflation system. Cases were divided into 2 groups: the early period (20 cases) and the later period (24 cases).

RESULTS

There was no case of conversion to video-assisted thoracoscopic surgery or thoracotomy. In the 44 cases of primary lung cancer, median operating time was 239.5 min, console time was 179 min, blood loss was 10 mL, drainage period was 2 days, morbidity of Grade 2 or more (Clavien-Dindo classification) was 18.2%, morbidity of Grade 3 or more was only 4.6%, and there was no 30-day mortality. Median operating and console times were significantly shorter in the later period (215 min and 159.5 min, respectively) than in the initial period (300.5 min and 228 min, respectively). Median blood loss was significantly lower in the later period (5 mL) than in the initial period (50 mL). Five-year overall and disease-free survival rates were 100% and 88.9%, respectively.

CONCLUSION

RATS for primary lung cancer is feasible and safe, has a faster learning curve, and provides satisfactory. Studies with longer follow-ups and larger numbers of cases are necessary.