How to get the best from robotic thoracic surgery

The COMPARE Study: Comparing Perioperative Outcomes of Oncologic Minimally Invasive Laparoscopic, da Vinci Robotic, and Open Procedures: A Systematic Review and Meta-analysis of the Evidence

OBJECTIVE

To assess 30-day outcomes of da Vinci robotic-assisted (dV-RAS) versus laparoscopic or video-assisted thoracoscopic​​​​​ (lap/VATS) or open oncologic surgery.

BACKGROUND

Complex procedures in deep/narrow spaces especially benefit from dV-RAS. Prior procedure-specific comparisons are not generalizable.

METHODS

PubMed, Scopus, and EMBASE were systematically searched (latest: November 17, 2023) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO (Reg#CRD42023466759). Randomized, prospective, and database studies were pooled as odds ratios (ORs) or mean differences (MDs) in R using fixed effects or random effects (heterogeneity significant). ROBINS-I/RoB 2 were used to assess bias.

RESULTS

Of 56,314 unique references over 12 years from 22 countries, 230 studies (34 randomized, 74 prospective, and 122 database) comparing dV-RAS to lap/VATS or open surgery across 7 procedures, 4 specialties, representing 1,194,559 dV-RAS; 1,095,936 lap/VATS and 1,625,320 open cases were included. Operative time for dV-RAS was longer than lap/VATS [MD: 17.73 minutes (9.80, 25.67), P < 0.01] and open surgery [MD: 40.92 minutes (28.83, 53.00), P < 0.01], whereas hospital stay was shorter [lap/VATS MD: -0.51 days (-0.64, -0.38), P < 0.01; open MD: -1.85 days (-2.09, -1.62), P < 0.01] and blood loss was less versus open [MD: -293.44 mL (-359.53, -227.35)]. There were fewer dV-RAS conversions [OR: 0.44 (0.40, 0.49), P < 0.01], transfusions [OR: 0.79 (0.72, 0.88), P < 0.01], postoperative complications [OR: 0.90 (0.84, 0.96), P < 0.01], readmissions [OR: 0.91 (0.83, 0.99), P = 0.04], and deaths [OR: 0.86 (0.81, 0.92), P < 0.01] versus lap/VATS, and fewer transfusions [OR: 0.25 (0.21, 0.30), P < 0.01], postoperative complications [OR: 0.56 (0.52, 0.61), P < 0.01], readmissions [OR: 0.71 (0.63, 0.81), P < 0.01], operations [OR: 0.89 (0.81, 0.97), P < 0.01], and deaths [OR: 0.54 (0.47, 0.63), P < 0.01] versus open surgery. Blood loss [MD:- 12.26 mL (-29.44, 4.91), P = 0.16] and operations [OR: 1.03 (0.95, 1.11), P = 0.48] were similar for dV-RAS and lap/VATS. There was significant heterogeneity.

CONCLUSIONS

Da Vinci-RAS confers benefits across oncological procedures and study designs. These results provide clinical evidence to multispecialty-care decision-makers considering dV-RAS.

Robot-assisted repair of delayed traumatic diaphragmatic hernia: a case report

Traumatic diaphragmatic hernia is a sign of severe thoracoabdominal trauma that is often difficult to detect because of nonspecific presenting symptoms, delayed presentation, and distracting injuries. Diagnosis depends on imaging and a high degree of suspicion in patients who present with respiratory or gastrointestinal symptoms after trauma, and prompt surgical repair is required. This case reviews a patient who presented to the emergency department with burning epigastric pain radiating to the left chest and hematemesis ~1 month after sustaining a blunt abdominal injury. Imaging studies revealed a substantial portion of the gastric body in the left hemithorax. Robot-assisted reduction of the stomach was performed followed by repair with tension-free primary closure without mesh reinforcement and gastropexy. The patient was monitored for return of bowel function and discharged upon recovery. This case report highlights the diagnostic challenges of traumatic diaphragmatic hernia and the benefit of robot-assisted repair.

Application of Artificial Intelligence in the Diagnosis, Treatment, and Prognostic Evaluation of Mediastinal Malignant Tumors

Artificial intelligence (AI), also known as machine intelligence, is widely utilized in the medical field, promoting medical advances. Malignant tumors are the critical focus of medical research and improvement of clinical diagnosis and treatment. Mediastinal malignancy is an important tumor that attracts increasing attention today due to the difficulties in treatment. Combined with artificial intelligence, challenges from drug discovery to survival improvement are constantly being overcome. This article reviews the progress of the use of AI in the diagnosis, treatment, and prognostic prospects of mediastinal malignant tumors based on current literature findings.

Suggested robotic-assisted thoracic surgery training curriculum

Robotic-assisted surgery, a technological advancement in the field of surgery, has become increasingly popular among surgeons of many specialties over time. Robotic-assisted thoracic surgery (RATS) is comparable to video-assisted thoracic surgery (VATS) in terms of patient care outcomes; however, the perception of increased operative time and a lack of cost-effectiveness have led to controversy regarding its alleged benefits. Nevertheless, robotic surgery is one of the preferred options for minimally invasive surgery by some thoracic surgeon over VATS, due to its ability to provide 3-D vision, precise wrist movements, enhanced magnification, and instrument stability and articulation. Notably, trainees in the field of thoracic surgery experience difficulty gaining knowledge and learning skills associated with RATS due to its complexity, limited access to robotic instruments, the lack of a standardized curriculum for trainees, and lack of mentorship or proctorship, thus leading to a steeper learning curve compared to laparoscopic or VATS procedures that are cost-friendly, easy to learn, and feasible to practice. Nevertheless, focusing on RATS training for thoracic surgeons will keep them familiar with robotic techniques, including the pre-operative setup and intra-operative process, which will ultimately decrease operative times. In this paper, we will review the literature, express and discuss the most viable training curriculum from authors' point of view to help achieve this goal.

Mediastinal Parathyroid Cancer

Parathyroid cancer (PC) is rare, but its pre-operative recognition is important to choose appropriate access strategies and achieve oncological clearance. This study characterizes features of mediastinal parathyroid cancer (MPC) and explores criteria aiding in the pre-operative recognition of malignancy. We assembled data from 502 patients with mediastinal parathyroid neoplasms (MPNs) from a systematic review of the literature 1968−2020 (n = 467) and our own patient cohort (n = 35). Thirty-two of the 502 MPNs (6.4%) exhibited malignancy. Only 23% of MPC patients underwent oncological surgery. Local persistence and early recurrence at a median delay of 24 months were frequent (45.8%), and associated with a 21.7-fold (95%CI 1.3−351.4; p = 0.03) higher risk of death due to disease. MPCs (n = 30) were significantly larger than cervical PC (n = 330), at 54 ± 36 mm vs. 35 ± 18 mm (χ2 = 20; p < 0.0001), and larger than mediastinal parathyroid adenomas (MPA; n = 226) at 22 ± 15 mm (χ2 = 33; p < 0.01). MPC occurred more commonly in males (60%; p < 0.01), with higher calcium (p < 0.01) and parathyroid hormone (PTH) levels (p < 0.01) than MPA. Mediastinal lesions larger than 3.0 cm and associated with a corrected calcium ≥ 3.0 mM are associated with a more than 100-fold higher odds ratio of being malignant (OR 109.2; 95%CI 1.1−346; p < 0.05). The composite 3 + 3 criterion recognized 74% of all MPC with an accuracy of 83%. Inversely, no MPN presenting with a calcium < 3.0 mM and size < 3.0 cm was malignant. When faced with pHPT in mediastinal location, consideration of the 3 + 3 rule may trigger an oncological team approach based on simple, available criteria.

Robot-assisted thoracoscopic surgery for large apical schwannoma in an obese patient

BACKGROUND

Neural tumors at the thoracic apex require a careful surgical technique because of the presence of vascular and neural structures and minimally invasive surgery can be challenging for these tumors, especially large tumor in obese patients. We report a case of a large apical schwannoma that treated with RATS in an obese patient.

CASE PRESENTATION

An obese, diabetic, 36-year-old obese man with a body mass index of 34.7 presented with a 5.0-cm mediastinal mass in the left thoracic apex diagnosed via chest computed tomography. The magnetic resonance images suggested a schwannoma. Surgery was scheduled after glycemic control. Robot-assisted thoracoscopic surgery (RATS) was performed with in the right lateral position, and tumor was dissected from the surrounding tissue without severe nerve injury using bipolar forceps. The pathological diagnosis was benign schwannoma. The patient had an uneventful clinical course and was discharged on postoperative day 3.

CONCLUSION

RATS may be a useful approach in the narrow space of the thoracic cavity in obese patients.

Quality assessment of robot assisted thoracic surgical resection of non-small cell lung cancer: nodal upstaging and mediastinal recurrence

Background

Robot assisted thoracic surgery (RATS) is the minimally invasive surgical technique of choice for treatment of patients with non-small cell lung cancer (NSCLC), at the Isala Hospital. The aim of this study is to compare clinical and pathological staging results and mediastinal recurrence after RATS for anatomical resections of lung cancer as surrogate markers for quality of mediastinal lymph node dissection (MLND).

Methods

This single institute retrospective study was conducted in patients who underwent RATS for NSCLC. Excluded were patients with a history of concurrent malignant disease, with other previous neoplasms, with small cell lung cancer (SCLC) and patients in whom the robotic technique was converted to thoracotomy, prior to lymph node dissection. Data were obtained from the hospital database. The difference between clinical and pathological staging was expressed as upstaging and downstaging. Computed Tomography scanning was used for follow-up, and diagnosis of mediastinal recurrence.

Results

From November 2011 to May 2016, 227 patients underwent RATS at Isala Hospital Zwolle, the Netherlands. Of those, 130 (mean age, 69.5±9.3 years) met the eligibility criteria. Preoperative mediastinal lymph node staging was done by endoscopic ultrasound/endobronchial ultrasound, by positron emission tomography (PET) or mediastinoscopy. In 14 patients (10.8%) unforeseen N2 disease was found, 6 patients (4.6%) were upstaged from cN0 to pN2 and 8 patients (6.2%) were upstaged from cN1 to pN2. Mediastinal recurrence was detected in 7 patients (5.4%) during a median follow-up of 54 months (range, 1.5-102 months).

Conclusions

In patients with NSCLC, who underwent anatomical resection by means of RATS, an unforeseen N2 disease rate of 10.8% was demonstrated and a mediastinal recurrence rate of 5.4%. It is concluded that robotic surgery provides an accurate lymph node dissection.

Training in robotic thoracic surgery-the European way

The increasing demand for robot-assisted thoracic surgery (RATS) in Europe requires a structured and standardized training module. Until now, Intuitive Surgical Inc. (Sunnyvale, CA, USA) has delivered the only available robotic surgery platform. Although the training program that is organized by Intuitive is divided in an initial and an advanced course, the success of the training depends on many external factors. Until now the training focused on experienced thoracic surgeons. The aim of this article is to offer a stepwise training module, which can be adopted by experienced open (thoracotomy) surgeons or video-assisted thoracic (VATS) surgeons but is primarily meant for thoracic surgery fellows and residents, as it is our sincere opinion that we should focus on training for this type of surgery as early in their careers as possible. In order to maintain surgical technique and minimize the chance of complications, on-going training and certification of the surgeons and the team is deemed necessary.