Perioperative outcomes of robotic versus video-assisted thoracoscopic surgery in non-small cell lung cancer patients after neoadjuvant chemoimmunotherapy

Background

Limited data are available regarding perioperative outcomes in patients with non-small cell lung cancer (NSCLC) who undergo robotic-assisted thoracic surgery (RATS) after neoadjuvant chemoimmunotherapy. This study aimed to compare the perioperative outcomes of RATS and video-assisted thoracic surgery (VATS) in NSCLC patients after neoadjuvant chemoimmunotherapy.

Methods

The study involved consecutive NSCLC patients treated with minimally invasive surgery (MIS) after neoadjuvant chemoimmunotherapy at a high-volume single center from September 2020 to October 2022. Short-term effects, including demographic, perioperative and pathological parameters, were compared between the RATS group and the VATS group.

Results

A total of 119 patients were included in this study. Of these, 33 (27.7%) patients received RATS and 86 (72.3%) patients received VATS. Major pathological response (MPR) and pathological complete response (pCR) rates were comparable between the two groups. The RATS group had a higher number of dissected lymph nodes (21 vs. 18, P=0.03) and lymph node stations (7 vs. 6, P=0.004) compared with the VATS group but no differences were found in perioperative outcomes.

Conclusions

These findings suggest that both RATS and VATS are safe and feasible options for NSCLC patients who have received neoadjuvant chemoimmunotherapy. Furthermore, RATS may offer advantages over VATS in patients who require a more extensive lymph node dissection.

Developing a Virtual Reality Simulation System for Preoperative Planning of Robotic-Assisted Thoracic Surgery

Background. Robotic-assisted thoracic surgery (RATS) is now standard for lung cancer treatment, offering advantages over traditional methods. However, RATS's minimally invasive approach poses challenges like limited visibility and tactile feedback, affecting surgeons' navigation through com-plex anatomy. To enhance preoperative familiarization with patient-specific anatomy, we devel-oped a virtual reality (VR) surgical navigation system. Using head-mounted displays (HMDs), this system provides a comprehensive, interactive view of the patient's anatomy pre-surgery, aiming to improve preoperative simulation and intraoperative navigation. Methods. We integrated 3D data from preoperative CT scans into Perspectus VR Education software, displayed via HMDs for in-teractive 3D reconstruction of pulmonary structures. This detailed visualization aids in tailored preoperative resection simulations. During RATS, surgeons access these 3D images through Tile-ProTM multi-display for real-time guidance. Results. The VR system enabled precise visualization of pulmonary structures and lesion relations, enhancing surgical safety and accuracy. The HMDs offered true 3D interaction with patient data, facilitating surgical planning. Conclusions. VR sim-ulation with HMDs, akin to a robotic 3D viewer, offers a novel approach to developing robotic surgical skills. Integrated with routine imaging, it improves preoperative planning, safety, and accuracy of anatomical resections. This technology particularly aids in lesion identification in RATS, optimizing surgical outcomes.

Robot-assisted resection of multiple lung nodules through combination of intercostal incisions and a subxiphoid incision as a utility port

INTRODUCTION

Robotic-assisted thoracic surgery (RATS) via subxiphoid incision may be superior in resection of multiple lung nodules.

METHODS

Outcomes of robot-assisted one-stage bilateral lobectomy or segmentectomy via intercostal and subxiphoid incisions for multiple ground-glass opacities were analysed.

RESULTS

Total 36 cases were analysed in this study. Thirteen cases had bilateral lobectomy + segmentectomy, 15 cases underwent bilateral segmentectomies, and 8 cases underwent lobectomy + segmentectomy + wedge resection. The average intraoperative blood loss was 110.2 ± 57.8 mL, operation time was 154 ± 64.2 min, thoracic draining time was 2.6 ± 3.2 days, and postoperative hospital stay was 4.8 ± 3.3 days. Three patients had atrial fibrillation and 3 patients had continuous air leakage for over 3 days, but there was no death or postoperative pain.

CONCLUSION

Robot-assisted one-stage bilateral resection of multiple lung nodules through combination of intercostal and subxiphoid incision as a utility port is safe and reliable.

Comparison of the perioperative outcomes between robotic-assisted thoracic surgery and video-assisted thoracic surgery in non-small cell lung cancer patients with different body mass index ranges

Background

Non-small cell lung cancer (NSCLC) is the most common malignancy and one of the most common causes of cancer-related death worldwide. Robotic-assisted thoracic surgery (RATS) has gradually become a prevalent surgical method for patients with NSCLC. Previous studies have found that body mass index (BMI) is associated with postoperative outcomes. This study aimed to investigate the effectiveness of RATS compared to video-assisted thoracic surgery (VATS) in the treatment of NSCLC with different BMI, in terms of perioperative outcomes.

Methods

The baseline and perioperative data, including BMI, of 849 NSCLC patients who underwent minimally invasive anatomic lung resections from August 2020 to April 2021 were retrospectively collected and analyzed. Propensity score matching analysis was applied to minimize potential bias between the two groups (VATS and RATS), and the perioperative outcomes were compared. Subgroup analysis was subsequently performed.

Results

Compared to VATS, RATS had more lymph nodes dissected {9 [inter-quartile range (IQR), 6–12] vs. 7 (IQR, 6–10), P<0.001}, a lower estimated bleeding volume [40 (IQR, 30–50) vs. 50 (IQR, 40–60) mL, P<0.001], and other better postoperative outcomes, but a higher cost of hospitalization [¥83,626 (IQR, 77,211–92,686) vs. ¥75,804 (IQR, 66,184–83,693), P<0.001]. Multivariable logistic regression analysis indicated that RATS (P=0.027) and increasing BMI (P=0.030) were associated with a statistically significant reduction in the risk of postoperative complications. Subgroup analysis indicated that the advantages of RATS may be more obvious in patients with a BMI of 24–28 kg/m², in which the RATS group had more lymph nodes dissected [9 (IQR, 6–12) vs. 7 (IQR, 5–10), P<0.001] and a decreased risk of total postoperative complications [odds ratio (OR), 0.443; 95% confidence interval (CI), 0.212–0.924; P=0.030] compared to the VATS group.

Conclusions

Both, RATS and VATS can be safely applied for patients with NSCLC. Perioperative outcome parameters indicate advantages for RATS, however at a higher cost of hospitalization. The advantages of RATS might be more obvious in patients with a BMI of 24–28 kg/m².

The impact of marginal lung function on outcomes in the era of minimally invasive thoracic surgery

Background

The effect of marginal lung function on outcomes after lung resection has traditionally been studied in the context of open thoracic surgery. Its impact on postoperative outcomes in the era of minimally invasive lung resection is unclear.

Methods

In this retrospective cohort study, we included adult patients who underwent minimally invasive lung resection at our institution between January 2017 and May 2020 for known malignancy or lung nodule. Marginal lung function was defined as pre-operative forced expiratory volume in 1 second (FEV1) and/or diffusion lung capacity of carbon monoxide <60% of predicted. Our outcomes included a composite outcome of pulmonary morbidity and/or 30- and 90-day mortality, and hospital length of stay. We used multivariable logistic and Poisson regression models to identify associations with outcomes, and Kaplan-Meier and Cox models to estimate survival.

Results

Of 300 patients, 88 (29%) had marginal lung function. Patients in the marginal group were more likely to be female (69% vs. 56%; P=0.028), and more likely to have: hypertension (HTN) (83% vs. 71%; P=0.028), chronic obstructive pulmonary disease (COPD) (38% vs. 12%; P<0.001), interstitial lung disease (ILD) (9% vs. 3%; P<0.019), and ischemic heart disease (28% vs. 18%; P=0.033). Patients were similar in terms of age (68±8 vs. 68±10 years; P=0.932), and other comorbidities. Anatomic lung resection comprised 56.8% of the marginal group vs. 74% in the non-marginal group (P=0.003). The most common complication was prolonged air leak (18.2% vs. 11.8%; P=0.479). Marginal lung function had a trend toward increased composite respiratory complications (22.7% vs. 15.1%; P=0.112) and 90-day mortality (5.7% vs. 4.2%; P=0.591), although they did not reach statistical significance. There was a statistically significant 1-day average increase in length of stay in the marginal lung function cohort (4.6 vs. 3.4 days; P<0.015) with a stronger association with diffusion lung capacity of carbon monoxide than FEV1. Survival was similar (marginal function HR =1.0; P=0.994).

Conclusions

In the era of minimally invasive thoracic surgery, lung resection in patients with marginal lung function may be considered in select patients. These findings aid in the selection consideration and counseling of this patient population.

Video-assisted thoracoscopy for lung cancer: who is the future of thoracic surgery?

As the computer processing technique and display technology evolved dramatically, the surgical approach to early-stage non-small cell lung cancer (NSCLC) has made a rapid progress within the past few years. Currently, the gold standard for NSCLC is lobectomy. After the introduction of video-assisted thoracoscopic surgery (VATS), lung resection can now be conducted mini-invasively, enabling better prognosis for patients and better operation condition for surgeons. At the very beginning, the conventional two-dimensional (2D) system enabled operators to have a closer, magnified and illuminated view inside the body cavity than open thoracotomy. With the introduction of the glasses-assisted three-dimensional (3D) and glasses-free 3D display system, multiple viewing angles were further enhanced, thus a more stable, easier to master and less invasive video-assisted thoracoscopic surgery (VATS) appeared. However, given that the standard VATS is associated with limited maneuverability and stereoscopy, it restricts the availability in more advanced cases. Hopefully, most of the limitations of standard VATS can be overcome with the robotic-assisted thoracic surgery (RATS). The RATS system consists of a remote console and a robotic unit with 3 or 4 arms that can duplicate surgeons’ movements. Also, it provides a magnified, 3D and high definition (HD) operation field to surgeons, allowing them to perform more complicated procedures. Apart from these, some new technologies are also invented in combination with the existing surgery system to solve difficult problems. It is hoped that the higher costs of innovative surgical technique can be offset by the better patient outcomes and improved benefits in cost-effectiveness.

Current status and evolution of robotic-assisted thoracic surgery in Germany-results from a nationwide survey

Background

Robot-assisted surgery has made a significant entry into surgical practice within Germany, including thoracic surgery. As no published data exists regarding robotic-assisted thoracic surgery (RATS), we conducted a survey to investigate its current status.

Methods

We performed a nationwide survey of all centers active in RATS, using a standardized questionnaire. The annual number of operations, mean duration of surgery, docking time, length of hospital stay(s), conversions, chest tube duration, the RATS program start date, robot system used, operating room capacity, and staplers and instruments used were recorded.

Results

Of the 22 centers contacted, 14 responded. In total, 786 RATS interventions were recorded. Most were anatomical lung resections, comprising 372 (bi-) lobectomies and 80 segmentectomies. During the study period, eight bronchoplastic procedures were performed robotically. There were 93 wedge lung resections, 148 thymectomies, 26 sympathectomies, and 59 other RATS procedures, and a single-center series of around 1,000 RATS thymectomies (excluded from statistical analysis). The average incision-suture time of the RATS lobectomy was 245 (range, 80-419) minutes, average residence time seven days. The conversion rate was 6.7% across all interventions, with significant inter-intervention differences. All surveyed centers plan to further expand RATS, with OR capacity being a frequent impediment. Five RATS interventions were performed in Germany in 2013, versus 320 in 2018.

Conclusions

Overall, RATS is becoming more established in everyday clinical practice in Germany. The number of operations, active centers, and trained RATS surgeons has increased steadily since 2013. A German-speaking operation course for entry into RATS already exists. Even extended resections can be carried out safely, and RATS has become standard procedure in some centers.

Nodal upstaging: effects of instrumentation and three-dimensional view in clinical stage I lung cancer

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) is defined as the presence of unsuspected pathologic hilar (pN1) or mediastinal (pN2) disease detected during the final histopathologic evaluation of surgical specimens. The prevalence of pathologic nodal upstaging is used as a quality measure for the definition of the completeness of the nodal dissection. Risk factors for nodal upstaging may be patient-related (history of tuberculosis, rheumatoid arthritis, and diabetes mellitus), or tumor-related (central tumor, higher T stage, higher SUVmax value, or adenocarcinoma). Actually, the theorical superiority of a minimally invasive resections is the lymph node dissection. Studies may suggest that, expert video-assisted thoracoscopic surgery (VATS) surgeon could do similar lymph node dissection as it is done in open. Robotic surgeons may replicate the results of lymph node dissection in the open techniques. The possible reason for this is the instrumental superiority provided by the higher technology.

Robotic-assisted double-sleeve lobectomy

Double-sleeve lobectomy, which includes bronchoplasty and pulmonary arterial angioplasty, is required for certain cases of central-type lung cancer. It is usually done by open surgery or video-assisted thoracoscopic surgery (VATS). In recently, da Vinci system and robotic surgery have been applied in such complicated cases. Here we describe the details associated with robotic-assisted double-sleeve lobectomy.

Robotic-assisted sleeve lobectomy for right upper lobe combining with middle lobe resection of lung cancer

Sleeve lobectomy for lung cancer using the robotic surgical system has been reported, which has widely expanded the indication of this technique. We now describe a sleeve bilobectomy of the right upper and middle lobes for squamous cell carcinoma, meanwhile the branch of vagus nerve sparing using the Da Vinci SI surgical system. In conclusion, complicated sleeve lobectomy with nerve sparing is feasible in robotic thoracic surgery.