Clinical Features

Robotic-Assisted Thoracic Surgery

Written by Ms Rebecca Weedle MCh FRCSI (CTh), Mr Ronan Ryan MD FRCSI (CTh), Mr Vincent Young MD FRCSI (CTh) & Mr Gerard J Fitzmaurice MSc FRCSI (CTh) Department of Cardiothoracic Surgery, St James’s Hospital, Dublin

Robotic-assisted thoracic surgery (RATS) represents the pinnacle of modern thoracic surgical practice. Pulmonary resections have seen many advances in both surgical technique and perioperative care since first performed in the 1800’s. Minimally invasive approaches have modified surgical practice, particularly in the past 20 years, and this evolution has demonstrated significant advantages for both patient and surgeon.

Robotic-assisted thoracic surgery involves a surgeon using a console to control a number of robotic arms that enable more advanced minimally invasive surgery (Figure 1). We use three or four small incisions to perform operations using wristed robotic instruments under direct vision with a stereoscopic magnified high-definition camera. It offers advantages in many cases over traditional minimally

invasive approaches such as conventional video-assisted thoracic surgery (VATS) due to improved visualisation with the 3-dimensional camera and less pressure on port sites due to the pivot feature of the robotic ports. It enables the surgeon to operate in a more natural orientation as the instruments move in the same fluid manner as human wrist joints.

For the surgeon, there is more direct hand-eye co-ordination with advanced manoeuvrability of the wristed instruments giving improved ergonomics compared to conventional VATS surgery.

Minimally invasive approaches represent an evolution in surgical care from the traditional open approaches to the chest, such as thoracotomy and sternotomy. At St James’s we offer a comprehensive minimally invasive thoracic surgical program with a minimally invasive approach undertaken in up to 70% of our lung cancer operations.

There remains some discussion regarding the advantages of robotic-assisted thoracic surgery compared with conventional video-assisted thoracic surgery, particularly given the significant financial costs involved. Despite that it is now generally accepted that robotic surgery results in smaller scars, less incidence of arrhythmia’s and respiratory tract infections, lower blood loss, less pain, shorter length of hospitalisation, and faster overall recovery time with a resultant earlier return to normal activity.

The median length of stay for VATS lung resections is 4 days while it is three days for robotic surgery; with traditional open surgery it remains 6 days.

For the surgeon, robotic surgery can be easier to learn than VATS particularly if already an experienced open surgeon or transitioning from the posterior VATS approach. There is a greater degree of precision with 10-times magnification allowing meticulous dissection and motion scaling eliminates tremor, there is minimal lung retraction / handling with the benefit of carbon dioxide (CO2) insufflation, and importantly the ability to undertake a systematic mediastinal lymph node dissection is comparable to an open approach. That said, there are some disadvantages including cost as it is significantly more expensive than VATS and one must accept that like a PC it will have a limited shelf-life and have to be upgraded or replaced about every 5-years.

So why did we consider a RATS program? There are three key tenets – it allows us to undertake more complex procedures via a minimally invasive approach building on our already significant minimally invasive program, there are smaller incisions with less pain for our patients, and we want to be able to offer state of the art treatment to our patient population.

As the largest centre for lung cancer surgery in Ireland, we use the latest da Vinci Xi robotic platform. This consists of a surgeon’s console which connects to a patient cart and a vision cart. The surgeon uses the console to control the view of the target anatomy and the instruments in real time. There is no delay in the transmission of the movements of the surgeons hands to the tips of the instruments. A second training console is also available to enable another surgeon to assist or train with the operating surgeon. The patient cart, which holds the camera and instruments, is docked to the ports and specially designed instruments are placed through the ports for the surgeon to control. The vision cart communicates between the other components and houses the energy technologies and screen for surgical assistants and scrub nurses to follow the operation.

Robotic-assisted thoracic surgery can be used for a wide variety of procedures in the chest, including on the lung, the diaphragm, and the mediastinum. RATS has particular advantages when dealing with mediastinal tumours enabling a higher degree of precision and facilitating a greater scope of patient access to minimally invasive surgical approaches. However the bulk of our thoracic surgical program are lung resections performed for the treatment of lung cancer.

At St James’s Hospital, we perform approximately 55% of all curative-intent lung cancer surgery in Ireland. Anatomical lung resections, predominately lobectomy, are the current gold standard for treating resectable non-small cell lung cancers however there has been recent interest in sub-lobar resections which are particularly amenable to a robotic approach.

Segmentectomy was primarily performed for patients who were not fit for lobectomy but may now be offered in select patients to treat small peripheral lung cancers with proven multi-level negative lymph nodes. There has been much interest in a recent study by the West Japan Oncology Group and Japan Clinical Oncology Group (JCOG0802) published in the Lancet in April 2022 that demonstrated a similar 5-year overall survival between patients with small (<2cm) peripheral tumours with pathologically confirmed negative lymph nodes who underwent segmentectomy or lobectomy. Caution lies in double the local relapse rate amongst the segmentectomy group at 10.5% and a much higher rate of airleak however in select patients it does offer an additional treatment avenue in the era of robotic surgery in patients with borderline respiratory reserve. Altorki and colleagues more recently presented similar results in the CALGB140503 Alliance study and publication of the full results is eagerly awaited. The robotic approach is particularly useful for segmentectomy due to the excellent anatomical visualisation and enhanced articulation of the instruments. It also enables the surgeon to undertake a comprehensive systematic mediastinal lymph node dissection which we know is so important amongst this patient population.

In Ireland lung cancer is the 3rd most common form of cancer but the leading cause of invasive cancer-related death in both men and women. Recently published outcomes from the National Cancer Registry show that lung cancer survival has improved more than 2.5-fold over the last 30 years, from 9% 5-year net survival in 1994-1998 to 24% in 2014-2018 (Figure 2). A significant part of this improvement is due to advanced surgical techniques and focused surgical care with improved technology as well as improved diagnostics and systemic therapies. Lung cancer screening has been shown to reduce lung cancer related mortality and large trials in the UK (UKLS), Europe (NELSON), and the US (NSLT) have all shown screening to be beneficial in targeted high risk populations. There is no public lung cancer CT screening available yet in Ireland, but this is likely to result in an increase in the detection of early stage lung cancers when introduced. Many of these cancers will be amenable to surgical treatment with a minimally invasive approach.

At St James’s Hospital, we launched our robotic thoracic surgical programme earlier this year and we have integrated it into our existing practice. One of our first patients was an 83-yearold gentleman with impaired lung function that placed him in a high risk surgical category. He had a large tumour measuring 55mm in his left lower lobe and he underwent a RATS left lower lobectomy and systematic mediastinal lymph node dissection, achieving complete resection on final histopathology. Once his chest drain was removed, he did not require any opiate analgesia. He mobilised independently and successfully completed his post-operative physiotherapy assessment on day 2. He went home well 3 days following surgery. Our patients have reported minimal pain after robotic-assisted thoracic surgery with many only requiring simple analgesia. We have found that elderly patients, in particular, with poor lung function are gaining a real advantage with this treatment modality.

As the largest centre for lung cancer surgery in Ireland, we aim to continually evolve and recognise that modern thoracic surgical oncology practice involves many individually small but combined significant steps that enhance the overall patient journey and contribute to improved overall survival.

As part of the evolution of our minimally invasive program at St James’s, we have developed a comprehensive enhanced recovery after thoracic surgery (ERATS) program. This involves a number of key components including prehabilitation, nutritional support, smoking cessation, avoidance of fasting and carbohydrate loading, regional anaesthesia, early mobilisation, and minimally invasive surgery. It is a 360-degree patient centred journey with input from a broad multi-disciplinary team with the sole aim to provide optimal patient outcomes in lung cancer care. Our robotic assisted thoracic surgical program is a welcome addition for our patients to assist them in this difficult journey.

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