Clinical FeaturesRespiratory

Robotic-Assisted Thoracic Surgery (RATS)– Early Results of an Expanding Program

Robotic-Assisted Thoracic Surgery (RATS) is the pinnacle of modern thoracic surgical practice and was introduced at St James’s Hospital in July 2022. RATS enables a surgeon to perform complex surgery on the chest using a console to control a number of robotic arms, offering advantages over traditional minimally invasive surgical techniques. 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.

Following a year of robotic thoracic surgical procedures, we have reviewed the early outcomes of our expanding program combined with our enhanced recovery protocol. Patient outcomes including length of stay, chest drain duration, postoperative complications, as well as our robotic training program were examined.

Literature reports a post-operative length of stay averaging 4 days for patients undergoing RATS procedures. Early results from the RVAL (Robotic-assisted versus video-assisted lobectomy for lung cancer) trial, as well as prospective studies, have shown reduced mortality, hospital stay and complication rates (28-45%). Patients also experience shorter chest drain duration and reduced post-operative pain.

Over the course of the first year, we have performed 32 robotic-assisted thoracic surgical operations in a stepwise incremental approach. This enabled the safe introduction of a new surgical technique within the department with a focus on case selection and staff engagement.

The operations performed included diagnostic lymph node dissection, thymectomies, sublobar resections, pleural-based chest wall tumour resections, and anatomical lobectomies.

The median age of our patient cohort was 65 years with equal distribution of gender. Our results demonstrated a median chest drain duration of 1 day with a median post-operative length of stay of 2 days. Pain was well controlled with intercostal nerve blocks, patient control analgesia, and oral analgesia that included paracetamol and Ibuprofen with the occasional addition of opioids in select patients on discharge.

RATS surgery has a number advantages when compared to traditional open or minimally invasive thoracic surgical techniques. First, there is improved visualisation due to a 3-dimensional camera that provides an enhanced view with highly magnified images. There is a 6-Hz motion filter and motion scaling system, which absorbs and filters physiological tremor, as well as offering dominant and non-dominant hand equivalence. The surgical movement is filtered by the robot, ensuring greater accuracy and precision. This ensures enhanced surgical dissection and suturing, with the resultant reduced surgical complications including blood loss. This facilitates improved systematic lymphadenectomies assisting with more accurate staging for lung cancer patients. As is evident in our patient cohort, RATS results in a shorter length of hospitalisation, facilitating a faster overall recovery time with the ability to return to normal activity.

RATS does not, however, come without challenges. Those specific to robotic surgery include high capital expenditure costs and initial longer operating times with a steep learning curve for the entire surgical team. Video-assisted thoracic surgery (VATS) and RATS share similar complications, although with reduced rates for RATS including lower rates of blood loss, infection and prolonged air leak. The complication rate in the first year of our robotic program were very low, with the main complication of prolonged air leak (18%), consistent with other centres. There were no mortalities in our patient cohort.

Training for robotic surgery can be a paradigm shift for surgeons, who are a group used to learning new techniques and approaches, given that the surgeon sits at a console un-scrubbed beside the patient controlling a number of robotic arms. The main robotic platform in use worldwide is the da Vinci® robotic platform produced by Intuitive Surgical Inc. At St James’s Hospital we have a dual console system comprising the latest da Vinci® Xi operating system. Training followed a pre-defined pathway involving initial online training, followed by simulator training on the da Vinci® Xi console at St James’s Hospital over a period covering approximately 30 hours. Surgical case observations were then undertaken overseas in Paris and London with international experts. The second stage of the training pathway involved local on-site training, with the Intuitive Surgical representative, involving both surgeon and theatre staff. Mr Fitzmaurice was the first Irishtrained surgeon to undergo 2-days of live simulation training as part of this pathway at The Royal College of Surgeons in Ireland, with this stage previously having to be undertaken overseas. Initial cases were then undertaken with a visiting European Thoracic Surgical proctor building from straightforward to more complex cases.

A typical patient can safely follow a fast track recovery pathway when appropriate. For example, recently a 74-year-old gentleman with an early stage Adenocarcinoma underwent a robotic-assisted right lower lobectomy and systematic mediastinal lymph node dissection, had his chest drain removed the following morning, and was discharged home well with pain controlled on oral analgesia that evening on the first post-operative day. The enhanced visualisation offered by the robotic platform also allows precise dissection near high-risk structures, such as major blood vessels. We recently resected a metastatic melanoma deposit from the aortic arch in a 71-year-old gentleman, who was discharged home well 2 days later.

What does the future hold for robotic surgery? At St James’s Hospital we perform approximately 55% of all curative-intent lung cancer surgery in Ireland. The robotic program is now well established and as our experience develops in robotic surgery, so too should the ability to perform more complex robotic operations. Due to the enhanced 3-D video quality and precision offered by the da Vinci® Xi system, cases including centrally-located tumours, sleeve resections, bilobectomies, pneumonectomies and resection post-neoadjuvant treatment have all been successfully reported. This offers great potential benefit to patients undergoing thoracic oncological surgery at St James’s Hospital, particularly with the transition towards neoadjuvant treatment for lung cancer patients.

Research remains a key tenet of our mission to optimise treatment for lung cancer patients in Ireland. We now have a lung cancer MD research doctor, Dr Laura Staunton, who is exploring the perioperative immune profile, tumour immune microenvironment and efficacy of immunotherapy in patient-derived organoids (PDOs) in Non-Small Cell Lung Cancer (NSCLC) patients. This research is integrated within the Cancer Liquid Biopsies Consortium (CLuB), a collaboration between Trinity College Dublin (TCD), Queens University Belfast (QUB) and NUI Galway (NUIG). A longitudinal biobank of blood and matched tumour tissue samples are collected from patients with resectable NSCLC at St James’s Hospital. Multiple components of liquid biopsies including Circulating Tumour Cells (CTCs), Circulating Tumour DNA (ct-DNA), methylated DNA and exosomes are currently analysed as well as the development of matched PDOs. This MD project, performed through TCD, aims to research the perioperative immune response and its association with clinical outcomes. This is essential for risk stratification and developing effective immunotherapeutic strategies to improve long term patient outcomes. PDOs will be used to measure the effect of immunotherapy, which will inform optimal timing of immune therapy to current treatment standards of care for NSCLC patients. With the recent approval of Pembrolizumab for neoadjuvant / adjuvant treatment in resectable NSCLC, this study is at the forefront of lung cancer research and innovation.

As part of our expanding robotic and minimally invasive program, we have also updated our enhanced recovery after thoracic surgery (ERATS) program. This involves a number of key components including prehabilitation, nutritional support, smoking cessation, avoidance of fasting with carbohydrate loading, regional anaesthesia techniques, early mobilisation, as well as minimally invasive surgery. It is a 360-degree patient-centred journey with the sole aim to provide optimal patient outcomes in lung cancer care. It’s important to recognise that any successful program is only as good as the individual parts. We are exceptionally fortunate to have a dedicated multi-disciplinary team of healthcare professionals who are constantly striving to deliver world class lung cancer care to

Written by: Dr Laura Staunton MCh MB BCh BAO, 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

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