Invited commentary

Abstract

The article by Bodner and colleagues is the largest single series to date detailing the use of robotic technology for the resection of various mediastinal masses. The authors utilize the DaVinci system (Surgical Intuitive Inc., Mountain View, CA), which combines the remote control console, the enhanced three-dimensional magnification technology, and multi-degree of freedom robotic instrumentation.The majority of the patients described in their series involve removal of the thymus gland. The intraoperative and perioperative course are quite acceptable and certainly laudable for an initial series with a complex new technology. Others have documented single case reports or several cases attesting to safety and feasibility [1Yoshino I Hashizume M Shimada M et al.Thoracoscopic thymomectomy with the Da Vinci computer-enhanced surgical system.J Thorac Surg. 2001; 122: 783-785Abstract Full Text Full Text PDF Scopus (84) Google Scholar]. Long-term follow-up will provide further support for the efficacy of this technique but insofar as the authors adhere to the usual principles of surgical resection for tumors in general or thymus in the case of myasthenia gravis then the results should be similar to open techniques. As with other minimally invasive techniques, benefit to the patient will come from earlier recovery including return to full activity and less pain-related morbidity. The absolute clarity of this in the field of gallbladder surgery is such that laparoscopic cholecystectomy is the procedure of choice.In the field of thoracic surgery thoracoscopic lung or pleural biopsy it is the standard approach. Lobectomy for lung cancer has been performed in a number of centers utilizing a purely thoracoscopic approach (no rib spreading, individual hilar vessel, airway and nodal dissection). An NCI-sponsored prospective, multi-institutional trial (CALGB 39802) reported positive results at a recent meeting of ASCO [2Swanson S.J Herndon J D'Amico A et al.Results of CALGB 39802: feasibility of video-assisted thoracic surgery (VATS) lobectomy for early stage lung cancer.Proc ASCO. 2002; 21: 290aGoogle Scholar]. On the other hand, in this issue of The Annals of Thoracic Surgery Bodner and colleagues report results of surgery for thymic disease. Myasthenia gravis is poorly understood with variable indications for surgery. Thymoma is a slowly growing tumor with recurrences that can occur 5 to 10 years following surgery. As a result the follow-up for these patients will need to be protracted to prove efficacy.The challenge to those leading the field of robotic surgery will be to document the benefit of rather costly technology particularly when the thoracoscopic approach for each of these procedures has been carried out safely and with good intermediate-term follow-up. The incision size is the same for both robotic and thoracoscopic surgery and each should avoid rib-spreading so the advantage to the patient over conventional procedures would be expected to be similar. The enhanced three-dimensional vision and 7 degrees of freedom of the robotic arms may improve the ability to perform fine dissection in a limited space. As with other new technology, it will take time and ingenuity to determine its proper place. With respect to training minimally invasive thoracic surgeons, there may be incremental value to the robotic approach. These issues will need to be carefully quantitated in the era of spiraling healthcare costs. Nonetheless, the technology is striking in its quantum change from current standards; the group from Austria among others will be looked to for leadership in this vital area. The article by Bodner and colleagues is the largest single series to date detailing the use of robotic technology for the resection of various mediastinal masses. The authors utilize the DaVinci system (Surgical Intuitive Inc., Mountain View, CA), which combines the remote control console, the enhanced three-dimensional magnification technology, and multi-degree of freedom robotic instrumentation. The majority of the patients described in their series involve removal of the thymus gland. The intraoperative and perioperative course are quite acceptable and certainly laudable for an initial series with a complex new technology. Others have documented single case reports or several cases attesting to safety and feasibility [1Yoshino I Hashizume M Shimada M et al.Thoracoscopic thymomectomy with the Da Vinci computer-enhanced surgical system.J Thorac Surg. 2001; 122: 783-785Abstract Full Text Full Text PDF Scopus (84) Google Scholar]. Long-term follow-up will provide further support for the efficacy of this technique but insofar as the authors adhere to the usual principles of surgical resection for tumors in general or thymus in the case of myasthenia gravis then the results should be similar to open techniques. As with other minimally invasive techniques, benefit to the patient will come from earlier recovery including return to full activity and less pain-related morbidity. The absolute clarity of this in the field of gallbladder surgery is such that laparoscopic cholecystectomy is the procedure of choice. In the field of thoracic surgery thoracoscopic lung or pleural biopsy it is the standard approach. Lobectomy for lung cancer has been performed in a number of centers utilizing a purely thoracoscopic approach (no rib spreading, individual hilar vessel, airway and nodal dissection). An NCI-sponsored prospective, multi-institutional trial (CALGB 39802) reported positive results at a recent meeting of ASCO [2Swanson S.J Herndon J D'Amico A et al.Results of CALGB 39802: feasibility of video-assisted thoracic surgery (VATS) lobectomy for early stage lung cancer.Proc ASCO. 2002; 21: 290aGoogle Scholar]. On the other hand, in this issue of The Annals of Thoracic Surgery Bodner and colleagues report results of surgery for thymic disease. Myasthenia gravis is poorly understood with variable indications for surgery. Thymoma is a slowly growing tumor with recurrences that can occur 5 to 10 years following surgery. As a result the follow-up for these patients will need to be protracted to prove efficacy. The challenge to those leading the field of robotic surgery will be to document the benefit of rather costly technology particularly when the thoracoscopic approach for each of these procedures has been carried out safely and with good intermediate-term follow-up. The incision size is the same for both robotic and thoracoscopic surgery and each should avoid rib-spreading so the advantage to the patient over conventional procedures would be expected to be similar. The enhanced three-dimensional vision and 7 degrees of freedom of the robotic arms may improve the ability to perform fine dissection in a limited space. As with other new technology, it will take time and ingenuity to determine its proper place. With respect to training minimally invasive thoracic surgeons, there may be incremental value to the robotic approach. These issues will need to be carefully quantitated in the era of spiraling healthcare costs. Nonetheless, the technology is striking in its quantum change from current standards; the group from Austria among others will be looked to for leadership in this vital area.