Robotic-assisted Lobectomy Research Articles

“Five on a dice” port placement for robot-assisted thoracoscopic right upper lobectomy using robotic stapler

Early versions of the da Vinci robot system (S and Si) have been used to perform pulmonary lung resection with severe limitations. The lack of a vascular robot stapler required the presence of a trained bedside assistant whose role was to place, manipulate and fire the stapler around major vascular structures. Thus, the techniques developed for the Si robot required a skilled bedside assistant to perform stapling of the hilar structure and manipulation of the lung. With the advent of the da Vinci Xi system with a vascular robot stapler, we postulated that we could develop a new port placement and technique to provide total control for the surgeon during the pulmonary lung resection. We found that the five on a dice port placement and technique allows for minimal assistance during the lobectomy with full control by the surgeon. This technique uses the full capability of the Xi robot to make the robot-assisted lobectomy a safe and ergonomic operation.

Robotic-Assisted, Video-Assisted Thoracoscopic and Open Lobectomy: Propensity-Matched Analysis of Recent Premier Data

Robotic-assisted lobectomy (RL) is becoming a popular alternative technique to video-assisted thoracoscopic lobectomy (VL), although open lobectomy (OL) remains the most common approach. The objective of this study is to provide a comparative analysis of perioperative clinical outcomes from elective RL, VL, and OL. The Premier Healthcare Database was analyzed for lobectomies performed from January 1, 2011, to September 30, 2015. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes were used to identify surgical approaches, complications, and mortality. Propensity score matching (1:1) for patient and hospital characteristics allowed comparison of RL versus OL (n= 2,775 each) and RL versus VL (n= 2,951 each). Compared with OL in propensity matched analysis, RL was associated with a lower postoperative complication rate (p < 0.0001), shorter hospital stay (p < 0.0001), and lower mortality rate (p= 0.0282). Patients in the RL group were more likely to be discharged home than to a transitional health care facility (p < 0.0001). Compared with VL, the RL group had a lower conversion rate to thoracotomy (p < 0.0001), lower overall postoperative complication rate (p= 0.0061), and shorter hospital stay (p= 0.006). The RL patients also were more likely to be discharged home than to a transitional health care facility (p= 0.0108). The postoperative mortality rates of RL and VL were similar (p= 0.44). There was no difference in iatrogenic injuries when comparing RL with OL and RL with VL (p= 0.1284 and p= 0.5477, respectively). Robotic-assisted lobectomy was associated with improved outcomes for certain perioperative clinical variables, including shorter length of stay and lower complication rates. It was also was associated with a lower conversion rate to OL compared with VL.

Robotic-assisted right upper lobectomy: with the further research, robot-assisted thoracic surgery (RATS) will be better in future.

We are grateful for the reviewers’ comments on our manuscript entitled “Robotic-assisted right upper lobectomy” (1).

Surgical Outcomes After Robotic-Assisted Pulmonary Lobectomy for Large (≥5cm) Lung Cancers: A 6-Year Experience

Surgical Outcomes After Robotic-Assisted Pulmonary Lobectomy for Large (≥5cm) Lung Cancers: A 6-Year Experience

Robotic assisted lobectomy for locally advanced lung cancer.

Some series report the use of video-assisted thoracic surgery (VATS) in patients with locally advanced non-small cell lung cancer (NSCLC) but, few studies describe the use of the robotic approach specifically for locally advanced disease. One potential advantage of the robotic approach over traditional VATS is the increased radicality. While the benefit of the robotic approach over open thoracotomy is directly related to reduced surgical trauma and the improved tolerability in fragile patients that have received induction treatment. In case of occult N2 disease, robotic assisted surgery can translate into a quicker recovery with improved compliance with adjuvant treatments following surgery. Technical details are reported and described. The robotic instrument technology allows sharp and controlled dissection compared to the typical blunt sweeping methods used in most VATS lobectomy techniques. The authors believe that robotic technology favors a more radical resection in the case of complex locally advanced tumors. Robotic technology has some limitations that have affected adoption such as significant capital and maintenance costs, reduced operating room efficiencies, and a steep learning curve.

Robot-assisted thoracoscopic lobectomy as treatment of a giant bulla

BackgroundA bulla is a marked enlarged space within the parenchyma of the lung. Bullae may cause dyspnea by compressing healthy lung parenchyma and can cause a pneumothorax. Also, bullae are associated with malignancy, therefore surgical bullectomy is indicated on preventive basis. This case is unique and therefore valuable because of the remarkable presentation, innovative treatment and the spectacular improvement of lung function and socio-economic performance of the patient.Case presentationIn this case report we describe the presentation, minimally invasive surgical treatment by means of a robot-assisted lobectomy and postoperative outcome of a young patient with a giant congenital bulla of the left upper lobe.ConclusionsIn this case robot-assisted lobectomy has shown spectacular improvement of lung function and fast-track recovery with beneficial socio-economic performance in a young patient with a giant congenital bulla.

P188 Effect of age on risk for atrial fibrillation following robotic-assisted video-thoracoscopic pulmonary lobectomy

P188 Effect of age on risk for atrial fibrillation following robotic-assisted video-thoracoscopic pulmonary lobectomy

P189 Perioperative outcomes after robotic-assisted pulmonary lobectomy for upper versus lower lobe lung malignancies

P189 Perioperative outcomes after robotic-assisted pulmonary lobectomy for upper versus lower lobe lung malignancies

P178 Smoking history as a risk factor for atrial fibrillation following robotic-assisted video-thoracoscopic pulmonary lobectomy

P178 Smoking history as a risk factor for atrial fibrillation following robotic-assisted video-thoracoscopic pulmonary lobectomy

Robotic Lobectomy: Left Lower Lobectomy by Surgery

According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation.

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

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

Conventional video-assisted thoracic surgery (VATS) vs. robot-assisted lobectomy: where is the money?

The past 20 years have seen growing evidence for minimally invasive thoracic surgery, namely the widespread adoption of video-assisted thoracic surgery (VATS). The pinnacle of this procedure is the VATS lobectomy, which has thus far spawned multiple adaptations, such as robot-assisted, single-port and subxiphoidal approaches to mention only a few (1-3). Despite much higher adoption rate and more advanced technology, boundaries to conducting safe, efficient, reliably reproducible, minimally invasive surgery persist. Currently, the single-port approach offers no reported benefits over the conventional VATS lobectomy (4,5). Likewise, the robot-assisted VATS approach is reportedly non-inferior to that of conventional VATS (6). Debate about the rationality of the robot-assisted VATS approach is ongoing, as many surgeons feels the costs do not yet offset the benefits of this approach, as direct costs were significantly higher (robot-assisted surgery cost $25,040.70 vs . $20,476.60 for VATS) (7,8). Single-center reports have described higher incidence rates of laryngeal nerve palsy and chylothorax with robot-assisted VATS than with conventional VATS (9). These reports confirm that all of the approaches mentioned here are non-inferior to the conventional multiport VATS approach, and use of these alternative approaches remains the prerogative of the experienced surgeon.

Perioperative Factors Associated with Prolonged Air Leaks after Robotic-Assisted Thoracoscopic Pulmonary Lobectomy

Perioperative Factors Associated with Prolonged Air Leaks after Robotic-Assisted Thoracoscopic Pulmonary Lobectomy

Hospital Volume and Outcomes of Robot-Assisted Lobectomies

The positive impact of hospital operative volume on outcomes following video-assisted thoracoscopic surgery has been established. The goal of this study was to determine whether or not this volume/outcome relationship translates to robot-assisted thoracoscopic surgery (RobATS) lobectomy. Patients who underwent RobATS lobectomy were identified between 2008 and 2013 in the Healthcare Cost and Utilization Project National Inpatient Sample database. Hospital volume, as well as demographic, clinical, and health-care system-related factors were selected as potential predictors of outcomes. Outcome variables included length of stay (LOS), inpatient mortality, and complications. Hospitals were designated by quartiles according to annual case volume, with very low-volume defined as the first quartile and high-volume defined as the fourth quartile. Regression analyses were used to identify independent predictors of the outcomes of interest. A total of 8,253 RobATS lobectomies were identified. Compared with very low-volume centers, patients at high-volume hospitals had a shorter mean LOS (5.8vs6.5days; P= .001) and decreased mortality rate (0.5%vs1.9%; P< .001) but more complications (28.1%vs27.6%; P= .025). In multivariable analysis, high hospital volume was prognostic for decreased mortality (OR, 0.134; P< .001) and shorter LOS (0.2days; SE,0.05; P<.001). Hospital volume was not prognostic for any complications, including pulmonary, cardiovascular, intraoperative, or infectious complications. Undergoing lobectomy at high-volume RobATS centers confers favorable mortality and LOS outcomes compared with very low-volume centers. In this relatively early phase of adoption of RobATS, the long-term clinical impact of differences in LOS as well as the lack of clinical impact on the incidence of complications remain to be determined more definitively. However, the beneficial effect of volume on mortality suggests a need for the careful adoption of this promising technology.

Upstaging and survival after robotic-assisted thoracoscopic lobectomy for non-small cell lung cancer

Mediastinal involvement in resected non-small-cell lung cancer mandates adjuvant therapy and affects survival. This study investigated lymph node dissection efficacy, lymph node metastasis detection, and survival after robotic-assisted lobectomy for non-small-cell lung cancer. We retrospectively analyzed patients who underwent robotic-assisted lobectomy for non-small-cell lung cancer. Survival was assessed through chart reviews, Social Security Death Registry, and national obituary searches. Kaplan-Meier survival curves by clinical and pathologic stage were compared by log-rank and Cox regression analysis. In 249 patients (mean age, 67.8±0.6years), mean individual mediastinal lymph nodes retrieved was 7.7±0.3 lymph nodes, with mean of 13.9±0.4 N1+ mediastinal lymph nodes. There were 159 (63.9%) clinical stage I versus 134 (53.8%) pathologic stage I patients, with 67 (26.9%) patients upstaged (20 cN0 to pN1; 17 cN0 to pN2; 4 cN1 to pN2) and 37 (14.9%) downstaged. One-year and 3-year survival rates, respectively, changed between clinical stage I (clinical stage I, 91% and 70%; clinical stage II, 80% and 64%; clinical stage III, 78% and 57%; clinical stage IV, 71% and 45%) and pathologic stage (pathologic stage I, 92% and 75%; clinical stage II, 83% and 73%; pathologic stage III, 75% and 44%; and pathologic stage IV, 67% and 0%). Mediastinal lymph node dissection during robotic-assisted lobectomy adequately assesses lymph node stations and detects occult lymph node metastasis. Stage-specific survival is affected by upstaging.

Efficacy of lymph node dissection during robotic-assisted lobectomy for non-small cell lung cancer: retrospective review of 159 consecutive cases.

We investigated whether robotic-assisted surgery improves mediastinal lymph node dissection (MLND). We analyzed patients (pts) who underwent robotic-assisted video-assisted thoracoscopic surgery (R-VATS) lobectomy for non-small cell lung cancer (NSCLC) over 36 months. Perioperative outcomes, tumor histology, numbers, locations, and status of all lymph nodes (LNs), and TNM (tumor, nodal, and metastasis) stage changes were analyzed. One hundred fifty-nine pts had mean tumor size 3.3±0.2 cm, most commonly being adenocarcinoma. Assessment of ≥3 N2 stations occurred in 156 (98.1%) pts, with 141 (88.7%) pts having >3 N2 stations reported. Mean total N1 + N2 stations assessed was 5.6±0.1 stations, including mean 4.1±0.1 N2 stations assessed. Mean N2 LNs reported was 7.2±0.3 LNs, and mean total N1 + N2 LNs reported was 13.4±0.4 LNs. There were 118 (74.2%) clinical stage-I pts versus 96 (60.4%) pathologic stage-I pts. Overall, 48 (30.2%) pts were upstaged, including 13 pts with cN0-pN1, 13 pts with cN0-pN2, 4 pts with cN1-pN2, and 18 pts with changes in T. R-VATS lobectomy is safe and results in perioperative outcomes comparable to those reported for conventional VATS. R-VATS MLND is effective at detecting occult metastatic disease during lobectomy for NSCLC.

Minimally invasive lobectomy for early stage non-small cell lung cancer—it can be done without sacrificing oncologic outcomes

The introduction of minimally invasive surgical techniques to perform lobectomy for non-small cell lung cancer (NSCLC) has significantly changed the practice of general thoracic surgery over the past two decades. Since the first reports of the use of video-assisted thoracic surgery (VATS) to perform lobectomy for NSCLC in the early 1990s (1), many more studies across a wide array of cohorts have reported on short-term and long-term outcomes. Initial studies focused on the feasibility and reproducibility of the procedure (2), and then subsequent studies demonstrated VATS lobectomy had less morbidity compared to thoracotomy (3). Over time, studies have shown that a minimally invasive approach may be particularly beneficial in those patients with higher peri-operative risk due to advanced age or poor pulmonary function (4,5). More recently, experience with robotic-assisted lobectomy has been increasingly reported and a robotic approach appears to provide similar advantages over thoracotomy as a VATS approach (6). Despite these demonstrated benefits, universal adoption of minimally invasive lobectomy for early-stage NSCLC has not occurred (4,7,8).

Effect of small body habitus on peri-operative outcomes after robotic-assisted pulmonary lobectomy: retrospective analysis of 208 consecutive cases.

Patients with smaller body surface area (BSA) have smaller pleural cavities, which limit visualization and instrument mobility during video-assisted thoracoscopic surgery (VATS). We investigated the effects of BSA on outcomes with robotic-assisted VATS lobectomy. We analyzed 208 consecutive patients who underwent robotic-assisted lobectomy over 34 months. Patients were separated into group A (BSA ≤1.65 m(2)) and group B (BSA >1.65 m(2)). Operative times, estimated blood loss (EBL), conversions to thoracotomy, complications, hospital length of stay (LOS), and in-hospital mortality were compared. Group A had 40 patients (BSA 1.25-1.65 m(2)), and group B had 168 patients (BSA 1.66-2.86 m(2)). Median skin-to-skin operative times [± standard error of the mean (SEM)] were 169±16 min for group A and 176±6 min for group B (P=0.34). Group A had median EBL of 150±96 mL compared to 200±24 mL for group B (P=0.37). Overall conversion rate to thoracotomy was 8/40 (20.0%) in group A versus 12/168 (7.1%) in group B (P=0.03); while emergent conversion for bleeding was 2/40 (5.0%) in group A versus 5/168 (3.0%) in group B (P=0.62). Postoperative complications occurred in 12/40 (30.0%) in group A, compared to 66/168 (39.3%) in group B (P=0.28). Patients from both groups had median hospital LOS of 5 days (P=0.68) and had similar in-hospital mortality. Patients with BSA ≤1.65 m(2) have similar perioperative outcomes and complication risks as patients with larger BSA. Patients with BSA ≤1.65 m(2) have a higher overall conversion rate to thoracotomy, but similar conversion rate for bleeding as patients with larger BSA. Robotic-assisted pulmonary lobectomy is feasible and safe in patients with small body habitus.

Clinical application of robot-assisted surgical system in the simultaneous radial resection of colorectal liver metastases

Objective To investigate the application value of robot-assisted surgical system in the simultaneous radical resection of colorectal liver metastases (CRLM). Methods The retrospective cross-sectional study was adopted.Thirty-one patients with CRLM were admitted to the Zhongshan Hospital of Fudan University between May 2013 and June 2015. After the discussion of multidisciplinary team, robot-assisted simultaneous radical resection of CRLM was performed. Of the 31 patients, a typical 59-year-old male patient was diagnosed as with rectal adenocarcinoma by preoperative colonoscopic biopsy and metastatic cancer at left lateral lobe of liver by preoperative MRI.The chemotherapy regimens were prepared according to the postoperative pathological examination. The follow-up of outpatient reexamination was performed till December 2015, including physical examination, serum tumor markers test, abdominal/pelvic enhanced CT, pulmonary CT, hepatic MRI, pelvic MRI and colonoscopy. Results All the 31 patients underwent successful operations, with no severe perioperative complications and death and without conversion to open surgery or laparoscopic surgery. The typical patient underwent robot-assisted left lateral lobectomy of liver+ partial left internal lobectomy of liver+ radical resection of rectal cancer. The lesion at the left internal lobe of liver was detected by intraoperative ultrasonic probe of robot-assisted surgical system with a diameter of 0.5 cm, and CRLM was confirmed by postoperative pathological examination. The operation time was 280 minutes, including robot-assisted surgery time of 210 mintues, assisted incision anastomosis time of 40 mintues and robotic arm assembly time of 30 minutes.Volume of intraoperative blood loss was 100 mL. The postoperative exsufflation, fluid diet intake, abdominal drainage-tube removal and discharge from hospital occurred at postoperative day 2, 3, 6 and 7, respectively, wiht no occurrence of complications. The postoperative pathological examination result showed ulcerative rectal adenocarcinoma with the grade Ⅱ-Ⅲ differentiation and T3NOM1 stage, and 18 mesenteric lymph nodes were detected without cancer metastasis. Three resectable lesions of liver metastasis were confirmed as with CRLM by postoperative pathological examination. The typical patient received adjuvant chemotherapy of mFOLFOX6 regimen once every 2 weeks up to 12 times from 2 weeks postoperativly, with no reccurrence of tumor during the follow-up. Conclusion Robot-assisted surgical system in the simultaneous radical resection of CRLM is safe, effective and feasible, with an advantage of faster postoperative recovery. Key words: Colorectal neoplasms; Liver metastases; Robot-assisted surgical system

Robotic-Assisted Videothoracoscopic Surgery of the Lung.

Despite initial concerns about the general safety of videothoracoscopic surgery, minimally invasive videothoracoscopic surgical procedures have advantages over traditional open thoracic surgery via thoracotomy. Robotic-assisted minimally invasive surgery has expanded to almost every surgical specialty, including thoracic surgery. Adding a robotic-assisted surgical system to a videothoracoscopic surgical procedure corrects several shortcomings of videothoracoscopic surgical cameras and instruments. We performed a literature search on robotic-assisted pulmonary resections and compared the published robotic series data with our experience at the H. Lee Moffitt Cancer Center & Research Institute. All perioperative outcomes, such as intraoperative data, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality rates were noted. Our literature search found 23 series from multiple surgical centers. We divided the literature into 2 groups based on the year published (2005-2010 and 2011-2014). Operative times from earlier studies ranged from 150 to 240 minutes compared with 90 to 242 minutes for later studies. Conversion rates (to open lung resection) from the earlier studies ranged from 0% to 19% compared with 0% to 11% in the later studies. Mortality rates for the earlier studies ranged from 0% to 5% compared with 0% to 2% for the later studies. Since 2010, our group has performed more than 600 robotic-assisted thoracic surgical procedures, including more than 200 robotic-assisted pulmonary lobectomies, which we also divided into 2 groups. Our median skin-to-skin operative time improved from 179 minutes for our early group (n = 104) to 172 minutes for our later group (n = 104). The overall conversion rate was 9.6% and the emergent conversion rate (for bleeding) was 5% for our robotic-assisted lobectomies. The most common postoperative complications in our cohort were prolonged air leak (> 7 days; 16.8%) and atrial fibrillation (12%). Hospital LOS for the early series ranged from 3 to 11 days compared with 2 to 6 days for the later series. Median hospital LOS decreased from 6 to 4 days. Our mortality rate was 1.4%; 3 in-hospital deaths occurred in the early 40 cases. Mediastinal lymph node (LN) dissection and detection of occult mediastinal LN metastases were improved during robotic-assisted lobectomy for non-small-cell lung cancer, as demonstrated by an overall 30% upstaging rate, including a 19% nodal upstaging rate, in our cohort. Robotic-assisted videothoracoscopic pulmonary lobectomy appears to be as safe as conventional videothoracoscopic surgical lobectomy, which has decreased perioperative complications and a shorter hospital LOS than open lobectomy. Both mediastinal LN dissection and the early detection of occult mediastinal LN metastatic disease were improved by robotic-assisted videothoracoscopic surgical compared with conventional videothoracoscopic surgical or open thoracotomy.