165: Robotics: Lobectomy

Introduction

Lobectomy via minimally invasive video-assisted thoracic surgery (VATS) has proved to be a feasible and oncologically acceptable approach for non–small-cell lung cancer (NSCLC) and other isolated tumors and conditions. However, despite multiple studies showing clear benefits over a traditional thoracotomy approach, such as decreased length of stay, decreased short-term postoperative pain, and fewer complications,^1–3 VATS is still not accepted as the standard approach for anatomic resection, and is only slowly being implemented more widely. The explanation is likely multifactorial including (1) technical issues, such as two-dimensional imaging and limited maneuverability of instrumentation; (2) lack of adequate training; and (3) concerns about the consequences of major vascular injury with a closed chest approach.

To address the perceived technical limitations of conventional minimally invasive platforms, a master–slave robotic surgical system was developed (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, California). The major advances were the three-dimensional visual system that reestablished binocular vision and wristed instrumentation capable of seven degrees of freedom enabling more natural bimanual movement for precise dissection. Initially, the system was approved by the Food and Drug Administration for cardiothoracic surgery because the original intent was to achieve true closed chest cardiac surgery. This, however, has not been fully realized. Instead, the most common applications that evolved were for pelvic procedures—prostatectomy and hysterectomy. Similarly, while use of robotics for general thoracic surgical procedures dates back to initial case reports in the early 2000s, it was not until 2004 and 2006 that actual series of robotic lobectomies were reported by Melfi et al. and Park et al., respectively.^4,5 These centers reported the initial technique and early perioperative experiences that demonstrated feasibility, safety, and concordance of outcomes with the largest series of VATS lobectomies. Subsequently, there has been a steadily increasing interest in robotic lobectomy with additional publications with greater numbers of patients and various modifications of the technique.^6–8

This chapter will focus on review of the general principles and clinical aspects of robotic lobectomy with an emphasis on patient selection, preoperative preparation, technical aspects, and perioperative outcomes.

General Principles

The guiding principle that must be remembered when one is considering utilizing robotic surgical systems for any procedure is that the robot is a tool like any other in the art of surgery. It is up to the surgeon to use his or her best judgment as to whether its use is appropriate and in the best interest of the patient. Robotic procedures are simply minimally invasive procedures, that are performed with a different, perhaps more advanced technology that has unique advantages and disadvantages. In the case of pulmonary lobectomy the robotic approaches that have been described all conform to the consensus criteria of a standard VATS lobectomy put forth in the Cancer and Leukemia Group B (CALGB) prospective, multi-institutional registry study (CALGB 39802).⁹ For early stage NSCLC (node-negative, peripheral tumors ...