Chapter 165: Overview of Robotics in Thoracic Surgery

Adding to the ever-growing armamentarium of minimally invasive surgical technology, robotic devices were first introduced in 1985 when an industrial robotic arm was modified to perform a stereotactic brain biopsy.¹ With the only U.S. Food and Drug Administration (FDA)-approved surgical system currently on the market, Intuitive Surgical Inc. (Sunnyvale, CA) launched the da Vinci Surgical System in 1999 and it was cleared by the FDA for laparoscopic surgery in 2000.² Although Intuitive’s initial market efforts were directed toward minimally invasive cardiac surgery, its applications have expanded, initially toward urologic and gynecologic surgery and now toward the full gamut of laparoscopic and thoracoscopic procedures. The robotic platform is an alternative approach for all operations performed by standard thoracoscopy and laparoscopy. Lobectomy³ (including 3-arm⁴ and 4-arm approaches⁵), chest wall resection with robotic assistance for the parenchymal dissection, removal of mediastinal masses (including thymectomy),⁶ diaphragm plication,⁷ anti-reflux procedures,⁸ and minimally invasive esophagectomy^9,10 have all been described in the thoracic robotic surgical literature.¹¹

After the first case series describing robotic lobectomy in 2002, the volume of thoracic robotic surgery has exploded. Since the first successful robotic excision of an anterior mediastinal mass was described in 2001,⁶ approximately 3500 robotic thymectomies have been documented in the literature.¹² Furthermore, currently 15% of lobectomies performed in the United States are performed with robotic assistance.^3,13 With the limited penetrance of standard thoracoscopic lobectomy and esophagectomy over the last 25 years, robotic technology has the potential to bring minimally invasive surgery to more patients.

The da Vinci surgical system is a telesurgical system where the surgeon sits at a remote console. The robotic unit has either 3 or 4 arms (depending on the model) and is placed in close proximity to the operating table. The console provides the surgeon a high-definition, 3-D view of the operating field. The surgeon manipulates “master” instruments at the console to control the “slave” robotic arms that are placed within the patient via 8- to 12-mm incisions. These arms utilize “remote center technology,” meaning the arms pivot on a defined point in space to minimize tissue stress while it moves during the operation. The proprietary EndoWrist instruments allow 7 degrees of freedom and 90 degrees of articulation that mimic the human wrist to allow the surgeon the best angle to conduct the operation. A second optional console allows for training and collaboration. Recent advances in robotic instrument technology include a Vessel Sealer (for cutting and sealing), suction irrigator, and robotic stapler. Another extension of the da Vinci system is the integration of the Firefly, a near-infrared optical system. Intravenous indocyanine green (ICG) is administered, Firefly is activated, and the ICG is visualized with the optical system, allowing the surgeon to identify vascular structures. For instance, this has been noted to be particularly useful when utilizing the pericardiophrenic vessels to identify the phrenic nerve.¹⁴ The breadth of ...