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INTRODUCTION

Robotic thoracic surgery continues to grow in popularity for patients and surgeons. Compared with open surgery, minimally invasive thoracoscopic surgical techniques have been shown to reduce overall morbidity and enhance the recovery of patients undergoing pulmonary resection.1 For patients with lung cancer, video-assisted thoracoscopic surgery (VATS) achieves similar long-term survival and has a number of oncologic advantages compared to thoracotomy, including superior postoperative immune response and greater ability to deliver adjuvant therapy.2 Similar to VATS, robotic thoracic surgery utilizes minimally invasive techniques to perform resections and repairs for a broad range of thoracic pathologies, initially most commonly for mediastinal pathology and now increasingly for pulmonary resection for lung cancer. Surgeons using a robot-assisted platform aim to utilize robotic technology to improve upon the limitations of a VATS approach. Robotic thoracic surgery gives the surgeon greater control of the operation: wide instrument angulation and precision movements, a 3-D and magnified operative view, and the ability to drive your own camera, assist yourself, and use new advanced technologies.

While the robot is not new, it is an evolving technology that we believe will continue to add value for patients and surgeons alike. In this chapter, we detail our approach to robotic pulmonary resection including lobectomy, segmentectomy, and sleeve lobectomy. The technical descriptions are accompanied by a review of current and evolving robotic technologies, perioperative care, and clinical outcomes. A systematic approach to both learning and executing robotic pulmonary resection is highly recommended in order to achieve operative efficiency and optimal clinical outcomes.

PATIENT SELECTION AND PREOPERATIVE CARE

Robotic pulmonary lobectomy may be considered in nearly all patients who are evaluated for pulmonary resection. There are no absolute contraindications. There are, however, several relative contraindications that are particularly relevant early in a surgeon’s learning curve. Some of these include vascular invasion, extensive mediastinal/esophageal invasion, Pancoast tumors, massive tumors greater than 10 cm or those obliterating the intrathoracic space, need for airway reconstruction, chest wall invasion, and significant pleural adhesions. Although all of these pathologies can be approached successfully using robotic technology, they are more challenging and may mandate conversion to an open thoracotomy after an initial attempt at robotic resection.

The preoperative evaluation of patients undergoing robotic lung resection is similar to patients undergoing planned VATS or open thoracotomy, including pulmonary function testing, cardiac stress testing in patients at risk of cardiovascular disease, and complete patient-specific staging. Oncologic staging involves a PET-CT scan in most patients and, in select patients, either brain MRI or CT. To enhance recovery after robotic pulmonary resection, our patients receive preoperative pain medications, including acetaminophen and gabapentin.

SURGICAL TECHNIQUE FOR ROBOTIC LOBECTOMY

Robotic operations can be anxiety-inducing for inexperienced surgeons and anesthesiologists. Preparation of the operating room and a cooperative team dynamic are imperative for safe, efficient robotic surgery. Movements are often orchestrated between the surgeon, anesthesiologist, and ...

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