ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 46 (2014) 626–631 doi:10.1093/ejcts/ezu079 Advance Access publication 9 March 2014
Robotic lobectomy for lung cancer: evolution in technique and technology† Franca M.A. Melfi, Olivia Fanucchi*, Federico Davini, Gaetano Romano, Marco Lucchi, Paolo Dini, Marcello C. Ambrogi and Alfredo Mussi Division of Thoracic Surgery, Department of Cardiac Thoracic and Vascular Surgery, University of Pisa, Pisa, Italy * Corresponding author. University of Pisa, Via Paradisa 2, 56124 Pisa, Italy. Tel: +39-050-995211; fax: +39-050-995352; e-mail: [email protected] (O. Fanucchi). Received 2 October 2013; received in revised form 10 January 2014; accepted 15 January 2014
Abstract OBJECTIVES: The aim of this study was to analyse the results of robotic lobectomy for lung cancer. The evolution of technique and technology was evaluated. METHODS: During the period 2004–12, all patients who underwent robotic lobectomy for clinical early-stage lung cancer were retrospectively reviewed. The patients were divided into two groups. Group 1 included 69 patients operated by the first generation of surgical robotic system. Group 2 included 160 patients treated with the latest generation of surgical robotic system. Age, gender, comorbidities, operative time, docking time, conversion rate, morbidity, mortality and length of postoperative stay were compared in both groups. RESULTS: The two groups were homogeneous in terms of age, gender and comorbidities. Histopathological analysis showed 41 and 107 adenocarcinomas, 27 and 37 squamous cell carcinomas, 1 and 7 large cell carcinomas, in Groups 1 and 2, respectively, and 5 sarcomatoid carcinomas and 4 carcinoids in Group 2. The pathological stage for Group 1 was Stage I (48 cases), Stage II (17 cases) and Stage III (4 cases). For Group 2, Stage I was found in 115 cases, Stage II in 30 cases and Stage III in 15 cases. The mean operative time was 237 (standard deviation (SD) + 66.9) and 172 (SD ± 39.6) min for Groups 1 and 2 (P = 0.002), respectively. The conversion rates were, respectively, 10.1 and 5.6% (P = 0.21), mortality rates 1.4 and 0% (P = 0.30) and morbidity rates 22 and 15% (P = 0.12). The mean length of postoperative stay was 4.4 (SD ± 3.1) and 3.8 days (SD ± 2.2) (P = 0.26), respectively. CONCLUSIONS: This study suggests a positive trend in the outcomes for patients who underwent the upgraded robotic system surgery compared with those treated by the standard system. Keywords: Minimally invasive surgery • NSCLC • Surgical technique • Early stage • Robotics
INTRODUCTION Robotic surgery can be defined as a procedure that adds a computer technology-enhanced device to the interaction between a surgeon and a patient during a surgical operation. Currently, the da Vinci system™ (Sunnyvale, CA, USA) is considered the only complete surgical system. In 2002, we reported the first series of robotic lobectomy for non-small-cell lung cancer (NSCLC) [1]. During last decades, the robotic system underwent improvements and upgrades, and at the same time, different techniques were described and developed for performing robotic lobectomy [2–4]. In our centre, all three generations of robotic system were applied to perform a wide range of surgical procedures (da Vinci standard, S and Si), with the intent to develop, standardize and optimize the technique of robotic lobectomy. In this study, the different techniques were analysed in relation to the different generations of
† Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013.
robotic system (standard vs S/Si), comparing operative and postoperative data.
MATERIALS AND METHODS We retrospectively reviewed all patients who underwent lobectomy with the da Vinci Surgical System™ (Sunnyvale, CA, USA), for clinical early-stage NSCLC, during the period 2004–12. The patients were divided into two groups based on the generation of the robotic system: Group 1 (Vinci standard); Group 2 (da Vinci S/Si) (Table 1). Demographic and clinical data were collected for each group. The main end-point of this study was to analyse the results of robotic lobectomy, in terms of the evolution of the technique related to technological development. All surgical procedures were performed by the same team (including scrub nurse). Operative time (defined as the time between skin incision and skin closure), docking time (defined as the time necessary for surgical cart positioning and robotic arms placement in the surgical
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
627
Table 1: Main features of robotic systems First generation (standard) 3D image Three robotic arms 0° scope (12 mm) Second generation (S) 3D-high definition vision 30° stereo endoscopes (12 and 8 mm) Four robotic arms Large range of motion robotic instruments Extended length instruments Third generation (Si) Advanced 3D-high definition visualization with up to ×10 magnification Dual console capability Figure 1: Port mapping for Group 1 patients (three-arm robotic system).
THORACIC
field), conversion rate, length of stay, morbidity and mortality were analysed with regard to the two groups. All patients signed the detailed informed consent. The Institutional review board approved this study.
Preoperative staging Patient evaluation was the same for both groups: chest X-ray, chest and upper abdomen computed tomography (CT) scan imaging with contrast media enhancement and positron emission tomography (PET) scan. Invasive staging procedures, such as mediastinoscopy, were omitted in patients with stage peripheral I NSCLC and negative PET scan, according to the European society of thoracic surgeon guidelines [5]. Comorbidity scores were collected by using the Adult Co-Morbidity Evaluation scoring system (ACE-27) [6].
Figure 2: Port mapping for Group 2 patients (four-arm robotic system).
Group 2. Group 2 included those patients operated by the latest
Surgical techniques All patients underwent double-lumen intubation and were positioned in the lateral decubitus position, in the same way as for posterolateral thoracotomy. In case of female patients, a pillow was positioned under the hip in order to have the patient’s hip and scapula at the same level.
Group 1. Group 1 included those patients operated by the first
generation system (Table 1). The first port was placed in the seventh or eighth inter-costal space on the midaxillary line for the camera (0°), the other port in the sixth or seventh inter-costal space in the posterior axillary line (one robotic arm), and a ‘service entrance’ was created in the fourth or fifth inter-costal space (3–4 cm in length) for the other robotic arm. An additional small incision was made between the ‘service entrance’ and the camera port for the assistant surgeon to insert conventional thoracoscopic instruments (Fig. 1). The dissection of the hilar structures was robotically performed with the two arms. Each structure was cleaned and surrounded by a sling. Endoscopic staplers were used to divide the vein, the arteries and the lobar bronchus. They are positioned by an expert surgeon with a traditional video assisted thoracic surgery (VATS) bidimensional vision. Small arteries were ligated (Linen 2.0) and then divided. No CO2 insufflation was utilized.
generation systems with four arms, using a totally endoscopic approach (Table 1). The first port was placed in the seventh to eighth inter-costal space on the midaxillary line for the camera (12 mm, 30° angled down scope). The other port incisions (8 mm) were performed in the fifth to sixth inter-costal space on the anterior axillary line, sixth to seventh inter-costal space on the posterior axillary line and in the auscultatory area (for the fourth arm) (Fig. 2). A utility port between the camera port and the anterior robotic port can be positioned for the assistant surgeon, who has to introduce a stapler or suction unit. The fourth arm was used for retracting the lung, allowing the exposure of the hilar structures, and was under direct control of the operating surgeon. The dissection of all hilar structures was achieved with the robotic instruments. Division of the lobar vein, the arteries and the lobar bronchus was performed with the endoscopic stapler. They are positioned by a young surgeon under bidimensional vision. Small arteries were ligated (Linen 2.0). CO2 insufflation was applied at a maximum level of 6–8 mmHg in order to facilitate lung collapse, and push down the diaphragm. In addition, it can be useful especially in emphysematous patients, in whom air trapping often occurs.
Operative and postoperative data Operative time, docking time, conversion rate, length of stay, morbidity and mortality were recorded for each patient.
628
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
Table 2: Clinical and demographic features of Groups 1 and 2
Number Gender (M : F) Mean age (SD) Mean ACE-27 score Site of the lesions Left upper lobe Left lower lobe Right upper lobe Middle lobe Right lower lobe
Group 1
Group 2
P-value
69 40 : 29 63.6 years (SD 7.7) 1.7 (SD 1.2)
160 101 : 59 64.3 years (SD 10.5) 1.8 (SD 1.1)
0.46a 0.64b 0.65 b
12 22 7 10 18
20 32 35 34 39
χ test. Unpaired Student’s t-test ACE-27: Adult Comorbidity Evaluating scoring system-27; SD: standard deviation.
a 2 b
Complications were stratified according to the Clavien–Dindo classification [7]. Follow-up for all patients was performed at our ambulatory unit, with a physical examination. A chest X-ray was performed three months after surgery, and subsequently chest and upper abdomen CT scan was performed every 6 months, for the first 12 months and then every year.
Statistical analysis The two cohorts were compared on the basis of clinical and demographic data. Statistical analysis was performed using Statistica software version 7.0 for PC (Stat-Soft, Inc., Tulsa, OK, USA). The measures were expressed in terms of mean and standard deviation (SD). The unpaired Student’s t-test, and the χ 2 test or Fisher’s exact test were used to compare the distributions of continuous data and categorical measures, respectively. Actuarial overall survival was estimated by Kaplan–Meier’s method. The log-rank test was used to compare survival between the two groups. A probability value 5 days) (9 cases; Grade I: 7 patients, Grade IIIa: 2 patients); supraventricular arrhythmia (3 cases; Grade II: 3 patients), medically resolved; acute renal failure (1 case; Grade II), medically treated and resolved; and pleural effusion (2 cases; Grade II: 2 patients), medically resolved. In Group 2, morbidity consisted of prolonged air leaking (>5 days) (11 cases; Grade I: 8 patients, Grade IIIa: 3 patients); supraventricular arrhythmia (7 cases; Grade II: 7 patients), pharmacologically treated and resolved; atelectasis (2 cases; Grade IIIa: 2 patients), requiring bronchoscopic aspiration; pleural effusion (1 case; Grade II); urinary retention (1 cases; Grade IIIa); and wound infection (1 case; Grade I). There was no statistically significant difference between the two groups in terms of morbidity (P = 0.12). The mean postoperative stay was 4.4 days (SD ± 4.6) for Group 1, and 3.8 (SD ± 2.2) for Group 2, with no statistically significant difference. Histopathological results were, respectively, 41 and 107 adenocarcinomas, 27 and 37 squamous cell carcinomas, 1 and 7 large cell carcinomas, for Groups 1 and 2, and 5 sarcomatoid carcinomas and 4 carcinoids for Group 2. The pathological stage was I (48 cases), II (17 cases) and III (4 cases) for Group 1, and was I (115 cases), II (30 cases) and III (15 cases) for Group 2. At a mean follow-up of 29 months (SD ± 12.7), the actuarial overall 5-year survival rate was 79%. This rate increased up to 89%, when Stage I is considered. The actuarial 5-year overall survival rate was 78 and 80% for Group 1 and Group 2, respectively, with no statistically significant difference.
DISCUSSION ‘Robotic surgery’ is an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted. For the purposes of this paper, we define robotic surgery as a surgical procedure that comprehends a computer technologyenhanced device, which is under the direct control of the surgeon, during the interaction between the surgeon and the patient. The first robotic system approved by the US Food and Drug Administration (FDA) to be used in laparoscopic surgery was Automated Endoscopic System for Optimal Positioning [8]. Subsequently, the same company (Computer Motion, Inc., Goleta, CA, USA) developed the ZEUS system to assist surgeons in minimally invasive surgery [9–11]. In parallel, the Vinci Surgical System was developed by Intuitive Surgical (Sunnyvale, CA, USA) and cleared by the FDA for laparoscopy and cardiac surgery [12–14]. Currently, the da Vinci Robotic system is the only complete surgical system applied in a wide range of surgical procedures. In 2002, we reported the encouraging results of five pulmonary lobectomies performed with the aid of robotic technology [1]. Subsequently, other authors and we described the utilization of a robotic system to perform lower lobectomy for Stage I NSCLC, demonstrating the safety and feasibility of this procedure [2–4, 15]. However, since that period many changes have happened with regard to the robotic system, robotic instruments and consequently to the surgical technique. The aim of this study was to analyse how the technological development of the robotic system influenced the surgical technique. Our study revealed that there was no statistically significant difference between patients operated with the first generation of robotic system (Group 1) and those operated on with the second and the third generation of robotic system (Group 2), in terms of mortality and morbidity. This fact theoretically supports the safety and feasibility of such a procedure. However, we observed that the docking time and operative time were significantly lower in Group 2. This evidence is related to different facts. First, the necessity of adequate surgical training for the acquisition of new skills: with the gained experience of both surgeons and scrub nurses, the mean operative time and docking time decreases. Secondly, we have to consider that, at the beginning of this experience, there was no standardized technique to precisely follow and reproduce. Gharagozolo et al. [16] described a hybrid technique: the robotic arms were positioned at the eighth (camera), sixth and fifth inter-costal spaces for the dissection of the hilar structures. After the dissection phase, the robot was removed, and the surgeon returned to the operating table for vascular, bronchial and parenchymal division. Ninan and Dylewski described a robotic lobectomy with three arms: the robotic camera port was placed in the fifth or sixth inter-costal space, directly over the midfissure area. The two other ports were placed in the same inter-costal space anteriorly and posteriorly. A utility port was inserted over the 11th rib and bluntly tunnelled over the 9th rib, with entrance into the chest cavity through the 8th inter-costal space [17]. Subsequently, Cerfolio et al. [18] described robotic lobectomy with four robotic arms all positioned along the seventh rib, between the midaxillary line and the paravertebral line, at a minimum distance of 9 cm from each other. Our long experience with all generations of robotic system gave us the possibility of optimizing trocar positioning and standardizing the procedure. Port-mapping was the same for both the left and right sides, and
629
also for upper, middle or lower lobectomy. In addition, currently, at our centre, robotic lobectomies are routinely performed with a totally endoscopic technique. Thirdly, the instrumentation initially available was designed to be used on coronary vessels, thus often resulting inadequate for thoracic surgery. Subsequently, some instruments were clearly thoracic surgery, such as a lung grasper. In addition, there were different features of the second and third generation of robotic systems that gave advantages to surgeons. The possibility of a 30° endoscope permitted one to reach remote areas easily. The fourth arm allowed the surgeon to directly control the tension of the retracted structure (for example: lung or vessels surrounded by the sling), that was previously performed by the assistant surgeon under bidimensional vision. In addition, 3D-HD vision and new dedicated instruments with an extended length and large range of motion of robotic arms greatly enhanced the surgeon’s ability to manipulate the hilar structure and lobar vessels, permitting a safe dissection of the anatomical structures, also in a closed chest setting. Nevertheless, advanced training on robotic systems and dedicated instruments allowed the improvement of robotic application in lung lobectomy on large series. Some authors reported the utilization of a four-arm robotic system on a large cohort, for lobectomy [19, 20] and for segmentectomy [21] with a low conversion rate, and low morbidity and mortality, demonstrating its feasibility and safety. In a recent paper of Schmid et al. [22] a hybrid VATS-robotic minimally invasive sleeve lobectomy was reported without intraoperative complications, while Nakamura et al. [23] described a robotic broncoplastic right upper lobectomy. These studies underlined how the articulation of robotic instruments was really useful for suturing and performing anastomosis, also in remote anatomical areas. This reinforces the assumption that the robot offers a benefit mainly in very complex procedures. However, an important criticism is represented by the oncological results. The first key point is regarding lymph node dissection: some recent studies, comparing mediastinal lymph node dissection, have demonstrated equivalence between the robotic and open approaches, both for total number of resected lymph nodes, and the median number of N1 and N2 lymph node stations assessed [18, 20]. In addition, it should be recognized that robotics, owing to its 3D vision and to the articulation of the instruments, allowed greater confidence in dissecting N1 lymph nodes adjacent to the lobar arteries and bronchus. This may ultimately have an impact on oncological outcomes in the long term, but in the immediacy of the operation it permits easier and safer dissection. The second key point is represented by the long-term outcomes. The only study on a large cohort evaluating robotic lobectomy in terms of long-term survival is the one by Park et al. [24]. They obtained a 5-year overall survival rate of 80% with a median follow-up of 27 months, and it increases up to 91 and 88% when Stage IA and IB, respectively, are considered. In our study, the actuarial 5-year overall survival rate was 79% and appeared to be comparable with the data in the literature. Nevertheless, our study has some limitations. First of all, it is a retrospective analysis. Another limitation is the absence of other outcome measures, such as postoperative lung function, postoperative pain and quality of life. This study was focused on the technological aspect of robotic systems and on the evolution of the technique. In conclusion, we can say that the progress of technology, together with gained experience, permitted the standardization
THORACIC
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
630
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
of the technique, applying the robotic system in a safe way. Currently, robotic lobectomy should not be considered experimental, but an established minimally invasive thoracic surgical technique. The acquired surgical skills, long experience, evolution of the technology and standardization of the technique permitted one to perform minimally invasive lobectomy in a safe manner, offering advantages also in complex procedures. However, this technique should be applied in high-volume referral centres, with a dedicated team (surgeon, scrub nurse, anaesthesiologist) with adequate skills. Conflict of interest: none declared.
[20] Veronesi G, Galetta D, Maisonneuve P, Melfi F, Schimid RA. Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg 2010;140:19–25. [21] Pardolesi A, Park B, Petrella F, Borri A, Gasparri R, Veronesi G. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg 2012;94:929–34. [22] Schmid T, Augustin F, Kainz G, Pratschke J, Bodner J. Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. Ann Thorac Surg 2011;91:1961–5. [23] Nakamura H, Taniguchi Y, Miwa K, Fujoka S, Matsuoka Y, Kubouchi Y. A successful case of robotic bronchoplastic lobectomy for lung cancer. Ann Thorac Cardiovasc Surg 2013;19:478–80. [24] Park H, Melfi F, Mussi A, Maisonneuve P, Spaggiari L, Da Silca RKC et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 2012;143:383–9.
REFERENCES [1] Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864–8. [2] Ashton RC Jr, Connery CP, Swistel DG, DeRose JJ Jr. Robot-assisted lobectomy. J Thorac Cardiovasc Surg 2003;126:292–3. [3] Bodner J, Wykypiel H, Wetscher G, Kirkhmayr W, Freund MC, Margreiter R et al. First experiences with the da Vinci operating robot in thoracic surgery. Eur J Cardiothorac Surg 2004;25:844–51. [4] Park BJ, Flores RM, Rusch VW. Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results. J Thorac Cardiovasc Surg 2006;131:54–9. [5] De Leyn P, Lardinois D, Van Schil PE, Rami-Porta R, Passlick B, Zielinski M et al. ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg 2007;32:1–8. [6] Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL Jr. Prognostic importance of comorbidity in a hostital-based cancer registry. JAMA 2004; 291:2441–7. [7] Seely AJ, Ivanovic J, Threader J, Al-Hussaini A, Al-Shehab D, Ramsay T et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010;90:936–42. [8] Miller DL, Allen MS. Set-up and present indications: video-assisted thoracic surgery. Semin Thorarc Cardiovasc Surg 1993;5:280–3. [9] Rechenspurner H, Damiano RJ, Mack M, Boehm DH, Gublins H, Deter C et al. Use of voice-controlled and computer-assisted surgical sysyem ZEUS for endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999;118:11–6. [10] Stephenson ER, Sankholkar S, Ducko CT, Damiano RJ Jr. Robotically assisted microsurgery for endoscopic coronary artery bypass grafting. Ann Thorac Surg 1998;66:1064–7. [11] Boehm DH, Reichenspurner H, Gulbins H, Detter C, Meiser B, Brenner P et al. Early experience with robotic technology for coronary artery surgery. Ann Thorac Surg 1999;68:1542–6. [12] Cichon R, Kappert U, Schneider J, Schramm I, Gulielmos V, Tugtekin SM et al. Robotically enhanced “Dresden technique” with bilateral internal mammary artery grafting. Thorac Cardiovasc Surg 2000;48:189–92. [13] Chitwood WR Jr, Nifong LW, Elbeery JE, Chapman WH, Aldrecht R, Kim V et al. Robotic mitral valve repair: trapezoidal resection and prosthetic annuloplasty with the da Vinci surgical system. J Thorac Cardiovasc Surg 2000;120:1171–2. [14] Meininger DD, Byhahn C, Heller K, Gutt CN, Westphal K. Totally endoscopic Nissen fundoplication with a robotic system in a child. Surg Endosc 2001;15:1360. [15] Melfi FMA, Ambrogi MC, Lucchi M, Mussi A. Video Robotic Lobectomy. Multimed Man Cardiothorac Surg 2005;doi:10.1510/mmcts.2004.000448. [16] Gharagozloo F, Margolis M, Tempesta B, Strother E, Najam F. Robotassisted lobectomy for early-stage lung cancer: report of 100 consecutive cases. Ann. Thorac Surg 2009;88:380–4. [17] Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38: 231–2. [18] Cerfolio RJ, Bryant BS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011;142:740–6. [19] Augustin F, Bodner J, Wykypiel H, Schwinghammer C, Schmid T. Initial experience with robotic lung lobectomy: report of two different approaches. Surg Endosc 2011;25:108–13.
APPENDIX. CONFERENCE AND DISCUSSION Dr. R Milton (Leeds, United Kingdom): I have some comments and then, if I may, two more general questions. This paper aims to analyse the evolution of the technique of robotic lobectomy using different generations of the DaVinci system. However, this is a niche market. I work at St. James University Hospital in Leeds in the UK. I have to confess, although we have the DaVinci system in our hospital, it is used by the urologists, the paediatric surgeons, and general surgeons. Certainly we do not use it. Unless our hospital purchases another robot, which I really doubt will ever happen, I don’t think I will ever get to use the robot in my own practice. So the way I see it, patient selection for robotic procedures is in part determined by geography, i.e., the patient happens to live in the catchment area of a thoracic department that has a DaVinci robot. So I don’t feel I am in a good position to criticize your paper; however, I applaud it. This remains an extremely important paper because it promotes the incorporation of new ideas and technological advancement in our specialty and, consequently, it does warrant discussion at this meeting. In group 2 you make use of an additional robot arm, a 30-degree camera, and CO2 insufflation. You demonstrate clear progression in terms of reduced operating times and, although not significant, fewer conversions. You reinforce in your manuscript something which is extremely important: the necessity of adequate training and experience that has been gained, not only by you, the surgeon, but by the entire surgical team. Now, my colleagues and I in Leeds are minimally invasive enthusiasts. Last year we performed 140 VATS lobectomies, which is about 50% of all of our lobectomies. I believe that if a patient has an early-stage cancer, the operation of choice is a VATS lobectomy. If the surgeon does not perform VATS lobectomies, they should give the patient the choice of changing to a surgeon who does. So my first question is this. Is robotic lobectomy horses for courses? In other words, should this technique, excellent though it is, simply be seen as a tool for fortunate enthusiasts or should the use of the robot in thoracic surgery become more generalized? My second question is, what will the future bring? Dr Fanucchi: Excuse me, can you repeat the first question? Dr Milton: Yes. Should this technique be seen as a tool for fortunate enthusiasts or should the use of the robot in thoracic surgery become more generalized? Dr Fanucchi: I don’t understand the question. I’m sorry. Can you say it in other words? Dr Milton: Yes. I will rephrase it. Do you think that you are just in a very fortunate position to be able to use the robot, and perhaps, since we are not fortunate to be in possession of one, we will just never get a chance to use it? Dr Fanucchi: We have had the opportunity to apply the robotic system since 2001 when it became available in our department, and we started our robotic programme for lobectomy in 2004. In the beginning, we had many difficulties in standardizing the technique and assembling an adequate surgical team to perform robotic lobectomy. Not only the surgeon who performs the robotic lobectomy and who is at the console of the robotic system, but also the assistant surgeon and the scrub nurse have to be prepared for this kind of operation in order to prevent any possible complications, related not just to the operation itself, but also to the technology of the robotic system. So all of this was not so easy to manage at the beginning of our experience. For this reason, we decided to perform a service entrance in order to have safer control of the operative field during the operation. We gained experience and decided to apply a totally endoscopic technique. At the beginning of our experience with the total endoscopic technique, we
also performed an additional utility port for the suction, for the introduction of the stapler, because not all Dr W. Klepetko (Vienna, Austria): Sorry to interrupt you, but maybe this is a very general question which should be answered by the senior author of the paper. I’m sure Franca has answered the question many times before and maybe you will repeat your answer that you have given before. Should the robotic technique be applied in a more general way or should it really be restricted to highly specialized enthusiasts, as you called it? Dr F. Melfi (Pisa, Italy): Robotic surgery, the robotic technique at present, is not only for the enthusiast, but it is clear that, if it is available, we can use it in our current practice. At the present time, there are not many possibilities to apply this technique, which is really, really expensive, but in the future, I think it will be possible to apply it in our work when there is a really good indication for a minimally invasive procedure. The point is, if you have a patient with the indication for a minimally invasive procedure for major lung resection, we have the possibility to apply this system because it is available in the department in our hospital. It is extremely valuable to be able to use this technique over the conventional minimally invasive technique. So it is not only for enthusiasts, it is just for people, for surgeons who have the opportunity to apply this technique. In the future, I hope that it will be possible for costs to decrease, making it feasible to apply this worldwide. It is a similar story as in VATS lobectomy. If you remember, in the beginning, it was extremely expensive and was only available in dedicated hospitals. Now it has changed. Probably there will also be a similar story for robotic lobectomy or for robotic procedures in thoracic surgery. Dr Klepetko: Thank you. Maybe you will continue with your discussion. Dr Milton: My second question was really probably an extension of what you just said. What will the future bring in terms of new technologies with the robot? Where do you see the robot technology going? Dr Melfi: The new technology developments probably will be the stapler, the robotic stapler, and the robotic stapler I think will be the switch, with a very huge application, especially in this particular field, in major lung resection. Probably it will take some years, again, for this to happen. Dr P. Tcherveniakov (Manchester, United Kingdom): Just a quick question regarding training. What was the experience of the lead surgeon performing the robotic lobectomies in terms of VATS lobectomy, and do you see VATS as a step towards robotic lobectomy or do you see it as an unnecessary step? Dr Fanucchi: When we started, we decided to directly apply this technique from the open surgery to the robotic one. We had little experience in VATS lobectomy. We think that the robotic system can combine the advantages of VATS lobectomy in terms of minimally invasive surgery with the high-definition vision and the advantages of open surgery with regard to the articulation of the instruments inside the chest cavity. So we think that it is not necessary to have experience in VATS lobectomy. Dr R. Schmid (Berne, Switzerland): In my centre we don’t do that much robotic lobectomy because I think the technology is not really ready, as Franca said, but we do a lot of mediastinal resections, and we experienced the switch from thoracoscopic mediastinal thymectomy, thymoma resection, to the robotic technique. I think it was very easy because there is a clear advantage, and this will also happen with new devices for lobectomy. In general, in surgery we are quite slow in introducing minimally invasive or new technology. Endoscopic surgery was introduced in the early ‘90s, and 20 years later, we were speaking about resection of early lung cancer. So we are quite slow. The first to introduce minimally invasive endoscopic surgery were the gynaecologists. It was not even the surgeons who started to do appendectomy and cholecystectomy. So we have to think a bit about how we surgeons introduce new technologies, and I think we should be a bit more open to introducing new techniques in order to evaluate and establish them more quickly.
631
Dr G. Cardillo (Rome, Italy): I would like to just discuss a point regarding VATS and robotic lobectomy. In my hospital, we have started both programmes. Up to now, my experience is greater with VATS lobectomy than with robotic lobectomy, but the numbers are very, very small. I can tell you that there is a wide difference between the two techniques. In my opinion, robotic lobectomy seems more close to the open approach because you follow the same rule. For example, I start it with the artery, then I ligate the vein only when all the vessels are ready. In VATS, it is the contrary. I do the anterior approach and I start with the vein. I cut the vein and then I go to the bronchus and last to the fissure. In the robotic approach, it is to the contrary. So I can tell you that they are very different. When I do the robotic approach, as I am a little bit more used to the open approach, it seems like the open approach. VATS lobectomy is something else, because you did a thoracotomy, so you have an open approach. Even if it is minimally open, it is 5 cm, but it’s something different, I think. The other question, do I need to have VATS experience in robotic lobectomy? I can tell you that maybe there is no need. Even if maybe in my hands the big experience in VATS resection is something that I can use, and it is important, I think, but it is not necessary. This is my answer. So different techniques, different approach. I have a question for Olivia, and this is a question from a beginner. I am starting with the 4-robotic-arm system. In your opinion, Olivia, is it easier for a beginner to do a robotic lobectomy with a 3-arm instrument or is it easier with the 4-arm? In the beginning, with the 4-arm, it looks very, very difficult, but it is because I’m at the first step of the learning curve. Dr Fanucchi: I think that it is easier with the fourth arm because the surgeon has total control over the structure and can give the right tension on the lung when retracting the lung in order to expose the hilum. With the 3-arm, the assistant surgeon has to retract the lung, so the operating surgeon does not have total control over the structure. With the fourth arm, you can do this and you can change at every moment the right tension on the lung or of the sling when you surround the vessel. I think that it is important. Dr P.B. Rajesh (Birmingham, United Kingdom): I would like to ask a question to the VATS lobectomists and the robotic lobectomists here. With VATS lobectomy, really you have 2-D imaging, it’s two-dimensional, and then with robotic lobectomy, it is three-dimensional imaging. So if you change from being a VATS operator to a robotic operator, do you have any problems with your viewing and do you have any problems with converting from a 3-D situation back to VATS, if that’s how you want to proceed? Dr Melfi: I have a comment about the VATS and the robotic. When I started with the robotic lobectomy, I didn’t have any experience in VATS lobectomy. I just moved from the open to VATS. I found that this was extremely helpful for me because the technique is really, really similar to the open lobectomy. This is the first comment. I want to stress this point because many people think that it is very important to have this learning curve through the VATS procedure. About your question, the problem is when you have to convert. This is really a terrible situation. When you use the robotic system, you have magnified imaging. This means that you have 10 times the vision, the imaging, and you have a three-dimensional vision. When you convert, of course you have threedimensional vision, but you see very small structures. You have to reset your mind, your brain, because this is a really big problem. From VATS to robotic, maybe it is extremely complicated for me, probably because I don’t have this experience. Probably for someone who performs VATS lobectomy, it is not really complicated. For me, yes, it is complicated in terms of vision, imaging, but also to expose the structures, to approach the structures, it is completely different. I use the open technique. I just dissect.
THORACIC
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
European Journal of Cardio-Thoracic Surgery 46 (2014) 626–631 doi:10.1093/ejcts/ezu079 Advance Access publication 9 March 2014
Robotic lobectomy for lung cancer: evolution in technique and technology† Franca M.A. Melfi, Olivia Fanucchi*, Federico Davini, Gaetano Romano, Marco Lucchi, Paolo Dini, Marcello C. Ambrogi and Alfredo Mussi Division of Thoracic Surgery, Department of Cardiac Thoracic and Vascular Surgery, University of Pisa, Pisa, Italy * Corresponding author. University of Pisa, Via Paradisa 2, 56124 Pisa, Italy. Tel: +39-050-995211; fax: +39-050-995352; e-mail: [email protected] (O. Fanucchi). Received 2 October 2013; received in revised form 10 January 2014; accepted 15 January 2014
Abstract OBJECTIVES: The aim of this study was to analyse the results of robotic lobectomy for lung cancer. The evolution of technique and technology was evaluated. METHODS: During the period 2004–12, all patients who underwent robotic lobectomy for clinical early-stage lung cancer were retrospectively reviewed. The patients were divided into two groups. Group 1 included 69 patients operated by the first generation of surgical robotic system. Group 2 included 160 patients treated with the latest generation of surgical robotic system. Age, gender, comorbidities, operative time, docking time, conversion rate, morbidity, mortality and length of postoperative stay were compared in both groups. RESULTS: The two groups were homogeneous in terms of age, gender and comorbidities. Histopathological analysis showed 41 and 107 adenocarcinomas, 27 and 37 squamous cell carcinomas, 1 and 7 large cell carcinomas, in Groups 1 and 2, respectively, and 5 sarcomatoid carcinomas and 4 carcinoids in Group 2. The pathological stage for Group 1 was Stage I (48 cases), Stage II (17 cases) and Stage III (4 cases). For Group 2, Stage I was found in 115 cases, Stage II in 30 cases and Stage III in 15 cases. The mean operative time was 237 (standard deviation (SD) + 66.9) and 172 (SD ± 39.6) min for Groups 1 and 2 (P = 0.002), respectively. The conversion rates were, respectively, 10.1 and 5.6% (P = 0.21), mortality rates 1.4 and 0% (P = 0.30) and morbidity rates 22 and 15% (P = 0.12). The mean length of postoperative stay was 4.4 (SD ± 3.1) and 3.8 days (SD ± 2.2) (P = 0.26), respectively. CONCLUSIONS: This study suggests a positive trend in the outcomes for patients who underwent the upgraded robotic system surgery compared with those treated by the standard system. Keywords: Minimally invasive surgery • NSCLC • Surgical technique • Early stage • Robotics
INTRODUCTION Robotic surgery can be defined as a procedure that adds a computer technology-enhanced device to the interaction between a surgeon and a patient during a surgical operation. Currently, the da Vinci system™ (Sunnyvale, CA, USA) is considered the only complete surgical system. In 2002, we reported the first series of robotic lobectomy for non-small-cell lung cancer (NSCLC) [1]. During last decades, the robotic system underwent improvements and upgrades, and at the same time, different techniques were described and developed for performing robotic lobectomy [2–4]. In our centre, all three generations of robotic system were applied to perform a wide range of surgical procedures (da Vinci standard, S and Si), with the intent to develop, standardize and optimize the technique of robotic lobectomy. In this study, the different techniques were analysed in relation to the different generations of
† Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013.
robotic system (standard vs S/Si), comparing operative and postoperative data.
MATERIALS AND METHODS We retrospectively reviewed all patients who underwent lobectomy with the da Vinci Surgical System™ (Sunnyvale, CA, USA), for clinical early-stage NSCLC, during the period 2004–12. The patients were divided into two groups based on the generation of the robotic system: Group 1 (Vinci standard); Group 2 (da Vinci S/Si) (Table 1). Demographic and clinical data were collected for each group. The main end-point of this study was to analyse the results of robotic lobectomy, in terms of the evolution of the technique related to technological development. All surgical procedures were performed by the same team (including scrub nurse). Operative time (defined as the time between skin incision and skin closure), docking time (defined as the time necessary for surgical cart positioning and robotic arms placement in the surgical
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
627
Table 1: Main features of robotic systems First generation (standard) 3D image Three robotic arms 0° scope (12 mm) Second generation (S) 3D-high definition vision 30° stereo endoscopes (12 and 8 mm) Four robotic arms Large range of motion robotic instruments Extended length instruments Third generation (Si) Advanced 3D-high definition visualization with up to ×10 magnification Dual console capability Figure 1: Port mapping for Group 1 patients (three-arm robotic system).
THORACIC
field), conversion rate, length of stay, morbidity and mortality were analysed with regard to the two groups. All patients signed the detailed informed consent. The Institutional review board approved this study.
Preoperative staging Patient evaluation was the same for both groups: chest X-ray, chest and upper abdomen computed tomography (CT) scan imaging with contrast media enhancement and positron emission tomography (PET) scan. Invasive staging procedures, such as mediastinoscopy, were omitted in patients with stage peripheral I NSCLC and negative PET scan, according to the European society of thoracic surgeon guidelines [5]. Comorbidity scores were collected by using the Adult Co-Morbidity Evaluation scoring system (ACE-27) [6].
Figure 2: Port mapping for Group 2 patients (four-arm robotic system).
Group 2. Group 2 included those patients operated by the latest
Surgical techniques All patients underwent double-lumen intubation and were positioned in the lateral decubitus position, in the same way as for posterolateral thoracotomy. In case of female patients, a pillow was positioned under the hip in order to have the patient’s hip and scapula at the same level.
Group 1. Group 1 included those patients operated by the first
generation system (Table 1). The first port was placed in the seventh or eighth inter-costal space on the midaxillary line for the camera (0°), the other port in the sixth or seventh inter-costal space in the posterior axillary line (one robotic arm), and a ‘service entrance’ was created in the fourth or fifth inter-costal space (3–4 cm in length) for the other robotic arm. An additional small incision was made between the ‘service entrance’ and the camera port for the assistant surgeon to insert conventional thoracoscopic instruments (Fig. 1). The dissection of the hilar structures was robotically performed with the two arms. Each structure was cleaned and surrounded by a sling. Endoscopic staplers were used to divide the vein, the arteries and the lobar bronchus. They are positioned by an expert surgeon with a traditional video assisted thoracic surgery (VATS) bidimensional vision. Small arteries were ligated (Linen 2.0) and then divided. No CO2 insufflation was utilized.
generation systems with four arms, using a totally endoscopic approach (Table 1). The first port was placed in the seventh to eighth inter-costal space on the midaxillary line for the camera (12 mm, 30° angled down scope). The other port incisions (8 mm) were performed in the fifth to sixth inter-costal space on the anterior axillary line, sixth to seventh inter-costal space on the posterior axillary line and in the auscultatory area (for the fourth arm) (Fig. 2). A utility port between the camera port and the anterior robotic port can be positioned for the assistant surgeon, who has to introduce a stapler or suction unit. The fourth arm was used for retracting the lung, allowing the exposure of the hilar structures, and was under direct control of the operating surgeon. The dissection of all hilar structures was achieved with the robotic instruments. Division of the lobar vein, the arteries and the lobar bronchus was performed with the endoscopic stapler. They are positioned by a young surgeon under bidimensional vision. Small arteries were ligated (Linen 2.0). CO2 insufflation was applied at a maximum level of 6–8 mmHg in order to facilitate lung collapse, and push down the diaphragm. In addition, it can be useful especially in emphysematous patients, in whom air trapping often occurs.
Operative and postoperative data Operative time, docking time, conversion rate, length of stay, morbidity and mortality were recorded for each patient.
628
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
Table 2: Clinical and demographic features of Groups 1 and 2
Number Gender (M : F) Mean age (SD) Mean ACE-27 score Site of the lesions Left upper lobe Left lower lobe Right upper lobe Middle lobe Right lower lobe
Group 1
Group 2
P-value
69 40 : 29 63.6 years (SD 7.7) 1.7 (SD 1.2)
160 101 : 59 64.3 years (SD 10.5) 1.8 (SD 1.1)
0.46a 0.64b 0.65 b
12 22 7 10 18
20 32 35 34 39
χ test. Unpaired Student’s t-test ACE-27: Adult Comorbidity Evaluating scoring system-27; SD: standard deviation.
a 2 b
Complications were stratified according to the Clavien–Dindo classification [7]. Follow-up for all patients was performed at our ambulatory unit, with a physical examination. A chest X-ray was performed three months after surgery, and subsequently chest and upper abdomen CT scan was performed every 6 months, for the first 12 months and then every year.
Statistical analysis The two cohorts were compared on the basis of clinical and demographic data. Statistical analysis was performed using Statistica software version 7.0 for PC (Stat-Soft, Inc., Tulsa, OK, USA). The measures were expressed in terms of mean and standard deviation (SD). The unpaired Student’s t-test, and the χ 2 test or Fisher’s exact test were used to compare the distributions of continuous data and categorical measures, respectively. Actuarial overall survival was estimated by Kaplan–Meier’s method. The log-rank test was used to compare survival between the two groups. A probability value 5 days) (9 cases; Grade I: 7 patients, Grade IIIa: 2 patients); supraventricular arrhythmia (3 cases; Grade II: 3 patients), medically resolved; acute renal failure (1 case; Grade II), medically treated and resolved; and pleural effusion (2 cases; Grade II: 2 patients), medically resolved. In Group 2, morbidity consisted of prolonged air leaking (>5 days) (11 cases; Grade I: 8 patients, Grade IIIa: 3 patients); supraventricular arrhythmia (7 cases; Grade II: 7 patients), pharmacologically treated and resolved; atelectasis (2 cases; Grade IIIa: 2 patients), requiring bronchoscopic aspiration; pleural effusion (1 case; Grade II); urinary retention (1 cases; Grade IIIa); and wound infection (1 case; Grade I). There was no statistically significant difference between the two groups in terms of morbidity (P = 0.12). The mean postoperative stay was 4.4 days (SD ± 4.6) for Group 1, and 3.8 (SD ± 2.2) for Group 2, with no statistically significant difference. Histopathological results were, respectively, 41 and 107 adenocarcinomas, 27 and 37 squamous cell carcinomas, 1 and 7 large cell carcinomas, for Groups 1 and 2, and 5 sarcomatoid carcinomas and 4 carcinoids for Group 2. The pathological stage was I (48 cases), II (17 cases) and III (4 cases) for Group 1, and was I (115 cases), II (30 cases) and III (15 cases) for Group 2. At a mean follow-up of 29 months (SD ± 12.7), the actuarial overall 5-year survival rate was 79%. This rate increased up to 89%, when Stage I is considered. The actuarial 5-year overall survival rate was 78 and 80% for Group 1 and Group 2, respectively, with no statistically significant difference.
DISCUSSION ‘Robotic surgery’ is an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted. For the purposes of this paper, we define robotic surgery as a surgical procedure that comprehends a computer technologyenhanced device, which is under the direct control of the surgeon, during the interaction between the surgeon and the patient. The first robotic system approved by the US Food and Drug Administration (FDA) to be used in laparoscopic surgery was Automated Endoscopic System for Optimal Positioning [8]. Subsequently, the same company (Computer Motion, Inc., Goleta, CA, USA) developed the ZEUS system to assist surgeons in minimally invasive surgery [9–11]. In parallel, the Vinci Surgical System was developed by Intuitive Surgical (Sunnyvale, CA, USA) and cleared by the FDA for laparoscopy and cardiac surgery [12–14]. Currently, the da Vinci Robotic system is the only complete surgical system applied in a wide range of surgical procedures. In 2002, we reported the encouraging results of five pulmonary lobectomies performed with the aid of robotic technology [1]. Subsequently, other authors and we described the utilization of a robotic system to perform lower lobectomy for Stage I NSCLC, demonstrating the safety and feasibility of this procedure [2–4, 15]. However, since that period many changes have happened with regard to the robotic system, robotic instruments and consequently to the surgical technique. The aim of this study was to analyse how the technological development of the robotic system influenced the surgical technique. Our study revealed that there was no statistically significant difference between patients operated with the first generation of robotic system (Group 1) and those operated on with the second and the third generation of robotic system (Group 2), in terms of mortality and morbidity. This fact theoretically supports the safety and feasibility of such a procedure. However, we observed that the docking time and operative time were significantly lower in Group 2. This evidence is related to different facts. First, the necessity of adequate surgical training for the acquisition of new skills: with the gained experience of both surgeons and scrub nurses, the mean operative time and docking time decreases. Secondly, we have to consider that, at the beginning of this experience, there was no standardized technique to precisely follow and reproduce. Gharagozolo et al. [16] described a hybrid technique: the robotic arms were positioned at the eighth (camera), sixth and fifth inter-costal spaces for the dissection of the hilar structures. After the dissection phase, the robot was removed, and the surgeon returned to the operating table for vascular, bronchial and parenchymal division. Ninan and Dylewski described a robotic lobectomy with three arms: the robotic camera port was placed in the fifth or sixth inter-costal space, directly over the midfissure area. The two other ports were placed in the same inter-costal space anteriorly and posteriorly. A utility port was inserted over the 11th rib and bluntly tunnelled over the 9th rib, with entrance into the chest cavity through the 8th inter-costal space [17]. Subsequently, Cerfolio et al. [18] described robotic lobectomy with four robotic arms all positioned along the seventh rib, between the midaxillary line and the paravertebral line, at a minimum distance of 9 cm from each other. Our long experience with all generations of robotic system gave us the possibility of optimizing trocar positioning and standardizing the procedure. Port-mapping was the same for both the left and right sides, and
629
also for upper, middle or lower lobectomy. In addition, currently, at our centre, robotic lobectomies are routinely performed with a totally endoscopic technique. Thirdly, the instrumentation initially available was designed to be used on coronary vessels, thus often resulting inadequate for thoracic surgery. Subsequently, some instruments were clearly thoracic surgery, such as a lung grasper. In addition, there were different features of the second and third generation of robotic systems that gave advantages to surgeons. The possibility of a 30° endoscope permitted one to reach remote areas easily. The fourth arm allowed the surgeon to directly control the tension of the retracted structure (for example: lung or vessels surrounded by the sling), that was previously performed by the assistant surgeon under bidimensional vision. In addition, 3D-HD vision and new dedicated instruments with an extended length and large range of motion of robotic arms greatly enhanced the surgeon’s ability to manipulate the hilar structure and lobar vessels, permitting a safe dissection of the anatomical structures, also in a closed chest setting. Nevertheless, advanced training on robotic systems and dedicated instruments allowed the improvement of robotic application in lung lobectomy on large series. Some authors reported the utilization of a four-arm robotic system on a large cohort, for lobectomy [19, 20] and for segmentectomy [21] with a low conversion rate, and low morbidity and mortality, demonstrating its feasibility and safety. In a recent paper of Schmid et al. [22] a hybrid VATS-robotic minimally invasive sleeve lobectomy was reported without intraoperative complications, while Nakamura et al. [23] described a robotic broncoplastic right upper lobectomy. These studies underlined how the articulation of robotic instruments was really useful for suturing and performing anastomosis, also in remote anatomical areas. This reinforces the assumption that the robot offers a benefit mainly in very complex procedures. However, an important criticism is represented by the oncological results. The first key point is regarding lymph node dissection: some recent studies, comparing mediastinal lymph node dissection, have demonstrated equivalence between the robotic and open approaches, both for total number of resected lymph nodes, and the median number of N1 and N2 lymph node stations assessed [18, 20]. In addition, it should be recognized that robotics, owing to its 3D vision and to the articulation of the instruments, allowed greater confidence in dissecting N1 lymph nodes adjacent to the lobar arteries and bronchus. This may ultimately have an impact on oncological outcomes in the long term, but in the immediacy of the operation it permits easier and safer dissection. The second key point is represented by the long-term outcomes. The only study on a large cohort evaluating robotic lobectomy in terms of long-term survival is the one by Park et al. [24]. They obtained a 5-year overall survival rate of 80% with a median follow-up of 27 months, and it increases up to 91 and 88% when Stage IA and IB, respectively, are considered. In our study, the actuarial 5-year overall survival rate was 79% and appeared to be comparable with the data in the literature. Nevertheless, our study has some limitations. First of all, it is a retrospective analysis. Another limitation is the absence of other outcome measures, such as postoperative lung function, postoperative pain and quality of life. This study was focused on the technological aspect of robotic systems and on the evolution of the technique. In conclusion, we can say that the progress of technology, together with gained experience, permitted the standardization
THORACIC
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
630
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
of the technique, applying the robotic system in a safe way. Currently, robotic lobectomy should not be considered experimental, but an established minimally invasive thoracic surgical technique. The acquired surgical skills, long experience, evolution of the technology and standardization of the technique permitted one to perform minimally invasive lobectomy in a safe manner, offering advantages also in complex procedures. However, this technique should be applied in high-volume referral centres, with a dedicated team (surgeon, scrub nurse, anaesthesiologist) with adequate skills. Conflict of interest: none declared.
[20] Veronesi G, Galetta D, Maisonneuve P, Melfi F, Schimid RA. Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg 2010;140:19–25. [21] Pardolesi A, Park B, Petrella F, Borri A, Gasparri R, Veronesi G. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg 2012;94:929–34. [22] Schmid T, Augustin F, Kainz G, Pratschke J, Bodner J. Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. Ann Thorac Surg 2011;91:1961–5. [23] Nakamura H, Taniguchi Y, Miwa K, Fujoka S, Matsuoka Y, Kubouchi Y. A successful case of robotic bronchoplastic lobectomy for lung cancer. Ann Thorac Cardiovasc Surg 2013;19:478–80. [24] Park H, Melfi F, Mussi A, Maisonneuve P, Spaggiari L, Da Silca RKC et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 2012;143:383–9.
REFERENCES [1] Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864–8. [2] Ashton RC Jr, Connery CP, Swistel DG, DeRose JJ Jr. Robot-assisted lobectomy. J Thorac Cardiovasc Surg 2003;126:292–3. [3] Bodner J, Wykypiel H, Wetscher G, Kirkhmayr W, Freund MC, Margreiter R et al. First experiences with the da Vinci operating robot in thoracic surgery. Eur J Cardiothorac Surg 2004;25:844–51. [4] Park BJ, Flores RM, Rusch VW. Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results. J Thorac Cardiovasc Surg 2006;131:54–9. [5] De Leyn P, Lardinois D, Van Schil PE, Rami-Porta R, Passlick B, Zielinski M et al. ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg 2007;32:1–8. [6] Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL Jr. Prognostic importance of comorbidity in a hostital-based cancer registry. JAMA 2004; 291:2441–7. [7] Seely AJ, Ivanovic J, Threader J, Al-Hussaini A, Al-Shehab D, Ramsay T et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010;90:936–42. [8] Miller DL, Allen MS. Set-up and present indications: video-assisted thoracic surgery. Semin Thorarc Cardiovasc Surg 1993;5:280–3. [9] Rechenspurner H, Damiano RJ, Mack M, Boehm DH, Gublins H, Deter C et al. Use of voice-controlled and computer-assisted surgical sysyem ZEUS for endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999;118:11–6. [10] Stephenson ER, Sankholkar S, Ducko CT, Damiano RJ Jr. Robotically assisted microsurgery for endoscopic coronary artery bypass grafting. Ann Thorac Surg 1998;66:1064–7. [11] Boehm DH, Reichenspurner H, Gulbins H, Detter C, Meiser B, Brenner P et al. Early experience with robotic technology for coronary artery surgery. Ann Thorac Surg 1999;68:1542–6. [12] Cichon R, Kappert U, Schneider J, Schramm I, Gulielmos V, Tugtekin SM et al. Robotically enhanced “Dresden technique” with bilateral internal mammary artery grafting. Thorac Cardiovasc Surg 2000;48:189–92. [13] Chitwood WR Jr, Nifong LW, Elbeery JE, Chapman WH, Aldrecht R, Kim V et al. Robotic mitral valve repair: trapezoidal resection and prosthetic annuloplasty with the da Vinci surgical system. J Thorac Cardiovasc Surg 2000;120:1171–2. [14] Meininger DD, Byhahn C, Heller K, Gutt CN, Westphal K. Totally endoscopic Nissen fundoplication with a robotic system in a child. Surg Endosc 2001;15:1360. [15] Melfi FMA, Ambrogi MC, Lucchi M, Mussi A. Video Robotic Lobectomy. Multimed Man Cardiothorac Surg 2005;doi:10.1510/mmcts.2004.000448. [16] Gharagozloo F, Margolis M, Tempesta B, Strother E, Najam F. Robotassisted lobectomy for early-stage lung cancer: report of 100 consecutive cases. Ann. Thorac Surg 2009;88:380–4. [17] Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38: 231–2. [18] Cerfolio RJ, Bryant BS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011;142:740–6. [19] Augustin F, Bodner J, Wykypiel H, Schwinghammer C, Schmid T. Initial experience with robotic lung lobectomy: report of two different approaches. Surg Endosc 2011;25:108–13.
APPENDIX. CONFERENCE AND DISCUSSION Dr. R Milton (Leeds, United Kingdom): I have some comments and then, if I may, two more general questions. This paper aims to analyse the evolution of the technique of robotic lobectomy using different generations of the DaVinci system. However, this is a niche market. I work at St. James University Hospital in Leeds in the UK. I have to confess, although we have the DaVinci system in our hospital, it is used by the urologists, the paediatric surgeons, and general surgeons. Certainly we do not use it. Unless our hospital purchases another robot, which I really doubt will ever happen, I don’t think I will ever get to use the robot in my own practice. So the way I see it, patient selection for robotic procedures is in part determined by geography, i.e., the patient happens to live in the catchment area of a thoracic department that has a DaVinci robot. So I don’t feel I am in a good position to criticize your paper; however, I applaud it. This remains an extremely important paper because it promotes the incorporation of new ideas and technological advancement in our specialty and, consequently, it does warrant discussion at this meeting. In group 2 you make use of an additional robot arm, a 30-degree camera, and CO2 insufflation. You demonstrate clear progression in terms of reduced operating times and, although not significant, fewer conversions. You reinforce in your manuscript something which is extremely important: the necessity of adequate training and experience that has been gained, not only by you, the surgeon, but by the entire surgical team. Now, my colleagues and I in Leeds are minimally invasive enthusiasts. Last year we performed 140 VATS lobectomies, which is about 50% of all of our lobectomies. I believe that if a patient has an early-stage cancer, the operation of choice is a VATS lobectomy. If the surgeon does not perform VATS lobectomies, they should give the patient the choice of changing to a surgeon who does. So my first question is this. Is robotic lobectomy horses for courses? In other words, should this technique, excellent though it is, simply be seen as a tool for fortunate enthusiasts or should the use of the robot in thoracic surgery become more generalized? My second question is, what will the future bring? Dr Fanucchi: Excuse me, can you repeat the first question? Dr Milton: Yes. Should this technique be seen as a tool for fortunate enthusiasts or should the use of the robot in thoracic surgery become more generalized? Dr Fanucchi: I don’t understand the question. I’m sorry. Can you say it in other words? Dr Milton: Yes. I will rephrase it. Do you think that you are just in a very fortunate position to be able to use the robot, and perhaps, since we are not fortunate to be in possession of one, we will just never get a chance to use it? Dr Fanucchi: We have had the opportunity to apply the robotic system since 2001 when it became available in our department, and we started our robotic programme for lobectomy in 2004. In the beginning, we had many difficulties in standardizing the technique and assembling an adequate surgical team to perform robotic lobectomy. Not only the surgeon who performs the robotic lobectomy and who is at the console of the robotic system, but also the assistant surgeon and the scrub nurse have to be prepared for this kind of operation in order to prevent any possible complications, related not just to the operation itself, but also to the technology of the robotic system. So all of this was not so easy to manage at the beginning of our experience. For this reason, we decided to perform a service entrance in order to have safer control of the operative field during the operation. We gained experience and decided to apply a totally endoscopic technique. At the beginning of our experience with the total endoscopic technique, we
also performed an additional utility port for the suction, for the introduction of the stapler, because not all Dr W. Klepetko (Vienna, Austria): Sorry to interrupt you, but maybe this is a very general question which should be answered by the senior author of the paper. I’m sure Franca has answered the question many times before and maybe you will repeat your answer that you have given before. Should the robotic technique be applied in a more general way or should it really be restricted to highly specialized enthusiasts, as you called it? Dr F. Melfi (Pisa, Italy): Robotic surgery, the robotic technique at present, is not only for the enthusiast, but it is clear that, if it is available, we can use it in our current practice. At the present time, there are not many possibilities to apply this technique, which is really, really expensive, but in the future, I think it will be possible to apply it in our work when there is a really good indication for a minimally invasive procedure. The point is, if you have a patient with the indication for a minimally invasive procedure for major lung resection, we have the possibility to apply this system because it is available in the department in our hospital. It is extremely valuable to be able to use this technique over the conventional minimally invasive technique. So it is not only for enthusiasts, it is just for people, for surgeons who have the opportunity to apply this technique. In the future, I hope that it will be possible for costs to decrease, making it feasible to apply this worldwide. It is a similar story as in VATS lobectomy. If you remember, in the beginning, it was extremely expensive and was only available in dedicated hospitals. Now it has changed. Probably there will also be a similar story for robotic lobectomy or for robotic procedures in thoracic surgery. Dr Klepetko: Thank you. Maybe you will continue with your discussion. Dr Milton: My second question was really probably an extension of what you just said. What will the future bring in terms of new technologies with the robot? Where do you see the robot technology going? Dr Melfi: The new technology developments probably will be the stapler, the robotic stapler, and the robotic stapler I think will be the switch, with a very huge application, especially in this particular field, in major lung resection. Probably it will take some years, again, for this to happen. Dr P. Tcherveniakov (Manchester, United Kingdom): Just a quick question regarding training. What was the experience of the lead surgeon performing the robotic lobectomies in terms of VATS lobectomy, and do you see VATS as a step towards robotic lobectomy or do you see it as an unnecessary step? Dr Fanucchi: When we started, we decided to directly apply this technique from the open surgery to the robotic one. We had little experience in VATS lobectomy. We think that the robotic system can combine the advantages of VATS lobectomy in terms of minimally invasive surgery with the high-definition vision and the advantages of open surgery with regard to the articulation of the instruments inside the chest cavity. So we think that it is not necessary to have experience in VATS lobectomy. Dr R. Schmid (Berne, Switzerland): In my centre we don’t do that much robotic lobectomy because I think the technology is not really ready, as Franca said, but we do a lot of mediastinal resections, and we experienced the switch from thoracoscopic mediastinal thymectomy, thymoma resection, to the robotic technique. I think it was very easy because there is a clear advantage, and this will also happen with new devices for lobectomy. In general, in surgery we are quite slow in introducing minimally invasive or new technology. Endoscopic surgery was introduced in the early ‘90s, and 20 years later, we were speaking about resection of early lung cancer. So we are quite slow. The first to introduce minimally invasive endoscopic surgery were the gynaecologists. It was not even the surgeons who started to do appendectomy and cholecystectomy. So we have to think a bit about how we surgeons introduce new technologies, and I think we should be a bit more open to introducing new techniques in order to evaluate and establish them more quickly.
631
Dr G. Cardillo (Rome, Italy): I would like to just discuss a point regarding VATS and robotic lobectomy. In my hospital, we have started both programmes. Up to now, my experience is greater with VATS lobectomy than with robotic lobectomy, but the numbers are very, very small. I can tell you that there is a wide difference between the two techniques. In my opinion, robotic lobectomy seems more close to the open approach because you follow the same rule. For example, I start it with the artery, then I ligate the vein only when all the vessels are ready. In VATS, it is the contrary. I do the anterior approach and I start with the vein. I cut the vein and then I go to the bronchus and last to the fissure. In the robotic approach, it is to the contrary. So I can tell you that they are very different. When I do the robotic approach, as I am a little bit more used to the open approach, it seems like the open approach. VATS lobectomy is something else, because you did a thoracotomy, so you have an open approach. Even if it is minimally open, it is 5 cm, but it’s something different, I think. The other question, do I need to have VATS experience in robotic lobectomy? I can tell you that maybe there is no need. Even if maybe in my hands the big experience in VATS resection is something that I can use, and it is important, I think, but it is not necessary. This is my answer. So different techniques, different approach. I have a question for Olivia, and this is a question from a beginner. I am starting with the 4-robotic-arm system. In your opinion, Olivia, is it easier for a beginner to do a robotic lobectomy with a 3-arm instrument or is it easier with the 4-arm? In the beginning, with the 4-arm, it looks very, very difficult, but it is because I’m at the first step of the learning curve. Dr Fanucchi: I think that it is easier with the fourth arm because the surgeon has total control over the structure and can give the right tension on the lung when retracting the lung in order to expose the hilum. With the 3-arm, the assistant surgeon has to retract the lung, so the operating surgeon does not have total control over the structure. With the fourth arm, you can do this and you can change at every moment the right tension on the lung or of the sling when you surround the vessel. I think that it is important. Dr P.B. Rajesh (Birmingham, United Kingdom): I would like to ask a question to the VATS lobectomists and the robotic lobectomists here. With VATS lobectomy, really you have 2-D imaging, it’s two-dimensional, and then with robotic lobectomy, it is three-dimensional imaging. So if you change from being a VATS operator to a robotic operator, do you have any problems with your viewing and do you have any problems with converting from a 3-D situation back to VATS, if that’s how you want to proceed? Dr Melfi: I have a comment about the VATS and the robotic. When I started with the robotic lobectomy, I didn’t have any experience in VATS lobectomy. I just moved from the open to VATS. I found that this was extremely helpful for me because the technique is really, really similar to the open lobectomy. This is the first comment. I want to stress this point because many people think that it is very important to have this learning curve through the VATS procedure. About your question, the problem is when you have to convert. This is really a terrible situation. When you use the robotic system, you have magnified imaging. This means that you have 10 times the vision, the imaging, and you have a three-dimensional vision. When you convert, of course you have threedimensional vision, but you see very small structures. You have to reset your mind, your brain, because this is a really big problem. From VATS to robotic, maybe it is extremely complicated for me, probably because I don’t have this experience. Probably for someone who performs VATS lobectomy, it is not really complicated. For me, yes, it is complicated in terms of vision, imaging, but also to expose the structures, to approach the structures, it is completely different. I use the open technique. I just dissect.
THORACIC
F.M.A. Melfi et al. / European Journal of Cardio-Thoracic Surgery
