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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
Robotic Pulmonary Lobectomy
31
AndreiI.Gritsiuta, AbbasE.Abbas, andRomanV.Petrov
Introduction toRobotic Lobectomy
Lung cancer remains the leading cause of cancer-related mortality in the United
States, with over 56,000 lung cancer resection surgeries performed annually nationwide [47]. Following years of minimal progress, the combination of early detection
and advancements in treatment over the past 10–15years, along with better access
to these treatments, has resulted in improved survival rates for lung cancer patients.
However, despite these recent advances, the overall 5-year relative survival rate is
still a concerning 23% [26]. In 2024, there are approximately 235,000 new cases of
lung cancer expected, and the disease is projected to cause 125,000 deaths [54].
Anatomic lung resections remain the cornerstone of curative treatment for lung
cancer, whether performed alone or as part of a multimodal approach. The rst successful anatomic lung resection, a pneumonectomy for lung cancer, was performed
by Evarts Graham in 1933, setting a precedent for the surgical approach [19]. The
choice of anatomical unit to be resected—whether it be a segment, a lobe, or an
entire lung—depends on multiple tumor and patient factors, including lesion location, size, histology, pulmonary function, comorbidities, and the performance status
A. I. Gritsiuta
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
e-mail: gritsiutaai@upmc.edu
A. E. Abbas
Department of Thoracic Oncology, Warren Alpert School of Medicine at Brown University,
Providence, RI, USA
e-mail: abbas_abbas@brown.edu
R. V. Petrov (*)
Department of Cardiothoracic Surgery, John Sealy School of Medicine at University of Texas
Medical Branch, Galveston, TX, USA
e-mail: rvpetrov@utmb.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_31
427
428
A. I. Gritsiuta et al.
of the individual. Safe surgical techniques require meticulous precision in dissecting hilar bronchovascular structures. Traditionally, this has been achieved through a
thoracotomy, a large open incision, involving a division of extrathoracic muscles
with rib spreading to allow adequate surgical exposure and effective bimanual dissection. However, this approach is associated with increased level of acute and
chronic pain and impaired respiratory function, leading to increased rates of postoperative morbidity, especially pulmonary complications such as atelectasis and pneumonia. Therefore, thoracic surgeons have sought less invasive alternatives to
traditional open procedures.
The rst breakthrough in the eld was the introduction of the video-assisted
thoracoscopic surgery (VATS) technique in the 1990s [34]. VATS allows for lobectomies to be performed through small incisions using a video thoracoscope and
modied instruments, signicantly reducing patient morbidity and recovery time,
compared to the traditional open thoracotomy. However, VATS lobectomy technique differs signicantly from the thoracotomy approach. Due to ergonomic limitations and the transition of the viewing angle in VATS to a more anterior rather than
superior position, all dissection of the hilum is performed in an anterior to posterior
manner, leaving the division of the ssure for last. Posterior dissection, which is
sometimes necessary, is particularly challenging with the VATS approach. Transition
from an open technique to VATS requires signicant changes in surgical strategies
and a complete new set of skills. Surgeons face multiple challenges with the adoption of the new VATS technique, including impaired precision due to the distance
and the use of, inexible, “straight stick” instruments. The counterintuitive fulcrum
motion of the instruments, xated at the port site in the chest wall, and the antiparallel convergent optic position in the multiport approach further complicate the procedure. Even more challenges arise in the uniportal conguration, where the limited
working area leads to space conicts. These challenges extend the learning curve
and impair adoption of the technique for lower-volume surgical centers. This has
translated into relatively stagnant rates of VATS adoption for oncologic lung resections in thoracic surgery.
In contrast, robotic-assisted thoracic surgery (RATS) offers numerous advantages over traditional VATS approach, including three-dimensional (3D) binocular
visualization, eld magnication, scaled motion, tremor ltration, and wristed
instruments with increased freedom of motion, thereby enhancing surgical eld
visualization, depth perception, and precise dissection. These advantages facilitate
a smoother transition to minimally invasive robotic lung resections, allowing surgeons to more easily replicate traditional surgical techniques in the new environment. Unsurprisingly, robotic portal resection has been likened by some surgeons to
a “virtual thoracotomy.” This technique offers surgeons the visual illusion of viewing the lung through an open chest while allowing for natural bimanual wristed
maneuvers to address the anatomy effectively [2]. Early clinical experiences reporting on safety and feasibility outcomes have generated signicant interest in the
robotic approach. Currently, the platform is widely accepted for providing all the
benets of a minimally invasive approach without the technical difculties associated with VATS.However, it also raises questions regarding the learning curve,
31 Robotic Pulmonary Lobectomy
429
costs, and perioperative outcomes. Reports suggest that prociency in robotic
lobectomies can be achieved after 20 procedures, whereas VATS lobectomy prociency ranges from 50 procedures for the multiportal approach to 140 for uniportal
thoracic surgery [27]. As such, robotic technology may facilitate the expansion of
minimally invasive lobectomies to surgeons who have not adopted traditional VATS
techniques, making it more accessible to a broader cohort of surgeons and
patients alike.
First robotic lobectomies were documented by Mel etal., Morgan etal., and
Ashton etal. as far back as 2002 and 2003, focusing initially on patients with earlystage lung cancer [3, 35, 36]. These pioneering procedures demonstrated the feasibility and potential benets of robotic technology in thoracic surgery. Since then,
robotic systems have signicantly evolved. Early RATS closely mirrored the techniques used in VATS, with initial port placement strategies developed using nowadays obsolete da Vinci S/Si platforms. However, introduction of more versatile da
Vinci Xi robot in 2016 further revolutionized port mapping strategy and the eld of
pulmonary lobectomy.
Despite growing popularity of robotic surgery among thoracic surgeons worldwide, ongoing debate regarding the optimal technique for lung resections remains
unsettled. The four-arm, look-up-view method with low robotic ports placement in
the seventh to ninth intercostal spaces provides a view of the intrathoracic cranial
side from the caudal position and is currently the mainstream approach globally
[43]. This method has evolved to incorporate adaptations such as utilizing fewer
ports or skin incisions. Conversely, new approaches have emerged that align the
patient’s intrathoracic craniocaudal axis with the horizontal direction of the surgeon’s console monitor. One notable innovation is the horizontal open thoracotomy
view, or horizontal view approach [49]. These advancements reect the continuous
evolution and optimization of port placements in RATS, driven by technological
progress and the renement of surgical techniques.
Robotic technology evolution has also affected the stapling technology. A propensity score matching analysis of robotic lobectomies, identied in the Premier
hospital database, compared perioperative outcomes, healthcare resource utilization, and costs between robotic and handheld staplers [63]. The analysis demonstrated that robotic staplers were associated with signicantly lower risks of
perioperative bleeding, conversion, possible air leaks, and overall complications
without an increase in total costs of the procedure. Additionally, the robotic platform signicantly facilitates teaching and training. A dual console enables two surgeons to operate together, allowing for seamless transfer of instrument control
between an expert and a trainee as needed. Utilizing telestration, the faculty surgeon
can guide the trainee through increasingly complex tasks while maintaining complete visual oversight and control of the procedure. Furthermore, surgical simulators have been developed to enhance trainees’ prociency with implementation of
this advanced technology.
While robotic surgery provides numerous advantages, it also has certain limitations. The high initial capital costs represent a signicant nancial investment, rendering it inaccessible to many surgeons and patients in smaller communities,
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A. I. Gritsiuta et al.
especially globally, in developing countries. A systematic review and meta-analysis
indicated an increased cost of robotic lobectomies per patient: $16,645 compared to
$13,310 for VATS [20]. This cost difference was largely attributed to the expense of
robotic equipment, with no statistically signicant differences in complication rates.
Although some studies have demonstrated equivalence between RATS and VATS in
terms of outcomes, most indicate that the overall direct cost of robotic lobectomy is
higher by approximately $3000 to $5000 per procedure [42, 48, 55, 58]. When both
direct and indirect costs are considered, the robotic procedure remains more expensive than VATS; however, both are less costly than an open thoracic procedure [37,
40]. Nonetheless, robotic surgery may become economically feasible and protable
in high-volume settings with distribution of the robotic capital costs. In an analysis
of costs between RATS and VATS lobectomies across all hospitals, the robotic
approach was found to be more expensive when hospital volume was not considered. This cost difference was primarily attributable to operating room and supply
costs. However, for hospitals performing more than 25 annual lobectomies, there
was no signicant difference in total costs between these approaches [39]. A recent
study indicated that positive net margins and protability were achieved in robotic
general thoracic surgical cases compared to other robotic surgery service lines and
open thoracic procedures [1]. These nancial benets were largely due to managing
variable costs associated with the length of stay. This nding was corroborated by
another cost analysis comparing RATS and VATS [12]. In this analysis, total direct
costs, including direct supply expenses, were not signicantly different between
two minimally invasive techniques ($6621 versus $6483; P=0.784). On the other
hand, median total operating costs and total unit support costs, both closely tied to
length of stay, were lower in the RATS group. In a study involving 697 patients who
underwent pulmonary lobectomy, an analysis utilizing propensity score adjustment
by inverse probability of treatment weighting (IPTW), found that both RATS and
VATS lobectomy demonstrated similar costs and enhanced clinical effectiveness
compared to the open thoracotomy approach [24]. The IPTW-adjusted direct costs
showed no signicant differences between the groups (robotic $17,223 versus VATS
$17,260 versus thoracotomy $18,075, P=0.48). Furthermore, there were no signicant differences in indirect costs or overall hospital charges among the three
approaches. Conversely, robotic surgery for simple outpatient procedures may not
be cost-effective at present [53]. Additionally, the setup time for robotic systems can
be longer than other approaches. Surgeons also lose the palpable feedback during
lung assessment, which is essential in lung resections, at least with previous generation robotic platforms. Moreover, the lack of haptic feedback means that surgeons
do not receive tactile sensations that help them gauge tissue resistance and texture.
However, the introduction of the new-generation surgical robot, Intuitive DV5,
addresses some of these concerns. These considerations must be carefully evaluated
when determining the most suitable surgical approach for each patient. Overall, the
expected benets of machine-surgeon interactions still need to be proven superior
to challenges such as cost, operating room management complexity, and the difculty of changing established surgical practices.
31 Robotic Pulmonary Lobectomy
431
Current Evidence
Over the past two decades, numerous studies have supported the adoption of robotic
lobectomy by demonstrating its safety, efcacy, and feasibility. Analysis of RATS
and VATS outcomes has largely shown similar results. Both techniques are associated with overall improved surgical outcomes, particularly decreased blood loss,
reduced postoperative pain, reduced chest tube durations and hospital stay, and
overall fewer complications compared to an open lobectomy [7, 14, 23]. This was
conrmed by analysis of the Premier hospital database, which evaluated 23,779
elective lobectomies from 2011 to 2015 [42]. The ndings demonstrated a lower
postoperative complication rate, shorter hospital stays, and decreased mortality in
the RATS group. Additionally, patients in the robotic lobectomy group were more
likely to be discharged home rather than to a transitional care facility. During this
period, the authors noted an approximately threefold increase in the adoption of
robotic techniques. When comparing RATS to VATS, the robotic group demonstrated a lower conversion rate to thoracotomy, a lower overall postoperative complication rate, and a shorter hospital stay. The postoperative mortality rates for
RATS and VATS were similar, and there was no signicant difference in iatrogenic
injuries. Another study conducted on 33,095 cases of lobectomies and segmentectomies from 2008 to 2010 compared RATS with VATS [21]. The results indicated that
RATS had lower mortality rates (0.2% versus 1.1%), shorter hospital stays (5.9days
versus 6.3days), and fewer complications (43.8% versus 45.3%). However, these
differences did not reach statistical signicance, potentially due to the underpowered robotic group (only 430 patients in the RATS group versus 12,427 patients in
the VATS group). Other studies demonstrated a higher number of lymph nodes harvested, improved postoperative and 30-day complication rates, and signicantly
lower incidence of conversion to an open surgery in the robotic group compared to
VATS [29, 48]. Conversion rates from minimally invasive to open lobectomy were
specically examined using data from The Society of Thoracic Surgeons General
Thoracic Surgery Database [52]. Analyzing 27,695 minimally invasive lobectomies, authors found that the conversion rate was higher in the VATS group (11%)
compared to the RATS group (6%; P<0.001). Anatomical challenges were identied as the primary reason for conversion in both the RATS and VATS groups, indicating that the robotic platform may offer enhanced ability of managing complex
anatomical scenarios. However, it was noted that emergency conversions due to
bleeding were signicantly more frequent in the RATS group, often necessitating
intraoperative blood transfusions. This nding suggests that surgeons might be
more inclined to undertake complex cases with the robotic technology, potentially
avoiding early conversion to thoracotomy. Despite these adverse outcomes, the data
imply that surgeons may feel safer and more condent in pursuing a minimally
invasive approach when utilizing the robotic platform.
Most studies, including systematic reviews and meta-analyses, suggest there is
no difference in outcomes between the two techniques [13, 62]. A comprehensive
meta-analysis of 145 studies encompassing 369,793 patients revealed no signicant
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A. I. Gritsiuta et al.
differences in terms of adverse events, the number of lymph nodes dissected, lymph
node stations evaluated, or nodal upstaging between RATS and VATS [38]. However,
when considering the cost of the procedure, RATS lobectomy proved to be more
expensive. Another meta-analysis of 14 studies including a total of 7438 patients
conrmed these results demonstrating comparable outcomes in terms of mortality
rates, blood loss, operative time, ICU stay, chest tube duration, length of hospital
stay, and complication proles [30] although the study showed benets of robotic
lobectomy in terms of shorter duration of narcotic use and quicker time to return to
regular activities. Similar ndings were observed in a retrospective case-control
analysis, which highlighted that patients in the RATS group required less narcotic
analgesia and were able to resume normal activities sooner compared to those
undergoing VATS [31].
In a comprehensive retrospective multicenter study examining Clavien-Dindo
grade III or higher events in 1264 patients, an overall major complication rate of
4.3% was observed [5]. Pneumonia was the most common major complication,
occurring in 1.2% of patients, followed by prolonged air leak, which occurred in
0.9% of patients. The overall mortality rate was 0.6%, with a 30-day mortality rate
of 15% for those who developed major complications. Factors increasing the risk of
major complications included male gender, lower FEV1 and DLCO, neoadjuvant
therapy, and extended resections. Notably, the stage of the disease was not a signicant risk factor for complications, although 74.1% of the patients were in clinical
stage I.Naturally, the robotic approach has been shown to be benecial for such a
challenging surgical population as octogenarians, offering improved outcomes,
including shorter hospital stays, fewer postoperative complications, and higher rates
of discharge to home, compared to open thoracotomy according to a retrospective
cohort study [50]. Cerfolio etal. highlighted the reliable performance of this platform in sublobar resections based on their initial experience with the rst 100
planned robotic anatomic segmentectomies [6, 9, 10]. In this study, 79% of patients
underwent curative lung cancer surgery using a fully robotic four-arm approach,
achieving R0 resection with a median of 19 lymph nodes dissected. There were no
conversions to open surgery, although 7% of the cases required an intraoperative
conversion to lobectomy due to inadequate margins or difculties with nodule
localization.
As more surgeons receive training in robotic techniques and technology continues to advance, the rate of robotic lobectomies is expected to increase. This trend
promises to offer patients a minimally invasive option that is likely to result in
improved overall outcomes for surgical resections of lung cancer.
Surgical Technique
The authors previously described their preferred technique of the robotic lobectomy
[46]. The procedure is performed using a completely portal-based, four-arm
approach with a 10mm Hg capnothorax. All ports are strategically placed in the
eighth intercostal space along the midclavicular, anterior axillary, posterior axillary,
and scapular lines, irrespective of the laterality or type of lobectomy being
31 Robotic Pulmonary Lobectomy
433
a b
Fig. 31.1 Robotic port placement strategy. (a) Schematic depiction of the Xi robotic port place-
ment for lobectomy. (b) Intraoperative image of the lobectomy ports
performed (Fig.31.1a). Notably, a utility incision is not utilized in this technique
(Fig.31.1b). All assistance is provided through a 15mm assistant port, advanced
through a subcostal position in the projection of the tenth intercostal space. This
port is utilized for specimen extraction (lymph nodes and pulmonary parenchyma at
the end of the procedure), the delivery of various supplies and disposables (such as
vessel loops and rolled gauze “cigars”), and clearing of the surgical eld with a suction instrument. Authors avoid using assistant-controlled handheld staplers, exclusively relying on robotic technology controlled by the console surgeon. The benets
of the portal-based approach include the creation of a tension capnothorax, which
results in an enlarged working space due to the contralateral shift of the mediastinum and downward displacement of the diaphragm with expansion of the intercostal spaces. In addition, this improves lung atelectasis and facilitates pneumodissection
of the hilar planes, thereby enhancing the visualization and identication of anatomical structures.
For the standard pulmonary resection, we adopted a “minimalist” lean philosophy, popularized by R.Cerfolio [6, 9, 10]. We have eliminated the use of beanbags,
axillary rolls, arm boards, epidurals, central lines, urinary catheters, and arterial lines
(Fig.31.2a). Following the induction of general anesthesia, lung isolation is achieved
either with a bronchial blocker or a double-lumen tube (Fig.31.3a, b). We have a
strong preference for using a bronchial blocker for intraoperative lung isolation
(Fig.31.3b). The bronchial blocker’s smaller prole allows for safer and easier airway dissection, facilitates pre- and post-procedure bronchoscopy by simply removing the blocker, and eliminates the need for potentially risky endotracheal tube
exchanges when the patient requires prolonged intubation postoperatively [25]. We
revert to using a double-lumen tube in cases of carinal resection, bilateral procedures, or instances of porcine bronchial anatomical variants during right-sided
resections (Fig.31.3a, c, and d). In the broader thoracic surgery community, there is
434
ab
Fig. 31.2 Patient positioning. (a) Patient position on the OR table. Please note absence of bean-
bag, axillary roll, and arm board. Gel rolls positioned along the chest and back, providing chest
elevation and brachial plexus protection. Arms are secured on the blankets in swimmers’ position
(135 upward). (b) Bed control positions during robotic lung lobectomy
A. I. Gritsiuta et al.
a
b
cd
Fig. 31.3 Lung isolation strategy and limitation in anatomical variants. (a) Left-sided double-
lumen endotracheal tube. (b) Fuji Uniblocker bronchial blocker device. (c) Porcine bronchus.
Bronchoscopy view. Please note separate takeoff of the RUL bronchus from distal trachea, above
RMSB. (d) CT image of the coronal reconstruction of the porcine bronchus anatomical variant
31 Robotic Pulmonary Lobectomy
435
a reluctance toward the use of bronchial blockers due to perceived difculties in their
management. However, the use of the Fuji Uniblocker (Fuji Systems Corporation,
Tokyo, Japan) mitigates the majority of these challenges due to the angled nature of
its tip, which facilitates easier placement in the desired location compared to the
more elaborate process required for Arndt blocker placement (Cook Medical,
Bloomington, Indiana, USA). Additionally, the Rusch double EZ-blocker (Teleex
Medical, Morrisville, North Carolina, USA) further decreases the challenges associated with lung isolation, although the authors have limited experience with its use.
The patient is positioned on the contralateral side and secured on two medium gel
rolls, which are placed along the chest and back (Fig.31.2a). The bed is exed at a
point between the lower ribs and the iliac wing. The bed is then transitioned to a 20°
reverse Trendelenburg position with a −25° back down position, resulting in approximately 155° exion (Fig.31.2b). The patient’s arms are secured over folded blankets in a swimmer’s position, angled at 135° toward the head. The patient is further
secured with two straps of 3-inch tape applied directly to the skin without a towel,
and a restraining belt is used for additional security. A lower body forced air warming
blanket is also positioned to maintain the patient’s body temperature (Fig.31.2a).
Due to the rotational capability of the Xi and DV5 surgical platforms (Intuitive
Surgical, Sunnyvale, California, USA), the patient cart can be positioned on either
side of the patient. The authors prefer docking the robot from the back, as this facilitates better access for the bedside assistant to the chest. However, the robot’s position remains unchanged regardless of the laterality of the procedure, as robot
relocation signicantly extends the turnover time between cases.
The rst 8mm camera port is placed at the anterior axillary line. To ensure safe
initial air entry and avoid injury to the raised diaphragm due to lung isolation, a
Kelly surgical clamp is inserted rst. This is followed by the initiation of a 10mm
Hg capnothorax, resulting in visible downward displacement of the diaphragm.
Subsequently, a 12mm robotic port is inserted at the midclavicular and posterior
axillary line locations. Finally, an 8mm port is placed at the scapular line, along
with the assistant port. Upon docking the robot, a 30° camera is placed in the anterior axillary port. Bipolar Maryland forceps are inserted into the midclavicular port,
Fenestrated Bipolar Forceps into the posterior axillary line port, and a Tip-Up
Fenestrated Grasper into the scapular port. These instruments are used for the hilar
dissection. Robotic staplers are employed for all stapling applications, with the
majority of the stapling performed through the midclavicular port. Occasionally,
especially during right middle lobectomy procedures, the use of the stapler through
the posterior axillary port can be advantageous. With the recent introduction of an
8 mm robotic stapler, 12 mm posterior axillary port may be replaced with a standard
8 mm port.
Once the initial inspection of the pleural cavity is performed and the decision to
proceed with lobectomy is conrmed, the procedure begins with the inferior and
posterior dissection of the hilum, regardless of the type of lobectomy. Bipolar
energy is utilized for dissection and safe tissue division. Using the posterior arm as
a static retractor, the lung is retracted cranially, and the inferior pulmonary ligament
is divided up to the level of the inferior pulmonary vein (Fig.31.4a). This maneuver
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ef
A. I. Gritsiuta et al.
Fig. 31.4 Technical steps of the RUL. (a) Exposure and division of inferior pulmonary ligament.
(b) Posterior hilar mobilization with dissection of the subcarinal LN. (c) Dissection of the bifurcation of the RUL and RBI with resection of the LN (Station 11R) and development of the plane
between the bronchus and PA. (d) Superior hilar dissection with development of the plan between
RUL bronchus and anterior apical trunk of the PA. (e) Dissection and division of the anterior apical
trunk of the PA. (f) Division of the RUL tributary of the SPV. (g) Dissection and division of the
posterior ascending branch of the PA after anterior apical trunk and SPV division. (h) Division of
the RUL bronchus from the posterior approach. (i) Division of the parenchymal bridge of the
minor and major ssures. (j) Placement of the specimen in Anchor tissue retrieval system. (k)
Dissection of the paratracheal lymph node pocket (stations 2R, 4R, and 3). (l) Completion of the
lobectomy with placement of the chest tube and visually conrmed lung reexpansion without torsion