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J Thorac Cardiovasc Surg 2006;131:54-59
© 2006 The American Association for Thoracic Surgery

General Thoracic Surgery

Robotic assistance for video-assisted thoracic surgical lobectomy: Technique and initial results

Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.

Read at the 2004 Annual Meeting of The Society of Thoracic Surgeons.

Received for publication March 16, 2005; revisions received July 26, 2005; accepted for publication July 29, 2005.

^_* Address for reprints: Bernard J. Park, MD, Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Room C-867, New York, NY 10021. (Email: parkb{at}mskcc.org).

	Abstract

Top Abstract Introduction Patients and Methods Results Discussion References

 
OBJECTIVES: There is little experience with telerobotic assistance for video-assisted thoracic surgical lobectomy. We developed a technique for robotic assistance during video-assisted thoracic surgical lobectomy and report our initial results.

METHODS: Video-assisted thoracic surgical lobectomy with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) was attempted in 34 patients (median age, 69.0 years; age range, 12-85 years). Robotic instruments were used for individual dissection of the hilar structures through 2 thoracoscopic ports and a 4-cm utility incision without rib spreading. Data on patient characteristics and perioperative results were collected prospectively.

RESULTS: Robot-assisted video-assisted thoracic surgical lobectomy was accomplished in 30 patients (19 female and 11 male patients). Every type of lobectomy was performed. Four (4/34 [12%]) patients required conversion to thoracotomy. The majority of patients had non–small cell lung cancer (32/34 [94%]), and 1 patient each had a typical carcinoid tumor and an extranodal B-cell lymphoma. Every patient underwent an R0 resection. The median number of lymph node stations dissected with robotic assistance was 4 (range, 2-7). Operative mortality was 0%, with no in-hospital or perioperative deaths. Nine (26%) patients experienced National Cancer Institute Common Toxicity Criteria for Adverse Events version 3.0 grade 2 or 3 complications. The median chest tube duration was 3.0 days (range, 2-12 days), and the median length of stay was 4.5 days (range, 2-14 days). The median operative time was 218 minutes (range, 155-350 minutes).

CONCLUSIONS: Robot assistance for video-assisted thoracic surgical lobectomy is feasible and safe. The utility and advantages of robotic assistance for video-assisted thoracic surgical lobectomy require further refinement and study of the technique.

	Introduction

Top Abstract Introduction Patients and Methods Results Discussion References

 
The technique of video-assisted thoracic surgery (VATS) pulmonary lobectomy was first reported in the early 1990s simultaneously by several authors. ^1-4 Since then, the practice of VATS lobectomy for primary surgical therapy of early stage non–small cell lung cancer (NSCLC) has been slowly increasing because of indications that the procedure is safe and oncologically acceptable in patients with stage I disease. ^5-11 Limitations of minimally invasive surgical (MIS) approaches for performance of major thoracic procedures include 2-dimensional imaging, an unsteady camera platform, and limited maneuverability of instruments used through small non–rib-spreading incisions. In an effort to improve standard MIS techniques, telerobotic surgery has evolved. The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) is a recently developed, US Food and Drug Administration–approved telerobotic system consisting of 4 components, including the Insite vision system, with a true 3-dimensional (3-D) endoscope providing a high-resolution binocular view of the surgical field, and the EndoWrist instrument system, which is capable of 7 degrees of freedom and 2 degrees of axial rotation to replicate human wrist-like movements. ¹² The advanced articulation of the robotic instruments is clearly their greatest potential improvement over straight instruments used in conventional VATS procedures. Because of this, the da Vinci Surgical System was initially designed for use in closed-chest cardiac surgery, and the earliest published experience was in the area of coronary artery bypass grafting. ¹³ In the field of general thoracic surgery, however, it is not clear whether this technology has any benefits, and there are only a few case reports of only a handful of procedures involving robotic assistance. ^14-16 For VATS anatomic pulmonary resections, there are no published data detailing a robot-assisted technique or its feasibility in a meaningful cohort of patients. We report our initial experience with development of an approach for and assessing feasibility of using the da Vinci Surgical System to perform VATS lobectomy. We reviewed the indications for the procedure, the technical aspects of incorporating robotic assistance, and the perioperative outcomes.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Discussion References

 
Patients with clinical stage IA NSCLC or other pathologic tumors that were peripheral and confined to the lung were considered eligible for VATS lobectomy. Robotic assistance is defined as use of the da Vinci Surgical System during a VATS lobectomy for individual dissection, isolation, and ligation of the pulmonary hilar structures, as well as mediastinal lymph node dissection. Informed consent for robotic assistance during VATS lobectomy was obtained. Data on patient characteristics, operative details, and postoperative recovery were collected in a prospective database approved by the institutional review board and analyzed retrospectively. All complications were graded according to the National Cancer Institute Common Toxicity Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov/reporting/ctc.html). Specific details about the development of a technique for robot assistance during VATS lobectomy, as well as key technical aspects, follow below.

Robotic Training and Technique Development
Before implementation of robotics into clinical practice, the authors and the operating room team of nurses, surgical technicians, and surgical physician assistants (PAs) attended an intense, 2-day certifying course given by Intuitive Surgical. Use of a human cadaver model and additional modifications in our institutional dry laboratory allowed for implementation of robotic assistance into our established VATS lobectomy technique. Once the entire surgical team became proficient with the da Vinci Surgical System, we incorporated it into treatment of our patients. The initial 10 cases were performed with a dedicated MIS surgical PA and at least 2 members of the attending staff working together, one as the operating surgeon at the surgeon's console and the other at the operating room table with the patient. Once each surgeon became comfortable with the procedure, we were able to incorporate the surgical fellows as first assistants. The majority of procedures are now performed with one attending surgeon, a surgical fellow, and a surgical PA.

At our institution, the surgeons who perform VATS lobectomy do so through a technique that uses two 1- to 1.5-cm access incisions and a 4-cm or smaller non–rib-spreading utility incision. The initial 2 robot-assisted cases used a different 4-incision technique that had the robot positioned perpendicular to the longitudinal axis of the patient. This was subsequently modified to conform to our standard VATS lobectomy technique by bringing in the robot at a 45° angle with respect to the long axis of the patient.

Preparation of the Robot
The operating room technical staff sets up the da Vinci Surgical System (robot, surgeon's console, and Insite vision system) the evening before its use. In the beginning of the case, the nursing staff power up the system, run the appropriate diagnostics, and drape the robotic arms and camera. This requires 2 individuals, typically takes 20 to 30 minutes for staff who are trained and familiar with the process, and occurs while the patient is undergoing induction of anesthesia and positioning.

Initial Exploration and Positioning of the Robot
For the intrathoracic portion of the case, the patient is placed in a maximally flexed lateral decubitus position after single-lung ventilation is established. Initial thoracic exploration is conducted with conventional thoracoscopy to verify tumor location, establish a tissue diagnosis if necessary, assess resectability and appropriateness of a VATS approach, and establish the VATS lobectomy access incisions. The incision for the camera is placed in the 7th or 8th intercostal space at the posterior axillary line. The next incision is then placed just above the diaphragm posterior to the tip of the scapula. The lung is retracted posteriorly to identify the hilar structures. The location of the main utility incision varies depending on the lobe of interest. For upper lobectomy, it is placed at the level of the superior vein in the midaxillary line. For middle and lower lobectomies, the incision is placed one intercostal space lower. Once the incisions have been made, no additional dissection is performed. The conventional VATS instrumentation is removed, and the da Vinci robot is brought into position from the posterior aspect of the patient, with the center column at an approximately 45° angle with respect to the longitudinal axis of the patient (Figure 1). This allows for the field of dissection to include the hilar structures and the majority of the chest.

View larger version (63K): [in this window] [in a new window]   Figure 1. Positioning of the da Vinci Surgical System. A, Overhead view; B, magnified view.

View larger version (67K): [in this window] [in a new window]   Figure 2. Robotic instrument configuration.

Once a pathologic diagnosis of NSCLC is confirmed, either preoperatively or intraoperatively, we are in the practice of beginning the procedure with mediastinal lymph node dissection. When indicated, these are sent for frozen section to rule out occult stage III disease.

If there are no contraindications to lobectomy, individual isolation of the hilar structures proceeds with dissection around the hilar vessels and bronchi performed through a combination of cautery and sharp and blunt dissection. Complete removal of all regional nodal tissue is performed. When either a vessel or the bronchus is mobilized sufficiently, 2 blunt-tipped Cadiere forceps are used to isolate the structure, using the 7 degrees of freedom to articulate the instruments at near right angles to do so.

For upper and middle lobectomy, individual ligation and division of the hilar structures are performed with endoscopic staplers introduced through the posterior access incision. This requires temporary repositioning of the left instrument arm. In contrast, for lower lobectomy, division of the hilar structures is best performed by placing the stapling devices through the anterior utility incision, which requires repositioning of the right instrument arm.

In our technique of VATS lobectomy, completion of the fissure is performed last, just before removal of the specimen. After isolation and division of all of the hilar structures, the robot is removed, and conventional thoracoscopy is re-established to complete the fissure. For upper lobectomy, the entire fissure is divided with endoscopic staplers; for middle and lower lobectomies, the anterior portion of the fissure is often divided with electrocautery in the course of dissection of the hilar structures. The remaining posterior portion of the fissure is then completed with the endoscopic staplers.

	Results

Top Abstract Introduction Patients and Methods Results Discussion References

 
Between November 2002 and December 2004, there were 34 consecutive patients who underwent attempted robot-assisted VATS lobectomy with the da Vinci Surgical System. There were 3 additional patients who underwent exploratory thoracoscopy but did not proceed to robot-assisted VATS lobectomy. Two had benign lesions and underwent VATS wedge resection only. One patient was found to have a lesion invading the pericardium and was converted to a thoracotomy for lobectomy. The patient characteristics are listed in Table 1. Upper lobe lesions predominated (24/34 [71%]), with right upper lobe tumors being the most common. ¹⁴ Patients were selected for a robot-assisted approach on the basis of the following criteria: (1) presence of a localized peripheral lung lesion without evidence of nodal or extrathoracic spread and (2) adequate cardiopulmonary reserve to tolerate a lobectomy. Five patients had no tissue diagnosis and underwent initial VATS and wedge resection in the same setting, and 6 patients had mediastinoscopy also in the same setting. The vast majority of our patients had NSCLC (32/34 [94%]), and 1 patient each had a typical carcinoid tumor and a primary pulmonary lymphoma. Those with NSCLC all had clinical stage IA disease preoperatively. As a result, only 1 patient had any therapy before resection. This patient was given a diagnosis of Hodgkin's lymphoma and NSCLC simultaneously and was treated at an outside institution with chemotherapy directed at both before presentation at our institution.

For the patients with NSCLC, the overwhelming majority had adenocarcinoma of some variation (27/32 [84%], Table 1). Pathologic stage in these patients correlated with clinical stage (T1 N0 M0, stage IA) in 78% (25/32). Two of 3 patients with pT2 N0 M0 disease had microscopic visceral pleural invasion, and there were 4 patients with pathologic stage II disease who had completely resected microscopic N1 disease. There were no patients with unsuspected stage III disease, and all underwent R0 resections. The median size of the lesions pathologically was 2.0 cm (range, 0.8-4.0 cm).

The median chest tube duration for the entire group was 3.0 days (range, 2-12 days), and the median length of stay was 4.5 days (range, 2-14 days). The complication rate for all patients was 26% (9/34, Table 1). The most common complication was supraventricular tachycardia (6/9). All complications were either National Cancer Institute Common Toxicity Criteria for Adverse Events version 3.0 grade 2 or 3. One patient with a history of coagulopathy had postoperative hemorrhage requiring re-exploration, with no clear source of bleeding identified. One patient experienced a postoperative myocardial infarction and underwent emergency cardiac catheterization and stent placement. There were no in-hospital deaths, and the 30-day mortality rate was 0%.

	Discussion

Top Abstract Introduction Patients and Methods Results Discussion References

 
Since the initial series in the early 1990s describing the technique, VATS lobectomy has not gained widespread acceptance as a standard approach to early-stage lung cancer. This might be due, in part, to wide variations in technique, even among its busiest practitioners, and the lack of a large randomized trial demonstrating equivalency to a standard thoracotomy approach for the treatment of resectable NSCLC. However, with ongoing refinements in minimally invasive techniques and instrumentation and with detection of primary lung cancers at smaller sizes and earlier stages, the use of minimally invasive VATS techniques for anatomic pulmonary resections is likely to become more commonplace. One of the newest advances in minimally invasive surgical intervention is the development of telerobotics. With its advanced 3-D optics, stable camera platform, and instrumentation that allows for 7 degrees of freedom of motion, the da Vinci Surgical System has been shown to be effective in performing complex cardiovascular surgical procedures in a closed-chest setting. We hypothesized that use of this technology during VATS lobectomy would be feasible and safe and wondered whether it afforded any advantages over conventional VATS in terms of ease of anatomic dissection.

There were 2 major reasons that a conscious decision was made to develop a robotic technique that used the incisions used for a conventional VATS lobectomy rather than develop a unique set of incisions. The first was that in the event of malfunction of the robot or any of the system's components that cannot be fixed in a timely fashion, the remainder of the procedure can be performed with conventional thoracoscopy without the need for additional incisions. The second reason was because there have been no large series describing a successful technique for robot-assisted VATS lobectomy, there was no way to know whether the goal of performing the entire hilar dissection with robotic instrumentation was technically feasible. Indeed, the major challenge in developing this technique was determining the optimal positioning of the surgical cart and the instrument arms. As a result, the median operative time for robot-assisted cases was more than 3 hours at 218 minutes. In 2 cases early in the series, the operative time was well over 5 hours, but as the technique was refined, this value decreased steadily, such that the operative times in 8 of the last 10 cases have been less than the median value. This required a multidisciplinary effort from a team of experienced MIS personnel that included the operating room nurses and technicians, anesthesiologists, and surgical staff.

Several key technical points were discovered in refining this robotic VATS lobectomy technique. First, having the patients in a lateral decubitus position limits the available surface area in which to position the camera and instrument arms. Close attention must be paid to the spacing and the range of motion of the arms so that they do not collide with one another or cause undo pressure on any portion of the patient, particularly the upper extremities.

Second, it is critical to have assistants at the operating table who are familiar with conventional VATS lobectomy techniques, especially with regard to retraction and exposure of pertinent anatomic structures and placement of vascular stapling devices. This is particularly true because the operating surgeon is seated at the surgeon's console, away from the patient.

Third, although there is excellent visual feedback with the 3-D robotic video system, there is absolutely no tactile feedback during traction and dissection with robotic instrumentation. The same technology that eliminates tremor also eliminates any sensation of the tissue planes.

Fourth, choosing the appropriate robotic instrumentation to use during dissection is critical. In doing so, one needs to remember that the majority of the instruments were designed for use on coronary vessels. The instruments used by the authors are by no means the only ones that should be considered. Each individual surgeon must evaluate and test the instrumentation to determine those that are safe and effective for dissection.

Finally, because of the reasons listed above and with any new procedure, we encourage a graded process of developing experience with the technique. Indeed, in a number of our early cases, we elected to use the robot in stages before completing the entire dissection robotically.

An additional issue to be considered is the additional costs associated with use of the da Vinci Surgical System. There are 3 major areas of expense: (1) initial capital cost of the system components, (2) annual maintenance cost, and (3) cost of disposable materials (instruments and drapes). Purchase of the robotic system was a capital investment by our institution, and it is used by multiple surgical services. The one-time cost of $1 million is not passed on to the patients. In addition, there is currently no CPT code for robot-assisted VATS lobectomy, only VATS lobectomy. Therefore to the best of our knowledge, patients are not being billed additional fees for our use of the da Vinci Surgical System. The annual maintenance cost is $100,000. The robotic instruments have a finite number of uses that varies from 10 to 12, depending on the instrument. Each instrument used in our technique costs $2000 and can be used 10 times, for a cost of $200 per case. The drapes used for the robot and camera cost $130, so that the total disposable cost per case is $730.

This study suffers from the limitations of any nonrandomized, retrospectively analyzed cohort of patients, the most obvious being selection bias. However, a significant effort was made to select patients on the basis of the identical criteria that would be used to offer them a nonrobotic VATS lobectomy. The results of the study demonstrate that use of the da Vinci Surgical System for the individual dissection, isolation, and division of the pulmonary hilar structures during VATS lobectomy is feasible and safe. The morbidity rate and type of complications were consistent with what was expected from pulmonary lobectomy in an elderly population with lung cancer. It is not surprising that postoperative supraventricular tachycardia was the most common complication. As with any new MIS technique, there was a low threshold to convert to thoracotomy, and this was required in 12% of cases. This is higher than those reported in the largest current series of VATS lobectomy ^10,11 but acceptable and likely to decrease as more experience is accumulated. Patients had their chest tubes in place a median of only 3 days and were discharged in good condition a median of 4.5 days postoperatively. No patients required readmission for delayed complications, and there were no in-hospital or 30-day mortalities. Again, these results are consistent with the VATS lobectomy experience from the most recent series. ^10,11 All patients underwent an R0 resection, and in the patients with NSCLC who underwent successful robot-assisted VATS lobectomy, a median of 4 lymph node stations were resected.

Are there any advantages in using telerobotic surgery during VATS lobectomy? Strictly speaking, this study was not designed to answer this question, but it was our observation that using the da Vinci System provided some enhancements over a nonrobotic VATS lobectomy. First, the 3-D Insite camera system resulted in a superior and stable image for the operating surgeon. Second, the 7 degrees of freedom of the EndoWrist robotic instruments allowed for truly intuitive bimanual dissection of the hilar structures. However, in the end, proving an improvement in the technical ease of a procedure is quite difficult. Currently, use of this new technology increases operating room time and adds cost for use of the robotic instrumentation. The technique is certainly still evolving and requires further study in clinical trials before it can be routinely adopted in clinical practice. The future directions for study of this technology include further refinement of the technique, validation of the adequacy of the oncologic results, and determination of methods to compare it with conventional VATS techniques.

See related editorial on page 19.

 

	Acknowledgments

 
We thank Hugh Thomas for providing the artwork for the figures.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bernard J. Park Raja M. Flores Valerie W. Rusch Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Park, B. J. Articles by Rusch, V. W. Search for Related Content PubMed PubMed Citation Articles by Park, B. J. Articles by Rusch, V. W. Related Collections Lung - other Related Article