Robots have become increasingly present in contemporary reality. One can find them working in places where humans cannot reach because of biologic limitations, and helping people in different fields, as in the area of health care. In this regard, there is emphasis on the advances in the use of these devices in different surgical procedures, among them thoracic surgery, with good results for a variety of thoracic procedures.¹

From the time of ancient civilizations, there have been many accounts of automated devices or automats representing humans in appearance. Through the industrial age, there appeared more practical applications, by replacing humans in performing repetitive or dangerous tasks, which humans prefer not to or are unable to do because of size limitations, or which take place in dangerous environments.

The term robot, which means forced labor in Czech language, was first used in the beginning of the last century by Karel Capek in his play entitled Rossum’s Universal Robots and presented in 1921, introducing the term robot into English and other languages.

Actually, a robot means a machine capable of carrying out a complex series of actions automatically. Robots have either their control embedded within, or are guided by external, human control. Robots have become incorporated into daily life over the last half-century: what was once only science fiction has now become a reality. Robots are used widely in all kinds and types of activities and domains: from house holding, to grass movers, to leisure, to industry, and most recently medicine, enhancing the development of certain types of surgical interventions. Today, everyone living in the developed countries benefits from the advances in robotics in the daily life. Although robots were commonly used in the healthcare laboratory setting, they have been increasingly integrated into clinical medicine. Over the last 2 decades, research in surgical robotics has been continually increasing as evident from the rise in the number of manuscripts published each year. Surgical robotics is an evolving field aiming to take advantage of the features of robotics which made them so valuable in other industries.

In 1985 the first surgical application of robotic technology in medicine was described when an industrial robotic arm was modified to perform a stereotactic brain biopsy with 0.05 mm accuracy. This served as the prototype device for Neuromate (Integrated Surgical Systems, Sacramento, CA, USA), which received U.S. Food and Drug Administration (FDA) approval in 1999.² In 1992 the Robodoc (Integrated Surgical Systems, Sacramento, CA, USA) was introduced for use in hip replacement surgery. Whereas the Robodoc has been used in thousands of patients in Europe, it has not yet received FDA approval in the United States because of concerns regarding complication rates.^3–5 Similar devices have been designed for use in knee replacement and temporal bone surgery, but neither of these devices has yet completed clinical testing or received FDA approval.^6,7

The potential for widespread clinical application of the newly developed telerobotic devices was commercially recognized in 1997, Intuitive Surgical’s daVinci® surgical system was used to perform a laparoscopic cholecystectomy in Belgium.⁸ In 1999 Computer Motion Inc. introduced the Zeus surgical system (after its predecessor AESOP, introduced in 1994), which differed from daVinci® primarily in the configuration of the surgeon’s workstation. It was cleared by the FDA, but after several lawsuits against a rival medical robotics company, in 2003, Computer Motion and Intuitive Surgical merged into a single company.

The da Vinci Surgical System® is a robotic surgical system made by the American company Intuitive Surgical and approved by the FDA in 2000. It is controlled by a surgeon seated at a console which gives him a three-dimensional (3D)-image of the surgical field. The second part of the robot is the actual robot—the patient-side cart—consisting of three or four robotic arms and housing different instruments and the endoscope with incorporated camera. The third component of the system is a video monitor, including optical devices for the robot.

A full range of Endo Wrists (Surgical Intuitive) instruments are at the disposal of the surgeon for the surgical procedure. These instruments provide seven degrees of motion, which exceeds the capacity of a normal hand during open surgery and two degrees of axial wrist-like rotations.⁹ The instruments are introduced via special ports and the surgeon’s movements at the console are transmitted in a highly sensitive manner to the instruments attached to the arms of the robot.

Usually, a first surgeon operates the console, while the second surgeon, at the operating table, introduces and changes the trocars and the different instruments necessary for the operation.

Robotic-assisted thoracic surgery (RATS) started in a few centers in the mid-late 1990s. The first report was made at the beginning of the year 2000.¹⁰

Despite the fact that thoracic surgery is one of the fastest growing techniques, the results of RATS are not widely reported. Yet, we may not recognize any major advantage in the outcome when compared with video-assisted thoracic surgery (VATS), but certainly, the superior capabilities of robotic surgery could be beneficial. Gaining more experience in RATS may provide superior results in oncologic, physiologic, and life quality measurements.¹¹

Advantages, Disadvantages, Learning Curves

In the beginning, RATS was mainly compared with VATS. The VATS technique gained recognition in thoracic surgery from the 1990s and some articles even reported significant improvements in comparison with open surgery. Advantages of VATS were less trauma,¹² shorter chest drainage duration, decreased hospital stay,^13–15 preservation of short-term pulmonary function,¹⁶ reduced pain and fewer complications. Robotic surgery is of course also a minimally invasive technique, and therefore it will be difficult to show differences in performance with VATS.

Similar to the introduction of VATS several years ago, RATS is a surgical technique that is getting more and more integrated in the spectrum of thoracic surgery. The spread of initial minimally invasive techniques was slow considering limitations (limited maneuverability and unstable camera platform)¹⁰ and poor ergonomics. Often, one specific technique, either VATS or RATS, is chosen by one particular surgeon. A minority of thoracic surgeons are trained in both minimally invasive techniques, and therefore it will be difficult to obtain large comparative studies with those equipoise experts. Also worldwide, the experience is widely differing; in some countries robotics platforms have integrated well, whereas in others, RATS programs are at the start-up point.

Of course, the costs for the use of a robotic system is an important factor. Because VATS has a less expensive price tag, its penetration became widespread faster. Unfortunately, there is no standardization of VATS, which seems to be the case with RATS. Furthermore, the learning curve for RATS is greater than for VATS (50 cases vs. 25 cases to be performed by the surgeon to be certified).^17,18 Obviously, the traditional way of surgical training must be taken into account. Previously everyone was trained for open surgery through the thoracotomy or sternotomy; later on, VATS was started up. In the group of people who have not switched to VATS, there are a number of surgeons who immediately switched to RATS, bypassing VATS. Most surgeons who switched from VATS to RATS already had a minimal invasive thoracic surgery experience.

Advantages of RATS are of course the 3D vision, the use of the robot-controlled and hinged instruments, and the ergonomic aspect for the surgeon. Movements are more precise, filtered, and scaled. Therefore improved surgical precision and accuracy are possible.

The robotic system is not perfect; disadvantages are loss of tactile feedback, increased operation time, distance between the surgeon and the patient. The significant disadvantage remains the high cost of the system and the parts that are needed for an operation. Instruments can only be used for a limited time (10–20 uses), which leads to considerable costs. Some data suggest that shorter hospital stays will offset some of the higher cost.

Another aspect is the specific training that is required. If this can be done on a dual console system, there is of course a better close guidance of the start up. The “student”-surgeon and the experienced surgeon (proctor) have the same picture and switching the instruments between the two consoles is easy. In addition, the da Vinci® robot surgical system has introduced the da Vinci skills simulator, where surgeon and surgical team can participate in the development of specific skills in a simulator center.

In case of bleeding, there is often a better control possibly because the robot’s arms remain firm in the same position and are not dependent on a human factor, such as movements or distraction. An emergency thoracotomy can always be performed while the bleeding remains stable and control can be achieved better than with a VATS procedure.

The major advantage is actually for the surgeon. Ergonomics for the surgeon on the robotic console cannot be compared with the situation during a video-assisted thoracic operation. Even physically, sitting down on a comfortable chair at the console is completely different from standing with two surgeons sideways from a patient and looking at a screen.

In the meantime, the technique has been considered safe and reproducible, and there is an association with a reduced duration of stay, as well as low morbidity and mortality.¹⁴ A recent publication confirmed that RATS achieves equally good oncologic results. Larger series show that the visualization and dissection of lymph nodes in the mediastinum can be performed more smoothly so that more nodal levels can be reached during dissection. This provides better staging of the disease and consequently a more adapted therapy.¹³ The robot was primarily intended to be used during cardiac surgery, but the current clinical use of the robot covers a wide range of surgical specialties.

The Robot-Assisted Lobectomy

The lobectomy is the most commonly performed oncologic procedure, in which a precise anatomic dissection of the lung is performed. Each center has now developed a technique, usually in function of the type of the robotic system. Modern robot machines have increased from three-armed systems to four arms, which allowed better access to the patient by the caregivers. This led to more standardization (3- or 4-arm) of the technique, and it can also be used for safe resection of all lobes. The older system is more dependent on correct positioning above the patient because of less mobility of the central attachment of the robotic arms. This created situations where accessibility for the anesthesiologist to the patient was impaired, and that may be crucial in critical situations.

The mortality is comparable to the other techniques, open and video-assisted surgery. Long-term oncologic results are consistent with other large series using VATS or thoracotomy.¹⁸ The morbidity is the same and there are no specific complications contributed to the robotic system described in the literature (in case of thoracic surgery). A retrospective study by Bao et al. compared 184 patients undergoing RATS versus VATS lung resection and found no improvement in clinical outcomes, whereas RATS procedures took longer and cost significantly more.¹⁹

Blood loss is not significantly different in comparative ranges between VATS and RATS.²⁰

The Robot-Assisted Segmentectomy

The number and proportion of early-stage lung cancers is likely to increase because of the growth and aging of the population and the low-dose chest computed tomography screening programs of high-risk populations.

Because of the wider range of well controlled movement of the robotic arms and improved operative visualization techniques of vascular structures with indocyanine green and creation of anatomic 3D-models for preoperative planning, segmentectomy can be performed by more surgeons using this mini-invasive approach. The meticulous dissection of hilar, bronchial, and vascular lymph nodes, which is important for the correct staging of early lung cancer, was made more accessible by RATS operations.

Metastases in the lungs can thus be removed and wider resection margins can be obtained. Resections of small early lung cancers in high-risk individuals are also possible with the aid of the robot system. To determine the oncologic validation for sublobar anatomic resections in small early stage lung cancer, two studies are currently in progress, namely, CATGB 140503 (United States) and JCOG 0802 (Japan). Future results will determine whether this approach can be applied to all patients with clinical stage 1A disease without oncologic compromises. Segmentectomy has been proven safer than lobectomies,^21,22 and it carries less complications when performed thoracoscopically compared with open surgery. For that reason, some surgeons advocate that a sublobar anatomic resection has to be done thoracoscopically, and the robotic platform is useful for this operation.

The surgical technique used in our institution is a 4-arm set-up. The anesthetized, ventilated patient is positioned on a vacuum mattress in lateral decubitus. The chest is elevated with an inflatable balloon placed under the patient so that the thorax is the highest point. The robot is positioned in the back of the patient. Four ports are used and one assistant’s port.

The camera is located on the intersection of the eighth or ninth intercostal space and posterior axillary line. From here, the second port is placed 8 cm to the anterior side, the third port 8 cm to the posterior side, the fourth 8 cm in 45 degrees up and posteriorly, respecting 6 cm from the midline of the spine. A 12-mm laparoscopic port is placed supradiaphragmatically, under visualization with a 30-degree camera, and after insufflation of carbon dioxide (CO2) at a pressure of 5–10 mm Hg. This port is used for suctioning, stapling, and retraction that will be enlarged to approximately 4 cm at the end of the operation for retraction of the specimen. Instruments that are used are the spatula in the right hand, the bipolar forceps in the right, and the tip-up forceps also in the right hand. The spatula is changed with the Cadière-forceps for passing behind structures. The assistant port is used for the stapling devices (Fig. 52.1).

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