Robotic Operations in Thoracic Surgery: Who Are the Candidates?

Overview

By Linda W. Martin, MD, MPH

Article

Robotic surgery is fairly new; it was first used in 1985 for a neurosurgical procedure. For chest operations, it was used by just a handful of surgeons beginning in 2001. However, it is being adopted by more surgeons each year, with use increasing from 0.2% to 3.4% of all thoracic operations from 2008 to 2010.

A wide range of thoracic surgeries can be performed with the assistance of a robot. For example, robots have been used for:

  • Wedge resection
  • Segmentectomy
  • Lobectomy
  • Whole lung removal (pneumonectomy)
  • Esophagectomy
  • Removal of masses in the center of the chest (such as thymectomy for tumors of the thymus)
  • Surgery for hiatal hernia or gastroesophageal reflux disease and other noncancerous conditions of the esophagus
  • Decortication for severe infections of the chest cavity

To date, we don’t have any concrete information on whether use of the robot is superior to standard techniques. Thoracic surgeons with robotics training generally agree that robotic techniques are particularly helpful to treat thymus diseases and some smaller masses in the chest cavity.

What is robotic surgery?

Robotic surgery involves the use of a robot to direct instruments that enter the patient through very small incisions, or ports, usually four to five total. Once the surgeon creates these port entries and attaches the robotic instruments to the patient and robot, she/he then leaves the operating room table and sits down a few feet away at a console that controls the robot. At the console, the surgeon has a nearly 3D view of the surgical field, can magnify or zoom out, and move the camera wherever she/he deems appropriate. Using foot and hand controls, virtually every instrument is controlled by the surgeon.

One port is reserved for the assistant who is at the operating room table. This assistant may be another surgeon, a surgeon in training (resident or fellow), or a physician assistant. The assistant retrieves tissues from the surgical site (such as lymph nodes, biopsies, or the organ or tissue that is being removed), adjusts or changes the robot instruments, and passes tools (such as sutures or sponges) into the surgical site. In many cases, this person also serves the important role of passing and firing the instrument that divides blood vessels. This is carefully directed by the surgeon at the robot console, but actually performed by the person standing next to the patient. Newer versions of the robot are allowing the surgeon to control the blood vessel division, but, presently, the assistant actually divides the vessels in most cases.

What are the advantages of robotic surgery?

Robotic surgery represents tremendous technological advances. It is new and exciting, and, frankly, sounds very “21st century.” The advantages include:

  • An enhanced view (The surgeon can see with highly advanced camera optics and maneuverability.)
  • The ability to control three arms at once (instead of the two we were born with)
  • Instruments that are able to move in ways that traditional surgical instruments cannot (It is referred to as “wristed” technology.)
  • A comfortable sitting position for the surgeon, potentially allowing her/him to perform even better without standing for hours or experiencing a sore neck or back
  • A correction for any hand tremor that the surgeon might have
  • Smaller surgical incisions, which produce smaller scars and may lead to a less painful recovery
  • Less blood loss (There may be a small difference compared to some techniques, but could be a big advantage with complicated surgeries.)
  • Possibly lower complication rates

Disadvantages also exist with robotic surgery. Training as a robotic surgeon takes a big investment of time, practice, and experience. Because it’s so new, precise standards for what is needed to deem a surgeon “competent and safe” with this new equipment is not universally established. Even a surgeon who has been removing lung cancers her/his entire career through standard incisions or minimally invasive surgery has to learn an entirely new technique, practice with the machinery, and develop a new skillset.

The surgeon isn’t the only one who must be trained; the entire operating room team (nurses, anesthesiologists, etc.) needs extensive training, and the hospital must make a large investment. Robots are very expensive (about $2 million, plus hefty maintenance costs, instrument costs, and training costs) and, thus, many hospitals don’t have a robotic program or a few robots are shared among multiple specialties, creating significant scheduling difficulties. This translates to delays for patients to have their operations.

Also, the cost of the same operation performed in a traditional manner is much less expensive than using the robot. A shorter recovery in the hospital balances this in some cases, but not always. So a hospital’s balance sheet can be negatively impacted. Insurance companies also are noting higher costs. Recently, I’ve heard of patients scheduled for robotic surgery, but the insurance company denied the pre-authorization and insisted on more “standard” approaches because robotic surgery hasn’t been proven to be better than the usual techniques.

Another issue is that the technology keeps evolving, so upgraded versions are needed – but at $2 million apiece it is not the same as trading in your old iPhone for a new one!

You and your doctor also must consider the type of surgery you need. Big tumors (in the lung, esophagus, or middle of the chest) can be difficult—if not impossible—to extract through small ports, so robotic surgery will have limited use in these cases. Large lymph nodes and other technical factors such as prior radiation therapy can make the operation more risky. Perhaps the most important disadvantage to a patient is that the surgeon is NOT at the operating table. Although the team rehearses and perfects these scenarios, if the team encounters something unusual or unexpected, there is still a slight delay in getting the surgeon to withdraw the robot and get her/him to the operating table.

So what should you do as a patient?

My best advice is to find a surgeon you trust and then trust her/him to help you make the best treatment choice possible for your situation. Having the surgeon treat you using techniques that she/he are comfort with and know best will be better than asking her/him to use a technology that is new and still maturing. 

Robotic surgery is extremely promising and exciting, but we need to continue to collect proof and see results across different types of surgery to determine whether it is better.  As stated in The Annals of Thoracic Surgery in a 2007 letter by Dr. A. Sampath Kumar, “Basically any surgical technique for universal adaptability should be better or advantageous in comparison with existing techniques. Being just as good is perhaps not good enough for change.”   

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The opinions expressed in this article are those of the author and do not necessarily reflect the views of The Society of Thoracic Surgeons.